Case notes

A 24 year old woman delivered a normal newborn and a papyraceous fetus (PF), along with a monochorial-biamniotic placenta, at 37 weeks’ gestation ( Figure ). Pliny the Elder first mentioned the PF in 70 AD; the dead fetus is remarkably flattened because of loss of fluid, and most of the soft tissue looks like papyrus, the paper used in ancient civilizations.

A, The patient delivered a normal newborn and a papyraceous fetus. B, A monochorial-biamniotic placenta was noted at delivery. C, In utero compression and maceration may be responsible for the characteristic musculoskeletal abnormalities.

Diaz-Perez. Like paper. Am J Obstet Gynecol 2012.

Conclusion

For years, the pathogenesis and clinical relevance of the PF, also described as mummified or noticeably compressed, have inspired debate. Historically the PF was considered to be an extraordinarily rare event. Widespread use of ultrasonic examination in early pregnancy and the increased reporting of fetal death have indicated that it is more common than previously believed, with an estimated frequency of 1 in 200 twin pregnancies.

Often the PF is noted to occur in women older than 35 years, and the clinical picture is variable. Symptoms such as bleeding, pain, or abdominal cramping may occur, but usually the mother is asymptomatic. When 1 fetus in a pair stops developing, it can be totally reabsorbed. Another possibility: evidence of its existence may be left behind as a PF, as in our patient’s case, or as a placental anomaly; a cyst, a subchorionic fibrin deposit; or a formless substance, for example.

When fetal death occurs in the first trimester, a PF may result without serious consequences. However, when the death occurs later in pregnancy, the living fetus can develop disseminated intravascular coagulation syndrome or blood loss. Cerebral palsy, another catastrophic outcome, is 50 times more likely in a newborn who shared the womb with a PF. Additional abnormalities reported in surviving twins include small-bowel atresia, gastroschisis, hydrothorax, renal cortical necrosis, and aplasia cutis. The musculoskeletal abnormalities found in the PF may result from maceration and compression in utero.