Vanishing twin syndrome was first described by Stoeckel et al. in 1945 and represents a multigestational pregnancy, characterized by abnormal formation of one of the fetuses, either completely reabsorbed, or mummified, or even being an amorphous mass attached to the placenta. The economic crisis in Greece has led to a high percentage of unemployment during the past decade that directly affects the decision-making of health providers and patients, reducing the quality of health of the reek population in general ( 1 , 2 ).

A 19-year-old primigravida presented to our clinic in labor at 35+1 weeks of gestation. She reported a normal antenatal course with excessive nausea only during the first trimester. Her hemoglobin was 9,2 g% and her blood group was AB Rh(-). Previous investigations were normal. She had a second level ultra sonography at 22 weeks that revealed singleton gestation with a viable fetus, with normal development of its anatomy, with a single placenta anterior in the upper uterine segment and a severe cervical insufficiency, confronted with a cervical cerclage at 22+2 weeks of gestation that was removed prior to delivery. The fetal heart rate of the fetus was 141 bpm, BPD-56 mm, FL-40 mm; maturity of 22 weeks. Clotting studies were normal.

Early contractions were the initiating event to end gestation at 35+2 weeks. Corticosteroids were administered to safely guard the maturity of the respiratory. Cesarean section (CS) was performed and a healthy baby boy of 2,8 kg was delivered.

During placenta delivery, we identified a second mass (≈10cm) attached to placenta’s membranes that with minor handling was easily detached and revealed a second placenta with a non-viable fetus of ≈16 weeks (Figure 1). The pregnancy was identified as dichorionic-diamniotic twin pregnancy with a viable fetus and a fetus papyraceus.

Multiple pregnancies exhibit increased fetal and maternal complication rates. Different studies report risk of specific complications which include neonatal distress syndrome, hyaline membrane disease, transient tachypnea of newborn, neonatal jaundice, necrotizing enterocolitis, neonatal sepsis, patent ductus arteriosus, twin to twin transfusion syndrome (TTTS), intrauterine growth restriction, defor-mational plagiocephaly, and other physical and mental disabilities ( 1 , 2 ). In monochorionic pregnancies, single intrauterine fetal Demise (IUFD) is associated with elevated perinatal mortality and serious neurological disabilities for the vital embryo. Congenital anomalies are also reported in the literature ( 3 , 4 ). Evaluation of the vital fetuses’ brain in a single fetal death of a monochorionic pregnancy should be performed after delivery. Fetal magnetic resonance imaging and neonatal cranial ultra sound are both recommended and provide detailed information about brain lesions and developmental delay in the surviving twin ( 5 ). In our case, the mother claimed that due to financial reasons, she wasn’t able to be monitored through her whole pregnancy. It is commonly accepted that regular pregnancy monitoring and screening reduces and prevents adverse perinatal outcomes ( 6 ). The economic crisis in Greece over the past decade has proven to directly affect the quality of health and medical care.

Greek Statistic Society released a research in 2014 that reported the percentage of patients that didn’t receive any medical care during the previous year. The long waiting lists of examination (12,9%), long distances from state hospitals and the patient mobility problems (6%, including lack of ambulances and financial difficulties for private transfer), lack of health-care workers (9,4%, such as doctors, nurses etc.) and medical care and treatment that was unable to be completed due to economic weakness (13,6% - 11,3% respectively), reduced the medical care quality of Greek ( 7 ). Also, unemployment levels (20,6% - 23,2%) reaching such high levels, directly affect patients' decisions on screening and/or on receiving treatment, as in our patient's case( 8 ). She stated that she didn’t experience any problems, however, the dead fetus seems to had a normal development until the 16 ^th week-of-gestation and a better monitoring and regular examination from the beginning of the pregnancy could have revealed both the twin pregnancy and a possible pathology that led To vanishing twin syndrome. It is commonly accepted that in many cases of multiple pregnancies with a dead fetus there are no adverse outcomes for the surviving fetus or the mother. Even though there are no reports of pregnancies that well monitoring forecasted and prevented a fetus papyraceus situation, and even though the economic problem seems to have a major participation in such cases, frequent-close maternal and fetal surveillance is essential, parental information for possible complications is highly recommended and pregnant women must be advised for the possible adverse outcomes of a gestation without monitoring.