Case
We present the case of a 19-year-old G3P0301 with pregnancies complicated by MPVFD of the placenta resulting in two third trimester IUFDs with subsequent delivery of healthy, late preterm infant with treatment during the prenatal period.
In the patient’s first pregnancy, prenatal course was largely unremarkable. Past medical and surgical history was only significant for mild persistent asthma. The patient’s prenatal labs were significant only for rubella and varicella non-immunity. The patient ultimately presented at 35w6d for labor and was subsequently diagnosed with an intrauterine fetal demise (IUFD). The patient underwent induction of labor and had an uncomplicated spontaneous vaginal delivery. On autopsy, the fetal exam was notable for maceration and organs small for gestational age. There were no signs of intrauterine infection. However, placental pathology was notable for MPVFD covering 75% of the placenta. Infectious workup and antiphospholipid (APLS) testing were negative, and the patient had no signs or symptoms of preeclampsia.
The patient was then seen for a new obstetric visit at a community clinic for the second pregnancy two months after the previous delivery. This pregnancy was complicated by an initial body mass index of 40 kg/m2 and asthma but was otherwise unremarkable. The patient ultimately transferred care to a tertiary care facility at 31 weeks and was referred to Maternal Fetal Medicine (MFM). The patient was subsequently seen at 36w6d for prenatal care however, the patient had not yet been seen in MFM clinic nor had antepartum testing at this time, so was then immediately sent to MFM clinic for a biophysical profile (BPP) and growth ultrasound. At that time, the fetus was found to have severe fetal growth restriction with reverse end diastolic flow and reverse ductus venosus flow. Fetal heart tones were additionally noted to be in the 90s. The patient was then taken immediately to labor and delivery triage where no fetal heart tones were auscultated and an IUFD was diagnosed. The patient then underwent induction of labor and had a vaginal delivery of a grossly normal appearing male fetus. Hemoglobin A1c, APLS, infectious and preeclampsia work-up was performed and was negative. Pathology showed a placenta that was small for gestational age with multifocally firm areas with increased intervillous fibrin and infarct, again consistent with MPVFD.
For the third pregnancy, the patient had an initial prenatal visit at 8w1d and subsequently established care with MFM at 11w4d. The patient was counseled on treatment options based on few available case reports including primarily thrombolytic therapies (aspirin, heparin) with or without combining immunologically directed treatments [e.g., intravenous immunoglobulin therapy (IVIG)]. The patient ultimately opted for treatment with aspirin 81 mg and enoxaparin 40 mg daily in addition to maternal serum alpha-fetoprotein testing, serial growth ultrasounds every 4 weeks beginning at 20w0d and weekly BPPs starting at 32w0d. Delivery was recommended between 34w0d-36w0d with betamethasone administration prior. The patient received betamethasone at 33w4d and 33w5d for planned delivery at 34w0d. However, while at antenatal testing at 33w5d, the patient was sent to labor and delivery triage for induction of labor due to a BPP of 6/8, minus two for gross movement. Ultimately, the patient delivered a live male infant via cesarean section at 33w6d for recurrent late decelerations unresolved with resuscitative measures in the setting of prolonged rupture of membranes after a 26-hour induction of labor. Apgar scores were 7 and 9 at 1 and 5 minutes respectively. Placental pathology again showed increased intervillous fibrin, intervillous thrombus, and calcifications (Figure 1) in addition to gross description with pink-yellow, rubbery tissue comprising approximately 90% of the total placental volume consistent with recurrent MPVFD (Figure 2). The infant was admitted to the neonatal intensive care unit secondary to prematurity and was ultimately discharged home on day of life 23. The infant was seen for a 2-month checkup and was noted to be doing well with appropriate growth and development. The patient was seen for a postpartum visit and was additionally noted to be doing well from a postpartum standpoint.