This case report describes a 31-year-old woman admitted at 35 weeks of gestation with severe preeclampsia, gestational diabetes, and abnormal Doppler scans showing absent umbilical and ductus venosus flow. She underwent an emergency c-section and delivered a live male infant weighing 2.03 kg. Placental examination was normal. The post-op period was uneventful and she was discharged on postoperative day 2.

1. PERINATAL MORTALITY
MEETING
APRIL 2022

2. Case 1
Mrs. M 31 years old, G2A1 at 35 weeks 2 days period of gestation with
cephalic presentation, IVF conception with Severe Pre-eclampsia ,GDM
, admitted with complaints of headache on and off & high blood
pressure readings, Obstetric scan showing AEF with reversal flow of
umbilical artery, no flow in ductus venosus for further management.

3. ANTENATAL HISTORY
• Patient is booked and immunized .
• Took iron and calcium regularly.
• She was on Cap Depin 10mg- BD & Tab Labetalol 200mg -TID for Pre-
eclampsia
• She was on Tab Metformin 850mg - BD for GDM.

4. CONDITION ON ADMISSION
• GC - Conscious, co-operative, Puffiness of face (+)
• BP - 172/112 mm Hg
• PR - 86/min
• Temp. - afebrile
• CVS/RS - NAD
• P/A - Uterus 34 weeks size,relaxed
• Head lower pole
• FHR (+)

5. INVESTIGATIONS
Blood Group - O POSITIVE
• Hb - 13.4 gm /dl
(11/04/2022)
• Platelet count - 2.65 Lakhs
• Total Leukocyte Count - 12,220
• (11/04/2022)
LFT
• ALT/SGPT - 38 U/L
• AST / SGOT - 49 U/L
• ALP - 217 U/L
RFT
• BUN - 4.95 mg/dl
• Uric acid - 4.40 mg/dl
• Creatinine - 0.40mg/dl
Electolytes
• Sodium - 135 mmol
• Potassium - 5.10 mmol
• Chlorides -107 mmol
• Urine exam ( /2021)
• Albumin - Present (+++)
• PT -11 sec
• APTT - 27 sec
• INR - 0.87

6. SCAN DETAILS
• IGScan (11/04/2022)
• SLIUG 35 weeks 2 days gestational age
• Cephalic
• AFI - 14 cm
• EFW - 2.32 kg
• Placenta - anterior high
• Fetal growth is on 18th centile
• Fetal AC is on 53rd centile
• Fetal BPD & FL <5th centile
• Fetal Doppler - Altered parameters noted- Fetus at risk
• Umbilical artery - Absent flow with end diastolic flow reversal seen
• MCA - PI - 1.3 - Normal
• DV - Reduced/ Absent 'a' wave noted at the time of scan
• Fetal abdomen and chest - Mild left pleural effusion , Minimal ascites seen

7. ADMISSION NST

8. COURSE OF TREATMENT
• GRBS and BP monitored.
• She received Inj Betamethasone 12 mg I/M,Depin tocolytics and Inj
Mgso4 infusion.
• She underwent Emergency LSCS under Spinal Anesthesia in view of
Abnormal Doppler, GDM & Severe PIH & delivered an alive male
baby of weight 2.03 kg at 4:02:00 PM, on 11/04/2022. 2 loops of
cord around the neck noted, True knot (+), released.
• Placenta & membranes expelled in toto and are healthy.
• Findings : Thin Meconium stained liquor (+)
• Bilateral tubes- normal , Ovaries - polycystic

9. POST-OP
• Post operative period uneventful. Recieved a course of i/v antibiotics
and analgesics.
• She was discharged with Tab Labetalol 200mg TID for 2 weeks, on
14/04/2022.

10. PLACENTAL MESENCHYMAL
DYSPLASIA

11. CASE SUMMARY
ANTENATAL HISTORY :
A 31 years old G2P1L0 /previous intrauterine fetal death /previous NVD
/admitted at 31 weeks in view of IUD on 27/4/2022
OBSTETRIC HISTORY :
1 - Stillborn baby ;pt had H/O severe IUGR ,severe preeclampsia ;@28 weeks IOL done
2 - present pregnancy
spontaneous conception
booked and immunized
karyotyping done -NORMAL
APLA -Negative
No evidence of preeclampsia
Antenatal period was uneventful till 31 weeks .

12. INVESTIGATIONS :
HB 12.8g/dl
platelet counts -2.54 lakhs
WBC count -16240/cmm
CRP -1.00
SEROLOGY -NEGATIVE
YSH -1.05
HbA1C -6.2% ;OGTT - Normal
coagulation profile -WNL
BLOOD GROUP O POSITIVE
USG revealed
inrauterine fetal demise corresponding to 28+2 weeks
anhydramnios
EFW 1.039 Kg
placenta posterior high

13. INTRAPARTUM EVENTS:
Termination induced with Tab.Misoprostol ; with good uterine
contractions and full cervical dilatations ,she expelled a male fetus of wt 1.06 kg on
28/4/20222 at 11.40.02 PM ;
placenta and membranes delivered in toto
Placenta sent for HPE
Mild atonic PPH noted controlled with uterotonics .
pt withstood the procedure well
GROSS EXAMINATION OF PLACENTA : normal
cord length :normal
no cord loop around the neck
liquor nil
Baby :No external congenital anomaly seen.

14. POSTPARTUM PERIOD EVENTS :
Satisfactory
received a course of antibiotics and analgesics
Discharged in a good condition on 29/4/2022

15. HPE report showed PLACENTAL MESENCHYMAL DYSPLASIA

16. PLACENTAL MESENCHYMAL
DYSPLASIA
• A distinctive rare
placental anomaly
characterized by
PLACENTOMEGALY and
Grapelike vesicles
resembling molar
pregnacy
• Incidence 0.02%
• Preponderance of
femles
• Mostly associated with
Beckwith - wiedemann
syndrome

17. CHARACTERISTICS
• PLACENTAL ENLARGEMENT
• Dilated and tortuous chorionic vessels with
thrombosis
• Focal distribution of cystically enlarged villi
• enlarged proximal stem villi
• ABSENCE of trophoblastic proliferation

18. CLINICAL FEATURES
USG -Large and thickened placenta with ,multicystic
hypoechoeic areas
• Typically has normal HCG and ELEVATED maternal ALPHA
FETOPROTEIN LEVEL.

19. FETAL PATHOLOGY
• The rate of perinatal demise is as high as 43%
• IUFD can be ACUTE due to massive haemorrhage
secondary to rupture of dilated vesssels
• or CHRONIC - Longstanding hypoxia secondary to
chorionic vessel thrombosis
• 50% associated with FGR
• P57KIP2 Immunohistochemical expression is abnormal

20. PATHOLOGY
• ANDROGENETIC BIPARENTAL MOSAICISM is
the pathology
• karyotyping is normal
• overexpression of IGF2 gene in the imprinted
paternal allele
• aberrant expression of CDKN1C
• RESULTS IN villous stromal overgrowth

21. Androgenetic/biparental mosaicism detected by p57kip2
immunohistochemical staining in the affected lesion. p57kip2-positive
stromal cells indicate biparental villi in a, and no p57kip2-positive stromal
cell in some villi (asterisks) suggests androgenetic villi in b. (objective
×10).

22. CONCLUSION
• PMD, a recently described entity, has a distinctive constellation of
pathologic features that are important to recognize because PMD
may have important implications for fetal and neonatal health, such
as an increased risk for intrauterine fetal demise (IUFD), IUGR, and
BWS
• Further investigation is needed to answer these interesting and
important questions about how the quantity and distribution of the
androgenetic cell line affect pregnancy outcomes in PMD.