key: cord-0023922-it1cokdh authors: Tjon, Jill K.; Lakeman, Phillis; van Leeuwen, Elisabeth; Waisfisz, Quinten; Weiss, Marjan M.; Tan‐Sindhunata, Gita M. B.; Nikkels, Peter G. J.; van der Voorn, Patrick J. P.; Salomons, Gajja S.; Burchell, George L.; Linskens, Ingeborg H.; van der Knoop, Bloeme J.; de Vries, Johanna I. P. title: Fetal akinesia deformation sequence and massive perivillous fibrin deposition resulting in fetal death in six fetuses from one consanguineous couple, including literature review date: 2021-10-12 journal: Mol Genet Genomic Med DOI: 10.1002/mgg3.1827 sha: d075c2cf8d6ec4a16b49f9f881f5096799da7f1b doc_id: 23922 cord_uid: it1cokdh BACKGROUND: Massive perivillous fibrin deposition (MPFD) is associated with adverse pregnancy outcomes and is mainly caused by maternal factors with limited involvement of fetal or genetic causes. We present one consanguineous couple with six fetuses developing Fetal Akinesia Deformation Sequence (FADS) and MPFD, with a possible underlying genetic cause. This prompted a literature review on prevalence of FADS and MPFD. METHODS: Fetal ultrasound examination, motor assessment, genetic testing, postmortem examination, and placenta histology are presented (2009–2019). Literature was reviewed for the association between congenital anomalies and MPFD. RESULTS: All six fetuses developed normally during the first trimester. Thereafter, growth restriction, persistent flexed position, abnormal motility, and contractures in 4/6, consistent with FADS occurred. All placentas showed histologically confirmed MPFD. Genetic analyses in the five available cases showed homozygosity for two variants of unknown significance in two genes, VARS1 (OMIM*192150) and ABCF1 (OMIM*603429). Both parents are heterozygous for these variants. From 63/1999 manuscripts, 403 fetal outcomes were mobilized. In 14/403 fetuses, congenital abnormalities in association with MPFD were seen of which two fetuses with contractures/FADS facial anomalies. CONCLUSION: The low prevalence of fetal contractures/FADS facial anomalies in association with MPFD in the literature review supports the possible fetal or genetic contribution causing FADS and MPFD in our family. This study with literature review supports the finding that fetal, fetoplacental, and/or genetic components may play a role in causing a part of MPFDs. Fetal Akinesia Deformation Sequence (FADS) is a rare disorder with, in general, autosomal recessive inheritance (Filges & Hall, 2013) with a prevalence of 1 per 13:000 pregnancies (Lowry et al., 2010) . The prenatal expression of FADS is visible by, among other things, reduced fetal motility and varies from the presence of multiple contractures, flattening of facial profile (FADS facial anomalies) during early pregnancy to observed growth restriction, polyhydramnios, and suspicion of lung hypoplasia during later gestation. In some cases additional abnormalities are seen such as brain or cardiac anomalies (Skaria et al., 2019) . FADS may mimic fetuses exposed to uteroplacental insufficiency as they both show reduced fetal movements and growth restriction. FADS, however, differs from severe uteroplacental insufficiency as FADS is usually accompanied by polyhydramnios and uteroplacental insufficiency has no or limited influence on body posture and joints (Bekedam et al., 1985; Sival et al., 1992a) . FADS prognosis is dependent on its cause, namely whether it is genetic and/ or neuromuscular (Hall, 2014; Hall & Kiefer, 2016; Hellmund et al., 2016) . The outcome of FADS varies with ~30% of fetuses being stillborn and the majority of live-born infants dying of pulmonary hypoplasia (Jones, 2013) . To improve the detection of FADS, we demonstrated in a prospective cohort study between 2007 and 2016 that motor assessment is of additional value to structural assessment in diagnosing FADS before 24 weeks of gestation (Tjon et al., 2019) . The underlying genetic cause of FADS was demonstrated in about half of the fetuses (Tjon et al., 2019) . Presently, more than 400 genes have been found to be associated with FADS (Kiefer & Hall, 2019) . In general, when the underlying cause is genetic, parents can be counselled about the prognosis and outcome of the genetic cause, the recurrence risk and their reproductive options including prenatal diagnostics or preimplantation genetic testing. Therefore a joint effort to mobilize knowledge about possible additional genetic abnormalities is paramount (Tjon et al., 2019) . Whole exome sequencing (WES) and whole genome sequencing (WGS) have been used with great success to identify novel disease genes for a broad spectrum of monogenic disorders including FADS (Neveling et al., 2013) . GeneMatcher can be helpful in collecting multiple cases/families with a similar phenotype and a (candidate) variant in the same gene (Sobreira et al., 2015) . However, many cases remain unresolved and a detailed description of such cases could aid in resolving these in the future. Massive Perivillous Fibrin Deposition (MPFD) of the placenta has a low prevalence of about 1.1% (Devisme et al., 2017) . The obstetrical outcome of MPFD varies with recurrent miscarriage, fetal demise, preterm birth, and fetal growth restriction in ongoing pregnancies being described (Faye-Petersen & Ernst, 2013; Katzman & Genest, 2002) . Histologically, MPFD is classified as: presence of perivillous fibrinoid material extending from the maternal to fetal surface, transmural, encasing ≥50% of the villi in at least one slide during pathological examination, whereas in borderline MPFD 25%-50% of the villi are encased by fibrinoid material (Katzman & Genest, 2002) . A related placental disorder, classical maternal floor infarction (MFI), is classified when basal villi of the entire maternal floor are encased by perivillous fibrinoid with a thickness of ≥3 mm on at least one slide (Katzman & Genest, 2002) . Recurrence of MPFD and MFI in following pregnancies varies between 12% and 88.9% (Becroft et al., 2004; Chen & Roberts, 2018; He et al., 2018) . This recurrence does not follow in 4/6, consistent with FADS occurred. All placentas showed histologically confirmed MPFD. Genetic analyses in the five available cases showed homozygosity for two variants of unknown significance in two genes, VARS1 (OMIM*192150) and ABCF1 (OMIM*603429). Both parents are heterozygous for these variants. From 63/1999 manuscripts, 403 fetal outcomes were mobilized. In 14/403 fetuses, congenital abnormalities in association with MPFD were seen of which two fetuses with contractures/FADS facial anomalies. The low prevalence of fetal contractures/FADS facial anomalies in association with MPFD in the literature review supports the possible fetal or genetic contribution causing FADS and MPFD in our family. This study with literature review supports the finding that fetal, fetoplacental, and/or genetic components may play a role in causing a part of MPFDs. a Mendelian inheritance pattern related to the fetus, but its recurrence rate is suggestive of a genetic or acquired mechanism originating in the mother (Redline, 2020) . Such a mechanism is probably not based on a single-disease entity but a reaction triggered by a variety of underlying conditions such as an autoimmune disease, thrombophilia and/or maternal hematogenous infections (Redline, 2020) . A few reports emphasize the possibility of a fetal contribution to the causation of MPFD concerning genetic abnormalities Long Chain 3-hydroxyacyl coenzyme A dehydrogenase (LCHAD) mutation and kidney abnormalities (Griffin et al., 2012; Matern et al., 2001; Taweevisit & Thorner, 2010) . Moreover, fetoplacental contribution has been reported in association with MPFD (Taweevisit & Thorner, 2010 . Oligohydramnios has been reported as a key feature of MFI/MPFD seen during prenatal ultrasound examination, together with placental thickening and cysts (Mandsager et al., 1994; Viero et al., 2004) . The aim of this article was to describe the phenotype of FADS inducing MPFD or vice versa and the genetic evaluation in six fetuses in one single consanguineous couple between 2009 and 2019 in the Netherlands. We performed a literature review to examine the prevalence of FADS and other congenital anomalies in pregnancies affected by MPFD. A 33-year-old woman of Mediterranean origin with a consanguineous relationship (first cousins) had nine pregnancies in the period 2009-2019. She had five intra-uterine fetal deaths between 20 and 24 weeks gestational age, one neonatal death after immature delivery at 21 weeks, one healthy child and two first-trimester miscarriages. The family tree is depicted in Figure 1 . In all deceased fetuses, the FADS phenotype was identified. All fetuses and the healthy son were born in Amsterdam UMC in the Netherlands. Since no definite underlying genetic cause was found, prenatal genetic diagnostic testing or preimplantation genetic testing could not be performed. Serial structural and motor assessments were performed in consultation with the parents in the subsequent pregnancies for detection of early signs and deterioration of motility (Donker et al., 2009; Tjon et al., 2019) . Motor assessments were performed from the third fetus onwards according to Donker et al. (2009) who described a prospective cohort between 1996 and 2007. The assessment consists of three aspects, see Table 1 . Characteristics of abnormal motility in fetuses with FADS have been described previously Donker et al., 2009; Tjon et al., 2019) . Serial fetal growth and Doppler flow velocities were measured to detect early signs of placental insufficiency. Aspirin and low molecular heparin were prescribed to the mother from fetus 4 onwards because of the unexplained recurrent abnormal sonographic and histological findings of the placenta compatible with MPFD, despite the absence of maternal thrombophilia factors. The placentas were examined for histological abnormalities and MPFD was classified according to Katzman and Genest (2002) . Postmortem examinations were performed in fetuses 4 and 5, in line with the parents wish. Additional tests, including genetic testing were performed with the available techniques over time and were repeated if indicated. c Isolated arm movements reduced variation in amplitude, mainly small, speed, mainly slow, reduced variation in participating joints. Isolated leg movements reduced variation in speed, amplitude and direction, small and slow, reduced variation in participating joints. General Movement reduced variation in; amplitude, mainly small, speed, mainly slow, direction, mainly one direction, participation no participation in head and trunk, no waxing and waning, fluency present/movement too short to evaluate fluency. d Quantity: normal is >3GM's in 15 minutes, motor assessment may be doubled in time to 30 minutes when <3GM's are seen during 15-minute exam. Normal age-related quantitative values are available (Donker et al., 2009 ). A systematic search was performed on January 18, 2021 (by GLB and JT) using the databases PubMed, Embase. com, Clarivate Analytics/Web of Science Core Collection, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Initially, a search was performed with keywords and free text terms for (synonyms of) "Fetal Akinesia Deformation Sequence" or "Arthrogryposis Multiplex Congenita" combined with (synonyms of) "contractures" combined with (synonyms of) "massive perivillous fibrin deposits" or "abnormal placenta." In addition, the synonyms Pena Shokeir syndrome, type 1 OR Pena-Shokeir OR Fetal akinesia OR Fetal akinesia sequence were used. These gave no relevant hits. A second search was performed with keywords and free text terms for (synonyms of) "massive perivillous fibrin deposits," "maternal floor infarction" or "abnormal placenta." A full overview of the search terms per database can be found in Appendix S1(A-D). No limitations on date or language were applied. All search results were screened by JT and JV by assessing the title and abstract for inclusion/exclusion criteria. The application Rayyan aided this process (Ouzzani et al., 2016) . If there was a disagreement in an article's inclusion or exclusion, the article's full text was read to reach a consensus. All articles describing cases with MPFD or MFI in the placenta were included. Articles were excluded in cases where there was either no full text available, when the MPFD/MFI could not be related to the outcome, where no cases were described (overview articles), if fibrin deposition was mentioned without definition of grading and when the article was a reply article. All included articles were read in full to examine the association between MPFD/borderline MPFD and fetal outcomes. The factors: live born, deceased, fetal growth restriction, congenital anomalies, and maternal underlying disease were assessed per article. From the seven fetuses, six affected and one healthy, the individual data together with obstetrical outcome are presented in Table 1 . All fetuses had a normal growth and position at the first trimester ultrasound examination (circa 12 weeks' gestational age). In the placentas of all the six affected fetuses, MPFD was found. The placental parenchyma showed an accelerated maturation. There were no other signs of maternal vascular malperfusion or inflammation. See Table 2 . for placental reports and Figure 2 . for macroscopic pictures of the placentas. The external inspection was performed. In all affected fetuses facial anomalies were found, in line with FADS, and contractures were found in four out of six (see Table 2 ). In addition, a complete postmortem autopsy was performed on fetuses 4 and 5. See Figure 3 . for pictures of fetus 1 and 3. An overview on the findings of the postmortem examination is presented in Table 2 . Since auto-antibodies for acetylcholine and MUSK are associated with FADS, these were examined in 2012 with the results being that both were negative in the mothers' blood. Within the context of the MPFD and the high grade of placental tissue maturity, maternal thrombophilia was tested for and revealed no inheritable or acquired clotting anomalies. The genetic testing performed over time is depicted in Table 3 . Postmortem DNA sampling was performed in all but the first affected fetus. During the first pregnancy, a karyotype was performed after amniocentesis. In 2014, trio-WES analysis was performed which identified no (likely) pathogenic variants but which found two homozygous variants of unknown significance (VUS) in two candidate genes, VARS1 (OMIM*192150) and ABCF1 (OMIM*603429). Both variants and genes were added to GeneMatcher, with no matching response thus far (Sobreira et al., 2015) . WES analysis in 2014 was performed at the Genome Laboratory of the VU medical center in Amsterdam and repeated in 2017. WES analysis on another fetus was performed in 2019 at the Genome Laboratory of Radboud UMC in Nijmegen, the Netherlands. In VARS1 (NM_006295.2), the variant c.518G>T, p.(Ar-g173Leu) was identified (Hg19 chr6:31,760,767 C>A), which is a non-conservative missense variant of an inmammals conserved amino acid. This variant of unknown (Friedman et al., 2019) . In addition, functional analysis of VARS1 in fibroblast cells of one of the fetuses was performed and showed a decreased VARS1 activity of 51% compared with normal controls, but a remaining activity that was higher than normally seen in defective VARS1 cell-lines (which is below 30%). This method has been previously described (Griffin et al., 2012) . These results, therefore, did not confirm a causal relationship between the p.(Arg173Leu) variant and the disease phenotype in our family. The second variant is c.1510G>A p.(Val504Ile) in ABCF1 (NM_001025091.1) which is a conservative missense variant of a highly conserved amino acid (Hg19 chr6:30,553,369 G>A). The variant has a low allele frequency in GnomAD v2.1.1; 3 heterozygous alleles out of a total of 246638 alleles. ABCF1 (ATP binding cassette subfamily F member 1) has not been associated with a human disease. Both genes, VARS1 and ABCF1 are located in an overlapping region of homozygosity (ROH) on chromosome 6 of ~22 Mb (Hg19 chr6:20,765,548-42,615,698) in which more than 750 genes are located. No additional homozygous (likely) pathogenic variants were identified in the remaining genes in this overlapping ROH. Additional ROH-analysis showed that there were no other overlapping ROH regions larger than 1 MB shared by all five affected fetuses for whom DNA was available as well as for the healthy son. The couple refrained from prenatal genotyping by chorion villus sampling or amniocentesis during subsequent pregnancies after the identification of the VUS in VARS1 and ABCF1. The search on MPFD with related search terms resulted in a total of 1999 publications with 129 eligible articles. Of these, 12 could not be included because no full text was available. After reading the full text of all of the remaining articles, 63 were included (Abdulghani et al., 2017; Achuthan et al., 2017; Adams-Chapman et al., 2002; Al-Adnani et al., 2008; Al-Sahan et al., 2014; Ananthan et al., 2019; Andres et al., 1990; Bane & Gillan, 2003; Batcup et al., 1985; Bendon & Hommel, 1996; Benirschke et al., 2000; Brown et al., 2002; Chaiworapongsa et al., 2016; Chang et al., 2006; Chisholm et al., 2016; Clewell & Manchester, 1983; da Cunha Castro & Popek, 2007; Devisme et al., 2017; Eom et al., 2008; Faye-Petersen et al., 2018; Feist et al., 2015 Feist et al., , 2019 Feist et al., , 2020 Gao et al., 2021; Gestrich et al., 2020; Gibbins et al., 2020; Griffin et al., 2012; Gupta et al., 2004; Hannaford et al., 2019; He et al., 2018; Heller et al., 2016; Hung et al., 2006; Jaiman et al., 2020; Katz et al., 1987 Katz et al., , 2002 Montenegro et al., 1997; Nickel, 1988; Pathak et al., 2011; Qi et al., 2016; Redline et al., 2003; Redline & O'Riordan, 2000; Sebire et al., 2002; Spinillo et al., 2019; Taweevisit et al., 2020; Taweevisit & Thawornwong, 2020; Taweevisit & Thorner, 2010 Weber et al., 2006; Whitten et al., 2013; Yu et al., 2015) . The reason for exclusion of the other 54 articles, 22 did not mention MPFD, 10 mentioned only fibrin depositions, 13 were overview articles with no original cases described, 7 contained no numbers of MPFD or did not relate MPFD to outcome and 2 were replies to an article. Based on these 63 articles, an overview of the pregnancy outcomes of MPFD is presented in Table 4 . which describes the cases where >50% of the villi was encased by perivillous fibrinoid or the placenta was defined as MFI. Table 5 describes the cases with borderline MPFD where 25%-50% villi was encased by perivillous fibrinoid. Fetuses with congenital abnormalities in association with MPFD were found in 12 out of 63 articles. Here we present a consanguineous couple who lost six fetuses before a gestational age of 24 weeks, but who all developed normally up to the beginning of the second trimester. From a gestational age of around 20 weeks onwards, all deteriorated in growth, posture, and motility, with the development of placental anomalies and oligohydramnios. The couple also conceived one healthy son. In all six cases, the fetal phenotype of the affected fetuses resembled FADS together with severe early onset of placental thickening with cysts on ultrasound examination and histologically confirmed MPFD in the placentas. We expected to find literature supporting our case with the association of FADS and MPFD since MPFD is known to cause oligohydramnios which can cause anomalies in face and extremities in line with FADS (Mandsager et al., 1994) . Our literature review describes the outcome of 403 fetuses of which only fifty percent were live born, a large proportion being delivered preterm. Congenital anomalies were described in only 14/403 cases, of which the majority in deceased fetuses. Despite our expectations, the search only revealed one report of bilateral clubfeet with normal karyotype (Chaiworapongsa et al., 2016) and one case with facial changes in line with FADS (Qi et al., 2016) . Other congenital anomalies reported were renal anomalies in seven cases with contractures in four out of seven (Chang et al., 2006; Leong et al., 2013; Linn et al., 2013; Taweevisit & Thorner, 2010) , three cases of mutation in LCHAD (Griffin et al., 2012; Matern et al., 2001) Author ( pulmonary valve dysplasia (Montenegro et al., 1997) . The combination of MPFD with hypercoiling of the umbilical cord was reported in six cases (Feist et al., 2020; Gestrich et al., 2020; Taweevisit & Thorner, 2016) . It is remarkable that borderline MPFD resulted in live born infants in the majority (84/89) and except for 1 trisomy 21, no other congenital or chromosomal anomalies were reported. The search contradicts the premise that the FADS phenotype in our cases is the result of MPFD only. Extensive genetic testing in our case was performed through the years. Repetitive WES identified two homozygous missense variants of unknown clinical significance, one in the VARS1 gene and one in the ABCF1 gene, both located on chromosome 6 in the only overlapping and shared 22 Mb ROH and within near distance of 1 Mb. Additional genetic analyses revealed no other likely or certain pathogenic cause. At this stage, it remains uncertain whether the homozygous variant in either the VARS1 gene or the ABCF1 gene might be associated with the fetal phenotype, or that the cause is still not elucidated but likely present in this homozygous region on chromosome 6. Amongst others lethal congenital contracture syndromes, types 1, 2, and 3 are located on chromosomes other than chromosome 6 (GLE1 on chromosome 9, ERBB3 on chromosome 12, and PIP5K1C on chromosome 19, respectively). Kiefer and Hall (2019) provide the most recent update of the diversity of genetic anomalies of various forms of AMC and FADS. In none of these genes, (likely) pathogenic variants were identified in our cases. This is the first article describing a possible association of a fetal genetic anomaly and MPFD other than LCHAD. In 2014, during the first WES analysis, no disease was associated with VARS1 pathogenic variants. However, at that time, mouse mutants of GARS, encoding glycyl-tRNA synthetase had been described to cause embryonic lethality suggesting a possible link between VARS1 and the phenotype in the foetuses (Seburn et al., 2006) . In 2019, biallelic pathogenic (missense) variants in VARS1 were associated with an autosomal recessive form of progressive neurodevelopmental epileptic encephalopathy with microcephaly and often associated with early-onset epilepsy (OMIM#617802; Friedman et al., 2019; Siekierska et al., 2019) . ABCF1 has been described to function in innate immune response and was studied in 2017 in mice by Wilcox et al (Arora et al., 2019; Wilcox et al., 2017) . They used a single gene trap insertion in the ABCF1 gene in murine embryonic stem cells and demonstrated that knockout mice (ABCF-/) were found to be embryonic lethal at 3.5 days post coitum, while ABCF1+/− mice appeared developmentally normal. The lethal consequences in ABCF1 knockout mice possibly resemble with the IUFD cases in the family. The literature on the phenotype FADS illustrates its variable expression, describing deterioration that starts either with its expression in the fetal motility or in contractures (Hellmund et al., 2016; Hoellen et al., 2011) . All fetuses in our case had FADS-like facial abnormalities, flexed posture, contractures in four out of six and abnormal motility in all. The sudden onset of abnormal motility and postural anomalies in these fetuses can, in our experience, not be explained by merely the placental abnormalities. Warrander et al. found placental abnormalities in correlation with reduced fetal movements consisting maternal vascular malperfusion lesions, but MPFD was not found (Warrander et al., 2012) . Reports of reduced variation in quality and quantity of general movements have been published in relation to placental insufficiency and fetal growth restriction with, first, reduced variation of the amplitude and thereafter a more flexed posture. Posture has been addressed as being slightly more crouched, with more flexion in cervical spine in fetal growth restriction related to placental insufficiency, however, not as extreme as in our case (Bekedam et al., 1985; Sival et al., 1990 Sival et al., , 1992a Sival et al., , 1992b . Despite the fact that fetal growth restriction is frequently found in fetuses with FADS, in general it has been found during the late second or third trimester of pregnancy, whereas it was already present during early second trimester in this family (Hellmund et al., 2016; Hoellen et al., 2011) . Moreover, placental abnormalities like MPFD have not been described in pregnancies with fetuses having the complete spectrum of FADS. Perivillous fibrin depositions show a high recurrence rate with intra-uterine fetal death though the underlying pathogenic cause is still unknown (Becroft et al., 2004; Chen & Roberts, 2018) . The clinical presentation, however, is generally later during the third trimester of pregnancy (Becroft et al., 2004) . The earlier onset of similar fetal and placental anomalies in all affected fetuses of the family suggests a genetic involvement too. This study's strength lies in the well-documented ultrasound and postpartum findings in six fetuses who underwent similar deterioration over time which can best be considered to be a form of FADS phenotype together with outspoken placental anomalies including cysts as have been found in MPFD. This was complemented with a literature review which included dedicated examination of the MPFD/MFI classification and fetal outcomes. While the literature review contradicted the expectation that the most severe form MPFD, often associated with oligohydramnios, would induce FADSlike anomalies, several congenital anomalies were described in association with MPFD. This leads to the conclusion that MPFD is not only associated with maternal factors influencing the vascular system through chronic endothelial damage (obesity, autoimmune disease, diabetes mellitus) or acute damage during viral infections (coxsackie virus A9/A16, cytomegaly virus, SARS-COV-2). Furthermore, from the literature search, the unexpected reports on four discordant twins with one normal placenta and one abnormal supports the theory that it is not simple maternal influence causing the MPFD (Faye-Petersen et al., 2018; Feist et al., 2015; Gupta et al., 2004; Redline et al., 2003) . Unfortunately, in the literature search from the 129 eligible articles only 63 could be included to relate MPFD with fetal outcome. This search should increase the awareness that lumping the histological placental data without individual outcomes hinders the examination for possible underlying causes. In one consanguineous couple a strikingly similar phenotype of FADS was encountered in six affected fetuses (male and female) causing intra-uterine fetal deaths between 20 and 24 weeks gestational age. No (likely) pathogenic cause was identified, but two homozygous variants, both of unknown clinical significance in the VARS1 gene and ABCF1 gene, both located in the only overlapping homozygous region larger than 1 Mb, on chromosome 6, were identified. These were the only consistent overlapping genetic finding in all five affected fetuses for whom DNA was available. The only healthy child is not a carrier of these variants. The severe fetal growth restriction, reduced variability of motility, flexed posture and oligohydramnios, together with MPFD in all placentas showed an extraordinary presentation of FADS. This study with literature review supports the finding that fetal, fetoplacental, and/or genetic components may play a role in causing some MPFDs. Recurrent massive perivillous fibrin deposition and chronic intervillositis treated with heparin and intravenous immunoglobulin: A case report Study of placental histopathology in idiopathic intrauterine growth retardation-a comparative study Maternal floor infarction of the placenta: Association with central nervous system injury and adverse neurodevelopmental outcome Recurrent placental massive perivillous fibrin deposition associated with polymyositis: A case report and review of the literature Maternal floor infarction: Management of an underrecognized pathology Placental findings in singleton stillbirths: A case-control study The association of maternal floor infarction of the placenta with adverse perinatal outcome The ATPbinding cassette gene ABCF1 functions as an E2 ubiquitinconjugating enzyme controlling macrophage polarization to dampen lethal septic shock Massive perivillous fibrinoid causing recurrent placental failure Placental and fetal pathology in Coxsackie virus A9 infection: A case report Placental infarcts, intervillous fibrin plaques, and intervillous thrombi: Incidences, cooccurrences, and epidemiological associations Motor behaviour in the growth retarded fetus Maternal floor infarction in autoimmune disease: Two cases Placental surface cysts detected on sonography Pravastatin to prevent recurrent fetal death in massive perivillous fibrin deposition of the placenta (MPFD) Intravenous immunoglobulin in antiphospholipid syndrome and maternal floor infarction when standard treatment fails: A case report Placental pathologic lesions with a significant recurrence risk -What not to miss! Correlation of preterm infant illness severity with placental histology Recurrent maternal floor infarction: A preventable cause of fetal death Osteochondral junction lesions in stillborn fetuses and their relationship to autopsy diagnoses Perinatal outcome of placental massive perivillous fibrin deposition: A case-control study Serial postural and motor assessment of Fetal Akinesia Deformation Sequence (FADS) Massive perivillous fibrin deposition in placenta Maternal floor infarction and massive perivillous fibrin deposition Dichorionic twins discordant for massive perivillous fibrinoid deposition: Report of a case and review of the literature Discordancy for placental massive perivillous fibrin deposition and fetal growth in dichorionic twins after in vitro fertilization Pathoanatomical lesions in placentas with excessively hypercoiled umbilical cords: Frequent detection of massive perivillous fibrin deposition Massive perivillous fibrin deposition of an enterovirus ainfected placenta associated with stillbirth: A case report Failure to identify antenatal multiple congenital contractures and fetal akinesia-proposal of guidelines to improve diagnosis Biallelic mutations in valyl-tRNA synthetase gene VARS are associated with a progressive neurodevelopmental epileptic encephalopathy Placental pathology of the third trimester pregnant women from COVID-19 Massive perivillous fibrin deposition in congenital cytomegalovirus infection: A case report Findings in Stillbirths Associated with Placental Disease Mutations in long-chain 3-hydroxyacyl coenzyme a dehydrogenase are associated with placental maternal floor infarction/massive perivillous fibrin deposition Massive perivillous fibrin deposition associated with discordant fetal growth in a dichorionic twin pregnancy Arthrogryposis (multiple congenital contractures): Diagnostic approach to etiology, classification, genetics, and general principles Arthrogryposis as a syndrome: Gene ontology analysis Recurrent chronic intervillositis: The diagnostic challenge -A case report and review of the literature Follow-up and management of recurrent pregnancy losses due to massive perivillous fibrinoid deposition Placental massive perivillous fibrinoid deposition associated with coxsackievirus A16-report of a case, and review of the literature Prenatal diagnosis of fetal akinesia deformation sequence (FADS): A study of 79 consecutive cases Arthrogryposis multiplex congenita and penashokeir phenotype: Challenge of prenatal diagnosis -Report of 21 cases, antenatal findings and review Pregnancy-related polymyositis and massive perivillous fibrin deposition in the placenta: Are they pathogenetically related? Arthritis & Rheumatism Disorders of placental villous maturation in fetal death Smith's Recognizable patterns in human malformation Maternal floor infarction of the placenta associated with elevated second trimester serum alpha-fetoprotein Activated protein C resistance associated with maternal floor infarction treated with low-molecular-weight heparin Maternal floor infarction and massive perivillous fibrin deposition: Histological definitions, association with intrauterine fetal growth restriction, and risk of recurrence Gene ontology analysis of arthrogryposis (multiple congenital contractures) Clinicopathological characteristics of miscarriages featuring placental massive perivillous fibrin deposition Recurrent placental transcriptional profile with a different histological and clinical presentation: A case report Another case of concomitant fetal renal tubular dysgenesis and placental massive perivillous fibrin deposition Recurrent massive perivillous fibrin deposition in the placenta associated with fetal renal tubular dysgenesis: Case report and literature review Prevalence of multiple congenital contractures including arthrogryposis multiplex congenita in Alberta, Canada, and a strategy for classification and coding Use of aspirin and lowmolecular-weight heparin to prevent recurrence of maternal floor infarction in women without evidence of antiphospholipid antibody syndrome Maternal floor infarction: Massive diffuse perivillous fibrin deposition Stillbirth and intrauterine fetal death: Role of routine histopathological placental findings to determine cause of death Maternal floor infarction of the placenta: Prenatal diagnosis and clinical significance Placental floor infarction complicating the pregnancy of a fetus with longchain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency Maternal floor infarction associated with fetal growth restriction: A case report COVID-19 during pregnancy: Non-reassuring fetal heart rate, placental pathology and coagulopathy Placental findings in fetuses with absent or reversed enddiastolic flow in the umbilical artery (ARED flow): A reappraisal A post-hoc comparison of the utility of sanger sequencing and exome sequencing for the diagnosis of heterogeneous diseases Maternal floor infarction: An unusual cause of intrauterine growth retardation Rayyan-a web and mobile app for systematic reviews Frequency and clinical significance of placental histological lesions in an unselected population at or near term Placental massive perivillous fibrinoid deposition is associated with adverse pregnancy outcomes: A clinicopathological study of 12 cases Extending the spectrum of massive perivillous fibrin deposition (maternal floor infarction) Discordancy for maternal floor infarction in dizygotic twin placentas Maternal floor infarction/massive perivillous fibrin deposition: A manifestation of maternal antifetal rejection? Placental massive perivillous fibrin deposition associated with antiphospholipid antibody syndrome An active dominant mutation of Glycyl-tRNA synthetase causes neuropathy in a charcot-marietooth 2D mouse model Biallelic VARS variants cause developmental encephalopathy with microcephaly that is recapitulated in vars knockout zebrafish Does reduction of amniotic fluid affect fetal movements? Early Human Development The effect of intrauterine growth retardation on the quality of general movements in the human fetus The relationship between the quantity and quality of prenatal movements in pregnancies complicated by intra-uterine growth retardation and premature rupture of the membranes GeneMatcher: A matching tool for connecting investigators with an interest in the same gene The impact of placental massive perivillous fibrin deposition on neonatal outcome in pregnancies complicated by fetal growth restriction Combined placental maternal floor infarction and cytomegalovirus placentitis: A case report Massive perivillous fibrin deposition associated with placental syphilis: A case report Maternal floor infarction associated with oligohydramnios and cystic renal dysplasia: Report of 2 cases Maternal floor infarction associated with umbilical cord hypercoiling Maternal floor infarction/massive perivillous fibrin deposition associated with hypercoiling of a singleartery umbilical cord: A case report Fetal akinesia deformation sequence, arthrogryposis multiplex congenita, and bilateral clubfeet: Is motor assessment of additional value for in utero diagnosis? A 10-year cohort study Prognostic value of placental ultrasound in pregnancies complicated by absent enddiastolic flow velocity in the umbilical arteries Maternal perception of reduced fetal movements is associated with altered placental structure and function Co-occurrence of massive perivillous fibrin deposition and chronic intervillositis: Case report Evidence of an imbalance of angiogenic/antiangiogenic factors in massive perivillous fibrin deposition (maternal floor infarction): A placental lesion associated with recurrent miscarriage and fetal death The role of the innate immune response regulatory gene ABCF1 in mammalian embryogenesis and development Coxsackie virus A16 infection of placenta with massive perivillous fibrin deposition leading to intrauterine fetal demise at 36 weeks gestation The authors have declared no conflicts of interest. Jill K. Tjon contributed to writing, analysis, and interpretation of article. Phillis Lakeman, Elisabeth van Leeuwen, Quintin Waisfisz, Marjan M. Weiss, Gita M. B. Tan, Peter G. J. Nikkels, Patrick J. P. van der Voorn, Ingeborg H. Linskens, Bloeme J. van der Knoop, and Johanna I. P. de Vries contributed to writing, analysis, and revising of article. Gajja S. Salomons contributed to research of specific part in article. George L. Burchell contributed to conducting the systematic review. The patient signed a consent form to publish this article, approval of the ethics committee was not applicable concerning the literature review. The data are available through the corresponding author. Jill K. Tjon https://orcid.org/0000-0002-6408-6881