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Beer N, Danieli-Gruber S, Bardin R, Berezowsky A, Hadar E, Arbib N. Adverse outcomes of nonnuchal umbilical cord entanglement. Int J Gynaecol Obstet 2024; 164:166-172. [PMID: 37485672 DOI: 10.1002/ijgo.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To evaluate perinatal effects of umbilical cord entanglement (UCE) of different body parts. METHODS The database of a tertiary medical center was retrospectively searched for women who gave birth to a liveborn singleton newborn in 2014-2018. Those diagnosed postpartum with UCE were matched 1:10 with women who were not and compared for adverse obstetric and neonatal outcomes, overall and by site of entanglement. RESULTS A total of 14 299 women were evaluated, of whom 1243 were diagnosed with UCE: 78.7% neck, 26% trunk, 6.7% limb. UCE was associated with lower birth weight percentile and higher rate of small for gestational age, but findings were significant only for neck and trunk UCE. On multivariate regression analysis adjusted for maternal age, parity, gestational age at birth, and history of cesarean delivery, UCE was an independent risk factor for nonreassuring fetal heart rate, labor induction, operative vaginal delivery, cesarean delivery, and meconium-stained amniotic fluid, but not for lower absolute birth weight/birth weight percentile, small for gestational age, low 1-min Apgar score, or neonatal asphyxia. CONCLUSION While fetuses with UCE might be more compromised during labor, they apparently recover shortly after birth. The impact on perinatal outcomes was similar for UCE of the neck and trunk and lower for UCE of the limb.
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Affiliation(s)
- Noam Beer
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel
| | - Shir Danieli-Gruber
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Bardin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexandra Berezowsky
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nissim Arbib
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
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Is There an Added Neonatal Risk in Vacuum-Assisted Deliveries with Nuchal Cord? J Clin Med 2022; 11:jcm11236970. [PMID: 36498545 PMCID: PMC9739457 DOI: 10.3390/jcm11236970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
This retrospective cohort study assessed the association between nuchal cord and adverse outcomes during vacuum-assisted delivery (VAD). Women with singleton pregnancies, 34−41-weeks gestation, who underwent VAD, from 2014 to 2020 were included. The primary outcome was umbilical cord pH ≤ 7.1. Secondary outcomes were neonatal intensive care unit admission, Apgar scores, pH < 7.15, subgaleal hematoma, shoulder dystocia and third/fourth-degree perineal tear. Outcomes were compared between neonates with (1059/3754, 28.2%) or without (71.8%) nuchal cord after VAD. No difference in cord pH ≤ 7.1 was found between groups. The nuchal cord group had a lower rate of nulliparity (729 (68.8%) vs. 2004 (74.4%), p = 0.001) and higher maternal BMI (23.6 ± 4.3 vs. 23.1 ± 5, p = 0.017). Nuchal cord was associated with higher rates of induction (207 (19.5%) vs. 431 (16%), p = 0.009) and lower birthweights (3185 ± 413 vs. 3223 ± 436 g, p = 0.013). The main indication for VAD in 830 (80.7%) of the nuchal cord group was non-reassuring fetal heart rate (NRFHR) vs. 1989 (75.6%) controls (p = 0.004). The second stage was shorter in the nuchal cord group (128 ± 81 vs. 141 ± 80 min, p < 0.001). Multivariate regression found nulliparity, induction and birthweight as independent risk factors for nuchal cord VAD. Although induction and NRFHR rates were higher in VAD with nuchal cord, the rate of umbilical cord acidemia was not.
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Młodawska M, Młodawski J, Świercz G, Zieliński R. The Relationship between Nuchal Cord and Adverse Obstetric and Neonatal Outcomes: Retrospective Cohort Study. Pediatr Rep 2022; 14:40-47. [PMID: 35225877 PMCID: PMC8883893 DOI: 10.3390/pediatric14010007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/13/2022] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: The twisting of the umbilical cord around the fetal neck is a common phenomenon in the delivery room, and despite the lack of univocal evidence of its negative impact on perinatal events, it causes anxiety and stress in patients. The aim of the study was to assess the prevalence of nuchal cord and its impact on adverse obstetric and neonatal outcomes. Methods: We conducted a retrospective cohort study. All patients who gave birth in the clinic within one year (n = 1467) were included in the study group. We compared the prevalence of nuchal cord in distinct subgroups of patients. In the next stage, we estimated the chance of specific perinatal outcomes and compared the neonatal outcomes between groups with and without nuchal cord. Results: Nuchal cord was present in 24% of labors. It was twice as common among patients giving birth vaginally (32.14%) than among patients giving birth by a caesarean section (16.78%, p < 0.001). Nuchal cord was also more frequent in births with meconium-stained amniotic fluid (33.88% vs. 23.34%, p = 0.009). In the group of patients with nuchal cord, we observed a slight increase in the risk of a non-reassuring fetal heart rate trace (OR = 1.55, CI 95% 1.02−2.36) as an indication of the completion of labor by caesarean delivery. We did not note an increase in the risk of completing natural childbirth by vacuum extraction. In the group of nuchal cord patients, there was a higher chance of a serious or moderate neonatal condition in the first minute of life (Apgar 0−7 points) (OR = 2.00, 95% CI = 1.14−3.49). Conclusions: Nuchal cord increases the risk of a caesarean delivery due to a non-reassuring fetal heart rate trace. Nuchal cord increases the chance of a reduced Apgar score (0−7 points) in the first minute of life. The observed relationships do not translate to neonatal arterial blood gas testing.
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Bohîlțea RE, Dima V, Ducu I, Iordache AM, Mihai BM, Munteanu O, Grigoriu C, Veduță A, Pelinescu-Onciul D, Vlădăreanu R. Clinically Relevant Prenatal Ultrasound Diagnosis of Umbilical Cord Pathology. Diagnostics (Basel) 2022; 12:diagnostics12020236. [PMID: 35204327 PMCID: PMC8871173 DOI: 10.3390/diagnostics12020236] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 12/10/2022] Open
Abstract
Umbilical cord abnormalities are not rare, and are often associated with structural or chromosomal abnormalities, fetal intrauterine growth restriction, and poor pregnancy outcomes; the latter can be a result of prematurity, placentation deficiency or, implicitly, an increased index of cesarean delivery due to the presence of fetal distress, higher admission to neonatal intensive care, and increased prenatal mortality rates. Even if the incidence of velamentous insertion, vasa praevia and umbilical knots is low, these pathologies increase the fetal morbidity and mortality prenatally and intrapartum. There is a vast heterogeneity among societies’ guidelines regarding the umbilical cord examination. We consider the mandatory introduction of placental cord insertion examination in the first and second trimester to practice guidelines for fetal ultrasound scans. Moreover, during the mid-trimester scan, we recommend a transvaginal ultrasound and color Doppler assessment of the internal cervical os for low-lying placentas, marginal or velamentous cord insertion, and the evaluation of umbilical cord entanglement between the insertion sites whenever it is incidentally found. Based on the pathological description and the neonatal outcome reported for each entity, we conclude our descriptive review by establishing a new, clinically relevant classification of these umbilical cord anomalies.
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Affiliation(s)
- Roxana Elena Bohîlțea
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania; (D.P.-O.); (R.V.)
- Department of Obstetrics, Gynecology and Neonatology, Filantropia Hospital, 11–13 Ion Mihalache Blv., Sector 1, 011171 Bucharest, Romania; (B.M.M.); (A.V.)
- Correspondence: (R.E.B.); (V.D.); (A.M.I.); (C.G.)
| | - Vlad Dima
- Department of Obstetrics, Gynecology and Neonatology, Filantropia Hospital, 11–13 Ion Mihalache Blv., Sector 1, 011171 Bucharest, Romania; (B.M.M.); (A.V.)
- Correspondence: (R.E.B.); (V.D.); (A.M.I.); (C.G.)
| | - Ioniță Ducu
- Department of Obstetrics and Gynecology, University Emergency Hospital, 169 Splaiul Independentei Bld., Sector 5, 050098 Bucharest, Romania;
| | - Ana Maria Iordache
- Optospintronics Department, National Institute for Research and Development in Optoelectronics-INOE 2000, 409 Atomistilor, 077125 Magurele, Romania
- Correspondence: (R.E.B.); (V.D.); (A.M.I.); (C.G.)
| | - Bianca Margareta Mihai
- Department of Obstetrics, Gynecology and Neonatology, Filantropia Hospital, 11–13 Ion Mihalache Blv., Sector 1, 011171 Bucharest, Romania; (B.M.M.); (A.V.)
| | - Octavian Munteanu
- Department of Anatomy, “Carol Davila” University of Medicine and Pharmacy Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania;
| | - Corina Grigoriu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania; (D.P.-O.); (R.V.)
- Department of Obstetrics and Gynecology, University Emergency Hospital, 169 Splaiul Independentei Bld., Sector 5, 050098 Bucharest, Romania;
- Correspondence: (R.E.B.); (V.D.); (A.M.I.); (C.G.)
| | - Alina Veduță
- Department of Obstetrics, Gynecology and Neonatology, Filantropia Hospital, 11–13 Ion Mihalache Blv., Sector 1, 011171 Bucharest, Romania; (B.M.M.); (A.V.)
| | - Dimitrie Pelinescu-Onciul
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania; (D.P.-O.); (R.V.)
| | - Radu Vlădăreanu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania; (D.P.-O.); (R.V.)
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Seyed Ahadi M, Sahraian MA, Shaygannejad V, Anjidani N, Mohammadiani Nejad SE, Beladi Moghadam N, Ayromlou H, Yousefi Pour GA, Yazdanbakhsh S, Jafari M, Naser Moghadasi A. Pregnancy outcome in patients with neuromyelitis optica spectrum disorder treated with rituximab: A case-series study. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:S491-S494. [PMID: 34760113 PMCID: PMC8559646 DOI: 10.22088/cjim.12.0.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/26/2021] [Accepted: 04/06/2021] [Indexed: 11/23/2022]
Abstract
Background: Neuromyelitis optica spectrum disorder (NMOSD) is a neuroinflammatory disorder with a tendency to affect the spinal cord and optic nerves. As NMOSDs have a predilection for women of reproductive age and adopt an aggressive course during pregnancy, appropriate treatment strategies before conception and during pregnancy should be well-considered. Case Presentation: In this report, the pregnancy outcome of eight pregnancies following rituximab treatment was assessed, which led to 50% live births with mean birth weight of 2777.50 (SD: 545.92) grams. Two patients had abortions due to doctor’s recommendation. One pregnancy led to intrauterine fetal death (IUFD) due to nuchal cord. No spontaneous abortions were encountered. Two patients received rituximab during pregnancy. No major malformations or serious neonatal infections were encountered. Conclusion: Rituximab should be administered by caution in NMOSD patients who want to be pregnant and the probable adverse effects of the drug should be discussed by patients.
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Affiliation(s)
- Maral Seyed Ahadi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | - Nahid Beladi Moghadam
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hormoz Ayromlou
- Department of Neurology, Faculty of Medicine, Tabriz University of Medical Sciences, Iran
| | | | - Sepideh Yazdanbakhsh
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Jafari
- Imam Khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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Sherer DM, Roach C, Soyemi S, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Complex Umbilical Cord Entanglement. Int J Womens Health 2021; 13:247-256. [PMID: 33658863 PMCID: PMC7917470 DOI: 10.2147/ijwh.s285860] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/23/2021] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of potential umbilical cord compromise, namely, true knots of the umbilical cord and nuchal cords has been enabled with increasing accuracy with current enhanced prenatal sonography. Often an incidental finding at delivery, the incidence of true knots of the umbilical cord has been estimated at between 0.04% and 3% of deliveries. This condition has been reported to account for a 4 to 10-fold increase of stillbirth and perinatal morbidity of 11% of cases. Nuchal cords, commonly observed at the delivery of uncompromised, non-hypoxic non-acidotic newborns occur more frequently with single nuchal cords noted in between 20% and 35% of all deliveries at term. Multiple nuchal cords are considerably less frequent, with decreasing frequencies inverse to the number of nuchal cord loops. While clearly single (and likely double) nuchal cords are almost uniformly associated with favorable neonatal outcomes, emerging data suggest that cases of ≥3 loops of nuchal cords are more likely to be associated with an increased risk of adverse perinatal outcome (either stillbirth or compromised neonatal condition at delivery). We define cases of a true knot of the umbilical cord, cases of ≥3 loops of nuchal cords, any combination of a true knot and nuchal cord, or any umbilical cord entanglement (nuchal or true knot) in the presence of a single umbilical artery, in singleton gestations as complex umbilical cord entanglement. Two concurrent developments, the increase in accuracy of prenatal sonographic diagnosis of complex umbilical cord entanglement and recent data confirming fatal compromise of the umbilical circulation in approximately 20% of cases of stillbirth, suggest that establishing governing body guidelines for reporting of potential umbilical cord compromise, and recommendation of consideration for early-term delivery of select cases, may be warranted. This commentary will address current perspectives of prenatal diagnosis and clinical management challenges of complex umbilical cord entanglement.
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Affiliation(s)
- David M Sherer
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Crystal Roach
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Sarin Soyemi
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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7
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Sherer DM, Ward K, Bennett M, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Nuchal Cord(s). Int J Womens Health 2020; 12:613-631. [PMID: 32982473 PMCID: PMC7500175 DOI: 10.2147/ijwh.s211124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/17/2020] [Indexed: 11/29/2022] Open
Abstract
Umbilical cord accidents preceding labor are uncommon. In contrast, nuchal cords are a very common finding at delivery, with reported incidences of a single nuchal cord of approximately between 20% and 35% of all singleton deliveries at term. Multiple loops occur less frequently, with reported incidence rates inverse to the number of nuchal cords involved. Rare cases of up to 10 loops of nuchal cord have been reported. While true knots of the umbilical cord have been associated with a 4–10-fold increased risk of stillbirth, nuchal cord(s) are most often noted at delivery of non-hypoxic non-acidotic newborns, without any evidence of subsequent adverse neonatal outcome. Prior to ultrasound, nuchal cords were suspected clinically following subtle (spontaneous or evoked) electronic fetal heart rate changes. Prenatal sonographic diagnosis, initially limited to real-time gray-scale ultrasound, currently entails additional sonographic modalities, including color Doppler, power Doppler, and three-dimensional sonography, which have enabled increasingly more accurate prenatal sonographic diagnoses of nuchal cord(s). In contrast to true knots of the umbilical cord (which are often missed at sonography, reflecting the inability to visualize the entire umbilical cord, and hence are often incidental findings at delivery), nuchal cord(s), reflecting their well-defined and sonographically accessible anatomical location (the fetal neck), lend themselves with relative ease to prenatal sonographic diagnosis, with increasingly high sensitivity and specificity rates. While current literature supports that single (and possibly double) nuchal cords are not associated with increased adverse perinatal outcome, emerging literature suggests that cases of ≥3 loops of nuchal cords or in the presence of a coexisting true knot of the umbilicus may be associated with an increased risk of stillbirth or compromised neonatal status at delivery. This commentary will address current perspectives of prenatal sonographic diagnosis and clinical management challenges associated with nuchal cord(s) in singleton pregnancies.
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Affiliation(s)
- David M Sherer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Kayana Ward
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Michelle Bennett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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Hinkson L, Pahlitzsch T, Henrich W. Sextuple loops of nuchal cord in breech presentation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:843-844. [PMID: 31237030 DOI: 10.1002/uog.20376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 06/09/2023]
Affiliation(s)
- L Hinkson
- Department of Obstetrics, Charité Universitätsmedizin, Berlin, Germany
| | - T Pahlitzsch
- Department of Obstetrics, Charité Universitätsmedizin, Berlin, Germany
| | - W Henrich
- Department of Obstetrics, Charité Universitätsmedizin, Berlin, Germany
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