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Eleje GU, Nwammuo CB, Nnamani KO, Igbodike EP, Nwankwo EU, Okafor CG, Njoku TK, Ekwebene OC, Egwuatu EC, Malachy DE, Dimgba OO, Ihekwoaba EC, Onu OA, Edokwe ES, Ofiaeli CI, Obi KE, Okwuosa CN, Egwim AV, Okoro CC, Onyejiaka CC, Nneji HC, Ugwu OD, Ezeigwe CO, Madubuko CC, Mathias AA, Udigwe GO. Double true umbilical cord knots coexisting with a nuchal cord with successful fetal outcome: A case report. SAGE Open Med Case Rep 2024; 12:2050313X241239524. [PMID: 38495733 PMCID: PMC10943703 DOI: 10.1177/2050313x241239524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/27/2024] [Indexed: 03/19/2024] Open
Abstract
Umbilical nodes and cords play a crucial role in fetal development and are essential for the transfer of nutrients and oxygen between the mother and the fetus. Sonographic diagnosis of umbilical nodes and cords has become an integral part of prenatal care, allowing for the early detection of abnormalities and potential complications. The umbilical cord is a vital structure connecting the fetus to the placenta, providing essential nutrients and oxygen for fetal growth and development. Sonographic examination of the umbilical cord and its associated nodes has become an indispensable tool in prenatal care, enabling the early detection of abnormalities and potential complications. This review aims to analyze the current literature on sonographic diagnosis of umbilical nodes and cords, highlighting the key points and advancements in this field. A 37-year-old booked G4P2+1A2 Nigerian woman was registered for prenatal tertiary health care at 12 weeks of gestation. The booking investigations were normal and the booking packed cell volume was 37%. She was compliant with scheduled clinic visits and routine drugs. Pregnancy was carried to term uneventfully. Elective cesarean section was successfully performed at 38 weeks of gestation owing to the patient's prior history of third-degree perineal tear. The intraoperative findings included a loose cord around the neck of the baby and double true knots along the length of the 65 cm umbilical cord. The baby was delivered with appearance, pulse, grimace, activity and respiration (APGAR) scores of 7 in the first minute, 9 in the fifth minute, and the birth weight was 3.0 kg. Mother and baby were discharged 48 h postpartum in stable clinical condition. Although the presence of true double umbilical knots is rare, its coexistence with the nuchal cord is even rarer. There are risk factors associated with true umbilical knots. The possible risk factor implicated in this index case is the gender of the fetus and maternal multiparity. True umbilical knots are usually associated with certain fetal negative outcomes of pregnancy. There are currently no evidence-based treatment options available.
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Affiliation(s)
- George Uchenna Eleje
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
- Effective Care Research Unit, Department of Obstetrics and Gynecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Chijioke Brenda Nwammuo
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Kenechi Ogbodo Nnamani
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Emeka Philip Igbodike
- Department of Obstetrics and Gynecology, Havana Specialist Hospital, Surulere, Lagos, Nigeria
| | | | - Chigozie Geoffrey Okafor
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Tobechi Kingsley Njoku
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | | | | | | | - Ogechi Odinakachukwu Dimgba
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | | | - Onyekachi Amos Onu
- Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Emeka Stephen Edokwe
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | | | - Kenechukwu Ezekwesili Obi
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Chizoba Ndidiamaka Okwuosa
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Adanna Vivian Egwim
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | | | | | - Henry Chinedu Nneji
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Obiora Donatus Ugwu
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Chijioke Ogomegbunam Ezeigwe
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Casmir Chukwudi Madubuko
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Alexander Arinze Mathias
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Gerald Okanandu Udigwe
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
- Effective Care Research Unit, Department of Obstetrics and Gynecology, Nnamdi Azikiwe University, Awka, Nigeria
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Al Qasem M, Meyyazhagan A, Tsibizova V, Clerici G, Arduini M, Khader M, M Alkarabsheh A, Di Renzo GC. Knots of the umbilical cord: Incidence, diagnosis, and management. Int J Gynaecol Obstet 2024. [PMID: 38264935 DOI: 10.1002/ijgo.15373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
Knot(s) of the umbilical cord have received emphasis because the clinical assessments and sonographic literature show a crucial role in fetal outcomes. The true umbilical cord knot could be a knot in a singleton pregnancy or an entanglement of two umbilical cords in monoamniotic twins. Clinical manifestations are almost silent, which can raise clinical challenges. They worsen outcomes, and the pathology can be easily missed during prenatal visits because ultrasonographers do not pay attention to the cord during an obstetric ultrasound scan. However, most medical centers now have ultrasound machines that improve fetal assessment. The umbilical cord should be routinely evaluated during a fetal assessment, and suspicion of an umbilical cord knot can be more frequently diagnosed and is detected only incidentally. Clinical outcome is usually good but depends on the knot's characteristics and if it is tight or loose. In this review, we discuss pathophysiology, the theories on formation, the main risk factors, ultrasound signs and findings, different opinions in the management, and features of pregnancy outcomes feature.
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Affiliation(s)
- Malek Al Qasem
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Arun Meyyazhagan
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- Department of Life Sciences, CHRIST (Deemed to be University), Bengaluru, Karnataka, India
- PREIS International School, Firenze, Italy
| | - Valentina Tsibizova
- PREIS International School, Firenze, Italy
- CEMER, European Centre for Medical Research, Perugia, Italy
| | - Graziano Clerici
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- CEMER, European Centre for Medical Research, Perugia, Italy
| | - Maurizio Arduini
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Mohammed Khader
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Ahlam M Alkarabsheh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Gian Carlo Di Renzo
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- PREIS International School, Firenze, Italy
- Department of Obstetrics, Gynecology and Perinatology, IE Sechenov First State University, Moscow, Russian Federation
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Hanna M, Martini N, Deeb Y, Mahmoud W, Issa SY. A misdiagnosed case of a 150-cm umbilical cord coiled twice around the fetal neck with a true cord knot: A rare Syrian case report. SAGE Open Med Case Rep 2023; 11:2050313X231164858. [PMID: 37032995 PMCID: PMC10074614 DOI: 10.1177/2050313x231164858] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/01/2023] [Indexed: 04/05/2023] Open
Abstract
The normal umbilical cord is a crucial component during pregnancy, but sometimes it could become compromised due to some abnormalities such as excessive long umbilical cord, and though they usually end up with a healthy baby, they may lead to severe consequences. Excessive long umbilical cords are found in 4% of pregnancies and represent a risk factor for nuchal cords and true knots. We report a case of a 37-year-old Syrian pregnant woman who presented to the hospital at 37 weeks of gestation asking for a C-section for a fear of ambiguous ultrasound findings that have been interpreted as fetal malformation. At delivery, a healthy baby was born with a 150-cm umbilical cord, a true knot, and double-looped nuchal cords; the formation of the loops and the knot had been attributed to the elongated cord. Besides, ultrasound imaging could sometimes be deceptive and lead to unnecessary interventions; therefore, cord anomalies should always be kept in mind because they do not always represent a justification for a C-section.
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Affiliation(s)
- Majd Hanna
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic
- Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic
| | - Nafiza Martini
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic
- Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic
| | - Yara Deeb
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic
- Al Andalus University, Qadmus, Syrian Arab Republic
| | - Wissam Mahmoud
- Tishreen Military Hospital, Damascus, Syrian Arab Republic
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Considering the Effects and Maternofoetal Implications of Vascular Disorders and the Umbilical Cord. Medicina (B Aires) 2022; 58:medicina58121754. [PMID: 36556956 PMCID: PMC9782481 DOI: 10.3390/medicina58121754] [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: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
The umbilical cord is a critical anatomical structure connecting the placenta with the foetus, fulfilling multiple functions during pregnancy and hence influencing foetal development, programming and survival. Histologically, the umbilical cord is composed of three blood vessels: two arteries and one vein, integrated in a mucous connective tissue (Wharton's jelly) upholstered by a layer of amniotic coating. Vascular alterations in the umbilical cord or damage in this tissue because of other vascular disorders during pregnancy are worryingly related with detrimental maternofoetal consequences. In the present work, we will describe the main vascular alterations presented in the umbilical cord, both in the arteries (Single umbilical artery, hypoplastic umbilical artery or aneurysms in umbilical arteries) and the vein (Vascular thrombosis, aneurysms or varicose veins in the umbilical vein), together with other possible complications (Velamentous insertion, vasa praevia, hypercoiled or hypocoiled cord, angiomyxoma and haematomas). Likewise, the effect of the main obstetric vascular disorders like hypertensive disorders of pregnancy (specially pre-eclampsia) and chronic venous disease on the umbilical cord will also be summarized herein.
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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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Sherer DM, Amoabeng O, Dryer AM, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of True Knot of the Umbilical Cord. Int J Womens Health 2020; 12:221-233. [PMID: 32273778 PMCID: PMC7115211 DOI: 10.2147/ijwh.s192260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/23/2020] [Indexed: 11/23/2022] Open
Abstract
Umbilical cord accidents preceding labor are rare. Single and multiple nuchal cords, and true knot(s) of the umbilical cord, are often incidental findings noted at delivery of non-hypoxic non-acidotic newborns without any evidence of subsequent adverse neonatal outcome. In contrast to single nuchal cords, true knots of the umbilical cord, which occur in between 0.04% and 3% of all deliveries, have been associated with a reported 4 to 10 fold increased risk of stillbirth. First reported with real-time ultrasound, current widespread application of color Doppler, power Doppler and three-dimension sonography, has enabled increasingly more accurate prenatal sonographic diagnoses of true knot(s) of the umbilical cord. Reflecting the inability to visualize the entire umbilical cord at prenatal ultrasound assessment, despite detailed second and third-trimester scanning, many occurrences of incidental true knot of the umbilical cord remain undetected and are noted only at delivery. Although prenatal sonographic diagnostic accuracy is increasing, false positive sonographic diagnosis of true knot of the umbilical cord cannot be ruled out with certainty, and must continue to be considered clinically. Notwithstanding the inability to diagnose all true knots, currently there is a clear absence of clinical management guidelines by governing bodies regarding patients in whom prenatal sonographic diagnosis of true knot(s) of the umbilical cord is / are suspected. As a result, in many prenatal ultrasound units, suspected sonographic findings suggestive of or consistent with true knot of the umbilical cord are often disregarded, not documented, and patients are not uniformly informed of this potentially life-threatening condition, which carries an associated considerable risk of stillbirth. This commentary will address current perspectives of prenatal sonographic diagnostic and management challenges associated with true knot(s) of the umbilical cord 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
| | - Opokua Amoabeng
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Alexandra M Dryer
- 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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