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Oualiken C, Martz O, Idrissi N, Harizay FT, Martin L, De Maistre E, Ricaud L, Tarris G. Case report: Umbilical vessel aneurysm thrombosis and factor V Leiden mutation leading to fetal demise. Front Med (Lausanne) 2023; 9:1083806. [PMID: 36687456 PMCID: PMC9845932 DOI: 10.3389/fmed.2022.1083806] [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: 10/29/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023] Open
Abstract
Complicated pregnancies are nowadays a major public health concern, with possible lethality or sequelae both for the mother and the fetus. Blood coagulation disorders (including antiphospholipid syndrome, factor V Leiden mutation and antithrombin deficiency) and hypertensive gestational disorders are very well-known contributors of complicated pregnancies with poor fetal outcome, such as intrauterine growth retardation (IUGR) and fetal demise. Less commonly, vascular malformations of the placenta can also potentially lead to serious complications such as IUGR and fetal death. These malformations include hypercoiled umbilical cord, umbilical cord knot, umbilical cord varix, umbilical cord arterial or venous aneurysm, and velamentous insertion of the umbilical cord potentially leading to Benckiser's hemorrhage. Here, we report the case of a 29-year-old Gravida 2 Para 0 mother with previous history of stillbirth and smoking, admitted to the obstetrics department for the absence of fetal movement at 38 weeks of amenorrhea (WA). First-trimester and second-trimester routine ultrasounds were otherwise normal. Ultrasound performed at 38 WA revealed a 83 × 66 × 54 mm cystic heterogenous mass at the umbilical cord insertion. After delivery, fetal and placental pathology as well as maternal blood testing were performed. Fetal pathology was otherwise normal, except for diffuse congestion and meconial overload suggesting acute fetal distress. Fetal karyotype was normal (46 XX). Placental pathology revealed an umbilical artery aneurysm (UAA) at the base of the insertion of the umbilical cord, lined with a CD34+ CD31+ endothelium. After dissection, the aneurysm was filled with hemorrhagic debris, indicating aneurysm thrombosis. Histopathology revealed associated maternal vascular malperfusion (MVM) and increased peri-villous fibrin (IPF). Maternal blood tests revealed heterozygous factor V Leiden mutation, without other associated auto-immune conditions (such as antiphospholipid syndrome). Umbilical artery aneurysms remain extremely rare findings in the placenta, with <20 reported cases. Umbilical artery aneurysms have tendency to be located at the base of the insertion of the placenta, and lead to fetal demise in more than 60% of cases, mainly due to aneurysmal thrombosis, hematoma, possible vascular compression and/or rupture. Umbilical vessel aneurysms can be associated with trisomy 18 or 13. In our case, the association of factor V Leiden mutation, a hypercoagulable state, with UAA could explain massive thrombosis of the aneurysmal lumen and sudden fetal demise. Further consideration of current guidelines for surveillance and management of UAA would allow appropriate planned delivery in maternal care settings.
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Affiliation(s)
- Camélia Oualiken
- Department of Pathology, University Hospital of Dijon, Dijon, France,Forensics Institute, University Hospital of Dijon, Dijon, France
| | - Olivia Martz
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Gynecology Emergency Services, University Hospital of Dijon, Dijon, France
| | | | | | - Laurent Martin
- Department of Pathology, University Hospital of Dijon, Dijon, France
| | | | - Lou Ricaud
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Gynecology Emergency Services, University Hospital of Dijon, Dijon, France
| | - Georges Tarris
- Department of Pathology, University Hospital of Dijon, Dijon, France,*Correspondence: Georges Tarris ✉
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Lewis GK, Dawkins JC, Tang X. Umbilical artery aneurysm without aneuploidy and delivery of a live neonate. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Umbilical artery aneurysm, a rare structural anomaly of the umbilical cord, is frequently associated with fetal aneuploidy, fetal growth restriction and fetal demise. At present there are no definitive protocols or guidelines for the surveillance and management of this condition.
Case presentation
The index case is an 18-year-old primigravida who had an ultrasound at 35 weeks and 5 days gestation due to lagging symphysio-fundal height measurement. The ultrasound scan revealed a normal fetus with estimated fetal weight that was appropriate for gestational age. There was a cystic structure with internal echoes originating from the placenta at the point of the umbilical cord insertion, which was determined to be a 1.9 × 1.8 cm umbilical artery aneurysm on 3D and Doppler imaging. On follow up imaging the aneurysm had increased in size and measured 3.06 × 1.79 cm. The patient subsequently had a cesarean section delivery of a live female. Karyotyping subsequently revealed 46 XX.
Conclusions
A total of 15 cases of umbilical artery aneurysm have been reported in the literature to date, of which there were 5 live born infants with normal karyotype. The remaining 10 cases were intra-uterine fetal demise or trisomy 18 with subsequent neonatal deaths. When monitoring the aneurysms with ultrasound, change in size and Doppler indices play a pivotal role in helping to determine time and mode of delivery and thus allow for a favorable perinatal outcome.
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Affiliation(s)
- Gregory K. Lewis
- Department of Obstetrics and Gynecology , Rochester General Hospital Rochester NY , USA
| | - Josette C. Dawkins
- Department of Obstetrics and Gynecology , Rochester General Hospital , Rochester NY , USA
| | - Xiangna Tang
- Department of Obstetrics and Gynecology , Rochester General Hospital , Rochester NY , USA
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Sherer DM, Al-Haddad S, Cheng R, Dalloul M. Current Perspectives of Prenatal Sonography of Umbilical Cord Morphology. Int J Womens Health 2021; 13:939-971. [PMID: 34703323 PMCID: PMC8541738 DOI: 10.2147/ijwh.s278747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022] Open
Abstract
The umbilical cord constitutes a continuation of the fetal cardiovascular system anatomically bridging between the placenta and the fetus. This structure, critical in human development, enables mobility of the developing fetus within the gestational sac in contrast to the placenta, which is anchored to the uterine wall. The umbilical cord is protected by unique, robust anatomical features, which include: length of the umbilical cord, Wharton’s jelly, two umbilical arteries, coiling, and suspension in amniotic fluid. These features all contribute to protect and buffer this essential structure from potential detrimental twisting, shearing, torsion, and compression forces throughout gestation, and specifically during labor and delivery. The arterial components of the umbilical cord are further protected by the presence of Hyrtl’s anastomosis between the two respective umbilical arteries. Abnormalities of the umbilical cord are uncommon yet include excessively long or short cords, hyper or hypocoiling, cysts, single umbilical artery, supernumerary vessels, rarely an absent umbilical cord, stricture, furcate and velamentous insertions (including vasa previa), umbilical vein and arterial thrombosis, umbilical artery aneurysm, hematomas, and tumors (including hemangioma angiomyxoma and teratoma). This commentary will address current perspectives of prenatal sonography of the umbilical cord, including structural anomalies and the potential impact of future imaging technologies.
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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
| | - Sara Al-Haddad
- 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
| | - Regina Cheng
- 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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Matsuki R, Nakago S, Kato H, Shibata T, Kotera T, Kotsuji F. Management strategy of umbilical artery aneurysm complicated by cardiac anomaly: case study and literature review. J Matern Fetal Neonatal Med 2016; 30:1809-1812. [DOI: 10.1080/14767058.2016.1226796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Rikako Matsuki
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Satoshi Nakago
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Hiroki Kato
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Takashi Shibata
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Tomoki Kotera
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Fumikazu Kotsuji
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
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Vyas NM, Manjeera L, Rai S, Devdas S. Prenatal Diagnosis of Umbilical Artery Aneurysm with Good Fetal Outcome and Review of Literature. J Clin Diagn Res 2016; 10:QD01-3. [PMID: 26894129 PMCID: PMC4740657 DOI: 10.7860/jcdr/2016/14800.7030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/15/2015] [Indexed: 11/24/2022]
Abstract
Umbilical artery aneurysm is a rare condition. Till date, 14 cases are reported and only 4 had good fetal outcome. Umbilical artery aneurysm is associated with high risk of fetal aneuploidy and fetal demise. Though umbilical cord anomalies are rare, they are associated with significant fetal morbidity and mortality. We report a case of umbilical artery aneurysm which was detected at 33 weeks of gestation on ultrasonography as an anechoic cyst close to cord insertion with turbulent blood flow in it. The patient was hospitalized and with intensive fetal surveillance and early delivery, a live born fetus was achieved. Baby's karyotype was normal. Pathologic examination confirmed umbilical artery aneurysm close to cord insertion.
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Affiliation(s)
- Neetha M Vyas
- Associate Professor, Department of Obstetrics and Gynaecology, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
| | - Lakshmi Manjeera
- Professor, Department of Obstetrics and Gynaecology, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
| | - Supriya Rai
- Professor, Department of Obstetrics and Gynaecology, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
| | - Sharath Devdas
- Postgraduate Student, Department of Obstetrics and Gynaecology, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
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Moshiri M, Zaidi SF, Robinson TJ, Bhargava P, Siebert JR, Dubinsky TJ, Katz DS. Comprehensive imaging review of abnormalities of the umbilical cord. Radiographics 2015; 34:179-96. [PMID: 24428290 DOI: 10.1148/rg.341125127] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A complete fetal ultrasonographic (US) study includes assessment of the umbilical cord for possible abnormalities. Knowledge of the normal appearance of the umbilical cord is necessary for the radiologist to correctly diagnose pathologic conditions. Umbilical cord abnormalities can be related to cord coiling, length, and thickness; the placental insertion site; in utero distortion; vascular abnormalities; and primary tumors or masses. These conditions may be associated with other fetal anomalies and aneuploidies, and their discovery should prompt a thorough fetal US examination. Further workup and planning for a safe fetal delivery may include fetal echocardiography and karyotype analysis. Doppler US is a critical tool for assessment and diagnosis of vascular cord abnormalities. US also can be used for follow-up serial imaging evaluation of conditions that could result in fetal demise. Recent studies suggest that three- or four-dimensional Doppler US of the fetal umbilical cord and abdominal vasculature allows more accurate diagnosis of vascular abnormalities. Doppler US also is invaluable in assessment of fetal growth restriction since hemodynamic changes in the placenta or fetus would appear as a spectral pattern of increased resistance to forward flow in the fetal umbilical artery. Early detection of umbilical cord abnormalities and close follow-up can reduce the risk of morbidity and mortality and assist in decision making.
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Affiliation(s)
- Mariam Moshiri
- From the Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 (M.M., S.F.Z., T.J.R., P.B., T.J.D.); Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (P.B.); Department of Laboratories, Seattle Children's Hospital, Seattle, Wash (J.R.S.); and Department of Radiology, Winthrop-University Hospital, Mineola, NY (D.S.K.)
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Umbilical artery aneurysm: a case report, literature review, and management recommendations. Obstet Gynecol Surv 2014; 69:159-63. [PMID: 25102347 DOI: 10.1097/ogx.0000000000000051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Umbilical artery aneurysm is a rare and often lethal condition frequently associated with fetal anomalies, fetal demise, and neonatal complications. CASE We report a case of umbilical artery aneurysm discovered at 21 weeks 2 days of gestation in a fetus of normal karyotype. Maternal hospitalization occurred at 28 weeks for antenatal testing, betamethasone administration, and monitoring for expansion of the aneurysm. Delivery of a live neonate by repeat cesarean delivery was performed at 32 weeks 2 days. Pathology confirmed a 3-vessel cord with an umbilical artery aneurysm. Neonatal course was complicated by respiratory distress of the newborn, hyperbilirubinemia, anemia, difficulty feeding, and cardiac defects. The newborn was discharged from the neonatal intensive care unit on day of life 19. CONCLUSIONS Umbilical artery aneurysm is highly associated with fetal complications including trisomy 18, single umbilical artery, cardiac anomalies, and intrauterine fetal demise. A normal karyotype, antenatal monitoring, and early delivery have been suggested to impact the likeliness of survival. Antenatal management strategies include consideration of nonstress testing 3 times daily, serial ultrasound assessments, testing to identify intrauterine growth restriction, and delivery by planned cesarean delivery between 32 and 34 weeks. We recommend that patients be counseled on the high risks associated with umbilical artery aneurysm and be included in discussions regarding antenatal management and delivery planning.
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