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Stanek J. Clinical Significance of the Large Fetal Vessel Lesions in Placental Fetal Vascular Malperfusion. J Transl Med 2024; 104:102089. [PMID: 38810837 DOI: 10.1016/j.labinv.2024.102089] [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: 03/12/2024] [Revised: 04/26/2024] [Accepted: 05/16/2024] [Indexed: 05/31/2024] Open
Abstract
Fetal vascular malperfusion (FVM) is an important pattern of placental injury. Although the significance of distal villous FVM (clusters of sclerotic and/or mineralized chorionic villi) is well documented, the clinical significance of proximal (large vessel) lesions of FVM is less clear, which is the aim of this retrospective analysis. To evaluate the clinical significance and placental associations of single and coexisting categories of lesions of large vessel FVM, 24 clinical and 44 placental phenotypes of 804 consecutive placentas with at least 1 lesion of proximal vessel FVM from the second half of pregnancy, divided according to the type or category of the individual FVM lesion (fetal vascular ectasia, fetal vascular thrombi, intramural fibrin deposition, and stem vessel obliteration): 689, 341, 286, and 267 placentas, respectively (first analysis) and single or coexisting large fetal vessel lesions (1, 2, 3, and 4 coexisting categories of lesions: 276, 321, 162, and 45 placentas, respectively) were statistically compared (analysis of variance, χ2, univariate analysis). Because of multiple comparisons, Bonferroni-corrected P < .001 was used as a threshold of statistical significance. In this population of high-risk pregnancies dominated by fetal congenital anomalies, single individual or 1 to 2 coexisting categories of lesions of the large vessel FVM, including fetal vascular thrombi, did not consistently correlate with clinical or placental variables and were not prognostically useful, but the coexistence of 3 or 4 lesions was associated with the most advanced gestational age, fetal congenital anomalies, distal villous FVM, particularly high-grade, chorangioma or chorangiomatosis, hypercoiled umbilical cord, perivascular stem edema, and marginate or vallate placenta. Therefore, the finding of multiple lesions of the large vessel FVM not only merits a diligent search for the distal villous lesions including the CD34 immunostaining, but also justifies putting the large vessel (global) FVM on the final placental diagnosis line, which in the case of up to only 2 lesions may not be justified.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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2
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Yu Z, Liu YZ, Zhang Z, Chen BD, Zhang X. Marginal cord insertion in the first trimester is associated with furcate cord insertion. BMC Pregnancy Childbirth 2024; 24:431. [PMID: 38879535 PMCID: PMC11179193 DOI: 10.1186/s12884-024-06562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 05/03/2024] [Indexed: 06/19/2024] Open
Abstract
OBJECTIVES To evaluate the potential connections between marginal cord insertion during the first trimester and furcate cord insertion later in pregnancy. METHODS This is a prospective study of screening data on the cord insertion site in 3178 singleton pregnancies. The cord insertion site was examined in two stages. The first stage was screening for the cord insertion site between 10-13 weeks of gestation, the purpose is to determine the category of umbilical cord insertion. The second stage, performed at 22-28 weeks of gestation, was to follow up on the relationship between the cord insertion site and the placenta and to identify any changes in the category of umbilical cord insertion. This was performed to diagnose or exclude furcate cord insertion by identifying whether the umbilical cord trunk separated or branched before it reached the placenta. Factors influencing progression to furcate cord insertion and perinatal complications were assessed. RESULTS Fourteen cases (0.44%) with progression to furcate cord insertion, all of which showed marginal cord insertion on ultrasound in the first trimester (p < 0.001). without progression to furcate cord insertion, there were no changes in the category of umbilical cord insertion in 3050 cases (96.40%) compared to the early pregnancy. 114 cases (3.60%) with changes in the category of umbilical cord insertion that was not consistent with furcate cord insertion. A total of 14 cases progressed to furcate cord insertion, all showed the cord insertion site were in close proximity, and 11 (78.57%) cases showed a low insertion site (p < 0.001). Regarding the choice of mode of delivery, elective caesarean delivery was done in 8/14 (57.14%). The incidences of spontaneous vaginal delivery were 5/14 (35.71%) (p < 0.001). One (7.14%) case of progression to furcate cord insertion due to haematoma at the root of the umbilical cord ended with an emergency caesarean section. In terms of perinatal complications, marginal cord insertion that progressed to furcate cord insertion had higher incidences of SGA infants, abnormal placental morphology, retention of the placenta, and cord-related adverse pregnancy outcomes than not progressed to furcate cord insertion (p < 0.05). CONCLUSIONS Marginal cord insertion in the first trimester has the potential to progress to furcate cord insertion. We suggest that ultrasound-diagnosed marginal cord insertion in the first trimester should be watched carefully in the second trimester, which is clinically useful to accurately determine the category of cord insertion and to improve the rate of prenatal diagnosis of furcate cord insertion.
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Affiliation(s)
- Zhuan Yu
- Department of Medical Ultrasonics, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China
| | - Yu-Zhou Liu
- Department of Obstetrics, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China
| | - Zheng Zhang
- Department of Medical Ultrasonics, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China
| | - Bao-Ding Chen
- Department of Medical Ultrasonics, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China.
| | - Xin Zhang
- Department of Medical Ultrasonics, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China.
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Allo G, Sitarik AR, Redding A, Coleman CM, Cassidy-Bushrow AE, Gaba A, Straughen JK. Maternal COVID-19 exposure and placental characteristics. PLoS One 2024; 19:e0302682. [PMID: 38781150 PMCID: PMC11115219 DOI: 10.1371/journal.pone.0302682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION The impact of COVID-19 on the placenta is poorly described, particularly among minority women. MATERIALS AND METHODS This is a retrospective case-control study. Micro- and macroscopic placental pathologic findings were compared for 15 COVID-19 positive and 36 negative mothers. Cases and controls were frequency matched on gestational age, race, maternal comorbidities, and delivery type. Data from the electronic medical record were supplemented with independent review of microscopic slides. RESULTS Placentas from cases and controls were similar except the median distance from the site of the cord insertion to the nearest disk margin was statistically significantly shorter among placentas from COVID-19 positive cases (3.5 versus 6.0 cm, p = 0.006). Case status was not associated with an increased risk of placental pathologies. CONCLUSION There are few pathologic differences between placentas of COVID-19 positive and negative mothers. Additional studies are needed to investigate the role of timing of infection.
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Affiliation(s)
- Ghassan Allo
- Department of Pathology, Henry Ford Hospital, Detroit, MI, United States of America
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, United States of America
| | - Alexandra R. Sitarik
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States of America
| | - Ashley Redding
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States of America
| | - Chad M. Coleman
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States of America
| | | | - Arthur Gaba
- Department of Pathology, Henry Ford Hospital, Detroit, MI, United States of America
| | - Jennifer K. Straughen
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, United States of America
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States of America
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Stanek J. Placental fetal vascular malperfusion in congenital diaphragmatic hernia. Virchows Arch 2024; 484:83-91. [PMID: 37439836 DOI: 10.1007/s00428-023-03600-y] [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: 05/11/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023]
Abstract
The success of in-utero or intrapartum treatment for congenital diaphragmatic hernia (CDH) can be impacted by poor placental function; however, this relationship has not yet been studied. To analyze placental histomorphology in CDH, the frequencies of 24 independent clinical and 48 placental phenotypes were compared. Slides from 103 CDH placentas (group 1) and 133 clinical umbilical cord (UC) compromise/anatomical UC abnormality placentas without CDH (group 2) were subjected to hematoxylin/eosin staining and CD34 immunostaining and then examined. CD34 immunostaining was performed to identify clustered distal villi with endothelial fragmentation of recent fetal vascular malperfusion (FVM). Cesarean delivery and ex utero intrapartum treatment were more common in group 1, but group 2 showed a higher frequency of statistically significant increases in other clinical phenotypes. The frequencies of large vessels and distal villous FVMs (clustered endothelial fragmentation by CD34 immunostaining, stromal vascular karyorrhexis, avascular, or mineralized villi) did not differ between the groups, but low-grade distal villous FVMs were statistically significantly more common in group 1 than in group 2, while high-grade distal villous FVMs were significantly more common in group 2 than group 1. Large vessel and distal villous FVMs were manyfold more common in both the CDH and UC compromise groups than in the general population. However, CDH placentas were more likely to show low-grade distal villous FVMs and less likely to show high-grade distal villous FVMs in UC compromise placentas. FVM of CDH may therefore be caused by a similar pathomechanism as that of UC compromise, resulting in impaired placental fetal blood outflow.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, and Department of Pathology, University of Cincinnati Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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Stanek J. Single Umbilical Artery Umbilical Cord Is Associated With High-Grade Distal Fetal Vascular Malperfusion. Pediatr Dev Pathol 2024; 27:52-58. [PMID: 37771135 DOI: 10.1177/10935266231200013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
PURPOSE AND CONTEXT Umbilical cord abnormalities with clinical signs of cord compromise are frequently associated with fetal vascular malperfusion (FVM). Single umbilical artery (SUA) has been reported to be associated with high-grade FVM in fetal growth restriction but not in an unselected population; our study aimed to address this issue. METHODS Clinical and placental phenotypes of 55 consecutive placentas with SUA (Group 1) were compared with those of 655 placentas with 3-vessel umbilical cord (Group 2) from patients who were in the second half of their pregnancy. The placentas were histologically examined using hematoxylin and eosin (H&E) staining and CD 34 immunostaining. KEY RESULTS Several umbilical cord phenotypes and high-grade distal FVM, based on H&E staining and endothelial fragmentation by CD34 were significantly more common in Group 1, whereas decidual clusters of multinucleate trophoblasts were more common in Group 2. Notably, H&E staining or CD34 immunostaining evaluated separately showed that high-grade distal FVM was more common in Group 1 than in Group 2, but the difference was not statistically significant. CONCLUSIONS SUA predisposes to remote, advanced, and recent high-grade distal villous FVM, with a pathogenesis partly different from that of stasis-induced FVM, likely related to fetal anomalies associated with SUA.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Dehner LP. The Placenta and Neonatal Encephalopathy with a Focus on Hypoxic-Ischemic Encephalopathy. Fetal Pediatr Pathol 2023; 42:950-971. [PMID: 37766587 DOI: 10.1080/15513815.2023.2261051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023]
Abstract
Background: Placental examination is important for its diagnostic immediacy to correlate with maternal and/or fetal complications and parturitional difficulties. In a broader context, clinicopathologic studies of the placenta have addressed a range of pathogenetic questions that have led to conclusive and inconclusive results and interpretations. Methods: Recent standardized morphologic criteria and terminology of placental lesions have facilitated the ability to compare findings from studies that have focused on complications and outcomes of pregnancy. This review is an evaluation of recent studies on placental lesions associated with hypoxic-ischemic encephalopathy (HIE). Conclusion: No apparent consensus exists on whether it is fetal inflammation with the release of cytokines or chronic maternal and/or fetal vascular malperfusion is responsible for HIE with a lowering of the threshold for hypoxic ischemia. The counter argument is that HIE occurs solely as an intrapartum event. Additional investigation is necessary.
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Affiliation(s)
- Louis P Dehner
- Lauren V. Ackerman Laboratory of Surgical Pathology, Barnes-Jewish and St. Louis Children's Hospitals, State of Washington University in St. Louis Medical Center, St. Louis, MO, USA
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Stapleton D, Darmonkow A, Ravi Chandran A, Milligan N, Saghian R, Shinar S, Whitehead CL, Hobson SR, Serghides L, Macgowan CK, Sled JG, Kingdom JC, Baschat AA, Parks WT, Cahill LS. Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:248-254. [PMID: 36971026 DOI: 10.1002/uog.26206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/17/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Stapleton
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Darmonkow
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Ravi Chandran
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - N Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - R Saghian
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Shinar
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - C L Whitehead
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | - S R Hobson
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - L Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology and Institutes of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - C K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - J G Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - J C Kingdom
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - A A Baschat
- Center for Fetal Therapy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - W T Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - L S Cahill
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
- Discipline of Radiology, Memorial University of Newfoundland, St John's, NL, Canada
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Ward S, Sun Z, Maresse S. Current practice of placental cord insertion documentation in Australia - A sonographer survey. Australas J Ultrasound Med 2023; 26:157-168. [PMID: 37701770 PMCID: PMC10493351 DOI: 10.1002/ajum.12360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Introduction During pregnancy, the umbilical cord attaches to the placenta in a central, eccentric, marginal or velamentous location. Maternal and fetal complications are associated with marginal and velamentous cord insertions, the most clinically significant being perinatal mortality due to undiagnosed vasa praevia. Current literature describes a wide variation regarding regulation of placental cord insertion (PCI) documentation during antenatal ultrasound examinations. This prospective cross-sectional study aimed to assess the current practice of antenatal PCI documentation in Australia. Methods Members of the Australian Sonographer Accreditation Registry were invited to participate in an online survey which was distributed between February and March 2022. Results Four hundred ninety sonographers met the inclusion criteria for the study of which 330 (67.3%) have more than 10 years' experience as a sonographer and 375 (76.5%) are employed primarily in a public or private setting offering general ultrasound. Most respondents (89.6%) indicated documentation of the PCI site is departmental protocol at the second trimester anatomy scan (17-22 weeks gestation), but PCI documentation is protocol in less than 50% of other obstetric ultrasound examinations listed in the survey. The PCI site is included in the formal ultrasound report at a rate significantly less than inclusion in the departmental protocol and the sonographer's worksheet. Conclusions Considering the potential maternal and fetal complications associated with abnormal PCI and the ease at which the PCI site is identified in the first and second trimesters, we believe that standard inclusion of the PCI site in departmental protocol and in the formal ultrasound report from 11 weeks gestation, regardless of whether it is normal or abnormal, would prove invaluable.
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Affiliation(s)
- Samantha Ward
- Discipline of Medical Radiation Science, Curtin Medical SchoolCurtin UniversityPerthWestern AustraliaAustralia
| | - Zhonghua Sun
- Discipline of Medical Radiation Science, Curtin Medical SchoolCurtin UniversityPerthWestern AustraliaAustralia
| | - Sharon Maresse
- Discipline of Medical Radiation Science, Curtin Medical SchoolCurtin UniversityPerthWestern AustraliaAustralia
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Zahedi-Spung LD, Stout MJ, Carter EB, Dicke JM, Tuuli MG, Raghuraman N. Obstetric Outcomes in Singleton Pregnancies with Abnormal Placental Cord Insertions. Am J Perinatol 2023; 40:89-94. [PMID: 33934323 DOI: 10.1055/s-0041-1729163] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE There is wide variation in the management of pregnancies complicated by abnormal placental cord insertion (PCI), which includes velamentous cord insertion (VCI) and marginal cord insertion (MCI). We tested the hypothesis that abnormal PCI is associated with small for gestational age (SGA) infants. STUDY DESIGN This is a retrospective cohort study of all pregnant patients undergoing anatomic ultrasound at a single institution from 2010 to 2017. Patients with abnormal PCI were matched in a 1:2 ratio by race, parity, gestational age at the time of ultrasound, and obesity to patients with normal PCIs. The primary outcome was SGA at delivery. Secondary outcomes were cesarean delivery, preterm delivery, cesarean delivery for nonreassuring fetal status, 5-minute Apgar score < 7, umbilical artery pH < 7.1, and neonatal intensive care unit admission. These outcomes were compared using univariate and bivariate analyses. RESULTS Abnormal PCI was associated with an increased risk of SGA (relative risk [RR]: 2.43; 95% confidence interval [CI]: 1.26-4.69), increased risk of preterm delivery <37 weeks (RR: 3.60; 95% CI: 1.74-7.46), and <34 weeks (RR: 3.50; 95% CI: 1.05-11.63) compared with patients with normal PCI. There was no difference in rates of cesarean delivery, Apgar score of <7 at 5 minutes, acidemia, or neonatal intensive care unit admission between normal and abnormal PCI groups. In a stratified analysis, the association between abnormal PCI and SGA did not differ by the type of abnormal PCI (p for interaction = 0.46). CONCLUSION Abnormal PCI is associated with an increased risk of SGA and preterm delivery. These results suggest that serial fetal growth assessments in this population may be warranted. KEY POINTS · Abnormal PCI is associated with SGA infants and preterm birth.. · If an abnormal PCI is identified, the provider should consider serial growth ultrasounds.. · There is no difference in obstetric outcomes between VCI and MCI..
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Affiliation(s)
| | - Molly J Stout
- Division of Maternal-Fetal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Washington University in St. Louis, Missouri
| | - Jeffrey M Dicke
- Division of Maternal-Fetal Medicine, Washington University in St. Louis, Missouri
| | - Methodius G Tuuli
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Washington University in St. Louis, Missouri
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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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11
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Andescavage NN, Limperopoulos C. Placental abnormalities in congenital heart disease. Transl Pediatr 2021; 10:2148-2156. [PMID: 34584887 PMCID: PMC8429875 DOI: 10.21037/tp-20-347] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 01/26/2023] Open
Abstract
Congenital heart disease (CHD) remains the most common birth defect in infants, and critical CHD is associated with significant rates of morbidity and mortality. With the advent of powerful yet noninvasive advanced fetal imaging, it is becoming increasingly evident that the presence of CHD in utero disrupts typical development and contributes to the lifelong morbidity in this population. Across healthy and high-risk populations, intrauterine influences can permanently alter fetal development that may manifest in complex morbidities later in life, the so-called fetal-onset-of-adult-disease (FOAD) phenomenon. The placenta plays a critical role in not only supporting fetal development, but also by adapting to specific intrauterine conditions. The role of placental health, adaptation and dysfunction, however, in CHD is not well understood. In this article, we will review current evidence relating placental health in CHD, appraise existing knowledge-gaps in the field and highlight promising new avenues to better understand the impact of placental function on fetal well-being. We will review evidence of ex vivo human placental studies that describe abnormal placental findings in pregnancies complicated by CHD, as well evidence for in vivo assessments of the human placenta. While overall clinical in vivo assessments of placental development are rather limited, we will also review emerging evidence from advanced quantitative and functional magnetic resonance imaging that are bringing new insights into placental structure and function throughout gestation. By providing novel information about placental development, we can now explore the maternal-fetal-placental connection in greater detail, and better understand the multi-factorial mechanisms that may contribute to adverse outcomes seen in survivors of CHD.
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Affiliation(s)
- Nickie N Andescavage
- Division of Neonatology, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Catherine Limperopoulos
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA.,Division of Diagnostic Imaging & Radiology, Children's National Health System, Washington, DC, USA.,Department of Radiology, George Washington University School of Medicine, Washington, DC, USA
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Bigelow CA, Robles BN, Pan S, Overbey J, Robin E, Melamed A, Bianco A, Mella MT. Placental cord insertion distance from the placental margin and its association with adverse perinatal outcomes. Eur J Obstet Gynecol Reprod Biol 2020; 255:51-55. [PMID: 33080485 DOI: 10.1016/j.ejogrb.2020.10.006] [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: 05/29/2020] [Revised: 09/28/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The placental cord insertion (PCI) to the placental margin has not been well studied as a continuous variable in relation to birth outcomes. We sought to evaluate the impact of PCI distance on outcomes associated with placental function and development of fetal growth restriction (FGR). STUDY DESIGN This was a retrospective study of singleton gestations that underwent a fetal anatomy ultrasound from 2011-2013. The PCI was recorded as the distance in centimeters from the placental margin. Patients had FGR if the overall estimated fetal weight was <10 % for gestational age or abdominal circumference <5 % in the third trimester. Delivery, obstetric, and neonatal outcomes were obtained via medical chart review. Logistic and linear regression models were used to assess the impact of PCI distance on maternal and neonatal delivery outcomes. RESULTS Of the 1443 women who met inclusion criteria, 93.6 % delivered at term. The mean (±SD) PCI distance was 4.4 ± 1.4 cm. There was no association between PCI and cesarean delivery, peripartum hemorrhage (PPH), pre-eclampsia, 5-min Apgar, or intrauterine fetal demise. PCI distance was statistically significantly shorter in patients requiring neonatal intensive care unit (NICU) admission (4.1 ± 1.5 cm vs. 4.4 ± 1.4 cm, p = 0.02) and was associated with lower birthweight (p = 0.01), though this association was no longer seen when corrected for gestational age. There were 3.5 % of patients who developed FGR; PCI distances from the placental edge were not significantly different for patients who developed FGR compared to those who did not (4.2 ± 1.4 cm vs. 4.5 ± 1.4 cm, p = 0.18). Furthermore, a receiver operating characteristic (ROC) curve for PCI had poor sensitivity (area under the curve [AUC] 0.57, 95 % CI 0.49-0.65). CONCLUSION PCI distance at the time of fetal anatomic survey is significantly associated with NICU admission, though does not appear to impact rates of preterm birth, pre-eclampsia, PPH or cesarean delivery. PCI distance in singleton gestations does not appear to be predictive of FGR.
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Affiliation(s)
- Catherine A Bigelow
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
| | - Brittany N Robles
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Stephanie Pan
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jessica Overbey
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Esther Robin
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Alexander Melamed
- Massachusetts General Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 55 Fruit Street, Boston, MA 02115, USA
| | - Angela Bianco
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Maria Teresa Mella
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
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13
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Link D, Many A, Ben Sira L, Tarrasch R, Bak S, Kidron D, Gordon Z, Yagel S, Harel S, Ben Bashat D. Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment. Placenta 2020; 101:252-260. [PMID: 32933767 DOI: 10.1016/j.placenta.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. METHODS 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location; number of bifurcations, generations and vessels diameters. RESULTS Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DISCUSSION This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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Affiliation(s)
- Daphna Link
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Many
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liat Ben Sira
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Pediatric Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ricardo Tarrasch
- Jaime and Joan Constantiner School of Education, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Stella Bak
- Division of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Debora Kidron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pathology, Meir Medical Center, Kfar Saba, Israel
| | - Zoya Gordon
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Medical Engineering Afeka, Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Simcha Yagel
- Obstretrics and Gynecology Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Shaul Harel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dafna Ben Bashat
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
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Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment. Placenta 2020; 96:34-43. [PMID: 32560856 DOI: 10.1016/j.placenta.2020.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/13/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. METHODS 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location, number of bifurcations, generations and vessels diameters. RESULTS Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DISCUSSION This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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15
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Asoglu MR, Crimmins S, Kopelman JN, Turan OM, Goetzinger KR. Marginal placental cord insertion: the need for follow up? J Matern Fetal Neonatal Med 2020; 35:1629-1635. [PMID: 32397941 DOI: 10.1080/14767058.2020.1763297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The objectives of this study were (1) to estimate the association between marginal placental cord insertion (PCI) and small for gestational age (SGA) and other adverse perinatal outcomes and (2) to determine if pregnancy-associated plasma protein A (PAPP-A) levels was altered in these patients.Methods: It was a retrospective cohort study of singleton pregnancies undergoing ultrasound between 2016 and 2018. Marginal PCI was defined as a distance of ≤2 cm from placental edge to PCI site, visualized in both sagittal and transverse planes, and diagnosed between 16 and 32 weeks. Velamentous PCI were excluded. The primary outcome was SGA, defined as birthweight below 10th percentile for gestational age. Pregnancies with marginal PCI were compared to those with normal PCI with respect to maternal characteristics, PAPP-A levels and adverse perinatal and delivery outcomes.Results: The incidence of marginal PCI was 4.2% (76/1819). Compared to those with a normal PCI, patients with a marginal PCI were more likely to be nulliparous and less likely to be African American or morbidly obese (p < .05). SGA rate was similar between the groups (17.6% vs. 18.1%). There was a trend toward an increased incidence of oligohydramnios, polyhydramnios and breech presentation in patients with marginal PCI; however, these did not reach statistical significance. The incidence of low PAPP-A level was comparable between the groups (18.4% vs. 14.3%, p > .05).Conclusion: Our study did not demonstrate any increase in adverse pregnancy outcomes in the presence of marginal PCI. These findings may provide reassurance for counseling patients with this sonographic finding.
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Affiliation(s)
- Mehmet R Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Crimmins
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jerome N Kopelman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine R Goetzinger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Wax JR, Pinette MG. Imaging the Placental Cord Insertion: Just Do It. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:811-815. [PMID: 31674049 DOI: 10.1002/jum.15143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Joseph R Wax
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
| | - Michael G Pinette
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
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17
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Wax IR, Cartin A, Craig WY, Pinette MG, Wax JR. Second-Trimester Ultrasound-Measured Umbilical Cord Insertion-to-Placental Edge Distance: Determining an Outcome-Based Threshold for Identifying Marginal Cord Insertions. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:351-358. [PMID: 31432561 DOI: 10.1002/jum.15113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES We sought to study potential diagnostic criteria for marginal placental cord insertions as determined by associations with obstetric outcomes. METHODS This single-center retrospective cohort investigation included singleton gestations delivering from January 1, 2012, to December 31, 2016, and having a standard or detailed fetal ultrasound examination from 18 weeks to 21 weeks 6 days. Cord insertion-to-placental edge distances were used to create a referent comparison group and 3 patient groups: greater than 3.0 cm (comparison); greater than 2.0 to 3.0 cm (group 1); greater than 1.0 to 2.0 cm (group 2); and 1.0 cm or less (group 3). The primary outcome consisted of any one of spontaneous delivery before 37 weeks, fetal growth restriction, oligohydramnios, placental abruption, or intrauterine fetal demise. RESULTS The numbers of participants and mean distances ± SDs for the comparison group and groups 1 to 3, respectively, were 628 and 4.68 ± 1.17 cm, 106 and 2.52 ± 0.26 cm, 131 and 1.60 ± 0.29 cm, and 77 and 0.36 ± 0.37 cm, respectively. The primary outcome was significantly associated only with cord insertion-to-placental edge distances of 1.0 cm or less (adjusted odds ratio, 3.05; 95% confidence interval, 1.73-5.38). CONCLUSIONS Marginal cord insertions may be diagnosed when the cord insertion-to-placental edge distance is 1.0 cm or less.
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Affiliation(s)
- Ian R Wax
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
| | - Angelina Cartin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
| | - Wendy Y Craig
- Maine Medical Center Research Institute, Scarborough, Maine, USA
| | - Michael G Pinette
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
| | - Joseph R Wax
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maine Medical Center, Portland, Maine, USA
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Nkwabong E, Njikam F, Kalla G. Outcome of pregnancies with marginal umbilical cord insertion. J Matern Fetal Neonatal Med 2019; 34:1133-1137. [PMID: 31164018 DOI: 10.1080/14767058.2019.1628206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the outcome of labor in cases of marginal umbilical cord insertions. MATERIAL AND METHODS This case-control study was carried out between December 1st, 2017 and April 30th, 2018. All singletons with marginal cord insertion (MCI) and three new-borns without MCI were recruited. The main variables studied included gestational age at delivery, occurrence of preeclampsia, intrapartum haemorrhage, mode of delivery, cord insertion, cord length, birth and placenta weights, presence of nuchal cord, Apgar score and admission of the new-born into the neonatal intensive care unit (NICU). Data from both groups were compared. Fisher exact test, t-test and logistic regression were used for comparison. p < .05 was considered statistically significant. RESULTS Our prevalence of MCI was 7.2% (85/1181). MCI was significantly associated with pre-eclampsia (aOR 2.94, 95%CI 1.14-7.59), placenta abruption (OR 33.68, 95%CI 9.80-115.76), nuchal cord entanglement (aOR 3.07, 95%CI 1.69-5.59), low birth weight (aOR 3.15, 95%CI 1.05-9.45) and transfer of the newborn to the NICU (OR 4.72, 95%CI 2.46-9.04). CONCLUSIONS MCI is associated with increased maternal, fetal and neonatal adverse morbidities. Therefore, pregnancy with MCI should be well followed up. Moreover, the delivery should be conducted in settings where rapid intensive neonatal care can be offered.
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Affiliation(s)
- Elie Nkwabong
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences & University Teaching Hospital, Yaoundé, Cameroon
| | - Fadimatou Njikam
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaoundé, Cameroon
| | - Ginette Kalla
- Department of Pediatrics, Faculty of Medicine and Biomedical Sciences & University Teaching Hospital, Yaoundé, Cameroon
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Melcer Y, Pekar-Zlotin M, Wolf B, Betser M, Dvash S, Zilberman Sharon N, Maymon R. Is scanning for vasa previa important for singleton pregnancies that started as multiple conceptions? Eur J Obstet Gynecol Reprod Biol 2019; 238:100-103. [PMID: 31128531 DOI: 10.1016/j.ejogrb.2019.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Vasa previa (VP) is a congenital placentation disorder in which fetal vessels run across the internal os of the cervix under the fetal presentation. This rare condition is associated with a high rate of perinatal morbidity and mortality when undetected before delivery. Roughly 85% of all cases of VP can be associated with one or more identifiable risk factors including in-vitro fertilization (IVF), multiple gestations, bilobed, succenturiate or low-lying placentas, and velamentous cord insertion (VCI). Recent evidence indicates the need for standardized prenatal targeted scanning protocols of pregnancies at risk of VP. The present study reports on pregnancies that began with multiple gestations but ended with a single fetus diagnosed with VP. STUDY DESIGN We retrospectively collected and reviewed medical records from 2006 to 2018 of early multiple pregnancies that ended with a single fetus diagnosed with VP in our medical center, including three cases of twin gestation complicated by a vanishing twin and a case of multifetal reduction in triplet pregnancy. This retrospective cohort study was approved by our Institutional Clinical Research Committee. RESULTS The database search identified 50 pregnancies that started as multiple gestations but continued as singletons. Of these, 4 pregnancies were diagnosed with VP, for a prevalence of 8.0%. For two of the four cases, the diagnosis was made during delivery as expressed by a low Apgar score at 1 and 5 min, a low cord blood pH value, newborn resuscitation, blood product transfusion, and NICU supervision. There was a statistically significant difference in the prevalence of VP in pregnancies that started as multiple gestations but continued later as singletons compared to multiple pregnancies (8.0% vs. 0.2% respectively, p < 0.0001). The OR for VP in pregnancies that started as multiple gestations but continued as singletons was 41.1 (95% CI, 12.77-131.94). CONCLUSIONS Our findings suggest there is an increased risk of VP in conceptions that started as viable multiple gestations but continued later as singletons. If our findings supported by others, it may be prudent to consider all twins at the beginning of pregnancy to be at risk for VP, irrespective of the actual number of life fetuses at later stages of gestation.
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Affiliation(s)
- Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Brian Wolf
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Moshe Betser
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Shira Dvash
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Nataly Zilberman Sharon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1)
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel(1).
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Allaf MB, Andrikopoulou M, Crnosija N, Muscat J, Chavez MR, Vintzileos AM. Second trimester marginal cord insertion is associated with adverse perinatal outcomes. J Matern Fetal Neonatal Med 2018; 32:2979-2984. [PMID: 29544383 DOI: 10.1080/14767058.2018.1453798] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objectives: To determine the feasibility in visualizing placental cord insertion (PCI) during second-trimester fetal anatomical survey and the association between marginal cord insertion (MCI) and preterm delivery (PTD) and low birth weight (LBW). Our secondary objectives were to evaluate the association of MCI with adverse composite obstetrical and neonatal outcomes. Methods: A prospective cohort study was performed over a 28-month period. Women with singleton pregnancies presenting for routine anatomical survey between 18 and 22 weeks' gestation were included. PCI site was visualized on 2D grayscale and color Doppler and the shortest distance from the sagittal and transverse planes to the placental edge were recorded. MCI was diagnosed when any of measured distances was ≤2 cm. Correlations were assessed via bivariate chi-squared, independent t-test analyses and Fisher's exact tests. Regression models evaluated associations between MCI and adverse composite outcomes. Results: Three hundred one women were included and PCI was feasible in all cases. The incidence of MCI was 11.3% (n = 34). Baseline characteristics between those with and without MCI were similar, except for story of prior PTD, which was greater among those with MCI (17.65 versus 7.17%, p = .04). MCI was associated with increased likelihood of LBW (RR four; 95%CI, 1.46-10.99) and PTD (RR 3.2; 95%CI, 1.53-6.68); in multivariate analysis, we found associations between MCI and composite adverse obstetrical (RR 2.33; 95%CI, 1.30-4.19) and neonatal (RR 2.46; 95%CI, 1.26-4.81) outcomes. Conclusions: Evaluation of PCI is feasible in all cases. Second-trimester MCI is associated with increased likelihood for LBW, PTD, and composite adverse obstetrical and neonatal outcomes.
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Affiliation(s)
- M Baraa Allaf
- a NYU Winthrop Hospital , Nassau County, Long Island , NY , USA
| | | | - Natalie Crnosija
- b Department of Obstetrics, Gynecology and Reproductive Medicine , Stony Brook University , Brookhaven, Suffolk County , NY , USA
| | - Jolene Muscat
- a NYU Winthrop Hospital , Nassau County, Long Island , NY , USA
| | - Martin R Chavez
- a NYU Winthrop Hospital , Nassau County, Long Island , NY , USA
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Nkwabong E, Ndoumbe Mballo J, Dohbit JS. Risk factors for nuchal cord entanglement at delivery. Int J Gynaecol Obstet 2018; 141:108-112. [DOI: 10.1002/ijgo.12421] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Elie Nkwabong
- Department of Obstetrics and Gynecology; Faculty of Medicine and Biomedical Sciences; Yaoundé Cameroon
- University Teaching Hospital; Yaoundé Cameroon
| | - Jacky Ndoumbe Mballo
- Department of Obstetrics and Gynecology; Faculty of Medicine and Biomedical Sciences; Yaoundé Cameroon
| | - Julius Sama Dohbit
- Department of Obstetrics and Gynecology; Faculty of Medicine and Biomedical Sciences; Yaoundé Cameroon
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22
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Melcer Y, Maymon R, Pekar-Zlotin M, Levinsohn-Tavor O, Tovbin J, Jauniaux E. Evaluation of the impact of vasa previa on feto-placental hormonal synthesis and fetal growth. Eur J Obstet Gynecol Reprod Biol 2017. [DOI: 10.1016/j.ejogrb.2017.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Albalawi A, Brancusi F, Askin F, Ehsanipoor R, Wang J, Burd I, Sekar P. Placental Characteristics of Fetuses With Congenital Heart Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:965-972. [PMID: 28258617 DOI: 10.7863/ultra.16.04023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To investigate whether there is an association between congenital heart disease (CHD) and placental abnormalities. METHODS We conducted a case-control study that included cases of infants with CHD who underwent cardiac surgery within 6 months of life at the Johns Hopkins Medical Center from 2000 to 2013, and gestational age-matched normal pregnancy controls (200 neonates per group). RESULTS Overall, abnormal placental cord insertion (ie, eccentric, marginal, or velamentous) was associated with CHD (odds ratio, 2.33-3.76). The main cardiac defects associated with abnormal cord insertion were conotruncal defects (relative risk, 3.08; 95% confidence interval [CI], 1.48-6.40; P = .003), left heart disease (relative risk, 2.40; 95% CI, 1.32-4.37; P = .004), and right heart disease (relative risk, 2.22; 95% CI, 1.21-4.07; P = .010). The Placenta-to-birth weight ratio was not associated with CHD. Intrauterine growth restriction was associated with CHD (odds ratio, 3.00; 95% CI, 1.41-6.39; P = .004). CONCLUSIONS Abnormal cord insertion, as well as intrauterine growth restriction, was determined to be correlated with the presence of CHD. On the basis of our results, we conclude that cord insertion should be evaluated at routine obstetric sonography, and further fetal heart evaluation is warranted if abnormal cord insertion is detected.
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Affiliation(s)
- Afaf Albalawi
- Department of Pediatrics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Flavia Brancusi
- Departments of Gynecology and Obstetrics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Frederic Askin
- Department of Pathology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert Ehsanipoor
- Departments of Gynecology and Obstetrics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jiangxia Wang
- Departments of Johns Hopkins School of Medicine, and Biostatistics Center, Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Irina Burd
- Departments of Gynecology and Obstetrics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Priya Sekar
- Department of Pediatrics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Khong TY, Mooney EE, Ariel I, Balmus NCM, Boyd TK, Brundler MA, Derricott H, Evans MJ, Faye-Petersen OM, Gillan JE, Heazell AEP, Heller DS, Jacques SM, Keating S, Kelehan P, Maes A, McKay EM, Morgan TK, Nikkels PGJ, Parks WT, Redline RW, Scheimberg I, Schoots MH, Sebire NJ, Timmer A, Turowski G, van der Voorn JP, van Lijnschoten I, Gordijn SJ. Sampling and Definitions of Placental Lesions: Amsterdam Placental Workshop Group Consensus Statement. Arch Pathol Lab Med 2016; 140:698-713. [PMID: 27223167 DOI: 10.5858/arpa.2015-0225-cc] [Citation(s) in RCA: 977] [Impact Index Per Article: 122.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -The value of placental examination in investigations of adverse pregnancy outcomes may be compromised by sampling and definition differences between laboratories. OBJECTIVE -To establish an agreed-upon protocol for sampling the placenta, and for diagnostic criteria for placental lesions. Recommendations would cover reporting placentas in tertiary centers as well as in community hospitals and district general hospitals, and are also relevant to the scientific research community. DATA SOURCES -Areas of controversy or uncertainty were explored prior to a 1-day meeting where placental and perinatal pathologists, and maternal-fetal medicine specialists discussed available evidence and subsequently reached consensus where possible. CONCLUSIONS -The group agreed on sets of uniform sampling criteria, placental gross descriptors, pathologic terminologies, and diagnostic criteria. The terminology and microscopic descriptions for maternal vascular malperfusion, fetal vascular malperfusion, delayed villous maturation, patterns of ascending intrauterine infection, and villitis of unknown etiology were agreed upon. Topics requiring further discussion were highlighted. Ongoing developments in our understanding of the pathology of the placenta, scientific bases of the maternofetoplacental triad, and evolution of the clinical significance of defined lesions may necessitate further refinements of these consensus guidelines. The proposed structure will assist in international comparability of clinicopathologic and scientific studies and assist in refining the significance of lesions associated with adverse pregnancy and later health outcomes.
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Affiliation(s)
- T Yee Khong
- From SA Pathology, Women's and Children's Hospital, University of Adelaide, North Adelaide, Australia (Dr Khong); the Department of Pathology, National Maternity Hospital, Dublin, Ireland (Drs Mooney and Kelehan); the Department of Pathology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel (Dr Ariel); the Department of Pathology, Kennemer Gasthuis, Haarlem, the Netherlands (Dr Balmus); the Department of Pathology, Boston Children's Hospital, and the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Boyd); the Departments of Pathology and Laboratory Medicine, and Pediatrics, University of Calgary, Calgary, Alberta, Canada (Dr Brundler); the Maternal & Fetal Health Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom (Ms Derricott); the Department of Pathology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (Dr Evans); the Department of Pathology, University of Alabama at Birmingham, (Dr Faye-Petersen); the Department of Pathology, Rotunda Hospital, Dublin, Ireland (Dr Gillan); the Institute of Human Development, Faculty of Medical and Human Sciences
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25
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He M, Curran P, Raker C, Martin S, Larson L, Bourjeily G. Placental findings associated with maternal obesity at early pregnancy. Pathol Res Pract 2016; 212:282-7. [DOI: 10.1016/j.prp.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/18/2015] [Accepted: 01/22/2016] [Indexed: 12/17/2022]
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26
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Abstract
The clinical utility of placental pathology is both overestimated and underestimated, and the overall quality of placental pathology reporting, even at major medical centers, is highly variable. Clear benefits of examining placentas include the immediate diagnosis of treatable conditions in both the mother and the infant, clarification of the underlying etiology of adverse pregnancy outcomes, estimation of recurrence risk, and guidance for the management of future pregnancies. In order to realize these benefits and get the most out of their pathology departments, it is critical for clinicians to understand the range and implications of placental lesions. This article will review the nomenclature, diagnostic criteria and pitfalls, and clinical significance of seven common placental disease processes and a handful of other lesions.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106.
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27
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Influence of the umbilical cord insertion site on the optimal individual birth weight achievement. BIOMED RESEARCH INTERNATIONAL 2014; 2014:341251. [PMID: 24967357 PMCID: PMC4055645 DOI: 10.1155/2014/341251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/27/2014] [Accepted: 04/30/2014] [Indexed: 11/17/2022]
Abstract
Study Question. To determine whether the umbilical cord insertion site of singleton pregnancies could be linked to the newborn birth weight at term and its individual growth potential achievement. Material and Methods. A cohort study including 528 records of term neonates was performed. Each neonate was assessed for growth adjusted for gestational age according to the infant's growth potential using the AUDIPOG module. We considered two categories of umbilical cord insertions: central and peripheral. Intrauterine growth restriction was defined as birth weight below the 10th percentile. Statistical analysis was performed using Chi-square, Student's t test, Wilcoxon test, ANOVA, and logistic regression. Results. We observed a total of 343 centrally inserted cords versus 185 peripheral cords. There were twice as many smokers in the mothers of the peripheral category compared to the centrally inserted ones. More importantly, we demonstrated that only 17/343 (5.0%) of infants with central cord insertion were growth restricted, compared to 37/185 (20.0%) of the infants born with a peripheral insertion. Neonates with centrally inserted cord were significantly heavier. Conclusion. The umbilical cord insertion site of singleton pregnancies is associated with the newborn's birth weight at term and its individual growth potential achievement.
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