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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; 166:559-566. [PMID: 38264935 DOI: 10.1002/ijgo.15373] [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: 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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Sherer DM, Roach C, Soyemi S, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Complex Umbilical Cord Entanglement. Int J Womens Health 2021; 13:247-256. [PMID: 33658863 PMCID: PMC7917470 DOI: 10.2147/ijwh.s285860] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/23/2021] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of potential umbilical cord compromise, namely, true knots of the umbilical cord and nuchal cords has been enabled with increasing accuracy with current enhanced prenatal sonography. Often an incidental finding at delivery, the incidence of true knots of the umbilical cord has been estimated at between 0.04% and 3% of deliveries. This condition has been reported to account for a 4 to 10-fold increase of stillbirth and perinatal morbidity of 11% of cases. Nuchal cords, commonly observed at the delivery of uncompromised, non-hypoxic non-acidotic newborns occur more frequently with single nuchal cords noted in between 20% and 35% of all deliveries at term. Multiple nuchal cords are considerably less frequent, with decreasing frequencies inverse to the number of nuchal cord loops. While clearly single (and likely double) nuchal cords are almost uniformly associated with favorable neonatal outcomes, emerging data suggest that cases of ≥3 loops of nuchal cords are more likely to be associated with an increased risk of adverse perinatal outcome (either stillbirth or compromised neonatal condition at delivery). We define cases of a true knot of the umbilical cord, cases of ≥3 loops of nuchal cords, any combination of a true knot and nuchal cord, or any umbilical cord entanglement (nuchal or true knot) in the presence of a single umbilical artery, in singleton gestations as complex umbilical cord entanglement. Two concurrent developments, the increase in accuracy of prenatal sonographic diagnosis of complex umbilical cord entanglement and recent data confirming fatal compromise of the umbilical circulation in approximately 20% of cases of stillbirth, suggest that establishing governing body guidelines for reporting of potential umbilical cord compromise, and recommendation of consideration for early-term delivery of select cases, may be warranted. This commentary will address current perspectives of prenatal diagnosis and clinical management challenges of complex umbilical cord entanglement.
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Affiliation(s)
- David M Sherer
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Crystal Roach
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Sarin Soyemi
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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Sherer DM, Ward K, Bennett M, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Nuchal Cord(s). Int J Womens Health 2020; 12:613-631. [PMID: 32982473 PMCID: PMC7500175 DOI: 10.2147/ijwh.s211124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/17/2020] [Indexed: 11/29/2022] Open
Abstract
Umbilical cord accidents preceding labor are uncommon. In contrast, nuchal cords are a very common finding at delivery, with reported incidences of a single nuchal cord of approximately between 20% and 35% of all singleton deliveries at term. Multiple loops occur less frequently, with reported incidence rates inverse to the number of nuchal cords involved. Rare cases of up to 10 loops of nuchal cord have been reported. While true knots of the umbilical cord have been associated with a 4–10-fold increased risk of stillbirth, nuchal cord(s) are most often noted at delivery of non-hypoxic non-acidotic newborns, without any evidence of subsequent adverse neonatal outcome. Prior to ultrasound, nuchal cords were suspected clinically following subtle (spontaneous or evoked) electronic fetal heart rate changes. Prenatal sonographic diagnosis, initially limited to real-time gray-scale ultrasound, currently entails additional sonographic modalities, including color Doppler, power Doppler, and three-dimensional sonography, which have enabled increasingly more accurate prenatal sonographic diagnoses of nuchal cord(s). In contrast to true knots of the umbilical cord (which are often missed at sonography, reflecting the inability to visualize the entire umbilical cord, and hence are often incidental findings at delivery), nuchal cord(s), reflecting their well-defined and sonographically accessible anatomical location (the fetal neck), lend themselves with relative ease to prenatal sonographic diagnosis, with increasingly high sensitivity and specificity rates. While current literature supports that single (and possibly double) nuchal cords are not associated with increased adverse perinatal outcome, emerging literature suggests that cases of ≥3 loops of nuchal cords or in the presence of a coexisting true knot of the umbilicus may be associated with an increased risk of stillbirth or compromised neonatal status at delivery. This commentary will address current perspectives of prenatal sonographic diagnosis and clinical management challenges associated with nuchal cord(s) in singleton pregnancies.
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Affiliation(s)
- David M Sherer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Kayana Ward
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Michelle Bennett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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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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Singh C, Kotoch K. Prenatal Diagnosis of True Knot of the Umbilical Cord. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:1065-1066. [PMID: 31402268 DOI: 10.1016/j.jogc.2019.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Chanchal Singh
- Fetal Medicine, BirthRight by Rainbow Hospitals, New Delhi, India.
| | - Kavita Kotoch
- Obstetrics and Gynecology, BirthRight by Rainbow Hospitals, New Delhi, India
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Singh C, Kotoch K. Diagnostic prénatal d'un vrai nœud du cordon ombilical. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:1067-1068. [PMID: 31402272 DOI: 10.1016/j.jogc.2019.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Chanchal Singh
- Fetal Medicine, BirthRight by Rainbow Hospitals, New Delhi, Inde
| | - Kavita Kotoch
- Obstetrics and Gynecology, BirthRight by Rainbow Hospitals, New Delhi, Inde
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Sherer DM, Dalloul M, Ward K, Nakagawa J, Joseph I, Grube S, Abulafia O. Coexisting true umbilical cord knot and nuchal cord: possible cumulative increased risk of adverse perinatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:404-405. [PMID: 27997052 DOI: 10.1002/uog.17389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/18/2016] [Accepted: 12/13/2016] [Indexed: 06/06/2023]
Affiliation(s)
- D M Sherer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - M Dalloul
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - K Ward
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - J Nakagawa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - I Joseph
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - S Grube
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - O Abulafia
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
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