Ultrasound diagnosis of placental and umbilical cord anomalies in singleton pregnancies resulting from in-vitro fertilization

INTRODUCTION

placental anomalies can affect fetal and maternal outcome due to severe maternal hemorrhage potentially resulting in hysterectomy and cord accident including abruption that can determine fetal damage or death. The aims of our study are to determine if the rate of placental and umbilical cord anomalies are more common in IVF singleton pregnancies compared to spontaneous pregnancies; to evaluate the role of ultrasound in screening for these anomalies and to investigate if oocyte donor fertilization is an additional risk factor for the development of these anomalies.

METHODS

this was a prospective cohort study involving two tertiary centers. Patients with a singleton pregnancy conceived with IVF and patients presenting with a spontaneous conception were recruited between 1^st May 2019 to 31^st March 2021. A total of 634 pregnancies were enrolled in the study. All patients underwent similar antenatal care, which included ultrasound examinations at 11-14, 19-22 and 33-35 weeks. Ultrasound findings of placental and/or umbilical cord abnormalities were recorded using the same protocol for both groups and confirmed after birth.

RESULTS

IVF pregnancies had a significantly higher risk of low-lying placenta, placenta previa, bilobed placenta and velamentous cord insertion (VCI) compared with spontaneous pregnancies. In the heterologous subgroup there was a significant increased incidence of placenta accreta spectrum (PAS) disorders than in spontaneous pregnancies. All these anomalies were identified prenatally on ultrasound imaging and confirmed at birth.

DISCUSSION

IVF pregnancies in general and those resulting from donor oocyte in particular are at higher risk of placental and umbilical cord abnormalities compared to spontaneous pregnancies. These anomalies can be diagnosed accurately at the mid-trimester detailed fetal anomaly scan and our findings support the need for a targeted ultrasound screening of these anomalies in IVF pregnancies.

Prenatal Diagnosis of Vasa Previa by Routine Transvaginal Color Doppler

The prenatal diagnosis of vasa previa is essential to achieving a safe delivery in patients who suffer from the condition. Transvaginal ultrasound with color Doppler performed at the time of a routine mid-trimester ultrasound is a valuable tool in terms of achieving a timely and accurate diagnosis of vasa previa.

Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study

BACKGROUND

It is crucial to interpret fetal heart rate patterns with a focus on the pattern evolution during labor to estimate the relationship between cerebral palsy and delivery. However, nationwide data are not available.

OBJECTIVE

The aim of our study was to demonstrate the features of fetal heart rate pattern evolution and estimate the timing of fetal brain injury during labor in cerebral palsy cases.

STUDY DESIGN

In this longitudinal study, 1069 consecutive intrapartum fetal heart rate strips from infants with severe cerebral palsy at or beyond 34 weeks of gestation, were analyzed. They were categorized as follows: (1) continuous bradycardia (Bradycardia), (2) persistently nonreassuring, (3) reassuring-prolonged deceleration, (4) Hon's pattern, and (5) persistently reassuring. The clinical factors underlying cerebral palsy in each group were assessed.

RESULTS

Hypoxic brain injury during labor (those in the reassuring-prolonged deceleration and Hon's pattern groups) accounted for 31.5% of severe cerebral palsy cases and at least 30% of those developed during the antenatal period. Of the 1069 cases, 7.86% were classified as continuous bradycardia (n=84), 21.7% as persistently nonreassuring (n=232), 15.6% as reassuring-prolonged deceleration (n=167), 15.9% as Hon's pattern (n=170), 19.8% as persistently reassuring (n=212), and 19.1% were unclassified (n=204). The overall interobserver agreement was moderate (kappa 0.59). Placental abruption was the most common cause (31.9%) of cerebral palsy, accounting for almost 90% of cases in the continuous bradycardia group (64 of 73). Among the cases in the Hon's pattern group (n=67), umbilical cord abnormalities were the most common clinical factor for cerebral palsy development (29.9%), followed by placental abruption (20.9%), and inappropriate operative vaginal delivery (13.4%).

CONCLUSION

Intrapartum hypoxic brain injury accounted for approximately 30% of severe cerebral palsy cases, whereas a substantial proportion of the cases were suspected to have either a prenatal or postnatal onset. Up to 16% of cerebral palsy cases may be preventable by placing a greater focus on the earlier changes seen in the Hon's fetal heart rate progression.

Assisted reproductive technologies (ART) and placental abnormalities

Objectives Assisted reproductive technologies (ART) may be associated with placental abnormalities including placenta previa, umbilical cord abnormalities, and placental abruption. Our study evaluates the relationship between ART and placental abnormalities compared with spontaneously conceived controls. Methods An IRB-approved cohort study was conducted including women who delivered between January 2013 and December 2018. We excluded delivery prior to 23 weeks and known fetal anomalies. Patients were matched with controls (2:1) for parity, age, and mode of delivery. Controls were women who had spontaneously conceived and delivered immediately preceding and following the index delivery. The primary outcome was placental abnormalities found on both antenatal ultrasound and pathology in ART gestations compared with spontaneously conceived gestations. Results There were 120 ART pregnancies and 240 matched control pregnancies identified. The groups were similar for parity, BMI, comorbidities, number of multiples, mode of delivery, and female newborns. The ART group had a higher maternal age (37.1±5 y vs. 30.0±5 y; p<0.001), greater preterm birth (29 vs. 6%; p<0.001), and lower BW (2,928±803 g vs. 3,273±586 g; p<0.001). The ART group had a higher incidence of placenta previa on ultrasound (4.0 vs. 0.4%, p=0.01), adherent placentas at delivery (3 vs. 0% p=0.014), placental abruption (2 vs. 0%; p=0.04), as well as an increased rate of velamentous cord insertion (12 vs. 3%, p<0.001) and marginal cord insertion (28 vs. 15%, p=0.002). ART demonstrated a two-fold likelihood of abnormal placental pathology. Conclusions ART is associated with increased rate of placental abnormalities, including abnormal umbilical cord insertion and increased rates of adherent placentation. This information may be beneficial in planning and surveillance in patients with ART pregnancies.

Umbilical cord characteristics and their association with adverse pregnancy outcomes: A systematic review and meta-analysis

Objective

Current data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes.

Methods

MEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks’ gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA.

Results

This review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37).

Conclusions

True umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.

Second-Trimester Ultrasound-Measured Umbilical Cord Insertion-to-Placental Edge Distance: Determining an Outcome-Based Threshold for Identifying Marginal Cord Insertions

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.

Two case reports: Early detection of amniotic band syndrome by adhesion between hand and umbilical cord at 11 to 14 weeks' gestation

RATIONALE

The significant ultrasonic characteristics of amniotic band syndrome (ABS) are the malformations of fetal affected parts and the band-like echoes in amniotic cavity. This article first suggests that the fetal hand adhered to umbilical cord with restricted movement provides some values in the diagnosis of ABS in early gestational weeks especially when the fetal malformation is not obvious and amniotic band is thin and fine.

PATIENT CONCERNS

Two pregnant women had no discomfort and underwent routine ultrasound examination at 11 to 14 gestational weeks.

DIAGNOSIS

Only the fetal hand adhered to umbilical cord with restricted movement was detected during the first ultrasound examination at 11∼14 gestational weeks, and the floating band-like echos were detected in the amniotic cavity with follow-up examinations 2 to 3 weeks later. Both of the 2 fetus were diagnosed as ABS by ultrasound INTERVENTIONS:: The two pregnant women underwent the prenatal counseling and were recommended closely follow-up and further examination.

OUTCOMES

Two fetuses died in utero between 17 and 19 weeks. After induction of labor, it was found that the hands and umbilical cord of the fetuses were wrapped by amniotic bands, which was proved pathologically as ABS.

LESSONS

The adhesion of the fetal hand and umbilical cord is an important ultrasonic sign suggesting ABS with poor prognosis in early pregnancy. We hope that this study can provide some guidance for the early diagnosis of ABS during 11 to 14 week's ultrasound examination.

Role of 2-Dimensional Ultrasound Imaging in Placental and Umbilical Cord Morphometry: Literature and Pictorial Review

Abnormalities of the placenta and umbilical cord have been associated with adverse pregnancy outcomes. Antenatal detection of placental and umbilical cord abnormalities using ultrasound (US) imaging is now gaining popularity with the advancements in obstetric US. This article reviews the use of 2-dimensional obstetric US as a tool to measure and assess placental and umbilical cord morphometry. It highlights the potential role of placental and umbilical cord morphometry as a valuable component of the screening tool for high risk pregnancies and identifies the need for further research to examine its feasibility.

Unexplained Case of Intrauterine Fetal Demise Resolved: Case Report and Literature Review

The association between umbilical cord ulceration and intestinal atresia has been previously established. Umbilical cord ulceration is a seemingly rare, potentially life threatening complication of intestinal atresia. The exact etiological mechanism is unknown and recent literature indicates more intensive prenatal monitoring may alter fetal outcome. In this paper we will review the previously reported cases of intestinal atresia complicated by umbilical cord ulceration and comment on the pathophysiological mechanism of umbilical cord ulceration, with emphasis on the unique location of the atresia at the gastroduodenal junction in our case.

Vaginal delivery in a pregnant woman with cord prolapse, velamentous cord insertion, and fetal vertex presentation: A case report

RATIONALE

We report a rare case of a pregnant woman with cord prolapse, velamentous cord insertion (VCI), and fetal vertex presentation who completed vaginal delivery.

PATIENT CONCERNS

Without having undergone regular antepartum examinations, a 31-year-old pregnant woman, gravida 6, para 4, abortion 1, presented at 37 weeks and 3 days of gestation. She had regular labor pain and bloody show.

DIAGNOSES

Cord prolapse during labor and VCI after delivery.

INTERVENTIONS

Per vaginal examination at 11:20 PM revealed a fully dilated cervix. Thirty minutes later, artificial rupture of the membrane was performed, and an overt prolapsed cord approximately 10-cm long was palpated in the vagina. Fetal heartbeat decelerated to 60 bpm. After fundal pushing for some minutes, a female baby weighing 2130 g was delivered at 11:54 PM with a pediatrician on standby. Apgar scores were 7 (0 minute), 9 (5 minutes), and 10 (10 minutes). The placenta weighed 870 g and was delivered 5 minutes later, and VCI was discovered.

OUTCOMES

Her postpartum course was uncomplicated and both the patient and infant were discharged 3 days later.

LESSONS

A pregnant woman with umbilical prolapse, VCI, and a fetal vertex presentation can successfully deliver a baby through the vagina. Factors contributing to the success of the reported vaginal delivery might have been a small fetus, multipara status, and immediate management.

True knot of umbilical cord: Case report and review of literat

True knot of umbilical cord (TKUC) is a rare abnormality. When it becomes tight, it may lead to the obstruction of the foetal circulation and intrauterine death (IUD). We present two cases of TKUC managed at The Aga Khan University Hospital with two extreme outcomes. A 22 years old primigravida was diagnosed with unexplained intrauterine foetal demise at 28th week gestation. She delivered vaginally after induction and tight TKUC was identified as a cause of IUD. The second patient delivered an alive healthy male baby vaginally who was found to have a lose TKUC.

[RISK FACTORS, COMPLICATIONS AND OUTCOMES OF PREGNANCIES WITH VELAMENTOUS CORD INSERTION]

INTRODUCTION

A velamentous cord insertion (VCI) describes a peripheral umbilical cord insertion to the placenta with blood vessels from the cord traversing fetal membranes before reaching the placental margin. These vessels remain unprotected and exposed to pressure and injury during pregnancy and labor.

OBJECTIVES

To determine the risk factors for VCI, and assess the risk for complications and adverse outcomes of pregnancies with VCI.

METHODS

A retrospective cohort study of women who gave birth at Soroka Medical Center between the years 1988 to 2011. We examined the risk factors, complications and adverse outcomes of pregnancies with VCI compared to those without VCI.

RESULTS

During the study period there were 246,488 births, of which 200 had VCI. Multifetal gestation (OR = 9.2), infertility treatments (OR = 4.3) and chronic hypertension (OR = 2.2 were found as independent risk factors for VCI. In addition, intrauterine growth retardation (OR = 4.3), polyhydramnion (OR = 2.3), fetal malformations (OR = 2.2), placental abruption (OR = 8.2), preterm birth (OR = 4.6), cesarean delivery (OR = 3.3) and low Apgar score (OR = 2.3) had significant correlation to VCI. Finally, the presence of VCI was found as an independent risk factor (OR = 4.07) for perinatal mortality.

CONCLUSION

Multifetal gestation and infertility treatments were the most important risk factors for VCI. These pregnancies had more complications and perinatal mortality. Given the results, we should consider close monitoring of pregnancies with the mentioned risk factors for the presence of VCI.

Vasa previa rupture in velamentous insertion of the umbilical cord: an analysis and report of a case

Ruptured vasa previa in tenn pregnancy is rare but usually catastrophic if emergency delivery is not achieved. The authors present a case of ruptured vasa previa in velamentous cord insertion placenta. The fetus survived after intensive treatment immediately after delivery by cesarean section, but, unfortunately, died after the family gave him up. Defects in the vessel wall architecture were'visualized and confirmed by histopathologic examination and might be responsible for the vessel rupture. Prenatal sonographic identification of cord insertion site into the placenta is encouraged as standard of practice to prevent this accident.

Umbilical cord and preeclampsia

INTRODUCTION

Preeclampsia is associated with abnormalities in the umbilical cord in several ways: morphological, biochemical and functional. Alteration in blood vessels of the placenta, decidua and circulatory system of the fetus might be related to factors that cause preeclampsia and may be associated with alterations of the umbilical cord.

OBJECTIVES

This study aimed to analyze the relationship between each type of umbilical cord abnormality and the different subtypes of hypertensive gestational disorders.

METHODS

We conducted a prospective study on consecutive autopsies and its placentas, looking for abnormalities in the umbilical cord's features and their clinical associations.

RESULTS

Umbilical cord abnormalities including length, diameter, insertion, entanglements, knots and coils were associated with maternal gestational hypertension.

CONCLUSION

In women with gestational hypertension, umbilical cord abnormalities are associated with fetal and neonatal consequences.

Severe antenatal strangulation and sudden fetal death occurs in term: case report

The authors report a case of a sudden antenatal death, by severe strangulation, unlikely related in a term pregnancy; multiple loops of nuchal umbilical cord (UC) (ten), rarely describe in literature, were observed around the fetal neck. The in utero fetal death (IFD) was suspected by the non-attendance of fetal movements and confirmed by US scan. The tight nuchal cord around the neck (tCAN) diagnostic was made during caesarean delivery, as it was not discovered in pregnancy US scan monitoring nor in the US scan made in emergency. The newborn examination shows severe fetal strangulation by the presence of many spires of a too long UC (1.50 m). Autopsy was not been accepted by the family. Through this reported case the authors wanted to show the difficulties of its diagnosis in less developed Sub-Saharan country were US scan practice is not usual.

A case of discordant monochorionic diamniotic twin with umbilical cord entanglement after spontaneous rupture of the dividing membrane

Spontaneous antepartum rupture of the dividing membrane in monochorionic diamniotic twins with discordancy is extremely rare. The rupture is difficult to diagnose prenatally and has a poor outcome. The authors report a case of cord entanglement after spontaneous rupture of the dividing membrane within discordant monochorionic diamniotic twins. The subject was a 30-year-old woman pregnant with discordant monochorionic diamniotic twin at 27+4 gestational weeks. The relatively thin dividing membrane was sound until it passed parallel to the two umbilical cords where it then became ill-defined. The patient was managed cautiously due to the possibility of spontaneous rupture of the dividing membrane and potential cord entanglement. Upon delivery at 29+3 weeks due to fetal compromise, the patient presented with a monochorionic diamniotic placenta, a remnant of the disrupted dividing membrane, and entangled umbilical cords. The authors report this subject with literature review.

Furcate Umbilical Cord Insertion: Disparate Outcomes of a Rare Obstetrical Finding. A Case Report

BACKGROUND

Furcate umbilical cord insertions are rare obstetrical findings. This variant is defined by an umbilical cord which branches prior to contacting the placental surface. The vessels are left vulnerable to injury as they often separate from the cord substance.

CASES

In case 1, a duplex placenta and bifurcate umbilical cord were diagnosed at routine anatomy ultrasound, and no significant fetal anomalies were associated with these findings. There was difficulty with placental extraction, leading to postpartum dilation and curettage. In case 2, the furcate umbilical cord was diagnosed on postpartum evaluation after emergent delivery. It was found in conjunction with VACTERL association of the fetus.

CONCLUSION

Abnormal placentation and umbilical cord insertion can be diagnosed prenatally. Earlier recognition will allow for earlier identification of possible associated fetal anomalies, delivery planning, and close observation for maternal and fetal complications.

Clinical associations to abnormal umbilical cord length in Latin American newborns

INTRODUCTION

Umbilical cord is vital to fetal development and its alterations are related to fetal and neonatal deaths and to late neurological complications. Abnormal cord length has been recognized as the most important cord feature leading to unfavorable outcomes. We aimed to examine the relationship between fetal abnormalities and the length of umbilical cord using the ECLAMC (Estudio Colaborativo Latinoamericano de Malformaciones Congénitas/Latin American Collaborative Study on Congenital Malformations) database.

METHODS

Using ECLAMC case-control registries, we conducted an observational study on the relationship between umbilical cord length and clinical variables such as chromosomal abnormalities and neonatal malformations.

RESULTS

Birth registries totaled 61820; of them 3411 had complete cord data. Abnormal length was found in 427, with 174 short (5.10%) cords and 253 long (7.41%) cords. No relation was found between abnormal cord length and gender, parity or parents' age. More abnormal length cords were found than reported in other series; unexpectedly, more long cords were observed in twin gestations. It was observed that among short cords (174), 105 were from newborns with some type of malformation and 69 with no malformation (OR = 2.92, CI (95%) 2.15-3.98, p = 0.0001); of the 253 long cords, 168 had malformation and only 85 did not (OR = 3.80, CI (95%) 2.91-4.96, p = 0.0001).

CONCLUSIONS

Abnormal cord length is associated with fetal malformation. Further studies are needed to determine the clinical applicability of using this parameter in counseling during prenatal visits.

UMBILICAL CORD PARAMETERS IN ILORIN: CORRELATES AND FOETAL OUTCOME

BACKGROUND

The anthropometric parameters of the umbilical cord have clinical significance. Current parameters of the cord, its correlates and related foetal outcome are lacking in our parturients.

OBJECTIVES

To describe the anthropometric parameters and abnormalities of the umbilical cord; and determine their maternal correlates and foetal outcome.

DESIGN

A cross sectional analytical study.

SETTING

The Obstetric and Gynaecology Department of the Universityof Ilorin Teaching Hospital, between September 2012 and June 2013.

SUBJECTS

Healthy pregnant women with singleton pregnancies.

RESULTS

Four hundred and twenty-eight (428) singleton deliveries were studied. The respective mean values of the cord length and width were 526.87 ± 115.5mm and 19.56 ± 11.12mm.Short cord (< 40cm) occurred in 7.2% while long cord (> 69cm) was found in 9.3% of the parturient. The incidences of single umbilical artery, cord round the body and knots were 7%, 8.4% and 14.5% respectively. Nuchal cord was the most common (91.4%). Only gestational age had significant statistical relationship with cord length abnormalities (P = 0.0093). The cord length was an important correlate of cord helices, knots and vessels (P < 0.05).Parity had correlations with the number of vessels (R = 0.099, P = 0.042). The cord coiling index was statistically related to the presence of congenital abnormalities (P = 0.011). Other perinatal events were not related to umbilical cord parameters. Perinatal asphyxia was the most common indication for NICU admission (3.5%) but there was no significant statistical difference between NICU admission and cord parameters.

CONCLUSION

The umbilical cord parameters in apparently healthy parturients in Ilorin were comparable with others elsewhere. The cord length and helix are important correlates of gestational age and congenital abnormalities. Parity may be related to abnormal umbilical vessels. Cord length, coils, coil index and umbilical vessels should be examined post-natally.

Recurrent umbilical cord accidents in a bottlenose dolphin Tursiops truncatus

Three successive umbilical cord accidents (UCAs) were diagnosed in the same female bottlenose dolphin Tursiops truncatus during consecutive gestations. In 2 of these, transabdominal ultrasonographic examination revealed coiling of the UC around the peduncle of the foetus. All 3 foetuses were male, died in utero during the last third of gestation and were spontaneously aborted. The 3 UCs were elongated, flattened and congested. For 3 subsequent pregnancies, a different sire was used for mating, handling protocols and treatments were adjusted, and 3 live female calves were successfully delivered. UC lengths were normal. UCAs are associated with excessively long UCs and are not uncommon in humans and horses but are unusual in other species. We believe this is the first detailed report of recurrent UCAs in a dolphin.

Umbilical cord coiling: clinical outcomes in an unselected population and systematic review

This study was conducted to determine the frequency of pre-defined clinical outcomes in relation to umbilical cord coiling indices >90th percentile and <10th percentile in an unselected population of >1,000 women with a singleton pregnancy resulting in livebirth delivering at or near term and to report these findings in the context of a systematic review. Placentas of consecutive deliveries from an unselected low-risk population with >15 cm attached umbilical cords were included in the study. Clinical outcomes included interventional delivery, birthweight <10th percentile, Apgar score <7 at 1 min, neonatal acidosis (pH<7.2) and admission to neonatal special care. Standard MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines were observed for the systematic review. Umbilical coiling index was determined for 1,082 placentas. Mean maternal age was 30.7 years (standard deviation [SD] =5.7) and 519 women (48 %) were primiparous. Mean cord length was 43 cm (SD=13) and mean cord coiling index 0.20 (SD=0.09). A total of 866 cords were normally coiled, and 108 cases were hypercoiled (>90th centile) and 108 cases were undercoiled (<10th percentile). There were no differences between cases of overcoiled, normally coiled or undercoiled cords for any clinical outcome studied. The systematic review yielded a small number of clinical studies which were too statistically and clinically heterogenous to permit meta-analysis. There is insufficient evidence either from this unselected cohort study or from a systematic review to support the previous suggestion that cord coiling index >90th centile or <10th centile is associated with adverse clinical outcome in an unselected population. Previous studies that draw a link between abnormal cord coiling and clinical outcome are generally too small and/or selective to allow meaningful conclusions or applicability to low-risk populations.

Prevalence, risk factors and outcomes of velamentous and marginal cord insertions: a population-based study of 634,741 pregnancies

Objectives

To determine the prevalence of, and risk factors for anomalous insertions of the umbilical cord, and the risk for adverse outcomes of these pregnancies.

Design

Population-based registry study.

Setting

Medical Birth Registry of Norway 1999–2009.

Population

All births (gestational age >16 weeks to <45 weeks) in Norway (623,478 singletons and 11,263 pairs of twins).

Methods

Descriptive statistics and odds ratios (ORs) for risk factors and adverse outcomes based on logistic regressions adjusted for confounders.

Main outcome measures

Velamentous or marginal cord insertion. Abruption of the placenta, placenta praevia, pre-eclampsia, preterm birth, operative delivery, low Apgar score, transferral to neonatal intensive care unit (NICU), malformations, birthweight, and perinatal death.

Results

The prevalence of abnormal cord insertion was 7.8% (1.5% velamentous, 6.3% marginal) in singleton pregnancies and 16.9% (6% velamentous, 10.9% marginal) in twins. The two conditions shared risk factors; twin gestation and pregnancies conceived with the aid of assisted reproductive technology were the most important, while bleeding in pregnancy, advanced maternal age, maternal chronic disease, female foetus and previous pregnancy with anomalous cord insertion were other risk factors. Velamentous and marginal insertion was associated with an increased risk of adverse outcomes such as placenta praevia (OR = 3.7, (95% CI = 3.1–4.6)), and placental abruption (OR = 2.6, (95% CI = 2.1–3.2)). The risk of pre-eclampsia, preterm birth and delivery by acute caesarean was doubled, as was the risk of low Apgar score, transferral to NICU, low birthweight and malformations. For velamentous insertion the risk of perinatal death at term was tripled, OR = 3.3 (95% CI = 2.5–4.3).

Conclusion

The prevalence of velamentous and marginal insertions of the umbilical cord was 7.8% in singletons and 16.9% in twin gestations, with marginal insertion being more common than velamentous. The conditions were associated with common risk factors and an increased risk of adverse perinatal outcomes; these risks were greater for velamentous than for marginal insertion.

[A pregnant woman with a blood vessel in the membrane]

In a 34-year-old woman with a dichorionic twin pregnancy, a velamentous insertion of the umbilical cord of the second twin was diagnosed with ultrasound. During caesarean section the second child was born within the membranes; the velamentous insertion was clearly visible.

First-trimester diagnosis of body stalk anomaly using 2- and 3-dimensional sonography

To determine the sonographic features of body stalk anomaly in the first trimester using 2-dimensional (2D) and 3-dimensional (3D) sonography, we conducted a retrospective analysis of all nuchal translucency sonographic examinations performed between January 1, 2006, and January 1, 2010, at our institution. From a total of 6952 nuchal translucency sonographic examinations, 4 cases of body stalk anomaly were identified. All cases were characterized by an absent umbilical cord and a large ventral wall defect with herniation of the abdominal contents into the extraembryonic coelom. Associated features included kyphoscoliosis, limb defects, and enlarged nuchal translucency measurements. Three-dimensional sonography was a useful adjunct to 2D techniques in determining the precise relationship of fetal structures to the amniotic cavity. Our case series emphasizes the importance of a thorough anatomic survey at the time of nuchal translucency screening and the value of 3D sonography in the delineation of first-trimester anomalies.

Cord occlusion followed by laser cord transection in monochorionic monoamniotic discordant twins

OBJECTIVE

To compare the outcomes of a consecutive case series of monochorionic (MC) monoamniotic (MA) discordant twins treated with umbilical cord occlusion and transection, with those of a cohort of MC diamniotic (DA) twins treated with conventional cord occlusion.

METHODS

This study included 17 MCMA twins (12 true MA and five iatrogenic) treated with cord occlusion and transection and a control group of 72 MCDA discordant twins treated during the same period with cord occlusion in a single center. Duration of surgery, rates of preterm delivery (PTD) or preterm premature rupture of membranes (PPROM) < 32 weeks and intrauterine fetal demise (IUFD), perinatal outcome and neonatal survival were prospectively recorded in both groups.

RESULTS

Median durations of surgery were 28.5 (range, 14.0-74.0) min and 24.0 (3.0-60.0) min in the cord transection and control groups, respectively (P = 0.24). There were no significant differences between cord transection and control groups in the rates of PPROM (35.3% vs. 20.8%, P = 0.22), PTD (41.2% vs. 28.2%, P = 0.29), IUFD (0% vs. 2.8%, P = 1.0) and neonatal survival (76.5% vs. 80.6%, P = 1.0). Gestational age at delivery (median 35.0 (24.5-39.0) vs. 37.1 (26.2-41.0) weeks, P = 0.21) and fetal birth weight (2215 (800-3200) g vs. 2605 (588-3830) g, P = 0.51) were similar between study groups.

CONCLUSION

Cord occlusion and transection in MCMA discordant twins resulted in similar perinatal outcomes to those of MCDA discordant twins treated with cord occlusion.

Supernumerary umbilical vein in a hydropic neonate with hypertrophic cardiomyopathy

The anomalies of the umbilical vessels are uncommon, with the exception of a single umbilical artery. We report a term female infant with fetal hydrops, hypertrophic cardiomyopathy, and a four-vessel umbilical cord consisting of two umbilical arteries and two umbilical veins. The presence of two veins in the umbilical cord has been attributed to persistence of both the normal left umbilical vein and the caudal part of the right umbilical vein. This fetal vascular pathology has been reported very rarely and may be associated with increased risk of congenital malformations and adverse perinatal outcome.

[Type of afterbirth and twin birth weight discordance]

Twin pregnancies are regarded as high risk pregnancies. It results from the possibility of occurrence of numerous complications both like the ones in singleton pregnancies and those characteristic for multiple pregnancy only. The complication occurring exclusively in multiple pregnancies is discordant intrauterine growth of the fetuses.

THE AIM

a response to the question if there a relationship between the type of afterbirth and twin birth weight discordance.

MATERIAL AND METHODS

Material of the research consisted of 186 afterbirths derived from successful twin pregnancies. In the study the following were taken into consideration: evaluation of placenta/placentas types (mono- or dichorionic), place of umbilical cords insertion, and differences concerning birth weight of newborns.

RESULTS

The birth weight discordance of less than 10% (l0) in the twins was noted in 52.7% of pregnancies (n=98), discordance of 10-20% (II degree) was observed in 30.1% (n=56), and over 20% (III degree) in 17.2% (n=32). The birth weight discordance of the third degree was observed significantly more often in dichorionic diamniotic pregnancies with fused placentas. The discordance of third degree (>20%) occurred in 38.2% of female-male pairs, in 35.7% of female-female ones and in 24.3% of male-male pairs. In case of coexistence of both normal umbilical cord insertions the birth weight discordance of third degree occurred in 17.8% of pregnancies, in case of co-occurrence of the abnormal insertion with the normal one--in 21.8% of cases, and in case of the two abnormal insertions--in 10.5%. No statistically significant differences were found.

CONCLUSIONS

There is a relationship between the type of afterbirth and birth weight in twins. The largest birth weight discordance between fetuses occurs in the following cases: in dichorionic pregnancies with fused placental discs, in case of co-existence of abnormal and normal umbilical cord insertions and in female-male pair of twins.

Prenatal sonographic diagnosis of short umbilical cord in a dichorionic twin with normal fetal anatomy

Short umbilical cords are associated with fetal anomalies, often including those with decreased or absent fetal movement, fetal akinesia/hypokinesia sequence, and restrictive dermopathies and aneuploidy. In normal fetuses, abnormally short umbilical cords have been associated with an increased risk of umbilical vessel hematomas, thrombosis, rupture, thrombocytopenia, cord compression, variable fetal heart rate decelerations, instrumental and operative deliveries, and fetal demise. We report a 24-year-old gravida 2, para 0 with a concordant dichorionic twin gestation, at 26 weeks' gestation, in whom sonography depicted fetuses with normal-appearing anatomy as well as short umbilical cord of the 1st twin. Increased fetal surveillance was conducted. Following delivery at 36 weeks' gestation, the presence of a short umbilical cord of the 1st twin measuring 19 cm was confirmed. Systematic review of the literature confirms that this is the first report of prenatal diagnosis of a short umbilical cord in an otherwise normal fetus.

[Velamentous insertion of the umbilical cord--diagnosis and management]

OBJECTIVE

To assess the feasibility of ultrasound to identify velamentous insertion of the umbilical cord in B-mode, combined with Color/Power Doppler and 3D Power Angio Doppler during routine obstetric ultrasound follow up.

DESIGN

This was a prospective cross-sectional ultrasound study in 145 second and third trimester high-risk singleton pregnancies. Color/Power Doppler ultrasound was done in all cases to identify the placental cord insertion site. Evaluation with three-dimensional (3D) ultrasound combined with Power Doppler (3D Power Angio Doppler) was also performed in all cases with suspected velamentous insertion.

RESULTS

The insertion placental site of the umbilical cord was identified in 143/145 (98.6%) cases by conventional gray-scale ultrasound, combined with Color/Power Doppler. Visualization was not accomplished in 2 third trimester cases (beyond 30 w.g.) with a posterior placenta, intrauterine growth restriction (IUGR) and tendency of oligohydramnios. Velamentous insertion of the umbilical cord was suspected prenatally in 9 cases, including 2 cases with vasa previa. Three-dimensional ultrasound was of little clinical value and compared poorly with conventional gray-scale and Color Doppler imaging.

CONCLUSIONS

Velamentous insertion of the umbilical cord can be reliably detected prenatally by gray-scale and Color/Power Doppler ultrasound. Three-dimensional imaging has limited clinical value in the evaluation of the placental cord insertion site. Its systematic assessment during routine obstetric ultrasound follow up has the potential of identifying most pregnancies with velamentous insertion and, therefore, those at risk for some important obstetric complications, including vasa previa.

Cord entanglement in monoamniotic twins: 2D and 3D colour Doppler studies

Cord entanglement affects the majority of monoamniotic (MA) twins, accounting for the high proportion of intrauterine deaths of MA twins, and it is often present from early gestation. 3D ultrasound can be used to acquire volume data comprising information on umbilical colour Doppler flow, providing a very graphic depiction of cord entanglement. We have used 2D, "conventional" and a novel 3D display of colour Doppler ultrasound showing cord entanglement.