Knots of the umbilical cord: Incidence, diagnosis, and management.

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.

Placenta Previa Percreta: A Case Report of Successful Management via Conservative Surgery.

Placenta percreta is one of the most serious complications of placenta previa and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. We present a case of placenta previa percreta diagnosed by ultrasound and magnetic resonance imaging techniques, in which we accomplished conservative management of postpartum hemorrhage. The management we propose includes the following steps: preventive catheterization of the descending aorta via transhumeral access; Stark cesarean delivery; uterotonics drugs; Affronti endouterine square hemostatic sutures; intrauterine application of Bakri balloon and partial filling with 100 mL of normal saline; B Lynch suture, hysterorrhaphy, and filling a Bakri balloon with up to 500 mL of normal saline; reversible radiological embolization; and/or surgical ligation of the uterine arteries. The bleeding stopped following placement of Affronti sutures combined with external (B-Lynch suture) and internal (Bakri balloon) uterine compression. Our experience indicates that this conservative method can be considered an option in the management of selected cases of pregnancy at high risk for intrapartum hemorrhage.

Cerebral blood flow autoregulation and congenital heart disease: possible causes of abnormal prenatal neurologic development.

OBJECTIVE: To determine whether the major congenital heart diseases (CHDs) can modify the cerebrovascular flow dynamics and the biometrical parameters in fetuses at third trimester of pregnancy. METHODS: We studied 60 fetuses with CHD. Data included prenatal versus postnatal cardiac diagnosis, cerebral and umbilical artery doppler, fetal biometrical parameters, fetal weight, and gestational age. The pulsatility index (PI) was used to determine blood flow velocities in the umbilical artery (UA) and middle cerebral artery (MCA), while the cerebro/placental ratio (CPR) was assessed as a measure of cerebral autoregulation. Fetuses with CHD were compared to normal controls and then analyzed after being divided into groups based on specific defects. RESULTS: Compared with control fetuses, those with CHD showed a decrease of resistance blood flow in the middle cerebral artery (1.76 vs 1.92 PI) especially considering the CPR (1.66 vs 2.03 PI) (p < 0.01). Furthermore, fetuses with CHD also had smaller head circumferences (30.6 cm vs 31.5 cm p < 0.01) and head/abdominal (HC/AC) ratio (1 vs 1.05 p < 0.01). When stratified for single cardiac diseases, fetuses with hypoplasic left heart syndrome showed a lower CPR and HC/AC ratio. CONCLUSIONS: Cerebrovascular resistance is significantly lower in fetuses with CHD, especially in cases of left side obstruction. The cerebro/placental hemodynamic changes are similar to that described in fetuses with placental insufficiency and may contribute to their abnormal neurologic development.

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta.

OBJECTIVE: To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta. METHODS: A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful. RESULTS: Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries. CONCLUSION: Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.

Ultrasonographic weight estimation in large for gestational age fetuses: a comparison of 17 sonographic formulas and four models algorithms.

OBJECTIVE: To evaluate the accuracy of different formulas and role of fetal parameters (cephalic, abdominal, femur) used for estimation fetal weight (EFW) in large for gestational age (LGA) fetus in diabetic and non-diabetic mothers. METHODS: Seventeen formulas were assessed individually and clustered in four algorithms (X, Y, Z, W) on the basis of fetal biometric parameters using the mean absolute % error, standard deviation (SD), prediction within +/-5%, +/-10%, +/-15% of error and introducing new variable hypotenuse test (HPT) that can sum up precision and accuracy of formulas employed. For predicting fetal macrosomia (BW > or = 4200 g) a receiver-operating characteristic curve was constructed. RESULTS: Warsof2 formula showed the lowest mean % error, SD and HPT (p < 0.01) with overall prediction +/-5, +/-10%, +/-15% of birth weight in 68, 94 and 98%. The formulas that were only based on abdominal measurement (Warsof2, Hadlock1, Campbell) showed the best ability to identify fetal macrosomia. The X algorithm confirming primary role of abdominal circumference for EFW in diabetic mothers. CONCLUSIONS: Accuracy of EFW in LGA fetuses is attributable to the biometric parameters used. Our findings show that the best formulas for EFW are those which only consider the abdominal measurements, especially in diabetic mothers. The new variable that we propose (HPT) confirms this result.