Persistent omphalomesenteric duct in an infant with trisomy 21.

We present the case of a term newborn with trisomy 21 who presented to the paediatric emergency department with periumbilical flare and green-brown discharge from a clamped umbilical cord, initially suspected to be omphalitis. However, it was noticed later, that when the infant strained or cried, a thick, bubbling and offensive green-brown discharge came out of the clamped umbilical cord with umbilical flatus. An ultrasound abdomen and umbilical cord confirmed the presence of a persistent omphalomesenteric duct (POMD). He was then transferred to the paediatric surgical unit. There, he underwent a laparotomy and surgical resection of the POMD and was discharged home 2 days later.

Development of Artificial Intelligence Image Classification Models for Determination of Umbilical Cord Vascular Anomalies.

OBJECTIVE: The goal of this work was to develop robust techniques for the processing and identification of SUA using artificial intelligence (AI) image classification models. METHODS: Ultrasound images obtained retrospectively were analyzed for blinding, text removal, AI training, and image prediction. After developing and testing text removal methods, a small n-size study (40 images) using fastai/PyTorch to classify umbilical cord images. This data set was expanded to 286 lateral-CFI images that were used to compare: different neural network performance, diagnostic value, and model predictions. RESULTS: AI-Optical Character Recognition method was superior in its ability to remove text from images. The small n-size mixed single umbilical artery determination data set was tested with a pretrained ResNet34 neural network and obtained and error rate average of 0.083 (n = 3). The expanded data set was then tested with several AI models. The majority of the tested networks were able to obtain an average error rate of <0.15 with minimal modifications. The ResNet34-default performed the best with: an image-classification error rate of 0.0175, sensitivity of 1.00, specificity of 0.97, and ability to correctly infer classification. CONCLUSION: This work provides a robust framework for ultrasound image AI classifications. AI could successfully classify umbilical cord types of ultrasound image study with excellent diagnostic value. Together this study provides a reproducible framework to develop AI-specific ultrasound classification of umbilical cord or other diagnoses to be used in conjunction with physicians for optimal patient care.

Color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst before 11 weeks of gestation: Diagnostic value.

OBJECTIVE: We describe transvaginal color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst (UCC) before 11 weeks of gestation. METHODS: In this cohort study, 135 transvaginal dating scans were performed at 7 to 10 + 6 weeks of gestation, and 17 UCCs were identified (12.6%). UCC was evaluated using color Doppler, HDlive, and HDlive Silhouette. The clinical characteristics, pregnancy courses, and outcomes were also investigated. RESULTS: UCC location was on the fetal side in six cases, at the free loop in 10 cases, and on the placental side in one case. There were seven single and 10 multiple cysts. Cyst diameters ranged from 3.3 to 11.3 mm (mean, 5.6; standard deviation, ±2.1). Blood flow inside the cyst was noted in three cases (17.6%). HDlive clearly showed the spatial relationships among UCC, the umbilical cord, midgut herniation, yolk sac, and embryo. Location of UCC could be clearly identified with HDlive. HDlive Silhouette showed central cysts inside UCCs in seven cases (41.2%). HDlive Silhouette also clearly demonstrated the sac of midgut herniation in the umbilical cord in 12 cases (70.6%). All UCCs resolved before 15 weeks (mean, 11.1 weeks; standard deviation, ±1.5). All fetuses with UCCs showed good neonatal outcomes. CONCLUSION: The incidence of UCC was high compared with that in previous reports. Color Doppler, HDlive, and HDlive Silhouette may provide information on the nature and origin of UCCs before 11 weeks of gestation. UCC before 11 weeks of gestation may be a common, transient, and benign finding.

Umbilical cord cysts: Classification, diagnosis, prognosis, and pregnancy recommendations.

Umbilical cord cysts (UCCs)-cysts located in the umbilical cord that are derived from an abnormal embryonic development process-are typically an incidental discovery during prenatal ultrasound. It can be described as either a pseudocyst or a true UCC, which results from focal edema or degeneration of Wharton jelly or the remnants of embryonic development, respectively. Due to the relative rarity of the UCC, the clinical guidance of UCCs is not yet available. Herein, the aim of this paper is to discuss the classification, diagnosis, prognosis, and clinical management of UCCs through a literature review, in order to improve the understanding of UCCs among clinical obstetricians and pediatricians.

Impact of Universal Vasa Previa Screening With Color Doppler During the OB Ultrasound Anatomy Scan.

OBJECTIVES: Our institution introduced universal vasa previa (VP) screening utilizing transabdominal ultrasound with color Doppler for all pregnancies at the second trimester anatomy scan. Our study sought to describe the clinical impact of this intervention. METHODS: Radiology records from the 12 months pre- and post-intervention were queried for "vasa previa." Records included for analysis were those with a first-time diagnosis or discussion of VP at the anatomy scan. Cases were categorized by outcome: (Group 1) True VP, with subgroups A, unresolved by time of delivery and B, resolved by delivery; (Group 2) False positives; (Group 3) Possible VP without definitive diagnosis; and (Group 4) VP ruled out, for example, "no features of VP." Group size was expressed as a percentage of total anatomy scans during pre- or post-intervention periods respectively. Absolute and relative percent change were calculated for each group. RESULTS: In the pre-intervention period, 1 case (0.36% of total scans) was categorized in Group 1A, 1 case (0.36%) in Group 3, and 7 cases (2.53%) in Group 4. In the post-intervention period, 2 cases (0.30%) were in Group 1A, 4 cases (0.61%) in Group 1B, 2 cases (0.30%) in Group 2, 1 case (0.15%) in Group 3, and 7 cases (1.06%) in Group 4. There was a +153% relative change in true positives, from 0.36 to 0.91%. CONCLUSIONS: Universal color Doppler screening may have increased detection (sensitivity) while simultaneously increasing false positives (decreased specificity). While decreasing sensitivity is not ideal, this is acceptable given the potential catastrophic outcome of a missed VP.

Intrauterine death in vasa previa without hemorrhage: case reports.

Antepartum and intrapartum hemorrhage from vasa previa (VP) is one of the main causes of intrauterine fetal death (IUFD). Here, we present two cases with type I VP in which velamentous cord insertion below the fetal head and overlying the cervix were reported by prenatal ultrasound scanning, and IUFD occoured after 35 weeks with no signs of prenatal bleeding but with engaged fetal head at presentation. We hypothesized that the IUFD may attributed to the compression of the unprotected umbilical vessels by the engaged fetal head. Thus we suggest that VP with a velamentous cord insertion should be considered for earlier termination of the pregnancy to avoid the risk of non-hemorrhagic adverse fetal outcomes.

The impact of placental anastomoses and umbilical cord insertions' sites on monochorionic twin pregnancy outcomes: Evidence from color-dye injection studies.

INTRODUCTION: Our knowledge of monochorionic pregnancies' complications is largely based on the extensive ongoing research on monochorionic placental structure. Previous studies on the concordance of umbilical cord insertions are limited. This study aimed to evaluate placental anastomoses and cord insertions as independent risk factors for neonatal adverse outcomes. METHODS: This was a prospective study conducted at Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy from April 2021 to December 2022. Seventy-six women with a monochorionic pregnancy were enrolled at their first-trimester scan. After delivery, all placentas that were confirmed to be monochorionic were analyzed according to standard protocols, including those of complicated monochorionic twin pregnancies. The primary outcomes were a Composite Monochorionic Pregnancy Outcome (CMPO) and a Composite Neonatal Adverse Outcome (CNAO). The secondary outcome was the birth weight discordance between the neonates. RESULTS: The CMPO occurred in 15.8 % pregnancies, and the CNAO occurred in 67.1 % pregnancies. The analysis confirmed a significant association between velamentous cord insertions and neonatal adverse events (p = 0.003). Also, a significant positive association (p = 0.0326) between twin birth weight discordance and discordance in twins umbilical cord insertions' sites was found. No significant association between the number and type of the anastomoses and both the CMPO or CNAO was detected. DISCUSSION: Our data suggest that the routine sonographic assessment of umbilical cords' insertion sites during the first trimester could be helpful in predicting fetal and neonatal adverse events. We believe that this sonographic assessment should start to be implemented in our routine care of monochorionic pregnancies.

Analysis of factors associated with the umbilical cord pitch value by ultrasound measurement in late pregnancy.

BACKGROUND: This study aimed to investigate the factors associated with the antenatal umbilical cord pitch value by ultrasound measurement in late pregnancy. We investigated the factors associated with the umbilical cord pitch value under prenatal ultrasound measurement. METHODS: This study included 528 pregnant women who underwent routine antenatal ultrasound examinations in Ningbo Women and Children's Hospital from December 2020 to August 2021. Their umbilical cord pitch values and diameter, Wharton's jelly thickness, amniotic fluid indexes, umbilical artery blood flow parameters, and other relevant data, such as ages and gestational ages, were measured. Information about delivery methods, placenta, umbilical cord, and neonatal weight were recorded during follow-up. Statistical analysis was performed on the above data, and the factors associated with the pitch values were analyzed by linear regression. RESULTS: This study revealed that cord torsion (p < 0.001, 95% confidence interval [CI]=-34.81 to -19.01), cord entanglement (p < 0.001, 95% CI = 10.71 to 20.11), thickening of Wharton's jelly (p = 0.001, 95% CI = 5.39 to 20.24), and cord edema (p = 0.015, 95%CI = 2.09 to 19.44), gestational age (p = 0.024, 95%CI = 0.14 to 1.89), age of pregnant woman (p = 0.009, 95%CI= -1.15 to -0.16), and neonatal weight (p = 0.011, 95%CI = 0.002 to 0.012) were significantly correlated with the pitch values. CONCLUSION: The umbilical cord pitch value significantly correlated with cord entanglement, cord torsion, cord edema, Wharton's jelly thickening, gestational age, age of the pregnant woman, and neonatal weight. Notably, the pitch value by prenatal ultrasound measurement is predictive of cord morphological abnormalities such as cord entanglement, cord torsion, cord edema, and Wharton's jelly thickening.

Prediction of postnatal abnormal umbilical cord coiling by antenatal evaluation in pregnant women: Diagnostic accuracy study; a systematic review.

STUDY OBJECTIVE: Umbilical cord abnormalities increase neonatal morbidity and mortality. Considering uncertainties about the best time of an antenatal ultrasonography scan to evaluate the umbilical coiling index (UCI), this systematic review was designed to assess the diagnostic accuracy value of antenatal ultrasound assessments to predict abnormal postpartum UCI. METHODS: All observational, cross-sectional, case-control, cohort, and diagnostic accuracy studies up to March 26, 2022, were searched and assessed according to PRISMA guidelines in Ovid, Cochrane, Scopus, PubMed, Web of Science, Embase, Proquest, Science Direct, and Clinical Key databases, and Google Scholar search engine. RESULTS: The total number of 63 190 documents were retrieved from databases. The duplicates (19 272) were removed, 43 918 articles were screened for relevance, and 56 papers were selected for full-text evaluation, resulting in 14 qualified pieces subjected to the quality CASP tools for each type of study. Finally, six articles were evaluated, extracted, and confirmed. Overall, we had 16 evaluations (11 normal pregnancies, 4 gestational diabetes mellitus, and 1 group at risk for small gestational age), from which 9 and 7 were respectively performed in the second and third trimesters. Most of the evaluations considered both hypocoiling and hypercoiling. The sensitivity, specificity, and area under curves (AUCs) change range between the evaluations were 0.09-0.97, 0.59-0.96, and 0.262-0.84, respectively. CONCLUSION: Observing any coiling abnormalities in every trimester, both the second and third, is highly sensitive to predicting abnormal postnatal UCI (pUCI). Conclusively, any detected antenatal abnormality is worth attention. Both trimesters' evaluations are essential, and no superiority is seen for any of them. The systematic review revealed statistical and clinical heterogeneity; a meta-analysis was impossible.

Intertwin Membrane Perforation and Umbilical Cord Entanglement after Laser Surgery for Twin-Twin Transfusion Syndrome: Prevalence, Risk Factors, and Outcome.

INTRODUCTION: Perforation of the intertwin membrane can occur as a complication of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). Data on the occurrence and the risk of subsequent cord entanglement are limited. The objective of this study was to assess the prevalence, risk factors and outcome of intertwin membrane perforation, and cord entanglement after laser surgery for TTTS. METHODS: In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes. RESULTS: Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement. CONCLUSION: Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.

Pulse wave Doppler ultrasound of umbilical cord in experimentally induced pregnancy toxemia in sheep.

Contrary to its widespread use in human cases, the use of Doppler ultrasonography is only recently becoming prevalent in farm animals. This study aimed to determine the effects of maternal metabolic and clinical changes on fetal hemodynamics during pregnancy toxemia with the doppler examination of umbilical cord. In the study twenty ewes with a single healthy fetus were included in the study. At the end of the 120th day of pregnancy, 20 single-bearing pregnant ewes were randomly categorized into two groups. Ewes in the control group were fed to meet all nutritional requirements. On the other contrary, the experimental ewes were fed to meet equivalent to 50 % of the daily needs and then fasted for 96 h. Doppler ultrasonographic examinations of umbilical cord were performed once every two days and once a day during fasting. Beta hydroxybutyric acid (BHBA) concentration was measured by taking blood from sheep on examination days. Pulse systolic velocity (PSV), end diastolic velocity (EDV), PSV/EDV, pulsatility index (PI), resistance index (RI), and fetal heart rate (FHR) as well as BHBA values and how those parameters has changed over time (time by treatment effect) due to energy deprivation during pregnancy were evaluated using repeated measure analysis of variance. No clinical signs were observed in both toxemia and control groups during restricted feeding. BHBA concentration increased and there was a significant time, time by treatment and main effect of treatment effect between groups. No significant main effect of treatment and time by treatment interaction was observed in the changes of PI, RI, FHR, and systolic/diastolic velocity values over time in both groups. FHR was reduced over time, and there was a significant time effect in FHR in both groups. Although doppler indices didn't increase, both PSV and EDV values increased significantly in the pregnancy toxemia group compared with the controls (Time P = 0.03, time by treatment interaction P < 0.05) and the main effect of treatment P < 0.05). The marked increase in blood velocities (PSV and EDV) in the umbilical cord is probably due to the compensatory functioning for excessive energy deprivation of the fetus. Therefore, PSV and EDV might be a valuable indicator for evaluating the fetus's health status during the management of the PT.