Comprehensive imaging review of abnormalities of the umbilical cord.

A complete fetal ultrasonographic (US) study includes assessment of the umbilical cord for possible abnormalities. Knowledge of the normal appearance of the umbilical cord is necessary for the radiologist to correctly diagnose pathologic conditions. Umbilical cord abnormalities can be related to cord coiling, length, and thickness; the placental insertion site; in utero distortion; vascular abnormalities; and primary tumors or masses. These conditions may be associated with other fetal anomalies and aneuploidies, and their discovery should prompt a thorough fetal US examination. Further workup and planning for a safe fetal delivery may include fetal echocardiography and karyotype analysis. Doppler US is a critical tool for assessment and diagnosis of vascular cord abnormalities. US also can be used for follow-up serial imaging evaluation of conditions that could result in fetal demise. Recent studies suggest that three- or four-dimensional Doppler US of the fetal umbilical cord and abdominal vasculature allows more accurate diagnosis of vascular abnormalities. Doppler US also is invaluable in assessment of fetal growth restriction since hemodynamic changes in the placenta or fetus would appear as a spectral pattern of increased resistance to forward flow in the fetal umbilical artery. Early detection of umbilical cord abnormalities and close follow-up can reduce the risk of morbidity and mortality and assist in decision making.

Cord entanglement and perinatal outcome in monoamniotic twin pregnancies.

OBJECTIVES: To assess the prevalence of cord entanglement and perinatal outcome in a large series of monoamniotic twin pregnancies and to review the recent literature on similar published large series. METHODS: Prospective observational study of all prenatally detected cases of monoamniotic twin pregnancies during an 8-year period in a tertiary fetal medicine unit. A Medline database review for publications since 2000 containing five or more cases of monoamniotic pregnancies that showed data on cord entanglement and perinatal outcome was also undertaken. RESULTS: A total of 32 monoamniotic pregnancies were diagnosed during the study period, including three conjoined twins, seven pregnancies with twin reversed arterial perfusion (TRAP) syndrome, three surgical pregnancy interruptions for discordant fetal abnormality and one miscarriage before 16 weeks' gestation. The remaining 18 monoamniotic pregnancies were included in the study analysis. All monoamniotic pregnancies were complicated with antenatal cord entanglement diagnosed by B-mode and color Doppler ultrasound. There were 34 live births and a double intrauterine death diagnosed at 19 + 2 weeks' gestation. There were two late neonatal deaths, one from congenital complete heart block and the other after surgery for transposition of the great arteries. The overall perinatal loss rate was 11.1% after 16 weeks and 5.9% after 20 weeks' gestation. The cumulative rates of cord entanglement and perinatal mortality in the reviewed literature were 74% and 21%, respectively. CONCLUSIONS: Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and color Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, TRAP, discordant anomaly and spontaneous miscarriage before 20 weeks' gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.