Marginal cord insertion in the first trimester is associated with furcate cord insertion.

OBJECTIVES: To evaluate the potential connections between marginal cord insertion during the first trimester and furcate cord insertion later in pregnancy. METHODS: This is a prospective study of screening data on the cord insertion site in 3178 singleton pregnancies. The cord insertion site was examined in two stages. The first stage was screening for the cord insertion site between 10-13 weeks of gestation, the purpose is to determine the category of umbilical cord insertion. The second stage, performed at 22-28 weeks of gestation, was to follow up on the relationship between the cord insertion site and the placenta and to identify any changes in the category of umbilical cord insertion. This was performed to diagnose or exclude furcate cord insertion by identifying whether the umbilical cord trunk separated or branched before it reached the placenta. Factors influencing progression to furcate cord insertion and perinatal complications were assessed. RESULTS: Fourteen cases (0.44%) with progression to furcate cord insertion, all of which showed marginal cord insertion on ultrasound in the first trimester (p < 0.001). without progression to furcate cord insertion, there were no changes in the category of umbilical cord insertion in 3050 cases (96.40%) compared to the early pregnancy. 114 cases (3.60%) with changes in the category of umbilical cord insertion that was not consistent with furcate cord insertion. A total of 14 cases progressed to furcate cord insertion, all showed the cord insertion site were in close proximity, and 11 (78.57%) cases showed a low insertion site (p < 0.001). Regarding the choice of mode of delivery, elective caesarean delivery was done in 8/14 (57.14%). The incidences of spontaneous vaginal delivery were 5/14 (35.71%) (p < 0.001). One (7.14%) case of progression to furcate cord insertion due to haematoma at the root of the umbilical cord ended with an emergency caesarean section. In terms of perinatal complications, marginal cord insertion that progressed to furcate cord insertion had higher incidences of SGA infants, abnormal placental morphology, retention of the placenta, and cord-related adverse pregnancy outcomes than not progressed to furcate cord insertion (p < 0.05). CONCLUSIONS: Marginal cord insertion in the first trimester has the potential to progress to furcate cord insertion. We suggest that ultrasound-diagnosed marginal cord insertion in the first trimester should be watched carefully in the second trimester, which is clinically useful to accurately determine the category of cord insertion and to improve the rate of prenatal diagnosis of furcate cord insertion.

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.

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.

Clinical Outcome of Monochorionic Diamniotic Twins with Intrauterine Growth Restriction.

OBJECTIVE: This study investigated the clinical outcome of monochorionic diamniotic (MCDA) twins with selective intrauterine growth restriction (sIUGR). STUDY DESIGN: International Peace Maternal and Child Health Hospital of Shanghai ultrasound database was investigated to identify all MCDA delivered from January 2013 to December 2017. After identifying 43 pairs of MCDA twins with sIUGR and 282 pairs of normal MCDA twins, we compared clinical outcomes between the two groups. RESULTS: Compared with normal twins, sIUGR fetuses had significantly shorter gestational age at delivery, smaller average birth weight of both twins, more significant intertwin difference in birth weight, lower Apgar scores, and higher intrauterine fetal demise (IUFD) rate, and smaller placental weight. The rate of abnormal umbilical cord insertions and abnormal blood flow in the ductus venosus (DV) and middle cerebral artery (MCA) is significantly higher in the sIUGR group. In addition, the subtype analysis of sIUGR groups indicated the poorest outcomes in type II with no significant difference between type I and III. CONCLUSION: MCDA twins with sIUGR generally exhibited limited clinical outcomes than normal MCDA twins. These limitations are mainly associated with abnormal umbilical cord insertions and blood flow in the DV and MCA. Clinical outcomes differed among the three types of sIUGR, with type II having the worst prognosis and the highest IUFD rate. KEY POINTS: · sIUGR generally exhibited limited clinical outcomes than normal MCDA twins.. · These limitations are mainly associated with blood flow of the DV and MCA.. · sIUGR with type II has the worst prognosis and the highest IUFD rate..

Hemodynamic Changes with Umbilical Cord Milking in Nonvigorous Newborns: A Randomized Cluster Cross-over Trial.

OBJECTIVE: To assess the hemodynamic safety and efficacy of umbilical cord milking (UCM) compared with early cord clamping (ECC) in nonvigorous newborn infants enrolled in a large multicenter randomized cluster-crossover trial. STUDY DESIGN: Two hundred twenty-seven nonvigorous term or near-term infants who were enrolled in the parent UCM vs ECC trial consented for this substudy. An echocardiogram was performed at 12 ± 6 hours of age by ultrasound technicians blinded to randomization. The primary outcome was left ventricular output (LVO). Prespecified secondary outcomes included measured superior vena cava (SVC) flow, right ventricular output (RVO), peak systolic strain, and peak systolic velocity by tissue Doppler examination of the RV lateral wall and the interventricular septum. RESULTS: Nonvigorous infants receiving UCM had increased hemodynamic echocardiographic parameters as measured by higher LVO (225 ± 64 vs 187 ± 52 mL/kg/min; P < .001), RVO (284 ± 88 vs 222 ± 96 mL/kg/min; P < .001), and SVC flow (100 ± 36 vs 86 ± 40 mL/kg/min; P < .001) compared with the ECC group. Peak systolic strain was lower (-17 ± 3 vs -22 ± 3%; P < .001), but there was no difference in peak tissue Doppler flow (0.06 m/s [IQR, 0.05-0.07 m/s] vs 0.06 m/s [IQR, 0.05-0.08 m/s]). CONCLUSIONS: UCM increased cardiac output (as measured by LVO) compared with ECC in nonvigorous newborns. Overall increases in measures of cerebral and pulmonary blood flow (as measured by SVC and RVO flow, respectively) may explain improved outcomes associated with UCM (less cardiorespiratory support at birth and fewer cases of moderate-to-severe hypoxic ischemic encephalopathy) among nonvigorous newborn infants.

Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology.

OBJECTIVE: To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS: Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS: A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS: This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

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.

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.

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.

Biplane mode for more precise intrauterine procedures.

The evolution of ultrasound and the introduction of 3- and 4-dimensional ultrasound techniques led to a shift in the perception and usage of ultrasound in fetal medicine. The biplane mode might help in multiple fetal procedures, including but not limited to basic intrauterine thoracocentesis, thoracoamniotic shunting, amnioreduction, amnioinfusion, cordocentesis, intraumbilical infusion, and umbilical cord coagulation, with a possible reduction in the complication rate. Despite its theoretical usefulness, more studies are required to assess the clinical importance of this technique.

Sonographic evaluation of umbilical cord thickness in monochorionic diamniotic twin pregnancies.

OBJECTIVE: To develop a nomogram of the thickness of the umbilical cord (UC) and its components in monochorionic diamniotic (MCDA) twin pregnancies. METHODS: This prospective longitudinal study involved 47 MCDA twin pregnancies (94 fetuses) between 18 and 33 weeks of gestation. Ultrasound assessments of UC cross-sections and measurements of the umbilical cord area (UCA), the umbilical vein area (UVA), the umbilical artery area (UAA), and the Wharton jelly area (WJA) were made. The UC measurements were correlated with gestational ages. Reference values for the gestational ages of MCDA pregnancies were determined and compared with those of dichorionic twins and singletons. The cases which developed selective intrauterine growth restriction were contrasted with normal cases. RESULTS: A positive correlation was found between all UC components and gestational age and fetal weight. The UCA of MCDA fetuses was significantly larger than that of DC fetuses (p < 0.001) at the expense of a larger WJA (p < 0.001) and similar to that of singleton pregnancies. The MCDA fetuses with an estimated fetal weight below the 10th percentile had a smaller UCA than fetuses with a normal estimated weight (p < 0.001). CONCLUSION: The MCDA twins exhibited a thicker UC than that of dichorionic twins.

Antenatal Detection of True Knot in the Umbilical Cord - How Accurate Can We Be?

BACKGROUND: Umbilical cord knot (UCK) is associated with increased risk of fetal death, but is usually diagnosed only after delivery. Our objective was to examine the accuracy of prenatal ultrasound in the diagnosis of UCK and the outcomes of these pregnancies. METHODS: A prospective study was performed on 56 patients in which UCK was suspected during a routine level-II anatomical scan (study group). Data included demographics, pregnancy outcome, and short-term neonatal follow-up. The control group included pregnant women with normal pregnancy without UCK in a 4:1 ratio matched for gestational age at delivery. RESULTS: True knot was observed postnatally in 54 out of 56 fetuses (detection rate of 96.4 %). Gestational age at diagnosis of UCK was 22.1 ±â€Š3.1 weeks. The female to male ratio was 1:1 in both groups. Maternal age and parity were significantly higher in pregnancies with UCK compared to controls. The mean gestational age at delivery was 37.1 weeks of gestation in the UCK group. There was no difference in the birthweight percentile. 47 patients (87 %) underwent induction of labor. There were no differences in the rate of cesarean section or Apgar scores. No neonate with UCK needed ventilation. None suffered from seizures and none needed brain imaging. There were no cases of fetal or neonatal death in the pregnancies with UCK. CONCLUSION: There is a high detection rate of UCK during targeted scan of the umbilical cord performed during the level-II anatomical scan. Careful pregnancy follow-up and early term delivery may result in excellent obstetrical outcomes.

Intertwin membrane cord insertion in dichorionic twin pregnancy: The description and comparison with other umbilical cord insertion types.

PURPOSE: Multiple pregnancy is associated with high perinatal mortality and morbidity. Abnormal cord insertions more common in twin pregnancies compared to singleton pregnancies and velamentous cord insertion is related with poor pregnancy outcomes. There is no definition of velamentous cord insertion into the intertwine membrane between two fetuses in the literature. METHODS: In our single-center cross-sectional study, monochorionic-diamniotic and dichorionic-diamniotic twins who were admitted to our clinic between 18 + 0 and 23 + 6 weeks of pregnancy were enrolled in this study. We evaluated fetal, placental, and umbilical cord abnormalities in addition to fetal growth restrictions and weight discordance by ultrasonography. RESULTS: Although abnormal cord insertion frequency was significantly higher in monochorionic twins (p = 0.003), intertwin membrane cord insertion could only occur in dichorionic twins. In cases with cord insertion anomaly; FGR and weight discordance was observed more frequently (p < 0.001 and p = 0.003, respectively). Weight discordance, the presence of abnormal cord insertion and abnormal UAD were found as statistically significant predictors of FGR (p < 0.001, p = 0.021, and p < 0.001, respectively). CONCLUSION: Intertwin membrane insertion is a novel umbilical cord insertion abnormality. The presence of abnormal umbilical cord insertion is a risk factor for poor pregnancy outcomes in twin pregnancies.

Umbilical cord diameter in the prediction of foetal growth restriction: a cross sectional study.

This was a cross sectional study with a prospective design conducted from October 2018 to October 2019. We recruited patients at risk for FGR and normal pregnant women. Each patient had ultrasound examination for the umbilical cord diameter in the 28th, 32nd, 36th, and the 40th week, Foetal growth restriction developed in 10/76 (13.2%) patients in the at risk group. The umbilical cord diameter was significantly lower in the at risk group (1.8 ± 0.2 versus 2.0 ± 0.2 in the control group with a p value of <.001). The umbilical cord diameter was highly predictive for the occurrence of FGR at each antenatal care visit as well as at delivery. We concluded that the umbilical cord diameter was a significant predictor of foetal growth restriction when applied through the antenatal care visits. It is a simple and easy method causing no distress for the patients.IMPACT STATEMENTWhat is already known on this subject? Conflicting results exist regarding the predictive role of the umbilical cord in foetal growth restriction.What do the results of this study add? Foetal umbilical cord diameter was correlated significantly to foetal weight and had a significant predictive role in the prediction of FGR. The cut off values for the umbilical cord diameter in women with FGR were not evaluated before.What are the implications of these findings for clinical practice and/or further research? Comparing the ultrasound findings with histopathologic examination of the umbilical cord and the placentas would be recommended.

Comparative study of umbilical cord cross-sectional area in foetuses with isolated single umbilical artery and normal umbilical artery.

Single umbilical artery (SUA) is one of the most common prenatal diagnoses in cases of foetal abnormality. This prospective study evaluated 77 foetuses with isolated SUAs and 77 healthy foetuses, both at 22-39 gestational weeks. We categorised gestational age into the second and third trimesters, measured the umbilical arterial blood flow parameters and calculated the umbilical vein (UV) area, umbilical artery (UA) area and UV area/UA area ratio. In the second and third trimesters, a higher UA area was obtained in the isolated SUA group than in the control group (p < .01). Furthermore, the isolated SUA group had a lower UV area/UA area ratio than the control group (p < .01), and a positive linear correlation was found between gestational age and UV area in both groups (p < .01). The presence of isolated SUAs was associated with low birth weight and a high prevalence of small for gestational age.IMPACT STATEMENTWhat is already known on this subject? Single umbilical artery (SUA) is one of the most common prenatally diagnosed foetal abnormalities and approximately 80% foetuses with SUA have isolated SUA, which is a soft indicator of chromosome abnormalities, congenital malformations and premature birth. Umbilical cord cross-sectional area can be evaluated prenatally by ultrasound imaging. Normal values increase with gestational age and foetal size in single pregnancies. Changes in umbilical cord thickness have been associated with complications during pregnancy.What do the results of this study add? The correlation between gestational age and umbilical vein area in the isolated single umbilical artery (SUA) group and control group was better than that between gestational age and umbilical artery area. UA area increased significantly in both groups before 28 weeks but not after 28 weeks, particularly in the isolated SUA group.What are the implications of these findings for clinical practice and/or further research? The study provides a reliable basis for maternal foetal monitoring during pregnancy in the isolated SUA and control groups. Objective assessment of the occurrence and development of foetuses with isolated single umbilical artery was performed.

Umbilical Cord Knots: Is the Number Related to Fetal Risk?

True knots of the umbilical cord (UC) are a rare occurrence and are reported in 0.4-1.2% of deliveries. The compression of true knot of the UC can cause obstruction of the fetal circulation, leading to intra-uterine growth retardation or fetal death. Predisposing factors for the genesis of the true UC knot are numerous and include all the conditions, which lead to a relatively large uterine volume. This situation may predispose to free and excessive fetal movements. Although not all true knots lead to perinatal complications, they have been associated with adverse pregnancy outcomes, including fetal distress, fetal hypoxia, intra-uterine growth restriction (IUGR), long-term neurological damage, caesarean delivery and stillbirth. We present a rare case of operative delivery with vacuum in a multiparous woman at term of pregnancy with a double true knot of the UC. As in most cases, the diagnosis was made after delivery, as there were no fetal symptoms during pregnancy. Some authors assume that 3D power sonography may be useful in the diagnosis of true UC knots. However, 3D power Doppler cannot be considered as a definitive method. There are no specific prenatal indications to induce the physician to look for ultrasound signs suggestive of umbilical true knot. Some studies argue that cases of fetal death and fetal risk are directly related to the number of knots. We also support this thesis, even if further observational and retrospective studies are needed to demonstrate it.

Umbilical cord prolapse: revisiting its definition and management.

Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.

MRI findings in children with congenital cytomegalovirus infection retrospectively diagnosed with dried umbilical cord.

PURPOSE: Brain MRI provides important information about suspected congenital CMV infection in neonatally underdiagnosed children. This study aimed to describe MRI findings in children in whom congenital CMV infection was not suspected during the neonatal period and was proven retrospectively. METHODS: We enrolled 31 children referred to the pediatric neurology clinic with neurological symptoms who were proven to have congenital CMV infection based on dried umbilical cord samples. Upon diagnosis, MR and CT images were assessed using the van der Knaap scoring system integrated with additional variables. Two investigators independently assessed all images. RESULTS: The age at diagnosis was < 12 months in 14, 12-24 months in 11, and > 24 months in 6 patients. The initial symptom triggering clinic referral was delayed development in 22, seizure in 5, deafness in 3, and hemiplegia in 1 patient. Of the 31 children, 30 had a white matter (WM) abnormality predominant in the deep WM of the parietal lobe (n = 25). Anterior temporal lesions were observed in 21 children. Cortical lesions were observed in 7 children, suggestive of polymicrogyria. No child had cerebellar or brainstem abnormalities. Brain CT was performed in 22 of 31 children, and 11 showed punctate cerebral calcification in the periventricular and/or deep WM. CONCLUSION: Patients with congenital CMV infection with delayed neurological symptoms show a relatively uniform pattern of parietal-dominant multifocal WM lesions and anterior temporal lesions, with or without polymicrogyria.

Necrotizing funisitis and calcification of umbilical vein: case report and review.

BACKGROUND: Necrotising funisitis (NF) is a rare, chronic stage of funisitis, a severe inflammation of the umbilical cord and an important risk factor for fetal adverse outcomes. NF is characterized by yellow-white bands running parallel to the umbilical blood vessels. These bands consist of inflammatory cells, necrotic debris, and calcium deposits. Calcification is visible in ultrasonography, which makes it possible to suspect NF when umbilical vascular wall calcification is detected by prenatal ultrasonography. CASE PRESENTATION: Ultrasonography revealed calcification of the umbilical venous wall in an expectant 31-year-old woman who was gravida 1, para 0. The woman required emergency cesarean section because of fetal distress and suspected umbilical cord torsion at 31 weeks gestation. The root of the umbilical cord was quite fragile and broke during the operation. The pathological results on the placenta showed histologic chorioamnionitis and NF. The infant was diagnosed to have neonatal sepsis and acidosis after delivery but was discharged without severe complications after a one-month hospitalization that included antibiotic and supportive therapy. CONCLUSION: NF is a rare and severe inflammation of the umbilical cord. Umbilical vascular wall calcification discovered in prenatal ultrasonography is diagnostically helpful.