Caesarean delivery of a breech singleton with eight loops of nuchal cord.

Nuchal cord accidents comprise a third of stillbirths in the third trimester. These are often due to higher order nuchal cords, with more than three loops. In this report, we discuss a case of a gestation complicated by a nuchal cord with eight loops and severe fetal growth restriction, requiring expedited delivery due to non-reassuring fetal heart tones. Our case demonstrates the value of high-quality ultrasound in detecting complex nuchal cords, as well as highlighting the potentially dynamic and unstable fetal status in an affected gestation. Antenatal knowledge of nuchal cord in the setting of non-reassuring fetal status can help guide patient counselling and assist with identifying possible aetiologies. Finally, our case demonstrates that close monitoring and early intervention can prevent potentially catastrophic outcomes.

Antenatal course and perinatal outcome after ultrasound detection of triple nuchal cord: a case series.

OBJECTIVE: To determine the antenatal course and perinatal outcome of pregnancies in which a triple nuchal cord was detected prenatally by ultrasound. METHODS: Singleton pregnancies presenting for ultrasound evaluation after 24 weeks of gestation were routinely screened for the presence of nuchal cord loops using two-dimensional and color-Doppler ultrasound. Fetuses with more than two nuchal cord loops were identified from our fetal medicine database and their ultrasound reports and medical records were reviewed. RESULTS: During the study period from July 2014 to February 2019, 10 singleton fetuses with triple nuchal cord were identified, for a prevalence of 1 in 506 or 0.2%. No cases of more than three nuchal cord loops were detected. No predisposing factors were identified. Cases detected after 36 weeks (n = 4) delivered by cesarean section after 37 weeks and the diagnosis of triple nuchal cord was confirmed in all of them. Cases detected before 36 weeks (n = 6) underwent fetal surveillance. Among these cases, the umbilical cord unraveled itself from around the fetal neck in at least one loop in 83% of these cases. Overall, eight (80%) of the neonates were delivered by cesarean section for different reasons; in only two, the sole indication for cesarean delivery was the presence of the triple nuchal cord. All the infants had a good perinatal outcome, although one newborn infant was small for gestational age. CONCLUSIONS: Ultrasound detection of triple nuchal cord during late pregnancy was associated with good perinatal outcomes. However, this prenatal finding was also associated with a high rate of cesarean section. In preterm pregnancies, multiple loops will reduce spontaneously in the majority of cases, so expectant management is indicated. In term pregnancies, the decision regarding the optimal timing and mode of delivery should be discussed with the parents taking into account the individual clinical scenarios.

Does first-trimester nuchal cord affect the blood flow in the ductus venosus? A prospective observational study.

INTRODUCTION: Main objective of the present study was to investigate the association between the presence of nuchal cord (NC) and the measurement of the ductus venosus pulsatility index for veins (ductus venosus (DV) PIV). METHODS: This was a prospective study of 1974 singleton pregnancies that underwent first-trimester screening at 11-13+6 gestational weeks. Color Doppler was used to demonstrate the presence of a NC in all cases and the DV PIV was calculated routinely, as part of the standard scan. The association between the presence of a NC and the DV PIV was then examined overall and at each gestational week. RESULTS: A NC was demonstrated in 17.1% of cases. The incidence of nuchal cord was significantly higher at 13-13+6 weeks (24.7%, n = 119) compared to the one at 12-12+6 (16.5%, n = 192) and 11-11+6 weeks (7.9%, n = 26) (p < .001). No significant correlation was found between NC presence and DV PIV (p = .344). The DV PIV was 0.99 (± 0.15) for patients without NC versus 0.99 (± 0.15) for patients with NC (p = .34). CONCLUSIONS: There was no association between the presence of a NC at 11-13+6 gestational weeks and the DV PIV.

Perinatal outcomes of sonographically detected nuchal cord in southeastern Turkey.

PURPOSE: To investigate the outcomes of pregnancies with a sonographically detected nuchal cord (NC) from a single center in south-eastern Turkey. MATERIALS AND METHODS: A retrospective study was carried out at Maternity and Child Health Hospital Diyarbakir, Turkey, between 2011 and 2013. A-total of 477 pregnancies with sonographically detected NC during the second and third trimesteri of gestation (20-40 weeks) were included. The control group consisted of 1,043 randomly selected pregnancies without NC matched for gestational age at the time of ultrasound examination. Outcome variables, including maternal age, parity, gestational age at delivery, mnode of delivery, intrapartum fetal heart abnormalities, meconium-stained amniotic fluid, birth weight, and one- and five-minute Apgar scores, were compared between the two groups. RESULTS: There were no statistically significant differences in any of the outcome variables between patients with sonographically detected NC and controls. CONCLUSIONS: The presence of NC indicates a need for increased care but is not associated with adverse perinatal outcomes.

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population.

OBJECTIVE: Evaluate the outcome of prenatally diagnosed nuchal cord. METHODS: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction. RESULTS: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops. CONCLUSION: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Nuchal cord complication in male small for gestational age increases fetal distress risk during labor.

OBJECTIVE: This study aimed to evaluate whether a nuchal cord increases the risk of perinatal complications during labor, and whether fetal growth and sex affect the risk of fetal distress. MATERIALS AND METHODS: Medical records of 1749 women with singleton pregnancies planning a vaginal delivery were enrolled. Patients were divided into two groups according to the presence or absence of a nuchal cord at birth. Multivariate logistic regression analyses, odds ratios (ORs), and 95% confidence intervals (CIs) were used to determine whether the risks of perinatal complications increased in the nuchal cord group. RESULTS: A nuchal cord is associated with higher risks of Rupture of membranes (ROM) prior to delivery (OR = 1.40, 95% CI: 1.12-1.76, p = 0.0031), need for augmentation during labor (OR = 1.68, 95% CI: 1.27-2.23, p = 0.0003), prolonged second stage of labor (OR = 2.54, 95% CI: 1.55-4.25, p = 0.0002), nonreassuring fetal heart risk during labor (OR = 2.89, 95% CI: 2.18-3.84, p < 0.0001), and instrumental delivery or cesarean delivery (OR = 2.00, 95% CI: 1.55-2.58, p < 0.0001). Fetal distress risk during labor was affected by fetal growth and sex, with male small for gestational age fetuses with a nuchal cord having a significantly higher risk than the control group (OR = 9.77, 95% CI: 3.67-25.79, p < 0.0001), despite there being no significant differences in the neonatal Apgar scores at 1 minute or 5 minutes, or in the need for neonatology between the two groups. CONCLUSION: Nuchal cord is associated with perinatal outcomes. Male small for gestational age fetuses with a nuchal cord have a significantly higher risk of fetal distress during labor. Our results suggest that evaluation of fetal sex and body weight is also important in antenatal ultrasonography if a nuchal cord is found.

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.

Prenatal diagnosis of placenta and umbilical cord pathologies by three-dimensional ultrasound: pictorial essay.

The authors present their experience in prenatal diagnosis of placental and umbilical cord pathologies, using three-dimensional ultrasound (3DUS) in the rendering and tomography ultrasound imaging (TUI) modes, associated with color Doppler in some cases. Cases of placenta accreta/placenta previa, circumvallate placenta, succenturiate lobe, true knot of the umbilical cord, nuchal cord, and marginal/velamentous umbilical cord insertion are presented. 3DUS can contribute to improve the accuracy of prenatal diagnosis of placenta and umbilical cord pathologies.

Impact of nuchal cord on fetal outcomes, mode of delivery, and management: a questionnaire survey of pregnant women.

OBJECTIVES: To explore pregnant women's views on the impact of nuchal cord on fetal outcomes, mode of delivery, and management. DESIGN: Questionnaire survey. SETTING: Antenatal clinic of two regional hospitals in Hong Kong. PARTICIPANTS: A questionnaire survey of all pregnant women at their first visit to the antenatal clinic of United Christian Hospital and Tseung Kwan O Hospital in Hong Kong was conducted between August and October 2012. RESULTS: Most participants (71.8%) were worried about nuchal cord, and 78.3% and 87.7% of them thought that nuchal cord could cause intrauterine death and fetal death during labour, respectively. Approximately 87.5% of participants thought that nuchal cord would reduce the chance of successful vaginal delivery and 56.4% thought that it would increase the chance of assisted vaginal delivery. Most (94.1%) participants thought that it was necessary to have an ultrasound scan at term to detect nuchal cord. In addition, 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed in the presence of nuchal cord. Participants born in Mainland China were significantly more worried about the presence of nuchal cord than those born in Hong Kong. However, there was no difference between participants with different levels of education. CONCLUSION: Most participants were worried about the presence of nuchal cord. Many thought that nuchal cord would lead to adverse fetal outcomes, affect the mode of delivery, and require special management. These misconceptions should be addressed and proper education of women is needed.

Prenatal diagnosis and management of monoamniotic twins.

PURPOSE OF REVIEW: The purpose of this article is to investigate the perinatal outcomes of monoamniotic twins under current standards of prenatal management involving intensive fetal surveillance. RECENT FINDINGS: The incidence of perinatal mortality in monoamniotic twins has fallen over the last 2 decades. Umbilical cord entanglement has long been considered one of the main causes of poor outcome among monoamniotic twins; however, new evidence shows that it appears to be less important than prematurity and congenital anomalies. If intensive fetal surveillance is provided, the risk of perinatal mortality is acceptably low regardless of setting. In uncomplicated monoamniotic twin pregnancies, delivery at around 33 weeks of gestation might reduce the risk of neonatal adverse events without increasing the risk of perinatal death. SUMMARY: Perinatal outcome in monoamniotic twins improved if intensive fetal surveillance was performed under either outpatient or inpatient management. Planned delivery in uncomplicated monoamniotic twin pregnancies can be considered at around 33 weeks of gestation.

Presence of an umbilical artery notch in monochorionic/monoamniotic twins.

OBJECTIVE: To examine the association between an umbilical artery notch and fetal deterioration in monochorionic/monoamniotic (MC/MA) twins. METHODS: Six MC/MA twin pregnancies were admitted at 24-28 weeks of gestation for close fetal surveillance until elective delivery at 32 weeks or earlier in the presence of signs of fetal deterioration. Ultrasound (US) examinations were performed twice weekly. The presence of cord entanglement, umbilical artery notch, abnormal Doppler parameters, a non-reassuring fetal heart rate pattern, or an abnormal fetal biophysical profile were evaluated. RESULTS: Umbilical cord entanglement was observed on US in all pregnancies. The presence of an umbilical artery notch was noted in four out of six pregnancies and in two of them an umbilical artery notch was seen in both twins. The umbilical artery pulsatility index was normal in all fetuses. Doppler parameters of the middle cerebral artery and ductus venosus, fetal biophysical profile and fetal heart rate monitoring remained normal until delivery in all pregnancies. All neonates experienced morbidity related to prematurity; however, all were discharged home in good condition. CONCLUSION: The presence of an umbilical artery notch and cord entanglement, without other signs of fetal deterioration, are not indicative of an adverse perinatal outcome.