Association of congenital uterine anomaly with abnormal placental cord insertion and adverse pregnancy complications: a retrospective cohort study.

OBJECTIVE: Congenital uterine anomalies during pregnancy increase the risk of pregnancy complications such as miscarriage, preterm delivery, fetal malpresentation, cesarean delivery, and fetal growth restriction. However, few studies have examined uterine anomalies in relation to perinatal complications other than those mentioned above. We investigated the association between pregnancies complicated by congenital uterine anomalies and various perinatal outcomes at our institution. METHODS: This retrospective cohort study was conducted from January 2009 to May 2021. We included cases of uterine anomalies, such as septate, bicornuate, unicornuate, and didelphic uterus. First, the perinatal complications and neonatal outcomes were compared between pregnancies complicated by uterine anomalies and those with normal uteri. Second, we conducted an analysis based on the type of uterine anomalies classified into two groups: the minor anomaly group consisted of anomalies limited to the uterine cavity, such as the septate uterus, whereas the major anomaly group included anomalies affecting the uterine shape, such as bicornuate, unicornuate, and didelphic uterus. We compared the incidence of perinatal complications among the major anomaly, minor anomaly, and normal uterus groups. RESULTS: During the study period, 45 pregnancies were complicated with uterine anomalies. The minor anomaly group included 11 patients and the major anomaly group included 34 patients. The incidence of fetal malpresentation was significantly higher in the uterine anomaly group than in the normal uterus group (18% vs. 3.7%, p = .04). Furthermore, the frequency of abnormal placental cord insertion was significantly higher in the uterine anomaly group (16% vs. 3.7%, p = .01). Examination based on the type of uterine anomaly revealed significant differences in cervical incompetence, malpresentation, cesarean section, and abnormal placental cord insertion. Cervical incompetence was more likely in patients with minor anomalies. In contrast, fetal malpresentation, cesarean section, and abnormal placental cord insertion were more likely in the major anomaly group. CONCLUSIONS: In addition to the findings reported in previous studies, abnormal placental cord insertion was more frequent in pregnancies complicated by uterine anomalies.

Magnetic resonance imaging diagnosis of abnormal placental cord insertions.

INTRODUCTION: Abnormal placental cord insertions (APCIs) are significant risk factors for pregnancy complications, encompassing marginal cord insertion (MCI), velamentous cord insertion (VCI), and vasa previa (VP). While ultrasound is the primary imaging modality, its accuracy can be limited by factors such as maternal obesity and fetal positioning. Complementary to ultrasound, magnetic resonance imaging (MRI) offers a more precise visualization of the fetus, placenta, and umbilical cord relationships. This study aims to investigate the diagnostic value of prenatal magnetic resonance imaging (MRI) for APCIs compared with prenatal ultrasound. METHODS: We retrospectively collected data from 613 patients who underwent prenatal placental ultrasound and MRI. Of those who were confirmed as APCIs through surgery or pathology, the prenatal MRI features were compared with prenatal ultrasound. The diagnostic efficacy of prenatal MRI and ultrasound for APCIs was assessed based on the clinicopathological findings. RESULTS: Fifty-six patients were confirmed as APCIs by surgery or pathology, comprising 31 marginal cord insertions (MCIs), 18 velamentous cord insertions (VCIs), 5 vasa previa (VP) cases, and 2 VCI cases combined with VP. Ultrasound examination showed 55.36 % sensitivity (31/56) and 98.38 % specificity (486/494) in diagnosing APCIs, whereas MRI demonstrated 87.50 % sensitivity (49/56) and 98.88 % specificity (531/537). CONCLUSION: For APCIs complicated by placental location or morphological abnormalities, MRI demonstrates superior diagnostic efficacy compared to ultrasound in late pregnancy.

Intrauterine fetal death due to rupture of umbilical vessels: a rare case of furcate cord insertion.

Furcate cord insertion refers to the separation of umbilical vessels before reaching the placenta, where the branching vessels normally attach at the edge of the placental parenchyma or near the placental membranes. This is an extremely rare abnormal umbilical cord insertion. This paper reported a case of a furcate cord insertion, where the rupture of exposed umbilical vessels led to intrauterine fetal death at full term. Through literature review, we analyzed the prenatal ultrasound characteristics and pregnancy outcomes of furcate cord insertions, with the aim to improve detection rates and reduce the risk of adverse pregnancy outcomes.

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.

European association of perinatal medicine (EAPM) position statement: Screening, diagnosis and management of congenital anomalies of the umbilical cord.

Congenital anomalies of the umbilical cord are associated with an increased risk of pregnancy and perinatal complications. Some anomalies of the cord have a higher prevalence than other fetal structural anomalies. The most common anomalies are the absence of an umbilical artery and velamentous insertion of the cord (with or without vasa previa). These anomalies, even when not associated with fetal structural defects, increase the risk of adverse perinatal outcome including, fetal growth restriction and stillbirth. In the absence of prenatal diagnosis, vasa previa is associated with the highest perinatal morbidity and mortality of all congenital anomalies of the umbilical cord. Most cases can be detected by ultrasound from the beginning of the second trimester and should be included in the routine mid-pregnancy ultrasound examination. Documentation should include cord insertion site, number of vessels in the cord, and if other pathologies have been detected. Pregnancies at increased risk of velamentous cord insertion should be screened for vasa previa using transvaginal ultrasound and colour Doppler imaging. If a velamentous cord insertion or isolated single umbilical artery is detected, individualised follow-up during pregnancy and tailored obstetric management are indicated.

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..

Ultrasound diagnosis of placental and umbilical cord anomalies in singleton pregnancies resulting from in-vitro fertilization.

INTRODUCTION: placental anomalies can affect fetal and maternal outcome due to severe maternal hemorrhage potentially resulting in hysterectomy and cord accident including abruption that can determine fetal damage or death. The aims of our study are to determine if the rate of placental and umbilical cord anomalies are more common in IVF singleton pregnancies compared to spontaneous pregnancies; to evaluate the role of ultrasound in screening for these anomalies and to investigate if oocyte donor fertilization is an additional risk factor for the development of these anomalies. METHODS: this was a prospective cohort study involving two tertiary centers. Patients with a singleton pregnancy conceived with IVF and patients presenting with a spontaneous conception were recruited between 1st May 2019 to 31st March 2021. A total of 634 pregnancies were enrolled in the study. All patients underwent similar antenatal care, which included ultrasound examinations at 11-14, 19-22 and 33-35 weeks. Ultrasound findings of placental and/or umbilical cord abnormalities were recorded using the same protocol for both groups and confirmed after birth. RESULTS: IVF pregnancies had a significantly higher risk of low-lying placenta, placenta previa, bilobed placenta and velamentous cord insertion (VCI) compared with spontaneous pregnancies. In the heterologous subgroup there was a significant increased incidence of placenta accreta spectrum (PAS) disorders than in spontaneous pregnancies. All these anomalies were identified prenatally on ultrasound imaging and confirmed at birth. DISCUSSION: IVF pregnancies in general and those resulting from donor oocyte in particular are at higher risk of placental and umbilical cord abnormalities compared to spontaneous pregnancies. These anomalies can be diagnosed accurately at the mid-trimester detailed fetal anomaly scan and our findings support the need for a targeted ultrasound screening of these anomalies in IVF pregnancies.

Fetal heart rate evolution patterns in cerebral palsy associated with umbilical cord complications: a nationwide study.

BACKGROUND: The aim of the present study was to clarify fetal heart rate (FHR) evolution patterns in infants with cerebral palsy (CP) according to different types of umbilical cord complications. METHODS: This case-control study included children born: with a birth weight ≥2000 g, at gestational age ≥33 weeks, with disability due to CP, and between 2009 and 2014. Obstetric characteristics and FHR patterns were compared among patients with CP associated with (126 cases) and without (594 controls) umbilical cord complications. RESULTS: There were 32 umbilical cord prolapse cases and 94 cases with coexistent antenatal umbilical cord complications. Compared with the control group, the persistent non-reassuring pattern was more frequent in cases with coexistent antenatal umbilical cord complications (p = 0.012). A reassuring FHR pattern was observed on admission, but resulted in prolonged deceleration, especially during the first stage of labor, and was significantly identified in 69% of cases with umbilical cord prolapse and 35% of cases with antenatal cord complications, compared to 17% of control cases (p < 0.001). CONCLUSION: Hypercoiled cord and abnormal placental umbilical cord insertion, may be associated with CP due to acute hypoxic-ischemic injury as well as sub-acute or chronic adverse events during pregnancy, while umbilical cord prolapse may be characterized by acute hypoxic-ischemic injury during delivery.

Abnormal umbilical cord insertions in singleton deliveries: placental histology and neonatal outcomes.

AIMS: This study aimed to identify any microscopic features associated with abnormal (membranous/velamentous or marginal) placental cord insertions and to analyse their adverse neonatal outcomes. METHODS: We retrospectively analysed the records-including pathological findings, clinical information and pregnancy outcomes-for 1060 singleton pregnancies, involving newborn delivered after 24 weeks of gestation. RESULTS: Marginal cord insertions were identified in 26.60% of cases and membranous cord insertions in 2.64%. Subchorionic vessel thrombus was more prevalent in marginal or membranous insertions (0.97%) than in normal cord insertions (0.27%) (p=0.129). Intervillous thrombi (13.73% vs 8.41%, p<0.05) and chorioamnionitis (8.53% vs 5.48%, p=0.089) were more prevalent in normal cord insertions. Premature rupture of membranes was significantly more commonly associated with abnormal (marginal 15.25% and membranous 17.86%) than with normal (9.87%) insertions (p<0.05). Pre-eclampsia was more common in the group with membranous cord insertions (7.14%) than in the other groups (marginal 0.35%; normal 0.80%) (p<0.05). Marginal and membranous placental cord insertions were associated with earlier gestational age at delivery and smaller fetuses than in the group with normal insertions. Intrauterine fetal demise, cardiac malformations and pregestational diabetes were also more common among cases of abnormal cord insertions. CONCLUSIONS: Subchorionic vessel thrombus and adverse pregnancy-related outcomes were more prevalent in cases of marginal/membranous cord insertion than for normal insertions.

Prenatal Diagnosis of Vasa Previa by Routine Transvaginal Color Doppler.

The prenatal diagnosis of vasa previa is essential to achieving a safe delivery in patients who suffer from the condition. Transvaginal ultrasound with color Doppler performed at the time of a routine mid-trimester ultrasound is a valuable tool in terms of achieving a timely and accurate diagnosis of vasa previa.

Marginal cord insertion among singleton births at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

BACKGROUND: Umbilical cord may insert abnormally i.e. marginal insertion to a placenta which can cause different birth and perinatal complications. Despite the increased effort taken by different responsible bodies, the prevalence of birth and perinatal complications are still high, possibly due to anomalous cord insertion. So far, anomalous cord insertion lacks proper attention in different medical settings. Hence, the present study aims to assess the magnitude, risk factors, and adverse birth outcomes of marginal cord insertion among singleton births. METHODS: An institution-based cross-sectional study design was conducted. A systematic random sampling technique was used to select study participants. Data were collected by using a structured questionnaire and it was entered into epi-data version 3.1 then exported to SPSS version 20 for data cleansing and analysis. Bi-variable and multivariable logistic regressions were employed to identify risk factors and adverse outcomes associated with marginal cord insertions. Crude and adjusted odds ratio (P-value < 0.05) with a 95% confidence interval were calculated. RESULT: The magnitude of marginal cord insertion was 6.4% (95% CI = 4.4-8.8%) in singleton pregnancies. Independent risk factors for marginal cord insertion were advanced maternal age (AOR = 2.24, 95% CI: 1.35-11.08), primiparity (AOR = 1.98, 95% CI: 1.37-8.69), maternal chronic hypertension (AOR = 3.07, 95% CI: 1.66-9.76), previous cesarean delivery (AOR = 2.51, 95% CI: 1.43-10.21), and use of intrauterine contraceptive device before pregnancy (AOR = 2.22, 95% CI: 1.36-12.30). Pregnancies complicated by marginal cord insertion are at higher risk to develop low birth weight (AOR = 2.89, 95% CI: 1.23-6.80), preterm birth (AOR = 4.00, 95% CI: 1.44-11.14), and emergency cesarean delivery (AOR = 3.68, 95% CI: 1.03-13.81). CONCLUSION AND RECOMMENDATION: Marginal cord insertion is a mistreated potential risk for low birth weight, preterm birth, and emergency cesarean delivery. Routine screening of marginal cord insertion should be considered in pregnancies with advanced age, nulliparity, hypertensive disorder, history of cesarean section, and intrauterine contraceptive device usage before pregnancy.

Prenatal ultrasonographic findings and fetal/neonatal outcomes of body stalk anomaly.

We studied 27 cases that were post or prenatally diagnosed with body stalk anomaly (BSA) using medical records of prenatal ultrasound findings, pregnancy outcomes, and fetal/neonatal prognosis during 1992 to 2018. Termination of pregnancy was chosen in 15 cases. Of the remaining 12 cases, seven were stillbirths and five were live births. Of seven stillbirths, intrauterine fetal demise occurred before onset of labor in four cases at 17 to 20th weeks of pregnancy. Pregnancy was continued in eight cases. Median gestational age of delivery was 33rd weeks of pregnancy. Median birth weight was 1198 g (range:482-1914 g). Vaginal delivery was chosen in six and caesarean delivery in two cases. Among six vaginally delivered cases, three (50%) fetuses were stillborn. All five live born neonates died within a few hours (16-133 minutes). Eighteen cases were confirmed as BSA postnatally by placental examination or autopsy at our hospital. Main prenatal ultrasonographic findings of them were abdominal wall defect (100%), absence of the umbilical cord (72%), abnormal spine (61%), and abnormal legs (50%). The most characteristic prenatal ultrasonography findings of BSA were the absence of free umbilical cord in the amniotic cavity and the presence of abdominal organs into the extraembryonic celom through abdominal wall defects. The autopsy showed severe pulmonary hypoplasia with the median lung/body weight ratio of 0.61% (range:0.34-0.85%). There were no cases of maternal morbidities. Our study provides important information about the pregnancy outcome and the fetal/neonatal outcome of BSA cases for the parents whose fetuses are diagnosed with BSA prenatally.

Heterotopic Liver Nodule Compressing a Two-Vessel Umbilical Cord: An Unusual Cause of Intrauterine Fetal Demise.

Heterotopic liver tissue in the umbilical cord is rare, and the outcome is quite unpredictable based on the few reported cases. We present a case of heterotopic liver nodule in the umbilical cord of a midtrimester fetus who died in utero. Although such association has only been reported once, heterotopic nodular tissue in the umbilical cord must be regarded as a potential cause of fetal demise by a mechanism analogous to the more common umbilical cord abnormalities resulting in umbilical vessel compromise.

10 cases of umbilical cord thrombosis in the third trimester.

BACKGROUND: Thrombosis of umbilical vessels is a rare occurrence that is difficult to detect during routine antenatal examinations but can lead to poor perinatal outcomes. OBJECTIVE: The aim of this study is to examine the association between meaningful clinical manifestations and features associated with thrombosis of umbilical vessels, and to evaluate optimal management options. METHODS: A retrospective study of umbilical cord thrombi cases enrolled between 2015-2019 was carried out. Data were analyzed from the medical archives where the diagnosis of all cases was established by histopathology. RESULTS: Gross examination reported additional cord abnormalities (7/10), including the irregular length of the umbilical cord, narrowed cord with hyper-coiling, swollen cord with deficiency of Wharton's jelly, placenta velamentous and umbilical infarction. Pathological examination accounted for 10 cases of umbilical cord thrombosis including umbilical artery embolism (3/10), umbilical vein thrombi (5/10) and funisitis (2/10). Clinical findings depicted that the chief complaint was decreased fetal movement companied by nonreactive NST tests (5/10). With the exception of two stillbirths, the remaining pregnancies (8/10) were terminated by cesarean section. All neonates are alive, including one VLBW and three LBW cases. CONCLUSION: We have observed that umbilical structural dysplasia, maternal coagulation disorder, vascular endothelial injury and elevated blood glucose may lead to the formation of thrombosis. Focus on specific signs during a prenatal ultrasound, EFM monitoring and counting fetal movements can help in early identification of umbilical cord thrombi. Our results support the more effective approach of emergency cesarean section during the third trimester.

Absence of Wharton's jelly.

Wharton's jelly is a specialised tissue which surrounds the vasculature within the fetal umbilical cord. We present the case of a 42-year-old woman who gave birth to a female infant via emergency caesarean section. At the time of delivery, absence of Wharton's jelly was noted. This finding was confirmed by histological examination. Emergency caesarean section was necessitated due to a fetal bradycardia, and of note, the patient had presented twice prior to this with reduced fetal movements.

Umbilical cord characteristics and their association with adverse pregnancy outcomes: A systematic review and meta-analysis.

OBJECTIVE: Current data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes. METHODS: MEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks' gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA. RESULTS: This review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37). CONCLUSIONS: True umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.

Furcate insertion of the umbilical cord: pathological and clinical characteristics in 132 cases.

Objectives Furcate cord insertion is a rare abnormality affecting approximately 0.1% of all pregnancies. Macroscopically, the umbilical vessels separate before reaching the placenta, lose their Wharton's jelly, and insert at the placenta centrally, eccentrically, or marginally. The aim of this retrospective study was to determine the prevalence of furcate cord insertion more accurately, the pathological characteristics, and clinical outcomes. Methods We conducted a retrospective study of 132 cases of furcate insertion of the umbilical cord using the pathological database of the Charité University Hospital Berlin, Germany, between 1993 and 2016. This included 99 cases, including one termination of pregnancy within our institution and 33 cases from external hospitals. An analysis of the pathological features of the 132 cases and the perinatal outcome of the 98 cases within our institution were performed. Results Furcate cord insertion occurred in 0.16% pregnancies. Of the 132 cases, seven cases of intrauterine fetal deaths were observed. Three of those could be linked to the furcate cord insertion. In two of those cases, single umbilical vessel rupture was identified as the cause of fetal death. Conclusions In most cases of furcate cord insertion, the outcome is good; however, intrauterine fetal death occurs in approximately 1.02% of cases.