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Furcate Cord Insertion of the Umbilical Cord: Pathological and Clinical Characteristics in 132 Cases and a Review of the Literature

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Aus der Klinik für Geburtsmedizin der Medizinischen Fakultät Charité – Universitätsmedizin Berlin DISSERTATION Furcate cord insertion of the umbilical cord: Pathological and clinical characteristics in 132 cases and a review of the literature zur Erlangung des akademischen Grades Doctor medicinae (Dr. med.) vorgelegt der Medizinischen Fakultät Charité – Universitätsmedizin Berlin von Dr. med. univ. Philipp Kosian aus Wien, Österreich Datum der Promotion: 23.06.2019 1 Table of contents Table of contents .................................................................................................................. 2 1. Abstract ........................................................................................................................ 4 1.1. Abstract in english ............................................................................................................. 4 1.2. Abstract in german ............................................................................................................ 5 2. Introduction .................................................................................................................. 7 2.1. Development of the umbilical cord.......................................................................................... 7 2.2. Anatomy of the umbilical cord and its insertion ....................................................................... 9 2.2.1. Amnionic epithelium .................................................................................................................. 9 2.2.2. Wharton’s jelly ........................................................................................................................... 9 2.2.3. Structure of the umbilical vessels ............................................................................................ 10 2.2.4. Contractility of the umbilical vessels ........................................................................................ 11 2.2.5. Spiral turns of the cord ............................................................................................................. 11 2.2.6. Length of the umbilical cord, cord entanglement.................................................................... 12 2.2.7. Sonographic assessment of the umbilical cord ........................................................................ 13 2.3. Pathology of the umbilical cord ............................................................................................. 14 2.3.1. Cysts and edema of the umbilical cord .................................................................................... 14 2.3.2. Single umbilical artery .............................................................................................................. 15 2.3.3. Rupture of the umbilical cord .................................................................................................. 15 2.3.4. Varices and aneurysms of the umbilical cord .......................................................................... 16 2.3.5. Thrombosis of the umbilical cord ............................................................................................. 16 2.4. Insertion of the umbilical cord and outcome.......................................................................... 18 2.4.1. Velamentous and marginal cord insertion ............................................................................... 19 2.4.2. Interpositional Cord insertion .................................................................................................. 20 2.4.3. Vasa praevia ............................................................................................................................. 20 2.4.4. Furcate cord insertion .............................................................................................................. 22 2.5. Research questions and the aims of this study ....................................................................... 28 3. Materials and methods ................................................................................................ 29 4. Results ........................................................................................................................ 31 4.1. Descriptive analysis .............................................................................................................. 31 4.2. Prenatal diagnostics of suspicious umbilical findings in furcate cord insertion ........................ 32 4.2.1. Subject ID Number 76 .............................................................................................................. 32 4.2.2. Subject ID number 141 ............................................................................................................. 33 4.3. Pregnancy-related diseases ................................................................................................... 34 4.4. Perinatal complications ......................................................................................................... 35 4.5. Neonatal outcome ................................................................................................................ 35 4.6. Pathological parameters ....................................................................................................... 40 4.7. Case series: IUFDs caused by furcate cord insertion ............................................................... 42 4.7.1. Case 1 – Subject ID 141 ............................................................................................................ 42 4.7.2. Case 2 – Subject ID 19 .............................................................................................................. 44 4.7.3. Case 3 – Subject ID 146 ............................................................................................................ 45 4.8. Results of the literature review ............................................................................................. 47 5. Discussion ................................................................................................................... 48 6. Appendix ........................................................................................................................ 53 6.1. Bibliography ......................................................................................................................... 53 6.2. List of figures ........................................................................................................................ 60 6.3. List of tables ......................................................................................................................... 61 2 6.4. List of abbreviations ............................................................................................................. 62 6.5. Eidesstattliche Versicherung ................................................................................................. 63 6.6. Curriculum vitae ................................................................................................................... 64 6.7. Acknowledgment .................................................................................................................. 65 3 1. Abstract 1.1. Abstract in english Introduction The furcate cord insertion with a prevalence of 0.1% is extremely rare and has only been reported in the literature in 18 cases. It is defined by a separation of the umbilical vessels prior to inserting at the placenta centrally, eccentrically or marginally. In the literature, an association with stillbirth, fetal hemorrhage, intrauterine growth restriction and varices and thrombosis of fetal vessels is described (1). The aim of this thesis is to evaluate the clinical and pathological characteristics of the furcate cord insertion of the umbilical cord in 132 cases and a review of the literature. Methods A retrospective study of the cases with a furcate cord insertion of the umbilical cord found in the pathological database of the Charité between 1993 and 2016 was performed and 132 cases were identified. A statistical analysis with SPSS of the pathological features and the perinatal outcome was done after the extraction of the data from the pathological database and the electronic medical records. A review of the literature and a comparison to our patient collective was done. Results The prevalence for the furcate cord insertion in our patient collective lies at 0.17% with a risk for intrauterine fetal death of 1.0% within the Charité. In seven cases in our analysis, intrauterine fetal death was observed. Three of those cases can be linked to the furcate cord insertion. In two out of these three cases, a rupture of the umbilical vessels was identified as the cause of death. The furcate cord insertion is not associated with an intrauterine growth restriction but with a higher rate of HELLP syndrome, retention of placenta and lower five-minute APGAR scores. Risk factors for an adverse outcome after analyzing our data are an above average long furcate cord insertion and additional abnormal findings of the umbilical cord such as thrombosis or ectasia of the umbilical vessels. Conclusion The furcate cord insertion is a very rare anomaly of the umbilical cord occurring in approximately 0.17% of all pregnancies. In most cases, the outcome is good but in around 1% of the cases intrauterine fetal death is observed. In case of identifying a furcate cord insertion prenatally, delivery should be planned after
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