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Prenatal Diagnosis of Umbilical Artery Thrombosis in the Second Trimester: a Case Report

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Prenatal Diagnosis of Umbilical Artery Thrombosis in the Second Trimester: a Case Report A L J O A T U N R I N R A E L P Case Report P L E R A Perinatal Journal 2021;29(1):79–82 I N N R A U T A L J O ©2021 Perinatal Medicine Foundation Prenatal diagnosis of umbilical artery thrombosis in the second trimester: a case report 1 2 Alev Esercan İD , Emre Ekmekci İD 1Clinic of Obstetrics and Gynecology, fianl›urfa Training and Research Hospital, fianl›urfa, Turkey 2Maternal Fetal Medicine Division, fianl›urfa Training and Research Hospital, fianl›urfa, Turkey Abstract Özet: ‹kinci trimesterde umbilikal arter trombozunun prenatal tan›s›: Olgu sunumu Objective: Thrombosis of umbilical artery is a rare condition. The Amaç: Umbilikal arter trombozu nadir bir rahats›zl›kt›r. Tan›s› diagnosis is established commonly in the third trimester after detec- genellikle üçüncü trimesterde fetal distres veya intrauterin geliflme tion of fetal distress or intrauterine growth retardation, or could be gerili¤inin tespitinden sonra konulur veya do¤umdan sonra tan› established after delivery. Also, the management of the condition is koyulabilir. Ayr›ca, rahats›zl›¤›n yönetimi de tan› sonras›nda conflicting after the diagnosis. çeliflkilidir. Case: Here we reported an umbilical artery thrombosis case that Olgu: Çal›flmam›zda, umbilikal kord kisti için baflvuru sonras›nda was diagnosed in the second trimester after referral for an umbilical ikinci trimesterde tan›s› konulan bir umbilikal arter tromboz cord cyst. After the diagnosis at 24th week of pregnancy, she had olgusunu sunduk. Gebeli¤in 24. haftas›ndaki tan› sonras›nda olgu been followed up weekly. She had been delivered electively at the haftal›k olarak takip edildi. Olgu, 34. gebelik haftas›nda sorunsuz 34th week of pregnancy uneventfully. The diagnosis was confirmed flekilde elektif olarak do¤um yapt›. Tan› postnatal olarak postnatally. do¤ruland›. Conclusion: The prenatal diagnosis of umbilical arterial thrombo- Sonuç: Umbilikal arter trombozunun prenatal tan›s›, perinatal sis is so important to prevent perinatal morbidity. When umbilical morbiditeyi önlemede çok önemlidir. Umbilikal kord kistleri cord cysts are detected, further evaluation is required in terms of tespit edildi¤inde, umbilikal arter trombozu bak›m›ndan ek umbilical artery thrombosis. de¤erlendirme yap›lmal›d›r. Keywords: Thrombosis, umbilical artery, umbilical cord. Anahtar sözcükler: Tromboz, umbilikal arter, umbilikal kord. Introduction ed an umbilical arterial thrombosis that is diagnosed at Thrombosis of umbilical cord vessels is a rare compli- the 24 weeks of gestation that is followed up to 34 cation during pregnancy and the incidence is reported weeks of pregnancy. We obtained the written informed as 1 in 1300 deliveries by Heifetz. Thrombosis of consent from the patient for publication of this case umbilical vein is more frequent than the arterial report and any accompanying images. thrombosis.[1] Umbilical arterial thrombosis is associat- ed with poor fetal outcomes including intrauterine Case Report growth restriction (IUGR) and increased fetal demise. Diagnosis is so difficult and challenging, also the man- A 28-year-old gravida 5 para 1 abortion 3, 24 weeks agement is so controversial that there is no approved pregnant patient was referred to our maternal-fetal timing of delivery after the diagnosis. Here, we report- medicine unit due to a cystic structure at the free loop Correspondence: Emre Ekmekci, MD. Maternal Fetal Medicine Division, fianl›urfa Training and Research Hospital, fianl›urfa, Turkey. e-mail: [email protected] / Received: October 30, 2020; Accepted: February 1, 2021 How to cite this article: Esercan A, Ekmekci E. Prenatal diagnosis of umbilical artery thrombosis in the second trimester: a case report. Perinatal Journal 2021;29(1):79–82. doi:10.2399/prn.21.0291012 ORCID ID: A. Esercan 0000-0002-6215-6532; E. Ekmekci 0000-0003-2494-3073 Esercan A, Ekmekci E Fig. 1. The periumbilical cord cystic structure. Fig. 2. Sonographic view of thrombus. of umbilical cord. Fetal anatomic survey was complete- Doppler flow confirmed two blood flows on cord, one ly normal at 21st week of pregnancy including two artery and one vein. The other umbilical artery vessel umbilical arteries. Patient had an unremarkable past blood flow was clogged by the thrombus. Minimal pas- medical history. Only she was using enoxaparin sodi- sage through the thrombus could be visualized by um is 4000 IU (40 mg) once daily that was started in power Doppler (Fig. 3). Only one paravesical umbili- the early first trimester by another physician due to cal arterial blood flow was present. Fetal biometric previous abortions in the first trimester. But the indi- measurements were coherent with gestational age. cation of the enoxaparin use was not clear. Acquired Umbilical artery pulse Doppler values were normal. and inherited thrombophilia tests were normal. Our Anatomic survey did not reveal any extra abnormality. transabdominal ultrasonographic examination Fetal echocardiography and cardiac rhythm was nor- revealed a 23×40 mm thin walled cystic structure sur- mal. Patient is informed about abnormality and called rounding around a part of free umbilical cord loop for weekly follow-up. The enoxaparin is not stopped (Fig. 1). Content of cystic structure was semi- and continued. The cystic structure surrounding the echogenic. At longitudinal section of umbilical cord cord in first sonography disappeared one week later. × visualized by sonography, a 25 8 mm sized echogenic On weekly follow-ups, the thrombus is evaluated and structure next to the cystic area is visualized (Fig. 2). the cord vessels were examined about a new thrombus. The cranial structures of the fetus is examined about a probable emboli. After the 28th week of pregnancy fetal well-being was also evaluated by weekly non- stress test. Timing of delivery was planned at 34th week. After the 31st week of pregnancy, a mild fetal intrauterine growth retardation was started but Doppler velocimetry was normal and patient was fol- lowed up to 34 weeks. A healthy female infant weigh- ing 2250 grams was delivered electively by cesarean section, with Apgar scores of 6 at 1 minute and 8 at 5 minutes on the 34 week of pregnancy. Baby did not have any signs associated with thrombosis. The throm- bus in the umbilical artery is confirmed macroscopical- ly after delivery (Figs. 4 and 5). Also, the diagnosis is confirmed histopathologically. The baby is followed in neonatal intensive care unit for 5 days and then dis- Fig. 3. Minimal blood flow on power Doppler sonography. charged from hospital. 80 Perinatal Journal Prenatal diagnosis of umbilical artery thrombosis in the second trimester Fig. 4. Thrombus in the umbilical artery and the intact artery and vein. Fig. 5. Macroscopically view of thrombosis part of umbilical cord. Discussion diagnosed postnatal when the baby has been delivered [7] The prognosis of umbilical arterial thrombosis is worse due to acute fetal distress. Klaritsch et al. described than umbilical venous thrombosis and arterial throm- ‘grabbed orange sign’ for the sonographic detection of bosis is associated with increased perinatal morbidity, umbilical artery thrombosis. In our case, we directly IUGR and increased fetal mortality. Thrombosis of detected the large echogenic thrombus in the vessel umbilical artery is rare and no clear data exists regard- but the cystic structure have attracted attention us on ing the management of this condition.[2] The reason of the cord loop to look more carefully. A cystic umbilical umbilical vessels thrombosis is unclear. It is asserted cord structure may be critical sign to alert the physi- that umbilical cord abnormalities cause thrombosis. cian about the thrombosis. These may be primarily the abnormal structure of the The thrombosis of vessels does not always com- umbilical cord, like hypercoiling or elongation or pletely block the circulation. Completely block of mechanical factors that applies pressure on the vessels umbilical vein is lethal for the fetus; however, that is like cystic structures, placental tumors.[3] Umbilical not same for the artery.[8] In our case the artery was vessel thrombosis may also be associated with abnor- completely blocked, and only minimal flow could be mal fetal coagulation, maternal diabetes mellitus, visualized by power Doppler at very low pulse repeti- infection, and smoking.[4] Matsumoto et al.[5] reported tion frequencies. Acute thrombosis may result with an umbilical arterial thrombosis that was associated sudden stillbirth, acute fetal distress or IUGR.[9] Sato with an extra-abdominal umbilical vein varix. Li et al.[6] and Benirschke also reported results of 11 cases with reported an umbilical arterial thrombosis that was umbilical arterial thrombosis and reported two with associated with hypercoiling of umbilical cord. These stillbirths and three with severe intrauterine growth abnormalities may induce flow stasis and thrombosis of restriction.[10] We had only a mild IUGR at fetus and the umbilical artery. In our case the diagnosis was was started around 31 weeks of pregnancy that was made after the detection of umbilical cord cystic struc- about two months later after the diagnosis. ture. However, we are not sure that it was a real cystic In the literature, because most cases were diagnosed structure or an extravasation subsequent to the throm- with acute fetal distress and babies were delivered bosis. Because the cystic structure disappeared one emergently, there is only a few cases whose pregnan- week later. cies were followed after prenatal diagnosis. We could Papers about prenatal detection of umbilical arteri- only find reports on two separate cases diagnosed at 32 al thrombosis are limited and most of them have been and 33 weeks of gestation and delivered electively at 34 Volume 29 | Issue 1 | April 2021 81 Esercan A, Ekmekci E weeks of gestation.[2,11] We electively delivered the baby 3. Tanaka K, Tanigaki S, Matsushima M, Miyazaki N, Hashimoto by cesarean section at 34 weeks of gestation. Our case R, Izawa T, et al.
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