Journal of Perinatology (2007) 27, 457–459 r 2007 Nature Publishing Group All rights reserved. 0743-8346/07 $30 www.nature.com/jp PERINATAL/NEONATAL CASE PRESENTATION Ruptured vasa previa in velamentous cord insertion placenta

S Jantarasaengaram1, C Suthipintawong2, S Kanchanawat3 and K Thanagumtorn3 1Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand; 2Department of Pathology, Rajavithi Hospital, Bangkok, Thailand and 3Department of Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand

145 b.p.m. with markedly decreased variability without Ruptured vasa previa is rare but usually catastrophic if delivery is not deceleration. Emergency cesarean section was performed. The imminent. We present a case of ruptured vasa previa in velamentous cord pediatricians were informed of the diagnosis. A normal, 1982 g insertion placenta. The fetus survived despite 6 h of a venous rupture female infant was delivered with Apgars 4 and 10 after resuscitation because of the tamponade effect from fetal head engagement. Defects in the with volume replacement. The initial infant hematocrit was 36%. vessel wall architecture were revealed by histopathologic examination and On examination of the placenta, velamentous cord insertion with might be responsible for the vessel rupture. Prenatal sonographic partial rupture of a fetal vein with a clot at the ruptured site was identification of cord insertion site into the placenta is encouraged as observed (Figure 1). Postpartum period was uneventful and the standard of practice to prevent this accident. patient was discharged on the fourth day after delivery. The infant Journal of Perinatology (2007) 27, 457–459; doi:10.1038/sj.jp.7211757 was transfused with a total of 40 ml packed red cells and was Keywords: Ruptured fetal vessel; umbilical cord vessel; fetal bleeding; discharged on the 14th day after treatment of neonatal jaundice prenatal diagnosis with phototherapy. Microscopic examination of the aberrant vessel revealed a vessel-wall abnormality. The venous wall showed segmental thinning in the muscular layer (tunica media) with it very thin in some areas (Figure 2a). The area of rupture showed Case acute inflammatory cells infiltrate, necrosis and fibrin deposition A 34-year-old Gravida 3, Para 2 patient at 34 weeks gestation (Figure 2b). developed spontaneous membrane rupture with vaginal bleeding after midnight. She then went to a community hospital nearby and was subsequently referred to us in the morning (6 h after the membrane rupture) with the impression of ‘suspected placental Discussion abruption’. Initial examination in our labor room revealed normal Ruptured vasa previa is rare but usually catastrophic if delivery is uterine tone without uterine contraction and minimal vaginal not imminent. It can occur in the setting of velamentous cord bleeding. The fetus was in vertex presentation with head deeply insertions or in the setting of succenturiate-lobed placentae when engaged. Fetal heart rate (FHR) was 150 beats/min (b.p.m.) by portions of the fetal vessels run freely through the fetal membranes 1 auscultation. Bedside ultrasound revealed a single viable fetus with without protection from Wharton’s jelly. When the membranes are scant amniotic fluid. The placenta lay posterior in the lower ruptured, complete tearing of fetal vessels through the torn uterine segment without retroplacental blood clot. Because the membranes or partial rupture near the site of membrane lower placental edge could not be delineated due to poor resolution rupture may occur. The mother, thereby, develops bleeding or from the fetal head, transvaginal sonography (TVS) was performed. blood-stained amniotic fluid per vagina. Owing to the fact that The vaginal probe was carefully inserted mid-vaginally and the bleeding from fetal vessel is frequently minimal, therefore, it is cervix was delineated. The cervix was closed. The placenta was low more likely to be misinterpreted as a bloody show in labor. lying. There was a small round cystic space over the internal Diagnosis is usually retrospective after fetal demise or fetal distress cervical os that turned out to be a tubular space on the from an abnormal FHR pattern on FHR monitoring and the 2 perpendicular scan plane. Immediate diagnosis of vasa previa was condition is revealed by postpartum examination of the placenta. made. Concurrent FHR monitoring showed FHR baseline of With the advances of ultrasonographic resolution, the site of umbilical cord insertion can be identified. This is possible in the Correspondence: Dr S Jantarasaengaram, Maternal-Fetal Medicine Unit, Department of vast majority of cases. Sepulveda et al.3 studied 832 non-selected Obstetrics and Gynecology, Rajavithi Hospital, 2 Phyathai Rd, Bangkok 10400, Thailand. E-mail: [email protected] singleton pregnancies between 16 and 40 weeks gestation. One fetal Received 11 January 2007; revised 19 February 2007; accepted 2 March 2007 medicine specialist performed the ultrasound scans with color Ruptured vasa previa S Jantarasaengaram et al 458

Figure 1 (a) Velamentous cord insertion with rupture of the fetal vein. Clot formation at the site of rupture is clearly seen. (b) Rupture ( ) Photomicrograph of the aberrant vessels shows marked site after removal of the clot (arrow). Figure 2 a segmental thinning of tunica media of the vein (arrows): H&E Â 10. (b) Photomicrograph of the area of rupture shows acute inflammatory cells infiltrate, necrosis and fibrin deposition (arrow): H&E Â 20. Doppler mapping in every case. They were able to identify placental cord insertion sites in 99% of cases; in more than 95% of these cases, they could accomplish the task in less than 1 min. would have enabled detection of vasa previa and, in the end, Velamentous cord insertion was determined by prenatal ultrasound provided more systematic management to shorten the time from in eight cases (1%) and was confirmed by gross inspection of the rupture of membranes to delivery in this setting.1,6 We strongly placentae at delivery in seven cases and one case was marginal suggest the addition of identification of the placental cord insertion cord insertion. Sepulveda4 subsequently reported a 100% success site and search for placentae with succenturiate lobes in routine rate in identifying cord insertion site at 11 to 14 weeks ultrasound obstetric ultrasound practice. If abnormal findings are observed, scan in 533 cases with only 30 s added to the overall time. At 18 to target ultrasound, preferably transvaginally in addition with 20 weeks scan in 3,446 pregnancies by general obstetricians and Doppler study at the area over the internal cervical os and lower gynecologists with and without additional color Doppler, uterine segment should be performed to identify vasa previa.6–9 Hasegawa et al.5 reported 62.5% sensitivity of antenatal detection If there is vasa previa, utilization of corticosteroids should be of velamentous cord insertion with 100% positive predictive value considered to accelerate lung maturation, and cesarean delivery and 99.6% negative predictive value. Although we perform obstetric performed preemptively. However, it is unclear at what gestational ultrasound in nearly all of our patients, only a minority of age both of these interventions should occur. The patient should be sonographers look for the site of cord insertion in the placenta. admitted to the hospital and prepared for emergency cesarean Prenatal detection of velamentous cord insertion in this patient when labor or membrane rupture occurs.

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As far as the unexpected favorable outcome of the case is of such imaging needs to be weighed against the possible neonatal concerned, we assumed that engagement of the fetal head after benefits and antepartum management when vasa previa is amniotic fluid leakage produced a ‘tamponade effect’ on the identified needs to be studied. ruptured vessel, which was fortunately the vein. Fetal bleeding was, then, slowed down and eventually stopped as the result of clot and fibrin deposition at the rupture site. Therefore, the fetus could References compensate and survive in utero even after 6 h of vessel rupture. 1 Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. The possibility that the fetal vein was injured in the cesarean Obstet Gynecol 2006; 107: 927–941. delivery, not spontaneously ruptured 6 h earlier, is not likely 2 Jaovisidha A, Herabutya Y. Vasa previa in Ramathibodi Hospital: a 10 years because of fetal anemia and inflammatory cells infiltration in the review. J Med Assoc Thai 1998; 81: 998–1002. rupture site. 3 Sepulveda W, Rojas I, Robert JA, Schnapp C, Lacalde JL. Prenatal Differentiation between fetal and maternal blood by acid elution detection of velamentous insertion of the umbilical cord: a prospective test or alkaline desaturation test is commonly used. A group has color Doppler ultrasound study. Ultrasound Obstet Gynecol 2003; 21: just reported a new rapid test for fetal hemoglobin (HbF) with good 564–569. sensitivity.10 We did not perform the tests due to nonreassuring 4 Sepulveda W. Velamentous insertion of the umbilical cord. A first-trimester fetal status from FHR monitoring and proceeded with emergency sonographic screening study. J Ultrasound Med 2006; 25: 963–968. cesarean. Clinically, these tests could be of help in case of 5 Hasegawa J, Matsuoka R, Ichizuka K, Sekizawa A, Farina A, Okai T. equivocal vaginal bleeding with reassure fetal status. Velamentous cord insertion into the lower third of the uterus is associated Veins are thought to more easily rupture than arteries, though with intrapartum fetal heart rate abnormalities. Ultrasound Obstet Gynecol 2006; 27: 425–429. objective clinical research substantiating this does not appear to 6 Oyelese Y, Catanzarite V, Prefumo F, Lashley S, Schachter M, Tovlbin Y et al. exist. Most of the ruptured vessels are usually those that run Vasa previa: the impact of prenatal diagnosis on outcomes. Obstet Gynecol unprotected over the membranes. Tensile force on the membranes 2004; 103: 937–942. during labor or when membranes themselves rupture is thought to 7 Lee W, Lee VL, Kirk JS, Sloan CT, Smith RS, Comstock CH. Vasa previa: be responsible for rupturing of the vessels. However, in this case, a prenatal diagnosis, natural evolution, and clinical outcome. Obstet Gynecol defect in the vessel wall architecture was detected, as there was 2000; 95: 572–576. segmental thinning of the muscular layer with it very thin in some 8 Catanzarite V, Maida C, Thomas W, Mendoza A, Stanco L, Piacquadio KM. areas. This might be an additional factor. Qureshi et al.11 found Prenatal sonographic diagnosis of vasa previa: ultrasound findings and this ‘segmental thinning’ in 1.5% of placenta specimens received obstetric outcome in ten cases. Ultrasound Obstet Gynecol 2001; 18: for histopathologic examination, with more frequent vein defect 109–115. and association with increased perinatal problems. Whether this is 9 Canterino JC, Mondestin-Sorrentino M, Muench MV, Feld S, Baum JD, more common in aberrant vessels that run through membranes in Fernandez CO. Vasa previa: prenatal diagnosis and evaluation with 3-dimensional sonography and power angiography. J Ultrasound Med velamentous or between the placenta with a succenturiate lobe 2005; 24: 721–724. needs to be further studied. 10 Lindqvist PG, Gren P. An easy-to-use method for detecting fetal Ruptured vasa previa is a catastrophic problem that can lead to hemoglobin-A test to identify bleeding from vasa previa. Eur J Obstet fatal fetal hemorrhage. Prenatal sonographic identification of the Gynecol Reprod Biol 2007; 131: 151–153. cord insertion site may prevent such tragic outcomes and should be 11 Qureshi F, Jacques SM. Marked segmental thinning of the umbilical cord considered to become the standard of practice. The additional cost vessels. Arch Pathol Lab Med 1994; 118: 826–830.

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