Clinics and Practice 2013; volume 3:e23

Intrauterine growth restriction analgesia was given. Cardiotocography at that moment demonstrated a normal reactive pat- Correspondence: Ann Schmid, Zaaldenrode 2, associated with excessively tern. Dilation progressed slowly, after 12 h fetal 2640 Mortsel, Belgium. long umbilical cord bradycardia, to 60 bpm, developed, with nor- Tel.: +32.486.22.93.64. malization at 8 min. At that moment cervical E-mail: [email protected] Ann Schmid, Yves Jacquemyn, dilation was 4 cm and monitoring for ST-analy- Contributions: SA, manuscript writing; JY, diag- Jeannette De Loor sis was placed (Figure 1). Two hours later, syn- nosis and treatment, correcting manuscript; DLJ tocinon was given because of bad progression Department of Obstetrics and revised this case report critically for important in labor. But it had to be interrupted because of Gynaecology, Antwerp University intellectual content and translation. a suboptimal pattern at the cardiotocography. Hospital UZA, Edegem, Belgium Because of not progressive labor and the Conflict of interests: the authors declare no impossibility to raise the uterotonica, the potential conflict of interests. gynecologist decided to perform caesarian sec- Key words: umbilical cord, intrauterine growth tion. The patient delivered a female infant restriction, cord abnormality. Abstract weighing 1550 g, with an Apgar-score of 9 after 1 and 5 min and 10 after 10 min. The pH-values Received for publication: 14 February 2013. We present a 37-week female baby, known on the umbilical cord blood samples were nor- Revision received: 16 April 2013. with intrauterine growth restriction since 25 mal (arterial 7.31 and venous 7.35). The child Accepted for publication: 24 April 2013. weeks of pregnancy, born with a placenta with did well in the intermediate care nursery. an excessive long umbilical cord (ELUC), with- Macroscopic evaluation of the placenta This work is licensed under a Creative Commons out any other abnormalities. ELUC is mostly an showed an excessively long umbilical cord, Attribution NonCommercial 3.0 License (CC BY- NC 3.0). incidental finding after delivery, but repre- measuring 125 cm, a size of 13 cm by 13 cm sents a potentially detectable intrauterine and a thickness of 2 cm (Figure 2). The weight ©Copyright A. Schmid et al., 2013 cause of growth restriction. A system that of the placenta was 270 grams, which is small Licensee PAGEPress, Italy allows ultrasound measurement of the length for 37 weeks of pregnancy (miscarriages.3 This suggests that umbili- use cal cord length is already established early in Introduction pregnancy and so it could be a reliable param- eter during the ultrasound follow up in prena- Intrauterine growth restriction (IUGR) is a Discussion tal care. Baergen et al. did a big case-control common diagnosis in obstetrics and carries an study in New York. They found an association increased risk of perinatal mortality and mor- IUGR is a common diagnosis in obstetrics between ELUC and women with systemic dis- bidity. The etiology of IUGR in a specific case and carries an increased risk of perinatal mor- eases and with postpartum and perpartum often stays unknown. We present a case of tality and morbidity. Decreased intrauterine complications.3 There was also a significant early onset IUGR related to an excessive long growth may have a negative effect on brain correlation with higher birth weight, adverse umbilical cord (ELUC), without any other growth and mental developmental potential. It neonatal outcome, low apgar-scores, male abnormalities. is important to identify IUGR because proper fetuses, fetal anomalies and cord entangle- evaluation and management can result in a ment. Fetal and neonatal mortality and IUGR favorable outcome. This case illustrates the were seen in a higher number in the ELUC- association between an extremely long umbili- group, but there was no statistical signifi- Case Report cal cord and intrauterine growth restriction. It cance. But Tantbirojn et al. did an evaluation of is known that in an excessive long cord, the placentas with gross cord abnormalities and A 22-yearold woman visited our hospital for risk of clinical umbilical cord entanglement their relationship to adverse clinical outcomes the prenatal care of her first pregnancy.Non-commercial At 25 (i.e. true knots or cord loops around the neck and stasis-associated histologic changes in the weeks gestational age intrauterine growth or body parts) and circulatory stasis and vascu- placenta.4 They found that gross cord abnor- restriction was diagnosed on ultrasound. lar thrombosis is higher.1,2 This can cause peri- malities were significantly associated with There was no history of any medical condition natal complications, like intrauterine growth stillbirth, intrauterine growth restriction, non- nor any abuse that could explain the IUGR in restriction, neurological complications and reassuring fetal tracing, meconium-stained this on ultrasound structurally normal fetus. fetal death. A normal umbilical cord is about 50 amniotic fluid, and increased rate of emer- Doppler velocimetry in the umbilical artery and to 60 cm. We talk about a short umbilical cord gency cesarean section. At microscopic evalua- the middle cerebral artery always was within if it is less than 30 to 40 cm and a long one tion, cases with gross cord abnormalities normal limits. The amniotic fluid index was from 70 to 80 cm.3 showed a statistically significant association normal and amniocentesis showed a normal The umbilical cord is responsible for the with both ectasia and thrombosis in the fetal karyotype, 46 XX. The estimated fetal weight at transport of nutrition, oxygen and fluid neces- vasculature, as well as changes of fetal throm- 37 weeks of pregnancy was 1600 grams. It was sary for the intrauterine existence of a fetus. botic vasculopathy in the terminal villi. decided to induce labor at 37 weeks gestation- So it’s not surprising there is an association Considering individual gross cord abnormali- al age. This was performed using an extra- between gross cord abnormalities and adverse ties, long cord and nuchal cord had the highest amniotic balloon, followed after 6 h by extra- perinatal outcome. rate of thrombosis-related histopathology. amniotic administration of prostaglandin (0.5 It is assumed that length of an umbilical Finally, cases with both abnormal cords and mg dinoproston, Prepidil gel®, Pfizer, cord is determined by environmental as well as histologic thrombosis had significantly higher Belgium). On the patients demand, epidural genetical factors. ELUC is associated with rates of adverse outcomes, including IUGR and

[Clinics and Practice 2013; 3:e23] [page 61] Case Report

Figure 2. Placenta with excessive long umbilical cord: 125 cm.

References

1. Redline RW. Clinical and pathological umbilical cord abnormalities in fetal thrombotic vascu- lopathy. Hum Pathol 2004;35:1494-98. 2. Chan JS, Baergen RN. Gross umbilical cord complications are associated with placental lesions of circulatory stasis and fetal hypoxia. Pediatr Dev Pathol 2012;15:487-94. 3. Baergen RN, Malicki D, Behling C, Benirschke K. Morbidity, mortality, and placental pathology inonly excessively long umbilical cords: retrospec- tive study. Pediatr Dev Pathol 2001;4:144-53. Figure 1. Fetal heart rate monitoring. Fetal bradycardia can be related to intrauterine 4. Tantbirojn P, Saleemuddin A, Sirois K. Gross growth restriction as well as to excessive long umbilical cord (ELUC) (for example cord entanglement is more frequently seen in ELUCs). abnormalities of the umbilical cord: related pla- use cental histology and clinical significance. Placenta 2009;30:1083-8. 5. Saleemuddin A, Tantbirojn P, Sirois K. stillbirth. We can found this association of an illustrates the unusual occurrence of FTV of Obstetric and perinatal complications in pla- abnormal cord, histologic thrombosis and such severe extent in association with ELUC centas with fetal thrombotic vasculopathy. IUGR also in our case. Unfortunately these his- leading to fetal demise. This case illustrates Pediatr Dev Pathol 2010;13:459-64. tological findings are only detectable postpar- that ELUC alone may be enough to predispose 6. Andres RL, Kuyper W, Resnik R. The associa- tum, but it is not unimaginable to examine the the placenta to massive FTV. We present this tion of maternal floor infarction of the placenta umbilical cord during prenatal care. case to emphasize the role of umbilical cord with adverse perinatal outcome. J Clin Pathol Ultrasound evaluation of the umbilical cord length as a predictor of adverse perinatal out- 2008;61:1276-84. should not be very incriminating in the assess- come. Umbilical cord abnormalities can be an 7. Taweevisit M, Scott Thorner P. Massive fetal ment of a fetus in the prenatal care. early warning system for fetal problems. A lean thrombotic vasculopathy associated with Aasia Saleemuddin describes that in a study or hypo-coiled umbilical cord has been excessively long umbilical cord and fetal of placentas reviewed for adverse neurodevel- described as a factor contributing to IUGR and demise: case report and literature review. opmental outcome, fetal thrombotic vasculopa- perinatal complications.8 Studies have been Pediatr Dev Pathol 2010;13:112-5. thy showed to be most commonly associated published on the relation between umbilical 8. El Behery MM, Nouh AA, Alanwar AM, Diab AE. with grossly abnormal umbilical cords (includ- cord thickness9 even from the first trimester Effect of umbilical vein blood flow on perinatal ing excessively long umbilical cords,Non-commercial nuchal and perinatal outcome,10 and prenatal indices outcome of fetuses with lean and/or hypo- cords, or cords showing hypertwisting and/or for coiling and umbilical cord diameter have coiled umbilical cord. Arch Gynecol Obstet abnormal insertions) which predispose to cord been published11 and related to fetal outcome, 2011;283:53-8. compression and compromise fetal blood flow.5 but no simple and reliable methods has been 9. Ghezzi F, Raio L, Günter Duwe D, et al. It is remarkable that fetal thrombotic vascu- developed to evaluate umbilical cord length Sonographic umbilical vessel morphometry lopathy was originally suspected to be mainly a sonographically, only sophisticated experimen- and perinatal outcome of fetuses with a lean marker for fetal and/or maternal thrombophil- tal models not yet applicable in clinical medi- umbilical cord. J Clin Ultrasound 2005;33:18-23. ia, but however, later studies found similar cine have been developed.12 10. Goynumer G, Ozdemir A, Wetherilt L, et sl. rates of fetal/maternal thrombophilias in pla- More research is needed to evaluate the role Umbilical cord thickness in the first and early centas with or without fetal thrombotic vascu- of umbilical cord length and to determine the second trimesters and perinatal outcome. J lopathy. Andres et al described an association possibility to develop simple methods, for Perinat Med 2008;36:523-6. between massive perivillous fibrin deposition, which we propose for instance the number of 11. de Laat MW, Franx A, Bots ML, et al. Umbilical also called maternal floor infarction, and transverse cuts through the umbilical cord in coiling index in normal and complicated preg- IUGR.6 Mana Taweevisit7 presented a case of a the four quadrants such as used in the amniot- nancies. Obstet Gynecol 2006;107:1049-55. 37-week male stillborn fetus whose placenta ic fluid index, to measure umbilical cord length 12. Rousian M. Verwoerd-Dikkeboom CM, Koning had an excessively long umbilical cord and no during routine sonographical examination or AH, et al. First trimester umbilical cord and other cord abnormalities associated with fetal in cases of IUGR. vitelline duct measurements using virtual real- ity. Early Hum Dev 2011;87:77-82. thrombotic vasculopathy (FTV). This case

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