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Clinical Significance of Velamentous Cord Insertion Prenatally

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Clinical Significance of Velamentous Cord Insertion Prenatally Journal of Clinical Medicine Article Clinical Significance of Velamentous Cord Insertion Prenatally Diagnosed in Twin Pregnancy Hyun-Mi Lee 1 , SiWon Lee 2 , Min-Kyung Park 3, You Jung Han 4, Moon Young Kim 4, Hye Yeon Boo 1 and Jin Hoon Chung 5,* 1 Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang 10414, Korea; [email protected] (H.-M.L.); [email protected] (H.Y.B.) 2 Department of Obstetrics and Gynecology, Mount Sinai Medical Center, Miami Beach, FL 33109, USA; [email protected] 3 Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul 03722, Korea; [email protected] 4 Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06135, Korea; [email protected] (Y.J.H.); [email protected] (M.Y.K.) 5 Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea * Correspondence: [email protected]; Tel.: +82-2-3010-3654 Abstract: Background: The purpose of this study was to evaluate the prevalence of velamentous cord insertion (VCI) and the actual association between pathologically confirmed VCI and perinatal outcomes in twins based on the chorionicity. Methods: All twin pregnancies that received prenatal care at a specialty clinic for multiple pregnancies, from less than 12 weeks of gestation until delivery in a single institution between 2015 and 2018 were included in this retrospective cohort study. Results: A total of 941 twins were included in the study. The prevalence of VCI in dichorionic (DC) twins and monochorionic diamniotic (MCDA) twins was 5.8% and 7.8%, respectively (p = 0.251). In all Citation: Lee, H.-M.; Lee, S.; Park, study population, the prevalence of vasa previa and placenta accreta spectrum was higher in VCI M.-K.; Han, Y.J.; Kim, M.Y.; Boo, H.Y.; Chung, J.H. Clinical Significance of group than that of non-VCI group (p = 0.008 and 0.022). In MCDA twins with VCI, birth weight, 1 Velamentous Cord Insertion and 5-min Apgar score were lower than DC twins with VCI (p = 0.010, 0.002 and 0.000). There was Prenatally Diagnosed in Twin no significant association between VCI and selective fetal growth restriction (p = 0.486), twin-to-twin Pregnancy. J. Clin. Med. 2021, 10, 572. transfusion syndrome (p = 0.400), and birth-weight discordance (>20% and >25%) (p = 0.378 and https://doi.org/10.3390/jcm100 0.161) in MCDA twins. Conclusion: There was no difference in the incidence of VCI in twins based 40572 on the chorionicity. Moreover, VCI was not a risk factor for adverse perinatal outcomes excepting vasa previa and placenta accreta spectrum, which had a high incidence in twins with VCI. Academic Editor: Michael G. Ross Received: 18 December 2020 Keywords: velamentous cord insertion; twin; perinatal outcomes; pregnancy outcomes; chorionicity; Accepted: 30 January 2021 twin specific complications Published: 3 February 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in 1. Introduction published maps and institutional affil- iations. Velamentous cord insertion (VCI), defined as an abnormal insertion of the umbilical vessels that insert into the fetal membranes before entering the placenta is one of the abnormal placental insertion findings of the umbilical cord. The incidence of VCI has been reported to be 0.1–1.8% in all pregnancies [1]. An increased prevalence of VCI had been reported for twin pregnancies (1.6–40%) especially Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. in monochorionic (MC) twin pregnancies, probably as a result of unequal sharing of the This article is an open access article placentas [2,3]. distributed under the terms and A number of previous studies have reported that VCI is associated with adverse conditions of the Creative Commons maternal and perinatal outcomes [1,4,5]. Likewise, VCI in MC twins has been proposed as Attribution (CC BY) license (https:// a risk factor in the development of selective fetal growth restriction (sFGR), twin-to-twin creativecommons.org/licenses/by/ transfusion syndrome (TTTS) and birth-weight (BW) discordance [4,6–9]. However, some 4.0/). studies were incongruent with the results and suggested that the adverse complications J. Clin. Med. 2021, 10, 572. https://doi.org/10.3390/jcm10040572 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, x FOR PEER REVIEW 2 of 9 J. Clin. Med. 2021, 10, 572 twin-to-twin transfusion syndrome (TTTS) and birth-weight (BW) discordance [4,6–9].2 of 9 However, some studies were incongruent with the results and suggested that the adverse complications in VCI were possibly due to the selection bias and pointed out that these unique adverse outcomes in MC twins are likely the consequences of the vascular com- in VCI were possibly due to the selection bias and pointed out that these unique adverse plications of the placental sharing rather than VCI [4,10,11]. outcomes in MC twins are likely the consequences of the vascular complications of the Therefore, this study aimed to assess the prevalence of VCI in twin pregnancy and placental sharing rather than VCI [4,10,11]. evaluate whether prenatally detected VCI was associated with adverse perinatal out- Therefore, this study aimed to assess the prevalence of VCI in twin pregnancy and comes including unique complications of twin pregnancies based on the chorionicity. evaluate whether prenatally detected VCI was associated with adverse perinatal outcomes including unique complications of twin pregnancies based on the chorionicity. 2. Material and Methods 2. MaterialThis study and Methodswas a retrospective cohort study of twin pregnancies with known preg- nancyThis outcomes study was and a pathologically retrospective cohortconfirm studyed VCI of in twin Cheil pregnancies General Hospital with known and Wom- preg- nancyen’s Healthcare outcomes andCenter pathologically between January confirmed 2015 VCI and in March Cheil General2018. The Hospital chorionicity and Women’s was de- Healthcaretermined by Center the first between trimester January ultrasonography 2015 and March by 2018. the Thenumber chorionicity of gestational was determined sacs, yolk bysacs, the and first fetuses. trimester The ultrasonography monochorionic bymonoam the numberniotic (MCMA) of gestational twin sacs,pregnancies yolk sacs, with and a fetuses.high risk The of perinatal monochorionic complications monoamniotic and twin (MCMA) pregnancies twin with pregnancies major congenital with a high anomaly risk ofor perinatalaneuploidy complications were excluded. and Ethical twin pregnancies approval of with the study major was congenital obtained anomaly from the or institu- aneu- ploidytional review were excluded. board (CGH-IRB-2018-37). Ethical approval ofThe the need study to obtain was obtained informed from consent the institutionalwas waived. reviewPlacenta board (CGH-IRB-2018-37).cord insertion site was The categori need tozed obtain into informedtwo groups: consent VCI and was non-VCI. waived. VCI was Placentadetermined cord during insertion the site anatomy was categorized ultrasound into by two a maternal groups: VCIfetal and medicine non-VCI. (MFM) VCI wasspecialist determined using high-resolut during the anatomyion sonography ultrasound equipments by a maternal (Voluson fetal E8 medicine (GE Healthcare, (MFM) specialistMilwaukee, using WI, high-resolution USA), EPIQ5 sonography(Philips, Amsterda equipmentsm, Netherlands)). (Voluson E8 (GE As Healthcare,part of this Mil- ex- waukee,amination, WI, MFM USA), specialist EPIQ5 (Philips, evaluated Amsterdam, the placen Netherlands)).tal umbilical cord As part insertion of this examination,site using the MFMappropriate specialist magnification evaluated the and placental settings. umbilical After identifying cord insertion the umbilical site using cord, the appropriate MFM spe- magnificationcialist followed and it settings.until it reached After identifying the placental the umbilical surface. cord,The insertion MFM specialist site was followed further itconfirmed until it reached with color the placental flow imaging surface. if Thenecessary. insertion The site VCI was was further diagnosed confirmed when with the color um- flowbilical imaging cord was if necessary. attached to The the VCI placental was diagnosed membranes when instead the umbilical of the placental cord was body. attached When toVCI the was placental detected, membranes the patient instead underwent of the sono placentalgraphy body. again When two VCIweeks was later detected, by another the patientMFM specialist. underwent The sonography MFM specialist again performed two weeks either later bya transabdominal another MFM specialist.or transvaginal The MFMscan (Figure specialist 1) [12]. performed The VCI either group a transabdominalwas defined as VCI or transvaginal in one or both scan of the (Figure fetuses.1)[ 12The]. Thechorionicity VCI group was was determined defined asby VCI assessing in one the or nu bothmber of theof the fetuses. gestational The chorionicitysac, yolk sac, was and determinedthe shape of by intertwin assessing membranes the number onof the the firs gestationalt trimester sac,ultrasound yolk sac, [13]. and We the confirmed shape of intertwinthe VCI and membranes the chorionicity on the first by trimester postpartum ultrasound pathological [13]. We examination confirmed theof VCIthe placenta and the chorionicity(Figure 2). by postpartum pathological examination of the placenta (Figure2). Figure 1. Velamentous cord insertion demonstrated with color Doppler imaging in
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