Velamentous Cord Insertion - an Important Obstetrical Risk Factor

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Velamentous Cord Insertion - an Important Obstetrical Risk Factor Gineco.eu [12] 129-134 [2016] DOI: 10.18643/gieu.2016.129 @ 2016 Romanian Society of Ultrasonography in Obstetrics and Gynecology gineco eu Velamentous cord insertion - an important obstetrical risk factor Abstract Monica Mihaela Cîrstoiu1,2, A velamentous insertion of the umbilical cord is characterized by the atypical aspect of the placental end of the cord, 2 consisting in divergent umbilical vessels surrounded by fetal membranes and with no Wharton’s jelly present, resulting a Natalia Turcan , cord that is inserted rather into membranes than the placental disk. By the divergence of the umbilical vessels as they travers E lv ira Brătilă1,3, the amnion and the chorion before reaching the placenta this condition associates important obstetrical complications Octavian and the diagnosis by ultrasonography as early is possible is important for the guidance of the subsequent management. Munteanu1,2, In this retrospective study we aimed to evaluate the incidence of velamentous cord insertion in University Emergency 2 Hospital of Bucharest for a period of five years and analyze the pregnancies outcome and the obstetrical impact of this Oana Bodean , condition. Using the statistics department of University Emergency Hospital Bucharest we determined an incidence of Diana Voicu2, 0.23% of pregnancies complicated by velamentous cord insertion. The examined parameters included intrauterine fetal Roxana Elena death, small for gestational age, preterm delivery (<37 weeks), single artery umbilical cord and low Apgar score at 1 Bohîlțea1,2, minute. We chose to exemplify with a case of early diagnosis of this condition, respectively at 15 weeks of gestation. The attempt to visualize cord insertion in the mid-trimester as a routine part of obstetric sonography is recommended. The Simona identification of velamentous cord insertion dictates the mode and timing of delivery and can improve fetal outcome Vladareanu1 Keywords: cord insertion, mid-trimester, sonography 1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2. University Emergency Hospital Bucharest, Romania 3. ”St. Pantelimon” Clinical placenta proliferates toward the uterine fundus, and Emergency Hospital, Introduction Bucharest, Romania Normally and physiologically the umbilical cord is the other half involutes(3). Association of velamentous Correspondence: inserted into the central portion of the placenta, abnor- marginal umbilical cord insertion with vasa praevia or Dr. Roxana Bohîlțea mally variants of placental cord insertion are the edge praevia/low-lying, bilobed or succenturiate placental e-mail: r.bohiltea@ of the placental disk or velamentous cord insertion. lobe is encountered in 90-95% of cases(4,5). Other pre- yahoo.com A velamentous insertion of the umbilical cord is cha- sumed risk factors are pregnancies obtained through racterized by the atypical aspect of the placental end assisted human reproduction techniques, regarded as of the cord, consisting in divergent umbilical vessels amplifying the risk of developing velamentous cord surrounded by fetal membranes and with no Wharton’s insertion by 10 times, multiparous pregnancies and jelly present, resulting a cord that is inserted rather single artery umbilical cord(6). into membranes than the placental disk (Figure 1). By By the divergence of the umbilical vessels as they the absence of the Wharton’s jelly protection, umbilical travers the amnion and the chorion before reaching the cord vessels are susceptible to compression and rup- placenta this condition associates important obstetrical ture, risk which is amplified if they are located in the complications and the diagnosis by ultrasonography as membranes that covers the internal cervical ostium. early is possible is important for the guidance of the This particular appearance of the placental insertion subsequent management. By ultrasonography this form of the umbilical cord has been associated with several of the placental insertion of the umbilical cord can by obstetrical complications such as fetal growth restric- diagnosed with a sensitivity of 67% and a specificity of tion, prematurity, placental abruption, vasa praevia, 100% in the second trimester(7a), in the third trimester congenital anomalies and low Apgar score or even this condition is also reflected through variable dece- intrauterine fetal death(1). lerations and abnormal fetal heart rate variability in With an occurrence of about 1 percent of singleton non-stress test. gestation and about 15 percent of monochorionic twin The most reliable method is the real-time color gestation(2), the pathogenesis of this condition is still Doppler transvaginal ultrasound examination, thus unknown. One of the hypothesis, based on the fact being able to emphasize the umbilical vessel pathway, that velamentous cord insertion (VCI) occurs more which crosses the internal os or passes at less than 2 Received: common in placenta praevia than in normally located cm from it and the study of umbilical artery end-di- May 06, 2016 placentas, suggests that the centrally inserted cord ini- astolic velocity. Revised: June 17, 2016 tially is unable to follow the migration of the placenta, On ultrasound can be observed the ending of the Accepted: becoming progressively peripheral as one half of the cord on several centimeters from the placenta that August 25, 2016 Vol. 12 • No. 45 (3/2016) 129 Cîrstoiu et al. Velamentous cord insertion... Figure 1. Schematic representation of the velamentous insertion of umbilical cord most often occur at the margin of the placenta but Methods the presence at the apex of the gestational sac is also In this retrospective study, 18 500 pregnancies were possible. Typically, the umbilical vessels lie parallel to analyzed between January 1 2010 and July 1 2016, the uterine wall as they penetrate the placental pole. using the statistics Department of University Emergen- Although these are high percentages, and the possibility cy Hospital Bucharest, of which, 43 were complicated for intrapartum diagnosis of various pathological chan- by VCI. ges evolves daily, VCI is one of the most undiagnosed The examined parameters included intrauterine fetal conditions in obstetrics(7b, 8). death, small for gestational age, preterm delivery (<37 The American College of Radiology, the American weeks), single artery umbilical cord and low Apgar Institute of Ultrasound in Medicine, and the American score at 1 minute. College of Obstetricians and Gynecologists(9) do not recommend the evaluation of the placental insertion Results of the cord by routine but “the umbilical cord should be From 2010 to 2016, 18.500 women delivered at our imaged, and the number of vessels in the cord should Department. be evaluated when possible”(9). The study group includes 43 (prevalence 0.23%) Regarding the management of pregnancies with VCI, pregnancies that were diagnosed intrapartum or post- Lockwood at al. in a recent published article(10) recom- partum with VCI. Among the cases studied no cases of mends the following: intrauterine fetal death was registered. 1. Detailed fetal anatomic survey, including evalua- The smallest gestational age at birth was 30 weeks tion for coexistent vasa praevia, and 5 cases of birth at 40 weeks of gestation (Figure 2). 2. Serial assessment of fetal growth, every four to In over 50% of pregnancies complicated with VCI six weeks, birth occurred at 38-39 weeks of gestation, and in 3. Fetal heart rate tracings weekly, beginning at 36 14 cases (32.54%) preterm birth was registered. For weeks of gestation, to look for recurrent variable de- assessing the weight of newborns in accordance with celerations from kinking or compression, gestational age we used international conventional 4. Counseling patients to call their providers as soon values. as labor begins, The highest recorded weight of a new born delivered 5. Delivery by 40 weeks of gestation, at term of a pregnancy with velamentous insertion of In this paper we aimed to evaluate the incidence of the umbilical cord was 4050 g and the lowest weight VCI in University Emergency Hospital of Bucharest of a delivered at term newborn was 2450 g. In preterm for a period of five years and analyze the pregnancies cases, the lowest weight was 1100 g at 31 weeks of outcome and the obstetrical impact of this condition. gestation preterm newborn. 130 Vol. 12 • No. 45 (3/2016) Cîrstoiu et al. Velamentous cord insertion... gineco eu 25 51.16% 20 15 10 Number of cases 16.27% 16.27% 16.27% 5 0 <36 36-37 38-39 40-41 Weeks of Gestation Figure 2. Classification by gestational age <2500 gr >3500 gr 7% 13% 3000-3500 gr 2500-3000 gr 33% 47% Figure 3. Delivery weight at term Over 50% of the newborns delivered at 38 to 41 weeks born with a 3000 g weight and the mother associated of gestation weighed under 3000 g at birth (Figure 3). preeclampsia. Only 3 newborns at term received the All of preterm newborns had the delivery weight maximal score at delivery. The lowest score for this within the appropriate for gestational age limits (Fi- category was 8. gure 4). Only 5 cases of natural delivery were registered (Figu- In the course of studying the collected data, we no- re 5), the Apgar score for all this cases was 8 and above. ticed a slight predominance of single artery umbilical cord associated with VCI, respective 12 cases (27.9%) Discussion with VCI associated single artery umbilical cord, and We report a case of velamentous insertion of the the reason of this association is unknown. umbilical cord observed at 15 weeks gestation in a The lowest value of the Apgar score at 1 minute primiparous woman, with no significant antecedents, was “3” and obtained by a 36 weeks of gestation new- during a routine ultrasound scan (Figure 6). These Vol. 12 • No. 45 (3/2016) 131 Cîrstoiu et al. Velamentous cord insertion... 7% 7% 57% 29% 1000-1500 gr 1500-2000 gr 2000-2500 gr >2500 gr Figure 4. Delivery weight in preterm newborns Natural Birth 12% Caesarean section 88% Figure 5.
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