Umbilical Cord  Two umbilical arteries + one umbilical vein The Umbilical Cord  Surrounded by Wharton’s jelly gelatinous mucopolysaccharides protect umbilical vessels  Outer amniotic layer  Inner sub-amniotic layer rich source of mesenchymal stem cells No Disclosures

Umbilical Cord Umbilical Cord

Ultrasound of normal umbilical cord

UmbilicalDiagram veinumb cordcarries 3 vessels — 2 arteries & 1 vein oxygen & nutrients from placenta to fetus Surrounded by small amount of Wharton’s jelly Coiled/helical configuration Umbilical arteries Umbilical Inserts into central part of placenta vein Umbilical arteries carry waste products from fetus to placenta

Abnormalities of Umbilical Umbilical Cord Cord  2 vessels, 1 artery & 1 vein  Anomalous venous return Are there really 3 vessels?  Masses or cysts  Nuchal cord  Abnormal placental cord insertion velamentous marginal  Cord presenting/prolapse

Page 1 2-Vessel Umbilical Cord

 Single umbilical artery  0.2 – 1% of pregnancies Zuckerman 3VC by bladder clip & Renta  Whites > Blacks, Asians  Multiple > Singleton gestations   incidence in monozygotic twins often discordant   incidence of fetal anomalies

2-Vessel Umbilical Cord

Ultrasound findings Diomede & 2-vessel cord Caldwell 2vc Color Doppler 2-vessel cord Single vessel by bladder

2-Vessel Umbilical Cord 2-Vessel Umbilical Cord

Outcome at birth Associated anomalies Cardiovascular (51%) 31% congenital anomalies* Gastrointestinal (38%) (4% aneuploidy) Central nervous system (24%) 69% normal Genitourinary (16%) Pulmonary (11%) *Most identified by prenatal ultrasound Musculoskeletal (8%)

Page 2 Isolated 2-Vessel Cord on Prenatal Ultrasound

Outcome at birth

Trott, 2VC TOF 7% Congenital anomalies 2-vessel cord 93% Normal Tetralogy of Fallot

Misdiagnosis of 3-vessel cord V Isolated 2-Vessel Cord on

Prenatal Ultrasound 17 weeks 30 weeks A Structural anomalies at birth not diagnosed at prenatal ultrasound

Powe misDx of 2vc Ventricular septal defect Tracheoesophageal fistula Ambiguous genitalia Clubfoot

Misdiagnosis of 3-vessel cord Misdiagnosis of 3-vessel cord

Krueger misDx of 2vc Freeman misDx of 2vc

Page 3 Anomalous Umbilical Venous Anomalous Umbilical Venous Return Return  Drainage of umbilical vein  Persistent right umbilical vein through channels other than  Absent ductus venosus ductus venosus in liver  Direct into systemic circulation  Alters flow to and through heart  Ductus venosus to systemic circulation  May lead to hydrops  Intrahepatic porto-systemic shunt  Associated with anomalies &  Extrahepatic porto-systemic shunt aneuploidy

Umbilical vein drains Right umbilical vein into infrahepatic inferior vena cava

Pena right UV Scola anom UV return *

*Gallbladder

Absent ductus venosus, Polyhydramnios Absent ductus venosus Umbilical vein drains into left hepatic vein

Zwick absent DV poly Ortiz absent DV

Normal Normal Abnormal hepatic portal hepatic vein vein vein waveform waveform waveform

Page 4 Umbilical vein drains into iliac vein Umbilical vein drains into iliac vein Dilated inferior vena cava, cardiomegaly

Scola anom UV return Scola anom UV return

Intrahepatic portosystemic shunt Lesions of Umbilical Cord

 Cyst - allantoic duct Philogene intrahep portosystemic shunt  Focal thickening of Wharton’s jelly  Venous varix  Mass — teratoma, hemangioma

Associated with adverse outcome fetal distress, intrauterine growth restriction, demise, anomalies

Umbilical Cord Cysts Umbilical Cord Cysts

1st Trimester 2nd Trimester  Prevalence ~ 0.4 – 3.4%  Cysts associated with  Usually detected at 8 – 9 weeks omphalocele patent urachus  Typically resolve before urinary anomalies 2nd trimester & normal outcome  Pseudocyst associated with  If persist into 2nd trimester aneuploidy  anomalies & aneuploidy anomalies

Page 5 Cyst of the umbilical cord – 9 weeks Cyst of the umbilical cord – 17 weeks

Boothroyd UC cyst Lymon UC cyst

Umbilical cord cyst Umbilical cord cyst 13 weeks 13 weeks ↓

Vazquez UC cyst & omphal Omphalocele Vazquez UC cyst & omphal 20 weeks

19 weeks 34 weeks Umbilical Umbilical Garney UC cyst cord cord Garney UC cyst patent urachus cysts thickening patent urachus

26 weeks 30 weeks

Page 6 Neonate: Patent urachus Opening from bladder to umbilical cord

UC Delivery: Garney UC cyst patent urachus Garney Baby UC cyst Umbilical Placenta patent urachus BL cord thickening

Placental Cord Insertion  Required element of 2nd & 3rd trimester scan  Assess for abnormal insertion Diaz PUBS Velamentous Marginal  Locate for percutaneous umbilical blood sampling (PUBS) Color Doppler follow umbilical vessels to placenta

Marginal and Velamentous Marginal and Velamentous Umbilical Cord Insertions Umbilical Cord Insertions Predisposing factors Abnormal insertion of cord into placenta Multiple gestation Marginal: < 1cm from placental edge Low-lying placenta or previa Velamentous: vessels travel unprotected Uterine scarring beneath membranes before insertion Uterine anomalies At risk for rupture, thrombosis Singletons Twins Risk higher for velamentous Marginal 7% 20% Velamentous 1% 12%

Page 7 Marginal cord insertion Velamentous cord insertion

Mangione Velamentous CI Lin marginal CI

Velamentous cord insertion

P

Velamentous Ortiz cord Velamentous CI insertion between succenturiate P P lobes Greenleaf Velamentous CI betw succ lobes P

Velamentous cord insertion On intertwin Vasa Previa membrane  Velamentous cord insertion in Santos intertwin memb lower uterine segment with 23 weeks Velamentous CI 31 weeks fetal vessels crossing cervix  Associated with high perinatal mortality  May develop from prior low-lying placenta

Page 8 Vasa Previa Vasa Previa Charbit vasa previa Ultrasound and Color Doppler findings Vessels lying across the cervix

Spectral Doppler findings Umbilical arterial & venous waveforms

Previa Vasa Previa 19w Vasa Previa

Vasa Previa McGrath vasa 26w previa *

Rueda vasa previa from* lowlying30w pl * *

Cord (Funic) Presentation

Associated with abnormal fetal heart rate patterns Collin cord presenting Obstetrical emergency Risk of cord prolapse

Color Doppler umbilical vessels between fetus and cervix

Page 9 Obligate cord presentation

Zuo obligate cord presenting

Rodriquez cord prolapse

Umbilical Vein Varix Umbilical Vein Varix

Focal dilatation of umbilical vein Associated with Fetal anomalies & normal karyotype Garang UV varix (12%) Aneuploidy (10%) Fetal demise (10%) Anemia (6%)

Umbilical Vein Varix False knot Umbilical Vein Varix

Godfrey UV varix Banik UV varix outside fetus false knot

Page 10 Umbilical Artery Doppler Umbilical Artery Doppler Assess fetal well-being Assess fetal well-being Concerning findings: Diminished end diastolic flow Absent or reversed end diastolic flow elevated systolic/diastolic (S/D) Associated with Absent or reversed  morbidity end diastolic flow Associated with  mortality morbidity mortality

Normal Diminished End Diastolic Flow

Brewer Nl UA Doppler Ahir diminished diastolic flow

Reversed End Diastolic Umbilical Cord Vessels Flow

Buccafusca Reversed diastolic flow Unusual cases

Page 11 3 - Or 2 - 22 weeks 32 weeks vessel Holiday 3 to 2 vessel cord? vessel cord clip cord?

Steed 3 to 2 vc

Hypoplastic Tetralogy of Fallot Thrombosed umbilical artery Umbilical Artery

Magalhaes hypoplA Pilgrim UA & TOF thrombosed UA

A V

How many 6 - vessels? Vessel Cord

Khalifa 6 vessel cord 1 Khalifa 3 6 4 2 conjoined twins 5

Page 12 Hall 3D face&UC

The end

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