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 Page 13.