Hiperenrollamiento con torsión del cordón umbilical como causa de muerte fetal: reporte de caso / Hypercoiled umbilical cord torsion as a cause of fetal death: case report

Resumen La torsión del cordón umbilical como causa de muerte fetal es rara, con pocos casos reportados. No se conoce con claridad la causa y se presenta principalmente en el segundo trimestre de embarazo. Los factores de riesgo descritos son la longitud del cordón umbilical y el aumento del número de giros. Se reporta el caso de una paciente de 37 años, grávida 2, para 1 con embarazo de 23 semanas, con hallazgo ecográfico de muerte fetal. En el estudio de histopatología se evidenció el cordón umbilical con hiperenrollamiento y torsión a nivel de la unión feto-umbilical con oclusión de la luz de los vasos umbilicales como causa de muerte fetal. Se requiere la investigación de esta patología para determinar los factores de riesgo y el riesgo de recurrencia en futuros embarazos con el fin de establecer métodos de vigilancia fetal antenatal.

Abstract Torsion of the umbilical cord as a cause of fetal death is a rare occurrence, with few reported cases. The cause is not clearly known, and it transpires mainly in the second trimester of pregnancy; the risk factors described are the length of the umbilical cord with increased number of twists. The case of a 37-year-old woman is reported, gravida 2 para 1, 23 weeks pregnant with ultrasound diagnosis of fetal death. Histopathology revealed hypercoiled umbilical cord torsion at the point where the umbilical cord attaches to the fetus, with occlusion of the lumen of the umbilical vein, as a cause of fetal death. Further research of this pathology is required to determine the risk factors and risk of recurrence in future pregnancies that will allow the preparation of antenatal fetal surveillance methods.

Diagnóstico posnatal de hematoma de cordón umbilical: reporte de un caso / Postnatal diagnosis of umbilical cord hematoma: case report

ANTECEDENTES: El hematoma espontáneo del cordón umbilical es una complicación rara del embarazo que representa una causa grave de morbilidad y mortalidad fetal. Se han descrito numerosos factores de riesgo, pero aún se desconoce su etiología exacta. CASO CLÍNICO: Mujer de 28 años, en su octava gestación, que consultó en urgencias por disminución de los movimientos fetales de varias horas de evolución tras una caída accidental traumática. La monitorización fetal mostró un patrón cardiotocográfico no tranquilizador, con disminución de la variabilidad y sin aceleraciones. Se realizó una cesárea urgente, sin complicaciones, con el nacimiento de un varón vivo de 4560 g, con Apgar 8/10/10 y pH de sangre de cordón umbilical 7.08, que precisó ingreso en la unidad de neonatología por hallazgo de un soplo cardíaco. Tras el alumbramiento se objetivó una gran colección hemática en el cordón umbilical. MÉTODO: Se aplicó una estrategia de búsqueda sistemática en Medline, PubMed y Cochrane de todos los artículos en inglés y español que tuvieran como palabras clave "Umbilical", "Cordón" y "Hematoma". RESULTADOS: Se encontraron 13 publicaciones de 15 casos de hematoma del cordón umbilical en los años 2008-2020. Se realizó una revisión sistemática de los informes de casos descritos en los últimos 12 años en la literatura para evaluar la epidemiología, los factores predisponentes, los resultados potenciales, el diagnóstico prenatal y el manejo clínico. CONCLUSIONES: Debido a la rareza de esta afección, se deben informar todos los casos nuevos de hematoma del cordón umbilical para mejorar el conocimiento de los factores predisponentes, el diagnóstico prenatal y el manejo clínico.

BACKGROUND: Spontaneous umbilical cord hematoma is a rare complication of pregnancy which represents a serious cause of fetal morbidity and mortality. There are many risk factors, but the exact etiology is still unknown. CASE REPORT: 28-year-old woman, eighth gestation, who consulted due to decreased fetal movements of several hours of evolution after traumatic accidental fall. Fetal monitoring showed a non-reassuring cardiotocographic pattern, with decreased fetal variability, without accelerations. An emergency cesarean section was performed without complications, with the birth of a living male weighing 4560 grams, with an 8/10/10 Apgar test, and an arterial pH of the umbilical cord 7.08, which required admission to the neonatology unit. After delivery, a large blood collection was observed in the umbilical cord. METHOD: A systematic search strategy was applied to several electronic bibliographic databases: Medline, PubMed and Cochrane. Key words used were "Umbilical", "Cord", "Hematoma". RESULTS: 13 publications of 15 cases of umbilical cord hematoma were reported in the years 2008-2020. A systematic review of the reports of cases, described in the last twelve years in the literature was carried out to evaluate the epidemiology, predisposing factors, potential results, prenatal diagnosis and clinical management of this phenomenon. CONCLUSIONS: Due to the rarity of this condition, every new case of umbilical cord hematoma should be reported in order to improve the knowledge of predisposing factors, prenatal diagnosis, and clinical management.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore

INTRODUCTION@#Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore.@*METHODS@#Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission.@*RESULTS@#Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5).@*CONCLUSION@#The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

Abortos em equinos na região sul do Rio Grande do Sul: estudo de 72 casos / Equine abortion in southern Brazil: study of 72 cases

Foi realizado um estudo retrospectivo das causas de aborto ocorridas em equinos na área de influência do Laboratório Regional de Diagnóstico (LRD), da Faculdade de Veterinária da Universidade Federal de Pelotas (UFPel), no período entre janeiro de 2000 e junho de 2011. Foram revisados os protocolos de necropsia e de 1.154 equinos ou materiais de equinos recebidos 72 (6,2 por cento) eram casos de abortos. A infecção bacteriana foi a principal causa de aborto neste estudo com 36,1 por cento dos casos. As causas não infecciosas corresponderam a 8,3 por cento dos casos, os abortos virais a 4,2 por cento, os parasitários a 1,4 por cento e os inflamatórios a 2,8 por cento. Em 47,2 por cento dos casos não foi possível determinar a causa/etiologia do aborto. Lesões macroscópicas e histológicas características foram observadas em casos de aborto por Leptospira sp. e por herpesvirus equino-1 sendo que nos demais casos as lesões foram inespecíficas. Ficou demonstrado que o envio do feto inteiro junto com a placenta, sob refrigeração, aumenta consideravelmente a eficiência do diagnóstico e o elevado número de abortos de causa não determinada foi atribuído em parte ao envio de material não adequado.

A retrospective study of the causes of equine abortion occurred in southern Rio Grande do Sul, Brazil, diagnosed from January 2000 to June 2011 by the Regional Diagnostic Laboratory (LRD) of the Veterinary School, Federal University of Pelotas (UFPel), is reported. Necropsy protocols were reviewed, and from 1.154 horses or equine materials received 72 (6.2 percent) were abortions. The main cause of abortion in this study was bacterial infection on 36.1 percent of the cases. Non-infectious causes accounted for 8.3 percent of the cases, viral abortions for 4.2 percent, parasitic for 1.4 percent and inflammatory for 2.8 percent. In 47.2 percent, it was not possible to determine the cause/etiology of abortions. Characteristic macroscopic and histological lesions were observed in abortion by Leptospira sp. and equine herpesvirus-1. No lesions were observed in the other cases. It was demonstrated that the analyses of whole fetus with the placenta under refrigeration increases the efficiency of diagnosis. The high number of abortions of undetermined cause was attributed in part to inadequate delivery of fetus material for diagnoses.

Espiralização, estenose e trombose do cordão umbilical e morte fetal / Hypercoiling, stricture, and thrombosis of the umbilical cord and fetal death

Anormalidades do cordão umbilical são inúmeras, desde nós falsos, que não tem significado clínico, até alterações que determinam a morte fetal intraútero. Aqui apresentamos o caso de uma paciente que foi acompanhada em regime de pré-natal de baixo risco, com queixa de parada súbita da movimentação fetal.

Umbilical cord abnormalities are numerous, ranging from false knots, which have no clinical significance, to changes that often lead to fetal death. As prenatal ultrasound becomes increasingly sophisticated, many of these conditions are now diagnosed in uterus. We describe the case of a patient that progressed from a low-risk pre-natal condition, with a complaint of sudden cessation of fetal movement, to a diagnosis of fetal death.

Indicações de cesariana baseadas em evidências: parte II: [revisão] / Evidence-based cesarean section indications: part II: [review]

A alta incidência de cesarianas desnecessárias é motivo de preocupação mundial. Estudos demonstraram que os benefícios conferidos ao feto pela cesariana são pequenos. Além de o procedimento se associar a maiores taxas de mortalidade materna, aproximadamente quatro a cinco vezes maiores que o parto vaginal, está também associado ao aumento da morbidade e mortalidade perinatal. Assim, a decisão para realização de uma cesariana deve ser criteriosa e discutida com a paciente. Realizou-se uma revisão da literatura em busca das melhores evidências disponíveis sobre indicações de cesariana. Foram abordadas algumas indicações, como placenta prévia, descolamento prematuro de placenta, vasa prévia, placenta acreta, infecção por HIV, herpes genital, hepatites e por HPV, condiloma genital, gestação múltipla, prolapso do cordão umbilical, distensão segmentar e ruptura uterina. Observou-se que a cesariana está formalmente indicada em algumas situações particulares, como na placenta prévia total. Em outros casos, pode haver indicação de cesárea intraparto, porém situações como HPV e gemelaridade não representam per se indicações de cesárea. Quando essas são relativas, tanto a mulher como seus familiares devem ser informados, e sua opinião deve ser considerada antes de se decidir pela realização da cesárea.

The increasing rate of unnecessary cesareans is a world preoccupation. Studies demonstrated that fetal benefits by cesarean are small, and the procedure is associated with higher rates of maternal death, 4-5-fold greater in relation with vaginal delivery, and increased perinatal morbidity and mortality. Indeed, the decision for a cesarean delivery should be rigorous and discussed with the patient. A literature review was performed searching the best current evidences evaluable. Indications for cesarean section were analyzed such as placenta praevia, abruptio placentae, vasa praevia, accretism, HIV infection, genital herpes, hepatitis, HPV and condiloma, multiple pregnancy, umbilical cord prolapse, distension and rupture uterine. In special circumstances like total placenta praevia an elective cesarean section is indicated. In other cases, an intrapartum cesarean section should be performed but situations like HPV and multiple pregnancy are not considered indications for cesarean per se. When relative indications for cesarean are present, both women and her family should be informed and their opinion considered when deciding for an operative delivery.

Experiencia comunicacional en el diagnóstico y manejo antenatal de nudo del cordón umbilical / Prenatal diagnosis and management of true knot of umbilical cord

Se comunica caso clínico de una madre que consulta en semana 31 de gestación por ausencia de movimientos fetales, y cuyo ultrasonido (US) con escala de grises, Doppler color y tridimensional (3D), demostró imágenes altamente sugerentes de nudo verdadero de cordón umbilical. Se efectuó vigilancia con prueba de movimientos fetales diaria, monitoreo electrónico, hemodinamia fetal y umbilical con doppler, alternados cada tres días, durante siete semanas, demostrando bienestar fetal. Se efectuó operación cesárea cumplida la semana 37 por antecedente de cicatriz uterina previa. El hallazgo intraoperatorio fue una aglutinación de asas del cordón y recién nacido sano. Se discute el diagnóstico falso positivo de nudo por US, el manejo antenatal orientado a la pesquisa oportuna de una eventual oclusión vascular y la experiencia comunicacio-nal con la paciente, que permitió esperar la madurez fetal sin incidentes y con aceptabilidad de la madre, pese al riesgo implícito del diagnóstico presuntivo. Conclusión: En el manejo de alto riesgo se requiere experiencia, apoyo tecnológico y técnicas de comunicación adecuadas con las pacientes, para que una alianza empática permita alcanzar la mayor edad gestacional y la comprensión de un falso positivo.

We report a case of a pregnant woman who presented with absence of fetal movement at the 31st gestational week. The ultrasound (US) images (gray scale, color Dopplerand 3 dimensional) clearly suggested a true knot of the umbilical cord. A close surveillance regime with daily fetal movement test, fetal electronic monitoring and umbilical hemodynamics with Doppler, alternated every three days, was kept for seven weeks, showing fetal wellbeing. At week 37, a cesarean section was performed because of a previous uterine scar. The intraoperative finding confirmed agglutinated and twisted loops, but not a knot of the umbilical cord. The antenatal management is discussed with a close fetal monitoring to detect eventual vascular occlusion in a tight knot and the communication experience with the mother in order to understand and accept a false positive US diagnosis. Conclusion: During a maternal and fetal high risk management is important the professional experience and technological support. On the other hand, the best medical patient communication through an empathetic alliance is required in order to reach a psychological support, longer gestational age and better understanding a false positive test.

Embarazo múltiple: estudio de sus placentas / Multiple pregnancy: study of their placentas

Establecer las características de las placentas de los embarazos múltiples a las que se le realizó estudio de anatomía patológica en un período de 10 años. Se realiza la revisión de 112 informes de biopsias correspondientes a las placentas y sus anexos en embarazos múltiples: 104 gemelares y 8 triples, se establecen sus características normales y patológicas comparándose con la literatura nacional e internacional. Servicio de Anatomía Patológica. Maternidad "Concepción Palacios". La mayor frecuencia correspondió a placenta monocorial diamniótica, forma discoide, inserción paracentral del cordón; se encontraron alteraciones macro y microscópicas en concordancia con la literatura, así como tres casos de molas parciales, cuatro fetos papiráceos y tres fetos malformados entre otros hallazgos

To establish the characteristics of placentas from multiple pregnancies that underwent a pathological study in a period of 10 years. A review of 112 reports of biopsies from placentas and its annexes in multiple pregnancies was performed: twin 104 and 8 triples, sets out the normal and pathological features compared with the national and international literature. Department of Pathology. Maternidad "Concepcion Palacios". The highest frequency corresponded to placenta monochorionic diamniotic, discoid form, para central cord insertion, were macro and microscopic changes consistent with the literature and three cases of partial molas, four papyraceous fetuses and three malformed fetuses among other findings

Absence of Wharton's jelly around the umbilical arteries.

Wharton's jelly is a specialized tissue which acts as supportive and protective structure substituting for the adventitia of the umbilical vessels. Absence of Wharton's jelly around the umbilical arteries is very rare and an unusual cause of perinatal mortality. We report a case of absent Wharton's jelly around the umbilical arteries with patent vitellointestinal duct--a rare association.

Muerte fetal intrauterina por nudo real: a propósito de un caso clínico / Intrauterine fetal death by royal knot: a purpose of a case clinical

El cordón umbilical tiene una longitud de 50-60 centímetros en una gestación de término y constituye la comunicación entre placenta y feto. Entre las patologías de cordón están los nudos falsos (debidos a asas vasculares recubiertas por la acumulación de la gelatina de Wharton que se forma porque la longitud de los vasos supera a la del cordón) y reales. Este último es el que con más frecuencia lleva a muerte fetal intrauterina por causa funicular. Inexplicable cuando el producto se encuentra dentro del útero y evidenciable al producirse su posterior salida, como ocurrió en el caso presentado a continuación.

Mortalidad fetal 2006 en la Maternidad Sardá / Fetal mortality 2006 in the Maternidad Sardá

Objetivos: 1) describir las tasas de mortalidad fetal del año 2006 incluyendo y excluyendo los fetos malformados; 2) describir sus posibles causas y 3) analizar la oportunidad diagnóstica y el manejo de la terminación del parto. Material y métodos: diseño observacional, retrospectivo. Fuente de datos: las historias clínicas de las embarazadas portadoras de un feto muerto nacidos en el Hospital Materno Infantil Ramón Sardá durante el año 2006. Resultados: durante el año 2006 se registraron 7282 nacimientos que incluyen 7220 recién nacidos vivos y 62 muertes fetales. El 35,5 por ciento de los fetos muertos eran malformados que incluyen, según la edad gestacional, 45,8 por ciento entre 20 a 27 semanas y 28,9 por ciento en >= 28 semanas. En los embarazos de termino las causas de muerte más frecuentes fueron los accidentes del cordón (44 por ciento). Excluyendo los fetos malformados la causa más frecuente entre 20 y 27 semanas fueron las infecciones. Sin embargo, en la franja de embarazos de 28 semanas o más, donde las malformaciones representan el 28,9 por ciento de los mismos, no se encontró la causa en el 37 por ciento de los casos. Conclusiones: se observaron altas cifras de pacientes nulíparas y una elevada contribución de las malformaciones y las infecciones.

Pilonidal disease simple pathogenesis but complex management

Retrospective study. The study was conducted on 75 patients suffering PND with a male to female ratio 59 to 16 done between May 2004 to June 2007 with a follow up range 8-13 and a median of 10.7 months. Sixty four patients had sacrococcygeal disease, 9 patients had umbilical disease, and 1 patient had suprapubic while 1 patient had axillary disease. For sacrococcygeal disease Limberg operation was done in 26.5% [n=17], abscess drainage and curettage in 31.2% [n=20], Bascom operation in 23% [n=15] while conservative treatment in 31.2% [n=20].For umbilical disease, omphalectomy was done in all cases [n=9]. Conservative treatment was done for suprapubic disease while excision followed by primary closure was done in axillary disease [n=1] after failure of conservation. To evaluate different modalities in treating pilonidal disease [PND]. For sacrococcygeal disease, patients who received Limberg procedure [n=17] showed complete resolution in 88.2% [n=15] with recurrence rate 11.8% [n=2]. Those who received Bascom operation showed complete resolution after all procedures with no recurrence during the follow up period. Patients who received conservative treatment [n=20] showed a success rate of 70% [n=14] with recurrence rate of 30% [n=6] who received Bascom procedure later for their recurrence. For umbilical, suprapubic and axillary disease; omphalectomy, conservative treatment and excision with primary closure were used respectively with no complications encountered. For sacrococcygeal disease, Bascom operation was found to be superior over other modalities with respect to smooth postoperative period and early healing while in umbilical disease conservation shows higher success rate

Avaliação do cordão umbilical pelo ultra-som tridimensional / Evaluation of umbilical cord by three-dimensional ultrasound

O cordão umbilical é uma estrutura de fundamental importância na vida intra-uterina ao manter conexão vascular entre feto e placenta. As patologias que acometem o cordão umbilical são responsáveis por altos índices de morbidade e mortalidade perinatais, sendo de extrema importância a sua detecção pré-natal. A ultra-sonografia bidimensional com o auxílio do Doppler colorido é utilizada rotineiramente no pré-natal na tentativa de diagnosticar as patologias funiculares, entretanto, em certas ocasiões o diagnóstico é impreciso e questionável. O surgimento da ultra-sonografia tridimensional nos modos multiplanar, reconstrução de superfície e Doppler colorido e de amplitude ao demonstrar a imagem nos três planos ortogonais facilita a visualização das relações espaciais do cordão umbilical. Com o maior desenvolvimento tecnológico da metodologia tridimensional espera-se maior fidedignidade no diagnóstico das patologias funiculares, principalmente nos casos nas quais a avaliação bidimensional é questionável

Extensive torsion of umbilical cord: a rare cause of fetal compromise.

Extensive torsion of umbilical cord, a rare complication, shown by 2 fetuses with too frequent changes in their lie and presentation with subsequent development of fetal growth restriction (FGR), culminating intrauterine fetal death of one with transverse lie and survival of the other with decreased fetal movement worsened by impending eclampsia both managed by caesarean section is reported.

Embarazo gemelar monoamniótico: experiencia de una serie de casos en el Hospital Padre Hurtado / Monoamniotic twin pregnancies: a case series at the Padre Hurtado Hospital

Se presenta el análisis de 7 casos de embarazo gemelar monocorial monoamniótico. Todos los casos con fetos vivos fueron resueltos por cesárea a las 32 semanas. La mortalidad perinatal a los 7 días de vida fue 143/1000 nacidos vivos.

Aspectos fisiológicos e ecográficos do cordão umbilical / Physiological and sonographic aspects of the umbilical cord

Anormalidades estruturais do cordão umbilical como a artéria umbilical única, nós de cordão, cistos e os tumores podem estar associados com o sofrimento fetal ou malformações. O estudo ultra-sonográfico da morfologia do cordão umbilical tornou-se importante método na propedêutica fetal que, associado à dopplervelocimetria, presta informações adicionais na avaliação de doenças que interferem diretamente na vitalidade e no adequado crescimento fetal. Objetiva-se com o presente estudo realizar atualização do assunto, tecendo considerações gerais sobre os aspectos fisiológicos e ecográficos do cordão umbilical, correlacionando-os com aspectos diagnósticos e doenças funiculares de interesse clínico e suas repercussões sobre o prognóstico perinatal

Cisto gigante de cordão umbilical: caso raro e inédito na literatura / Giant umbilical cord cyst

O autor apresenta um caso raro e inédito, na literatura mundial, de um cisto congênito gigante de cordäo umbilical.

Alteraçöes Cromossômicas e cardíacas: novas perspectivas com o emprego do doppler colorido / Chrmossomal and cardiac anomalies: new perspectives using color Doppler

Resumo: Os autores descrevem consideraçöes sobre a possibilidade da utilizaçäo do Doppler colorido da artéria umbilical e do fluxo venoso (veia cava inferior, duto venoso e veia umbilical) na detecçäo de trissomias fetais e defeitos cardíacos no primeiro trimestre da gestaçäo. Os achados sugerem que a combinaçäo damedida de translucência nucal com o Doppler entre 10 e 14 semanas de gravidez pode ser eficaz no rastreamento de anomalias cromossômicas e cardíacas. No entanto, a conclusäo é preliminar, necessitando de estudos posteriores para confirmar essa proposiçäo.

Vasa previa in Ramathibodi Hospital: a 10 years review.

Vasa previa is presented when fetal vessels cross the internal os as a velamentous insertion of the umbilical cord. This retrospective study is to review the diagnosis, the management, and the outcome of this condition over the 10 years period in Ramathibodi Hospital, Bangkok, Thailand. Five cases were diagnosed after the rupture of membranes with only one case diagnosed prior to the rupture of membranes. The fetal mortality was 50 per cent. Despite continued advances in diagnostic procedures, vasa previa still presents considerable risk to the fetus.

Patología funicular hallada en 17.157 nacimientos. Resultados pernatales / Funicular patholoy found in 17.157 births. Perinatal results

Comentamos los resultados hallados en 17.157 nacimientos en relación a ala patología funicular. 1) circulares de cordón: 4.354 casos. El 95 por ciento correspondió a embarazos de término y el 5 por ciento a pretérminos. Nacieron vigorosos al término el 89.8 por ciento, deprimidos el 9.6 por ciento y muertos el 0.6 por ciento. Entre los préterminos el 64d.7 pr ciento vigorosos, 25.6 por ciento deprimidos y el 9.7 por ciento muertos. 2) nudos reales de córdon: 0,37 por ciento 3) procidencia de cordón: 0.10 por ciento. 4) brevedad real de cordón: 0,09 por ciento. 5) laterocidencia de cordón: 0.05 por ciento. 6) Procúbito de cordón: 1 cada 8.578 nacimientos 7) nudo aparente de cordón: 1 cada 17.157 nacimientos