Caesarean delivery of a breech singleton with eight loops of nuchal cord.

Nuchal cord accidents comprise a third of stillbirths in the third trimester. These are often due to higher order nuchal cords, with more than three loops. In this report, we discuss a case of a gestation complicated by a nuchal cord with eight loops and severe fetal growth restriction, requiring expedited delivery due to non-reassuring fetal heart tones. Our case demonstrates the value of high-quality ultrasound in detecting complex nuchal cords, as well as highlighting the potentially dynamic and unstable fetal status in an affected gestation. Antenatal knowledge of nuchal cord in the setting of non-reassuring fetal status can help guide patient counselling and assist with identifying possible aetiologies. Finally, our case demonstrates that close monitoring and early intervention can prevent potentially catastrophic outcomes.

Electronic Fetal Monitoring and Neonatal Outcomes when a Nuchal Cord Is Present at Delivery.

OBJECTIVE: This study aimed to determine the association between nuchal cord, electronic fetal monitoring parameters, and adverse neonatal outcomes. STUDY DESIGN: This was a prospective cohort study of 8,580 singleton pregnancies. Electronic fetal monitoring was interpreted, and patients with a nuchal cord at delivery were compared with those without. The primary outcome was a composite neonatal morbidity index. Logistic regression was used to adjust for confounders. RESULT: Of 8,580 patients, 2,071 (24.14%) had a nuchal cord. There was no difference in the risk of neonatal composite morbidity in patients with or without a nuchal cord (8.69 vs. 8.86%; p = 0.81). Nuchal cord was associated with category II fetal heart tracing and operative vaginal delivery (OVD) (6.4 vs. 4.3%; p < 0.01). CONCLUSION: Nuchal cord is associated with category II electronic fetal monitoring parameters, which may drive increased rates of OVD. However, there is no significant association with neonatal morbidity.

The effect of nuchal cord on perinatal mortality and long-term offspring morbidity.

OBJECTIVE: To evaluate perinatal and long-term cardiovascular and respiratory morbidities of children born with nuchal cord. STUDY DESIGN: A large population-based cohort analysis of singleton deliveries was conducted. Maternal and birth characteristics, as well as cardiovascular and respiratory morbidity incidence were evaluated. Kaplan-Meier survival curves were used to compare cumulative hospitalization incidence between groups. Cox regression models were used to control for possible confounders and follow-up length. RESULTS: 243,682 deliveries were included. Of them, 34,332 (14.1%) were diagnosed with nuchal cord. Perinatal mortality rate was comparable between groups (0.5 vs. 0.6%, p = 0.16). Kaplan-Meier survival curves demonstrated no significant differences in cumulative cardiovascular or respiratory morbidity incidence between groups (log rank p = 0.69 and p = 0.10, respectively). Cox regression models reaffirmed a comparable risk for hospitalization between groups (aHR = 0.99 (95% CI 0.85-1.14, p = 0.87) and aHR = 0.97 (95% CI 0.92-1.02, p = 0.28). CONCLUSIONS: Nuchal cord is not associated with higher rate of perinatal mortality nor long-term cardiorespiratory morbidity.

Adverse pregnancy outcomes and multiple nuchal cord loops.

PURPOSE: To evaluate the effects of nuchal cord and the number of loops during labor and delivery on delivery outcomes among women with singleton pregnancy who delivered vaginally. METHODS: This retrospective cohort study included 42,798 women with singleton, vertex, and vaginal deliveries at 24-43 weeks of gestation. We analyzed delivery outcomes based on the number of nuchal cord loops. RESULTS: A total of 42,798 deliveries met the inclusion criteria, of which, 3809 (8.9%) had nuchal cord with 1 loop at delivery, 1035 (2.42%) had 2 loops, and 258 (0.6%) had 3 loops. Nuchal cord with 3 loops compared to no nuchal cord has been associated with higher incidence of intrauterine fetal death (1.9%), Apgar scores less than 7 at 1 and 5 min (7.4%, 2.3%), and higher rate of operative vaginal deliveries (17.5%). Nuchal cord with 2 or 3 loops was associated with higher incidence of intrauterine growth restriction (10.2%, 11.6%).  In a multiple logistic regression model, nuchal cord with 3 loops was an independent risk factor for operative vaginal delivery and Apgar score less than 7 in 1 min. CONCLUSIONS: In the case of vaginal delivery in the presence of nuchal cord, as the number of nuchal cord loops increased, so did the number of adverse delivery outcomes. While 3 loops were associated with higher incidence of intrauterine fetal death, intrauterine growth restriction, increased operative vaginal deliveries, and low Apgar scores, 1 loop was not associated with adverse perinatal outcomes.

Evaluation of fetal serum thiol/disulphide homeostasis in deliveries complicated by nuchal cord.

Aim: To investigate the serum thiol/disulphide homeostasis in deliveries complicated by nuchal cord (NC) and to compare the results with healthy deliveries (without NC). Methods: This prospective controlled study included 48 pregnant women complicated by NC and 48 similar gestational aged healthy pregnant women during labor. Fetal umbilical cord serum samples were collected during labor and the thiol/disulphide homeostasis was measured by using an automated assay method. The patients were followed up until end of the delivery and perinatal outcomes were recorded. Results: Fetal umbilical cord native thiol, total thiol, and disulphide levels as well as disulphide/native thiol and disulphide/total thiol ratios are impaired in labor with the presence of NC. There were no statistically significant differences in terms of maternal and gestational age at delivery and maternal number of gravida and parity, fetal gender, fifth Apgar scores <7, mode of delivery and fetal birth weight between groups. The group of patients with NC had higher emergency C/S numbers indicated for fetal distress and lower first Apgar scores <7. There were no neonatal intensive care unit admissions among these babies. Conclusions: Maternal serum thiol/disulphide homeostasis reflect transient effects of NC during labor regardless of labor type. Vaginal delivery can be safely and successfully performed in pregnancies complicated with NC.

Umbilical cord twist - Does it play a role in placental morphology?

Studies have described the placental morphology and its changes in a pathological scenario. But the role of a twisting pattern of umbilical vessels in determining the placental morphology of uncomplicated pregnancy has not been discussed. The objective of the study was to determine the clinical significance of umbilical cord twist in determining the umbilical cord coiling index, the diameter of hyrtl's anastomosis, branching pattern of the placental vasculature, placental weight, Eccentricity index and Cord centrality index. The proportion of umbilical cords with left and right twist were 246 (78.6%) and 67 (21.4%) respectively. The right twisted cords had significant higher umbilical artery diameter, higher umbilical cord coiling index and preferential magistral pattern of blood vessels. This proves that twisting of the cord might play a minor role in altering the blood flow and determining the vasculature pattern but not sufficient enough to influence the placental weight, the shape of the placenta and umbilical cord insertion

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Multiple part umbilical cord entanglement and neonatal outcomes.

OBJECTIVE: Umbilical cord entanglement is known to be a major cause of fetal hypoxia and to be correlated with several neonatal complications, but almost all of the previous reports were restricted to nuchal cord. In this study, we retrospectively examined the correlation between multiple part cord entanglement and pregnancy outcomes. MATERIALS AND METHODS: A total of 2156 cases were recruited from term deliveries in our hospital from 2008 to 2012. We counted umbilical cord loop numbers not only for nuchal cord but also for trunk and limb cord entanglement. We classified the cases into three groups: no loop, single loop and multiple loops group. We statistically analyzed pregnancy outcomes statistically in the three groups. RESULTS: One thousand, four hundred and fifty-eight cases had no cord entanglement, 594 cases had single loop entanglement and 104 cases had multiple loops entanglement. Values of umbilical artery blood, pH (p = 0.002) and base excess (p < 0.001) showed significantly unfavorable status in entanglement cases, especially in the multiple loops group. A significantly larger percentage of neonates in the multiple loops group needed for oxygen (p < 0.001). CONCLUSION: Multiple umbilical cord entanglement is highly correlated with early neonatal unfavorable status and need for resuscitation.

Nuchal cord complication in male small for gestational age increases fetal distress risk during labor.

OBJECTIVE: This study aimed to evaluate whether a nuchal cord increases the risk of perinatal complications during labor, and whether fetal growth and sex affect the risk of fetal distress. MATERIALS AND METHODS: Medical records of 1749 women with singleton pregnancies planning a vaginal delivery were enrolled. Patients were divided into two groups according to the presence or absence of a nuchal cord at birth. Multivariate logistic regression analyses, odds ratios (ORs), and 95% confidence intervals (CIs) were used to determine whether the risks of perinatal complications increased in the nuchal cord group. RESULTS: A nuchal cord is associated with higher risks of Rupture of membranes (ROM) prior to delivery (OR = 1.40, 95% CI: 1.12-1.76, p = 0.0031), need for augmentation during labor (OR = 1.68, 95% CI: 1.27-2.23, p = 0.0003), prolonged second stage of labor (OR = 2.54, 95% CI: 1.55-4.25, p = 0.0002), nonreassuring fetal heart risk during labor (OR = 2.89, 95% CI: 2.18-3.84, p < 0.0001), and instrumental delivery or cesarean delivery (OR = 2.00, 95% CI: 1.55-2.58, p < 0.0001). Fetal distress risk during labor was affected by fetal growth and sex, with male small for gestational age fetuses with a nuchal cord having a significantly higher risk than the control group (OR = 9.77, 95% CI: 3.67-25.79, p < 0.0001), despite there being no significant differences in the neonatal Apgar scores at 1 minute or 5 minutes, or in the need for neonatology between the two groups. CONCLUSION: Nuchal cord is associated with perinatal outcomes. Male small for gestational age fetuses with a nuchal cord have a significantly higher risk of fetal distress during labor. Our results suggest that evaluation of fetal sex and body weight is also important in antenatal ultrasonography if a nuchal cord is found.

Severe antenatal strangulation and sudden fetal death occurs in term: case report.

The authors report a case of a sudden antenatal death, by severe strangulation, unlikely related in a term pregnancy; multiple loops of nuchal umbilical cord (UC) (ten), rarely describe in literature, were observed around the fetal neck. The in utero fetal death (IFD) was suspected by the non-attendance of fetal movements and confirmed by US scan. The tight nuchal cord around the neck (tCAN) diagnostic was made during caesarean delivery, as it was not discovered in pregnancy US scan monitoring nor in the US scan made in emergency. The newborn examination shows severe fetal strangulation by the presence of many spires of a too long UC (1.50 m). Autopsy was not been accepted by the family. Through this reported case the authors wanted to show the difficulties of its diagnosis in less developed Sub-Saharan country were US scan practice is not usual.

Risk Factors for Neonatal Arterial Ischemic Stroke: The Importance of the Intrapartum Period.

OBJECTIVE: To investigate risk factors for neonatal arterial ischemic stroke (NAIS), and compare them with those present in term controls and infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: Antepartum and intrapartum data were collected at presentation from 79 infants with NAIS and compared with 239 controls and 405 infants with HIE. The relationships between risk factors and NAIS were explored using univariable and multivariable regression. RESULTS: Compared with controls, infants with NAIS more frequently had a family history of seizures/neurologic diseases, primiparous mothers, and male sex. Mothers of infants with NAIS experienced more intrapartum complications: prolonged rupture of membranes (21% vs 2%), fever (14% vs 3%), thick meconium (25% vs 7%), prolonged second stage (31% vs 13%), tight nuchal cord (15% vs 6%), and abnorm8al cardiotocography (67% vs 21%). Male sex (OR 2.8), family history of seizures (OR 6.5) or neurologic diseases (OR 4.9), and ≥1 (OR 5.8) and ≥2 (OR 21.8) intrapartum complications were independently associated with NAIS. Infants with NAIS and HIE experienced similar rates though different patterns of intrapartum complications. Maternal fever, prolonged rupture of membranes, prolonged second stage, tight nuchal cord, and failed ventouse delivery were more common in NAIS; thick meconium, sentinel events, and shoulder dystocia were more frequent in HIE. Abnormal cardiotocography occurred in 67% of NAIS and 77.5% of infants with HIE. One infant with NAIS and no infant with HIE was delivered by elective cesarean (10% of controls). CONCLUSIONS: NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum events may play a more significant role in the pathogenesis of NAIS than previously recognized.

Impact of nuchal cord on fetal outcomes, mode of delivery, and management: a questionnaire survey of pregnant women.

OBJECTIVES: To explore pregnant women's views on the impact of nuchal cord on fetal outcomes, mode of delivery, and management. DESIGN: Questionnaire survey. SETTING: Antenatal clinic of two regional hospitals in Hong Kong. PARTICIPANTS: A questionnaire survey of all pregnant women at their first visit to the antenatal clinic of United Christian Hospital and Tseung Kwan O Hospital in Hong Kong was conducted between August and October 2012. RESULTS: Most participants (71.8%) were worried about nuchal cord, and 78.3% and 87.7% of them thought that nuchal cord could cause intrauterine death and fetal death during labour, respectively. Approximately 87.5% of participants thought that nuchal cord would reduce the chance of successful vaginal delivery and 56.4% thought that it would increase the chance of assisted vaginal delivery. Most (94.1%) participants thought that it was necessary to have an ultrasound scan at term to detect nuchal cord. In addition, 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed in the presence of nuchal cord. Participants born in Mainland China were significantly more worried about the presence of nuchal cord than those born in Hong Kong. However, there was no difference between participants with different levels of education. CONCLUSION: Most participants were worried about the presence of nuchal cord. Many thought that nuchal cord would lead to adverse fetal outcomes, affect the mode of delivery, and require special management. These misconceptions should be addressed and proper education of women is needed.

Neonatal outcome and mode of delivery in the presence of nuchal cord loops: implications on patient counselling and the mode of delivery.

PURPOSE: To review and compare the foetal outcomes and mode of delivery in patients with nuchal cord for single loop, double loops, and multiple loops. METHODS: A retrospective study of 4,404 singleton term pregnancies which underwent spontaneous labour was conducted. The patients were classified into five groups: without nuchal cord, nuchal cord of any turns, nuchal cord for 1 turn, nuchal cord for 2 turns and nuchal cord for 3 turns or above. The perinatal outcomes and mode of delivery were then compared. RESULTS: Nuchal cord of any turns was not shown to be associated with intrauterine death, neonatal death, Apgar score <7 at 1 and 5 min. Only nuchal cord for three turns or more were associated with higher incidence of meconium-stained liquor, neonatal unit admission, suspected foetal distress during labour and emergency caesarean section. CONCLUSIONS: Only nuchal cord for 3 turns or more was associated with higher incidence of suspected foetal distress. However, the Apgar scores were not affected. Therefore, nuchal cord of any turns was not associated with adverse foetal outcomes. Prenatal ultrasound scan for nuchal cord is, therefore, unnecessary and there should be no differences in management of nuchal cord of any turns.

Presence of an umbilical artery notch in monochorionic/monoamniotic twins.

OBJECTIVE: To examine the association between an umbilical artery notch and fetal deterioration in monochorionic/monoamniotic (MC/MA) twins. METHODS: Six MC/MA twin pregnancies were admitted at 24-28 weeks of gestation for close fetal surveillance until elective delivery at 32 weeks or earlier in the presence of signs of fetal deterioration. Ultrasound (US) examinations were performed twice weekly. The presence of cord entanglement, umbilical artery notch, abnormal Doppler parameters, a non-reassuring fetal heart rate pattern, or an abnormal fetal biophysical profile were evaluated. RESULTS: Umbilical cord entanglement was observed on US in all pregnancies. The presence of an umbilical artery notch was noted in four out of six pregnancies and in two of them an umbilical artery notch was seen in both twins. The umbilical artery pulsatility index was normal in all fetuses. Doppler parameters of the middle cerebral artery and ductus venosus, fetal biophysical profile and fetal heart rate monitoring remained normal until delivery in all pregnancies. All neonates experienced morbidity related to prematurity; however, all were discharged home in good condition. CONCLUSION: The presence of an umbilical artery notch and cord entanglement, without other signs of fetal deterioration, are not indicative of an adverse perinatal outcome.

Factores asociados al doble circular de cordón y resultados materno-perinatales en gestantes atendidas en el Hospital Nivel I Jorge Voto Bernales Corpancho durante el periodo 2012-2013 / Factors associated with double nuchal cord and maternal and perinatal outcomes in pregnant women treated at the Hospital Level I Jorge Voto Bernales Corpancho during the period 2012-2013

Objetivo: Determinar los factores asociados al doble circular de cordón y los resultados materno-perinatales en gestantes atendidas en el Hospital Nivel I Jorge Voto Bernales Corpancho durante el periodo 2012-2013. Materiales y Métodos: El estudio es Observacional, 108 gestantes con doble circular de cordón (caso) y 108 con circular simple de cordón (control) de parto por cesárea. Se utilizó la prueba de Chi-cuadrado y Fisher, la estimación del OR con un nivel de confianza del 95 por ciento. Resultados: Durante el periodo 2012 y 2013 se atendieron 9697 partos, 163 fueron doble circular de cordón (1,68 por ciento), 57 por ciento diagnosticados como hallazgo en el momento de la cesárea y 43 por ciento diagnosticados por ecografía. Las características sociodemográficas no presentan diferencias entre ambos grupos. El grupo etario >=35 años como factor materno asociado a doble circular de cordón presento hasta 13 veces más riesgo. El índice de líquido amniótico >25 cm3 tuvo hasta 22 veces más riesgo de producir doble circular de cordón (p=3,500 gr. estuvo relacionado dos veces más a doble circular de cordón. Con respecto a los resultados materno-perinatales ninguno de ellos fueron relacionados con el doble circular de cordón en forma estadísticamente significativa, excepto con el puntaje de Apgar bajo: al primer minuto (p=0,024). Conclusión: Existen algunos factores asociados a doble circular de cordón como la edad materna, polihidramnios y peso del recién nacido. Rara vez se asocian con una morbilidad o mortalidad importante en los recién nacidos.

Objective: To determine the factors associated with double nuchal cord and maternal and perinatal outcomes in pregnant women at the Hospital Level I Jorge Voto Bernales Corpancho during the period 2012-2013. Materials and Methods: Observational study, 108 pregnant women with double nuchal cord (case) and 108 with single nuchal cord (control) of cesarean delivery. The Chi-squared and Fisher, the estimated OR with a confidence level of 95 per cent was used. Results: During the period 2012 and 2013 9697 deliveries, 163 were double nuchal cord (1.68 per cent), 57 per cent diagnosed as finding at the time of caesarean section and 43 per cent diagnosed by ultrasound were treated. The sociodemographic characteristics did not differ between groups. The age group >=35 years as a maternal factor associated with double nuchal cord present up to 13 times the risk. The amniotic fluid index >25 cm3 had up to 22 times more likely to produce nuchal cord (p=3.500 g. was related twice to double nuchal cord. With regard to maternal and perinatal outcomes none were related to the double nuchal cord statistically significant, except with low Apgar score at one minute (p=0.024). Conclusion: There are some factors associated with double nuchal cord as maternal age, polyhydramnios and birth weight. Rarely associated with morbidity or mortality in newborns.

Notching of the umbilical artery waveform associated with cord entanglement in a monoamniotic twin pregnancy.

Cord accidents are the principal cause of the high rates of morbidity and mortality associated with monoamniotic twins. Observation of an umbilical artery notch might be a highly specific sign for cord entanglement involving a tight cord knot. It thus justifies the implementation of intense surveillance and should be one of the factors taken into account in deciding on early delivery of the twins.