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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 234-237

Umbilical cord thrice around the abdomen of the fetus leading to intrauterine death (IUD) of the fetus: A cause or effect


1 Department of Obstetrics and Gynecology, Sri Venkateswara Medical College (SVMC), Government Maternity Hospital (GMH), Tirupati, Andhra Pradesh, India
2 Department of Obstetrics and Gynecology, AKSR Medical College, Nellore, Andhra Pradesh, India

Date of Web Publication10-Oct-2016

Correspondence Address:
Geetha Lakshmi Sreerama
18-1-731, Bhavani Nagar, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.191844

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  Abstract 

The umbilical cord transmits oxygen and nutrients through the blood from the mother to the fetus. The umbilical cord abnormalities and cord compression leads to a decreased blood supply through the umbilical cord causes intrauterine growth restriction (IUGR) and even intra uterine death (IUD). We are reporting a case a 25-year-old gravida 3, para 2, live 2 in the 9th month of gestational age (GA) who was a known asthmatic with previous two caesarean sections (C/S) with IUGR, severe oligohydramnios, and IUD with elevated liver enzymes and abnormal coagulation profile was referred from Rajiv Gandhi Institute of Medical Sciences (RIIMS) Kadapa, Andhra Pradesh, India. Clinically, 28-30 weeks of gestation in the transverse lie are with absent fetal heart sound (FHS). Fetal findings were confirmed by ultrasound (USG) examination. Emergency lower segment caesarean section (EMLSCS) was performed, which delivered a dead 2-kg male child with the cord thrice around the abdomen of the fetus. A lengthy cord of 76 cm entangling thrice around the fetal abdomen and associated oligohydramnios leads to cord compression causing fetal death. On USG examination of oligohydramnios, IUGR can be treated and any decreased fetal movements during the antenatal period, abnormal Doppler velocimetry, and abnormal cord position may need early intervention results to salvage the baby. Hence, routine Doppler studies for the cord position may be useful.

Keywords: Compression, entanglement, lengthy cord


How to cite this article:
Sreerama GL, Bharathi T, Chandrasekharan PA. Umbilical cord thrice around the abdomen of the fetus leading to intrauterine death (IUD) of the fetus: A cause or effect. J NTR Univ Health Sci 2016;5:234-7

How to cite this URL:
Sreerama GL, Bharathi T, Chandrasekharan PA. Umbilical cord thrice around the abdomen of the fetus leading to intrauterine death (IUD) of the fetus: A cause or effect. J NTR Univ Health Sci [serial online] 2016 [cited 2019 Dec 14];5:234-7. Available from: http://www.jdrntruhs.org/text.asp?2016/5/3/234/191844


  Introduction Top


The umbilical cord is a vital structure between the mother and the fetus. It has three vessels, one umbilical vein, and two umbilical arteries, and is covered by protective Wharton's jelly. The umbilical cord transmits oxygenated blood and nutrients from the mother to the fetus and deoxygenated blood from the fetus through the umbilical cord and placenta to the mother.[1] Length of the cord is 30-100 cm, diameter 0.8-2.0 cm [2], and is helical in nature with as many as 380 helices.[3] The average length of the cord is 55 cm 2, average diameter 1-2 cm, and it has 11 helices on an average.[3] Abnormalities of the umbilical cord cause decreased blood supply to the fetus.[3] Blood supply through the umbilical cord can be obstructed by stricture of the cord,[4] thrombus formation,[5] and mechanical obstruction by true knot formation in the cord,[6] entanglement of the cord tightly round the body parts,[7] and compression of the cord between the body parts and uterus in severe oligohydramnios.[8] If the cord is lengthy, there are chances of repeated coiling around the body parts that leads to decreased blood supply causing intrauterine growth restriction (IUGR) and even intrauterine death (IUD).[9] Among cord entanglement around the body parts, cord entanglement around the neck and shoulder are more common than the abdomen and other body parts. Nuchal cord 1 loops 20-34%, 2 loops 2.5-5%, and 3 loops 0.2-0.5%.[10] Cord entanglement around the abdomen is rare and three times is exceptionally rare. One case of fetal demise by the cord thrice around the abdomen and stricture was reported by Shun-Jen Tan et al.[7]


  Case Report Top


This is a case report of the umbilical cord thrice around the abdomen of the fetus with severe oligohydramnios with IUD. A 25-year-old gravida 3, para 2, and live 2 with 9 months of gestational age (GA), who was a known asthmatic with two prior caesarian sections (C/S) with IUGR, severe oligohydramnios, IUD, mild elevated liver enzymes, and elevated coagulation factors was referred from Rajiv Gandhi Institute of Medical Sciences (RIIMS), Kadapa, Andhra Pradesh, India. The present pregnancy was diagnosed at 2 months of amenorrhea by urine pregnancy test. She had irregular antenatal checkups by the local doctor and had taken two doses of tetanus toxoid (TT) as administered by the local health personnel. The patient was a known asthmatic since 4 years of age. During the present pregnancy, there was a history of on-and-off attacks of breathlessness for which she was prescribed inhalers by the local doctor. She went to RIIMS Hospital, Kadapa, Andhra Pradesh, India for breathlessness where one unit of blood transfusion was given as was later referred here.

In her first pregnancy, emergency lower segment caesarean section (EMLSCS) was performed for failed induction; she gave birth to an alive female baby who is now 4 years and healthy. ELLSCS was performed for the second issue, the indication was previous C/S and she delivered an alive female child who is now 3 years and healthy. The patient was not taking inhalers regularly. On general examination, her clinical condition was good except for a slight icterus. The vitals signs were stable and the cardiovascular system and respiratory system were normal. On abdominal examination, the findings were as follows: The suprapubic transverse scar present and there was no scar tenderness. At 28 weeks, the contour of the uterus was normal and the fetal parts palpable; the fetus presented in transverse lie, fetal heart sound (FHS) was absent, liquor appeared less clinically, and the uterus was not acting. Per vaginal examination, the cervix was uneffaced, os closed, no leak of liquor, and the pelvis was gynaecoid and adequate.

Investigations

Hemoglobin (Hb) was 9.5 g, bleeding time (BT) was 1.00”, clotting time (CT) was 3.30”, random blood sugar (RBS) was 72 mg/dL, blood urea was 16mg, serum creatinine 0.42, blood grouping Rhesus (Rh) typing was B-positive, human immunodeficiency virus (HIV) and hepatitis B surface antigen (HBsAg) were nonreactive, serum uric acid was 37 mg/dL, serum glutamic oxaloacetic transaminase (SGOT) was 16 IU/L, serum glutamic-pyruvic transaminase (SGPT) was 12 IU/L, serum bilirubin was T-2.5, C-0.3, alkaline phosphatase was 255 IU/L, prothrombin time (PT) was 13.3 (C:12.2), activated partial thromboplastin time (APTT) was 33.1 (C:31.1), and international normalized ratio (INR) was 1.14.

On ultrasound examination, the fetus was in 28-30 weeks of gestation in transverse lie with absent fetal heart and absent pulse wave Doppler flow, amniotic fluid index (AFI)-2, and placenta upper segment with calcifications. The case was undertaken for EMLSCS in view of the two prior lower segment caesarian sections (LSCSs) with severe oligohydramnios in transverse lie. Under spinal anesthesia, EMLSCS with bilateral tubectomy was done. Operative findings were as follows: Liquor was brown in color and scanty, the baby presented in transverse lie, a dead male child was delivered as breech with umbilical cord thrice around the abdomen tightly along with placenta as shown in [Figure 1]. The length of the cord was measured to be 76 cm. The postoperative period was uneventful. An autopsy of the baby was advised to find out any other causes such as stricture and thrombus for the death of the fetus but the patient and her relatives were not willing due to religious factors.
Figure 1: Dead macerated fetus with umbilical cord thrice around the abdomen of the fetus, along with placenta

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  Discussion Top


While the fetus is moving in the liquor inside the uterus, there are chances of cord entanglement around the body parts.[8] Cord entanglement around the fetal parts happen normally during the 1st trimester (25.3%), at 20 weeks (16.8%), at 32 weeks (18.2%), and at delivery (29.3%).[8] If the cord is lengthy [3] and the liquor quantity is more, the chances of entanglement and true knotting are also increased. The incidence of the cord entangled thrice around the neck is 0.2-0.5%[10] and thrice around the abdomen is extremely rare.

In this case, the length of the cord was 76 cm more than normal (average: 55 cm). The cord entanglement thrice around the abdomen [as shown [Figure 2] might be happened in the early weeks of gestation.[8] The baby might have grown, along with the cord loops around the abdomen. Cord entanglement thrice around the abdomen causes shortening of the remaining cord.[8] The fetus might have been settled in a transverse position. As the baby grew slowly, the cord might have tightened slowly. In other words, oligohydramnios affects the fetus by decreasing fetal movements. This leads to a situation where the fetus is unable to escape from the entanglement, which happened in the early weeks of gestation and is settled in a transverse position. When there is umbilical cord entanglement thrice around the abdomen — Either as a cause or an effect — The blood supply to the fetus might be slowly compromised.
Figure 2: Umbilical cord thrice (three loops) around the abdomen of the fetus

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During the antenatal period, if there are multiple cord loops around the fetus it causes decreased fetal movements and the fetal heart shows variations.[1] When the compression is episodic, the fetus can clear the increased carbon dioxide and maintain oxygenation by using oxygen reserve.[1] More episodic compressions lead to variable decelerations and late decelerations and severe repeated decelerations cause fetal demise.[1] This is reflected as decreased fetal movements during the antenatal period and ultrasound (USG) Doppler velocimetry shows abnormalities such as decreased or absent or reverse diastolic flow patterns.[11] The impedance of blood flow to the fetus through the umbilical cord or a risk of IUGR and developmental abnormalities is assessed by USG during prenatal evaluation.[1] Oligohydramnios, IUGR, and congenital anomalies can also be detected in ultrasound.[7] A lengthy cord is not possible to detect in prenatal diagnosis [8] but to some extent, the position of the cord can be determined.

IUD was the end result in the compromised IUGR fetus due to multiple factors such as decreased blood flow due to cord entanglement thrice round the abdomen, hypoxic status of the asthma in the mother, and cord compression in severe oligohydramnios. Other causes such as stricture and thrombus in the umbilical cord could have been determined in autopsy but it was not carried out due to traditional causes.

The patient developed mild elevated liver enzymes and the coagulation factors may have been due to prior blood transfusion. After delivery, the elevated liver enzymes and coagulation profile became normal within 10 days. The postoperative period was uneventful.

The patient does not have regular antenatal checkups even with asthma complication. IUGR can be diagnosed clinically by decreasing the interval growth of the fetus and confirmation by USG, which can be treated. Early diagnosis of oligohydramnios in USG can also be treated. Decreased fetal movements during the antenatal period, variation of FHS clinically or decelerations in cardiotocographic monitoring, and abnormal Doppler changes reflect fetal hypoxia. In severe oligohydramnios with abnormal Doppler pattern, early intervention is advised to save the baby. This will reduce fetal morbidity, mortality, and maternal morbidity.

In conclusion, prenatal diagnosis of multiple loops of the cord, oligohydramnios, IUGR, in ultrasound may alter the management and improve the outcome of the fetus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bangal V, Kwatra A, Shinde K. Umbilical cord accidents: Predictable and preventable. J MGIMS 2011;16:54-8.  Back to cited text no. 1
    
2.
Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D, Spong CY. Implantation, embyogenesis, and placental developments. In: Spong CY, Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D, editors. William's Obstetrics. 23rd ed. 2010. p. 61-2.  Back to cited text no. 2
    
3.
Bharat Chaudhari, Rajesh Kulkarni, Arati Kinikar. Long umbilical cord with multiple loops around the fetal neck. Pediatric On call [serial online] 2010 [cited 2010 December1]; 7. Art#74. Available From: http://www.pediatriconcall.com/Journal/Article/Full Text. Assessed in internet on 30-12-2014.   Back to cited text no. 3
    
4.
Sun Y, Arbuckle S, Hocking G, Billson V. Umbilical cord stricture and intrauterine fetal death. Pediatr Pathol Lab Med 1995;15: 723-32.  Back to cited text no. 4
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5.
Heifetz SA. Thrombosis of the umbilical cord: Analysis of 52 cases and literature review. Pediatr Pathol 1988;8:37-54.  Back to cited text no. 5
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6.
Airas U, Heinonen S. Clinical significance of true umbilical knots: A population-based analysis. Am J Perinatol 2002;19:127-32.  Back to cited text no. 6
[PUBMED]    
7.
Tan SJ, Chen CH, Wu GJ, Chen WH, Chang CC. Fetal demise by umbilical cord around abdomen and stricture. Arch Gynecol Obstet 2010;281:137-9.  Back to cited text no. 7
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8.
Martinez-Aspas A, Raga F, Machado LE, Bonilla F Jr, Castillo JC, Osborne NG, et al. Umbilical cord entanglement: Diagnostic and clinical repercussions. Donald School Journal of Ultrasound in Obstetrics and Gynecology 2012;6:225-32.  Back to cited text no. 8
    
9.
Muppala H, Bedoya-Ronga A, Martindale E. Abnormally long umbilical cord with marked spiraling and true knots: A case report. Int J Gynaecol Obstet 2006;7:1.   Back to cited text no. 9
    
10.
Cunninghams FG. Leveno KJ. Bloom SL. Hauth JC, Rouse DJ, Sponge CY. Abnormalities of the placenta, umbilical cord, and membranes in Williams obstetrics, Williams obstetrics, 23rd Edition, 2010. p. 581-84.  Back to cited text no. 10
    
11.
Raio L, Ghezzi F, Di Naro E, Duwe DG, Cromi A, Schneider H. Umbilical cord morphologic characteristics and umbilical artery Doppler parameters in intrauterine growth-restricted fetuses. J Ultrasound Med 2003;22:1341-7.  Back to cited text no. 11
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