Search

Background: Umbilical cord true knot is a rare condition which affects about 1% of all pregnancies. Though the incidence is lower, it often goes undetected in antenatal period despite the availability of prenatal sonography and may lead to a compromised fetal outcome as presented in this case. In this case the presence of true knot of umbilical cord was missed despite routine sonography done just 1 week prior to delivery, when patient presented to casualty with complains of decreased fetal movements since 24 hours. This modality is said to be associated with adverse fetal outcome such as birth asphyxia or in adverse cases intra uterine fetal demise. Risk factors include long cord, polyhydramnios, small sized fetus, etc. Case Summary: 27 years old gravida two, para two, with 1 live issue with k/c/o hypothyroidism with previous lesions came with complaints of decreased fetal movement since 24 hours at 36 weeks 3 days of gestational period. The patient recorded regular ANC checkups and routine investigations within normal limits. Her USG scan done at 34.2 wks showing single loop of cord around neck and normal doppler findings. On examination her vitals were normal .Her abdominal examination showed uterus of 34 wks size, longitudinal lie, cephalic presentation and irritable with mild contractions present with scar tenderness . Her FHS were present/irregular/112 bpm with less variability. On p/v examination os was admitting tip of finger, cervix soft, 25% effaced, station high up, presenting part vertex, membrane present. She was advised admission and a cardio-tocography (CTG) was done which showed recurrent deep atypical variable decelerations with decreased beat to beat variability. An emergent cesarean section was taken. Newborn was a female diagnosed with true umbilical cord knot, 2 cm away from fetal insertion with cord length of 84 cm. The baby was shifted to NICU in view of respiratory distress. Conclusion: Despite of modern day ultrasonography and Doppler studies, true umbilical cord knot still remains a lesser diagnosed entity and so every pregnant patients should be monitored carefully with a watch for daily fetal movement count (DFMC)and weekly non stress test (NST) for fetal well being.

Objective:To analyse the prenatal diagnostic value of ultrasound in umbilical cord knot(UCK) and the correlation of UCK and fetal perinatal outcome.Methods:Firstly, retrospective analysis was conducted on the prenatal ultrasound and clinical data of newborns or induced fetuses with UCK.Secondly,the incidence of UCK and its relationship with fetal perinatal outcome were summarized and analyzed.Then,the value and image characteristics of prenatal ultrasound in diagnosing UCK were analyzed.Finally,fetuses who were diagnosed as UCK after delivery were UCK group, and control group was 200 cases randomly selected from other normal fetuses.The differences of ultrasonic parameters and related clinical parameters were compared.Results:During 5 years, there were 40346 fetuses were born, including 209 cases stillbirths in the third trimester.99 fetuses were confirmed with UCK by postnatal diagnosis (including 3 stillbirths died of UCK),accounting for 3% of the diagnosis of UCK.2D ultrasonic images can be classified as excessively distorted, stacked or cloverleaf.The 3D-US can clearly identify the true and false UCK,which can be divided into loose UCK,tight UCK,spiraling umbilical cord and twisted and stacked umbilical cord.RI of middle cerebral artery in UCK group was lower than that in normal control group (P

An umbilical cord knot is an unexpected event that should not change obstetric approach for delivery.

Umbilical cord knots occur in 1-2% of all deliveries can lead to increase in fetal death and asphyxia. A thorough cord examination is important to discern abnormalities. Although there are not set guidelines for diagnosing and managing umbilical cord knots; increase of reporting with complications will aid in decision making for better future patient management. We describe one such case in a primigravida who was found to have an umbilical cord knot.

A true umbilical cord knot (TUCK) is a rare event, complicating 0.3-1.3% of all pregnancies. Prenatal diagnosis is not usual, as it is mostly discovered at delivery, when the knot is identified. True cord knots are mostly asymptomatic, but can be associated with adverse perinatal outcomes such as birth asphyxia and foetal demise, owing to compression of the umbilical vessels within the knot. This compression, however, is largely dependent on how tightly the knot is formed. We report a 30-year-old booked gravida 2, para 1, with a living child, who had spontaneous vaginal delivery of a healthy male baby at term, with incidental finding of a single loose TUCK at delivery. The umbilical cord was 81 cm long. The baby weighed 3600 g at birth, with 1- and 5-minutes Apgar scores of 9 and 10 respectively, and no adverse perinatal occurrence.

The author reports the following case from his practice

Graphical abstract, Highlights • A novel two-stage pipeline for automated placental examination and assessment. • A novel application of “similar/overlapped domains, different tasks” transfer learning. • Curation of the first-of-its-kind large-scale dataset for placenta research. • A fast and objective solution for placental measurement and assessment. • Highly promising results for a number of diagnoses that may possess clinical impact., Post-delivery analysis of the placenta is useful for evaluating health risks of both the mother and baby. In the U.S., however, only about 20% of placentas are assessed by pathology exams, and placental data is often missed in pregnancy research because of the additional time, cost, and expertise needed. A computer-based tool that can be used in any delivery setting at the time of birth to provide an immediate and comprehensive placental assessment would have the potential to not only to improve health care, but also to radically improve medical knowledge. In this paper, we tackle the problem of automatic placental assessment and examination using photos. More concretely, we first address morphological characterization, which includes the tasks of placental image segmentation, umbilical cord insertion point localization, and maternal/fetal side classification. We also tackle clinically meaningful feature analysis of placentas, which comprises detection of retained placenta (i.e., incomplete placenta), umbilical cord knot, meconium, abruption, chorioamnionitis, and hypercoiled cord, and categorization of umbilical cord insertion type. We curated a dataset consisting of approximately 1300 placenta images taken at Northwestern Memorial Hospital, with hand-labeled pixel-level segmentation map, cord insertion point and other information extracted from the associated pathology reports. We developed the AI-based Placental Assessment and Examination system (AI-PLAX), which is a novel two-stage photograph-based pipeline for fully automated analysis. In the first stage, we use three encoder-decoder convolutional neural networks with a shared encoder to address morphological characterization tasks by employing a transfer-learning training strategy. In the second stage, we employ distinct sub-models to solve different feature analysis tasks by using both the photograph and the output of the first stage. We evaluated the effectiveness of our pipeline by using the curated dataset as well as the pathology reports in the medical record. Through extensive experiments, we demonstrate our system is able to produce accurate morphological characterization and very promising performance on aforementioned feature analysis tasks, all of which may possess clinical impact and contribute to future pregnancy research. This work is the first for comprehensive, automated, computer-based placental analysis and will serve as a launchpad for potentially multiple future innovations.

True umbilical cord knot appears to be a relatively common complication that occurs in 0.3%-1.3% of all pregnancies and it is correlated with an increased incidence of SGA infants, premature birth, need for neonatal intensive care and fetal death. The aim of the article was to evaluate the incidence of the true umbilical cord knot in the University Emergency Hospital, Bucharest, for a period of 5 years and its association with premature birth, low birth weight, low Apgar score at 1 minute and the need for neonatal intensive care. By reviewing the total number of women who delivered in this unit between January 1st 2011 and December 31st 2015, the percentage of the diagnosis antepartum and intrapartum, the outcome of these pregnancies, and the reflection of this condition on the fetal status, were evaluated. During 5 years, 133 (0.71%) of 18.500 deliveries were diagnosed with true umbilical cord knot, only 16 (0.08%) cases were diagnosed by ultrasound antepartum. The mean maternal age was 34.3 years. About 30% of the studied cases (39) presented this condition at the third delivery or more. A personal history for diabetes corresponded to 27 cases (20.3%). From our database, it resulted that only 12 fetuses (10.5%) required neonatal intensive care and presented an Apgar score lower than 7 at 1 minute. Prenatal diagnosis of a true umbilical cord knot is rarely encountered and sonography skills are needed. Complementary methods such as color Doppler and 3D HD Flow are reliable for the diagnostic when true umbilical cord knots are suspected after a 2D scan. Several risk factors can guide the expectancy, such as advanced maternal age, polyhydramnios, multiparty or diabetes.

We report the case of a 33 weeks pregnant woman who was admitted in our hospital for recent jaundice. The controversial results of medical investigations and the patient’s clinical outcome indicated the necessity for immediate caesarian-section along with exploratory laparotomy. The surgeons extracted gelatinous membranes from the main biliary duct. At the Department of Pathology from University Emergency Hospital from Bucharest, we received the placental components, were we noted the presence of one true umbilical cord knot and meconium impregnation, a non-slatted gallbladder of 18 cm long and the numerous, heterogeneous membranes. On histopathological examination we found uteroplacental hypoxia-related features in the placenta together with retroplacental hematoma, umbilical cord edema, and inflammatory content of the gallbladder and hydatid cyst fragments on the common bile duct samples. The premature new-born survived and both the mother and the infant were discharged in good health condition after 2 weeks.

Objective: To evaluate the relationship of fetal sex with obstetric risk factors and perinatal outcomes. Material and methods: Retrospective study of deliveries during 2003–2009 at a tertiary hospital based on the analysis of obstetric and neonatal risk variables according to neonatal sex. Results: Of the 29,530 deliveries studied, the neonate was a boy in 15,038 (50.92%) and a girl in 14,492 (49.08%). The rates of gestational diabetes, prematurity, true umbilical cord knot and nuchal cord were higher for male newborns, whereas the rate of echographic diagnosis of intrauterine fetal growth retardation was higher for female newborns. Mothers of male fetuses had higher rates of cesarean delivery and instrumental vaginal delivery. The indication for ending labor due to the non-reassuring fetal heart rate was also more frequent among male newborns. This group had higher rates of acidemia, although there were no significant differences between sexes in other short-term neonatal outcomes. In all subgroups analyzed here, fetal weight was higher in male newborns. Conclusions: Male sex is an independent risk factor for unfavorable outcomes of pregnancy and delivery.

a Fetal Medicine, Hospital Materno Infantil Presidente Vargas (HMIPV), Porto Alegre, RS, Brazil b Graduation in Medicine, Universidade Luterana do Brasil (ULBRA), Canoas, RS, Brazil c Graduate Program in Pathology, Universidade Federal de Ciencias da Saude de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil d Clinical Genetics, Universidade Federal de Ciencias da Saude de Porto Alegre (UFCSPA) and Complexo Hospitalar Santa Casa de Porto Alegre (CHSCPA), Porto Alegre, RS, Brazil e Clinical Genetics, Hospital Materno Infantil Presidente Vargas (HMIPV), Porto Alegre, RS, Brazil

The incidence of true knot of the umbilical cord is not only very low but it is often undiagnosed antenatally when present despite the availability of prenatal ultrasonography. When the true knot remains tight, it may impede the circulation of the fetus and may result to fetal death in utero especially in labor. We report a very uncommon case of true knot of the umbilical cord that ultimately led to a fetal demise. A 39‑year‑old booked G7 P5+1 with four living children, who booked for antenatal care at a gestational age (GA) of 17 weeks. The fundal height was compatible with the GA throughout pregnancy. An ultrasound done at a GA of 36 weeks showed normal findings. She had onset of labor at a GA of 40 weeks and 5 days following cervical ripening with two courses of 50 μg misoprostol inserted at the posterior fornix 6 h apart. The fetal heart tones were monitored using Doppler sonicaid. They remained normal throughout labor that lasted 13 h. She subsequently had spontaneous vertex delivery with poor Apgar score. The baby died immediately after birth. The umbilical cord was more than double the normal length and a true knot of the umbilical cord was diagnosed after delivery of the baby. We have reported a case of true umbilical cord knot in Nnewi, South‑East Nigeria. Although this entity can be diagnosed antenatally, current experience is limited to incidental observation and consequent fetal demise.Keywords: Fetal demise, True knot, Umbilical cord

The objective of this study is to determine the risk of adverse pregnancy outcomes resulting from a true umbilical knot. We analyzed 288 singleton pregnancies with a true umbilical knot among the women who gave birth at Kuopio University Hospital from January 1990 to December 1999. Logistic regression analysis was used to compare pregnancy outcomes of the affected cases with those of the general obstetric population (n = 23,027). The incidence of true knot was 1.25% and it was associated with advanced maternal age, multiparity, previous miscarriages, obesity, prolonged gravidity, male fetus, long cord, and maternal anemia. The women having a fetus with a cord knot underwent cesarean delivery less frequently than unaffected controls. Fetal death and low Apgar score at 1 min occurred significantly more frequently in the study group than in the general obstetric population, the adjusted odds ratios being 3.93 (95% CI, 1.41-11.0) and 1.73 (95% CI, 1.10-2.72), respectively. Otherwise, the pregnancy outcome measures were comparable in the two groups. Fetuses with true umbilical knots are at a four-fold increased risk of stillbirth, but little can be done to prevent fetal deaths during pregnancy. Surviving fetuses with true knots are likely to suffer temporary distress during delivery, but affected newborns recover soon after birth. Thus, monitored vaginal delivery appears to be a safe option for fetuses with true knots.

Objective: To determine obstetrical risk factors and pregnancy outcome of fetuses with true knot of the umbilical cord. Methods: Study population included 69,139 singleton deliveries occurring between the years 1990–1997. Data were retrieved from the database of the Soroka University Medical Center. Fetuses with malformations were excluded. Results: The incidence of true knots was 1.2% (841/69,139). In a multivariate analysis the following factors were found to be significantly associated with true knot of cord: grandmultiparity, chronic hypertension, hydramnios, patients who undergone genetic amniocentesis, male gender and cord problems (prolapse of cord and cord around the neck). The incidence of fetal distress and meconium stained amniotic fluid was significantly higher among patients with true knots of cord (7% versus 3.6%, P

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.

A 30-year-old para 1 woman presented to labour ward with pre-labour spontaneous rupture of membranes at 41 weeks' gestation. Labour was augmented with the use of oxytocics. Fetal cardiotocography s...

A 30-year-old primigravida presented for ultrasound and Doppler evaluation for loss of fetal movements. The ultrasound showed a normal 36 weeks fetus with a single loop of nuchal cord, with umbilical artery and other Doppler flows within normal limits for gestational age. The liquor was adequate (deepest vertical pocket—5 cm). On tracing the cord for Doppler interrogation, a cross-section of the cord was seen surrounded by a complete loop of cord raising suspicion of a true knot of the cord. The suspicion was confirmed by acquiring three dimensional high definition power Doppler volume and rotating it along x and y axis and displaying it in angiographic and glass body modes [1, 2] (Fig. 1). The fetus was delivered two days later by cesarean section for nonreassuring heart rate, and a healthy male fetus weighing 2510 g was delivered. The true knot of the cord was confirmed at 20 cm from the placental end of a 64 cm long cord (Fig. 2). True knot of the cord is relatively rare and is found in 0.3–2.1 % of pregnancies [3] but is important to diagnose as it is associated with a fourfold increase in fetal death rate, nonreassuring heart rate patterns, and cesarean delivery. Other factors associated with true knot of the cord include polyhydramnios, gestational diabetes, male fetus, amniocentesis, long cord and small fetus [3]. Notching in the umbilical artery waveform has been demonstrated and correlated with cord compression in fetuses with true knot of the cord. Stenotic effect of the true knot on umbilical venous blood flow was demonstrated by Gembruch et al. in a mid-trimester ultrasound [4, 5]. Prenatal diagnosis of true umbilical cord knot has been random and the true impact of this condition on neonatal outcomes is yet to be evaluated. However, prenatal diagnosis of true knot of umbilical cord should warrant closer Fig. 1 3D power Doppler angiogram showing true knot of the cord Fig. 2 True knot of the cord

Introduction Many abnormalities are observed in the morphology and pathology of the umbilical cord. The aim of the study was to assess the role of 3D sonography in pathology of true umbilical cord knots. Material and methods In our materials we observed 10 cases of true umbilical cord knots in a population of 2,864 deliveries. The 2-dimensional transverse scan of the umbilical cord was shown in 3- and 4-dimensional volume scan in order to get a precise image. Results Four knots were diagnosed prenatally, 3 knots were not diagnosed before the delivery and in the 3 remaining cases ultrasound examinations were not undertaken because the patients were in the course of delivery. In the pregnant subjects with diagnosed true umbilical cord knot once a week the Doppler blood flow indices were examined in the umbilical cord sections before and after the knot. In the three shown cases there were no signs of constriction or tightening of the knot. Four newborns were delivered spontaneously and five by caesarean section. In none of the cases was a pathological FHR trace an indication for emergency delivery. Conclusions Four-dimensional and Color Doppler examination is very important to diagnose a true umbilical cord. To make a precise diagnosis a longer observation of the abnormality is necessary and its repeated confirmation by color Doppler and power Doppler. This diagnosis requires strict monitoring of fetal wellbeing during pregnancy and the delivery. Perfection of true umbilical cord knot diagnoses may reduce sudden and unforeseen fetal distress.

Prenatal diagnosis of a true knot of the umbilical cord is often an incidental observation at ultrasound with a difficult differential diagnosis between true and false knots. Furthermore, little is known about the optimal management of these cases. We report the importance of color Doppler and four-dimensional ultrasound for the differential diagnosis in the case of true cord knot and the role of Doppler flow velocimetry in the management of that case. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2011

Umbilical cord is the lifeline of the fetus connecting it to the mother. It provides nutrition, oxygen, various trophic factors, and hormones from the mother to the fetus. Knotting of the umbilical cord is relatively a rare occurrence and is of two types. True knot of the umbilical cord is a serious condition which can result in fetal distress and catastrophic neonatal complications. We report a case of true umbilical cord knot, in a 28-year-old second gravida, which was diagnosed after elective cesarean section. The knotting was not found during her routine ante-natal scans. The newborn did not have any complications due to the knotting. Although prenatal diagnosis of a true knot is challenging, newer imaging techniques are promising.

To the Editor: The “compound” umbilical-cord knot reported by Camann and Marquardt (July 10 issue)1 is topologically two distinct knots that were probably “tied” at separate times. First, an overha...

True umbilical cord knot often remains undiscovered prenatally due to a lack of characteristic clinical or ultrasound signs. We present a pregnancy with favorable outcome in which a non-stress test (NST) found non-reassuring fetal status. Abnormal Doppler blood flow patterns in the descending aorta and in the middle cerebral artery revealed fetal arterial redistribution with normal circulation in the umbilical artery despite a true cord knot. The benefit of fetal Doppler assessment is discussed. Increased aortic-cerebral ratio may reflect acute hypoxic compromise caused by the transitory constriction of the true umbilical cord knot with unrecognized morphologic and circulatory signs.

EDITORIAL COMMENT: We accepted this paper for publication because cord problems should interest readers and it is generally accepted, as the author notes, that a true knot is seldom a cause of death before the onset of labour in contradistinction to entanglement of the cord around the baby's limbs and body. As far as the Editor is aware, diminished or absence of fetal movements has never been shown cardiotocographically to be caused by a true knot with successful delivery of the fetus although one can imagine that this could occur. It is interesting to speculate, as the author has done, concerning how a true knot tightens when the umbilical cord is of normal length. In Chew's (A) paper the cardiotocographic findings were analyzed in 2,601 women who reported diminished fetal movements and there was no example of a knotted cord in any of the 21 perinatal deaths or in any of the 24 infants who had loss of baseline variation and type 2 decelerations, which was regarded as evidence of critical fetal reserve. A Medline search identified a case where a sinusoidal fetal heart rate pattern and moderate fetal hypoxia was associated with a true knot of the cord (B). Another study of 12 pregnancies in which fetal distress and death resulted from umbilical cord abnormalities included 8 where the patients had a history of decreased fetal movements, and where nonstress cardiotocography was abnormal (C). These authors concluded that antepartum fetal deaths due to umbilical cord abnormalities are still difficult to prevent, as it is often impossible to detect distress in time for appropriate intervention. Prompt action to deliver the baby after an abnormal cardiotocograph appears to be a necessary step to prevent such deaths, yet even this failed in Case 2 reported in this paper. These 2 cases may inspire us to keep looking. One can imagine that the fetus may have been saved in Case 1 had the patient reported change in fetal movements earlier. (A). Chew FTK, Beischer NA. Antepartum cardiotocographic surveillance of patients with diminished fetal movements. Aust NZ J Obstet Gynaecol 1992; 32: 107–113. (B). Goldstein I, Timor-Tritsch IE, Zaidise I, Divon M, Paloi E. Sinusoidal pattern together with signs of moderate fetal hypoxia associated with a true knot of cord. Eur J Obstet Gynecol reprod Biol 1981; 11: 221–225. (C). Ghosh A, Woo JS, MacHenry C, Wan CW, O'Hoy KM, Ma HK. Fetal loss from umbilical cord abnormalities: a difficult case for prevention. Eur J Obstet Gynecol Reprod Biol 1984; 18: 183–198.

A 29-year-old woman was in spontaneous labor at term after an uncomplicated pregnancy. The second stage of labor was notable for persistent, severe, and variable decelerations in the fetal heart rate. She had spontaneous vaginal delivery of a 3.7-kg infant. The Apgar score was 8 and 9 at one and five minutes, respectively. The umbilical cord was noted to have a compound knot. True knots in the umbilical cord occur in approximately 1 percent of all deliveries. Most knots are single, are innocuous, and do not lead to an adverse neonatal outcome. Compound knots, as in this case, are rare, . . .

Fifty umbilical cords were prepared and examined and their venous perfusion pressures measured with and without a true knot in the cord. Contrary to information in the literature, a loose umbilical cord knot did not affect the venous perfusion pressure. With a tightened knot, the smaller the umbilical cord diameter, the greater was the pressure required to perfuse past the knot. The umbilical vessels, protected by the myxomatous structure of the Wharton's jelly, were rarely completely occluded. These findings correlate clinically with the relatively high incidence yet low fetal mortality rate actually due to a true knot in the umbilical cord.