INTENSIVE CARE
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Umbilical Cord Knot Leading To Fetal Demise<br />
Maria Monica Ossa*, Tarik Zahouani, Tony Abdelmaseeh, Sara Lillo, Benamanahalli Rajegowda<br />
Introduction<br />
Umbilical cord accidents (UCA) represent 10% to 15% of<br />
stillbirths. 1 They are thought to be caused by cord compression<br />
with cessation of blood flow to the fetus in the setting of a<br />
cord prolapse, nuchal cord or true knot in the umbilical cord.<br />
True umbilical cord knot is a common complication that<br />
occurs in 0.3 to 2.1% of all pregnancies. 2 Predisposing factors<br />
include advanced maternal age, multiparity, obesity, chronic<br />
hypertension, gestational diabetes, previous spontaneous<br />
abortion, male fetuses, small fetuses, long umbilical cord,<br />
polyhydramnios, and genetic amniocentesis. 3 True knots of the<br />
umbilical cord are associated with a four-fold increased risk of<br />
antepartum fetal death and they are present in about 3-5% of all<br />
stillbirths. 4 We are reporting a case of intrauterine fetal demise<br />
(IUFD) secondary to tightened true knot of the umbilical cord.<br />
Case Presentation<br />
A 36 year-old woman, multigravida (7 pregnancies, 2 voluntary<br />
terminations of pregnancy, 1 spontaneous abortion) at 32 weeks<br />
of gestation presented to the emergency room (ER) complaining<br />
of no fetal movements. Her medical history was remarkable for<br />
chronic hypertension and obesity. Her previous pregnancies<br />
were complicated with severe preeclampsia. She had regular<br />
prenatal care during current pregnancy. At 15 weeks of gestation,<br />
due to advanced maternal age, she underwent an amniocentesis<br />
which confirmed a normal male karyotype with elevated alphafetoprotein<br />
(AFP). Fluorescence in-situ hybridization did not<br />
show numerical chromosomal abnormalities. At 19 weeks of<br />
gestation, transabdominal ultrasonography (US) depicted a<br />
single intrauterine gestation with detectable heartbeat and<br />
posterior placenta; no gross abnormalities were detected and<br />
umbilical cord was not visual. At 32 weeks of gestation, the<br />
patient did not feel any fetal movements for 12 hours, which<br />
prompted her to go the ER. During the bedside sonogram, no<br />
fetal heart rate was detected and IUFD was diagnosed. The<br />
patient underwent induction of labor. A deceased baby boy was<br />
delivered with Apgar scores of 0 and 0, at 1st and 5th minute<br />
respectively. His weight was 1960 grams. On initial examination,<br />
the baby had a tight one-loop cord around his neck with a tight<br />
knot of the cord interrupting blood supply (Figures A and B). An<br />
examination of the umbilical cord showed vascular congestion<br />
in the umbilical vein with possible long umbilical cord. There<br />
were no gross fetal abnormalities. The placenta was delivered<br />
The authors are from the Department of Pediatrics/Obstetrics Lincoln<br />
Medical and Mental Health Center/Weill Medical College of Cornell<br />
University, New York, USA.<br />
spontaneously and noted to be intact. The placental pathology<br />
showed a 1.5 cm in diameter umbilical cord containing 3 mildly<br />
distended blood vessels but otherwise unremarkable.<br />
Discussion<br />
Umbilical cord lengths vary from 5 to 175 cm with an average<br />
length of approximately 55 cm. After 28 weeks of gestation,<br />
the cord does not significantly lengthen. 2 The Umbilical cord is<br />
helical in nature, with as many as 380 helices. Umbilical cord<br />
complications or accidents have been reported in 10-15% of<br />
stillbirths. 1 They are thought to be caused by cord compression<br />
with cessation of blood flow to the fetus in the setting of a cord<br />
prolapse, nuchal cord or true knot in the umbilical cord. The<br />
reported frequency of cord prolapse of the umbilical cord varies<br />
between 0.2 and 0.6% of births. In most series of cord prolapse,<br />
the perinatal mortality is approximately 15%. Among term infants<br />
and among all infants delivered by Cesarean within 10 minutes<br />
of cord prolapse, mortality is