Prenatal Diagnostic Ultrasound in Application of Umbilical Cord

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Prenatal Diagnostic Ultrasound in Application of
Umbilical Cord

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What Ultrasound Can Do?
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In Diagnosis

• Vessel Number Normal cord has 3 vessels encased
  in Wharton jelly. (2A1V)
• Arteries flanking the bladder.
• Cord Coiled Arteries coil around vein.
• Connections Abdominal wall central placenta.
  (vesa previa, velamentous insertion)

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Cord Length (5060 cm)

• Short cord
• Akinesia sequence
• Trisomy 21
• Body stalk anomalies
• Long cord
• Hyperactivity
• Increased likelihood of true cord knot

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Morphological Abnormalities
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Single Umbilical Artery

• 3 in 1st trimester, 12 2nd tri., 0.63
  newborn.
• 70 absent LT UA, 30 RT
• Size is larger than 3 vessel cord UA
• Less coiled
• 15 develop IUGR
• Non-isolated SUA 50 aneuploidy (T18 13)
• D/D
• Fused UAs.
• Umbilical vessel thrombosis
• Excessive Wharton jelly

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Umbilical Cord Cyst (UCC)

• Para-axial (60), axial (40), mid-UC (39)
• 2 in 1st trimester, 2nd3rd trimester
  aneuploidy? (T18 T13)
• Single UCC (75) good prognosis
• Multiple UCC (25) 2/3 aneuploidy anomalies.
• D/D
• Normal yolk sac
• UC aneurysm
• Resolving UC hematoma (rare)
• UC supernumerary vessels (very rare, conjoined
  twins)

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Umbilical Cord Aneurysm (UCA)

• UV varix (UV gt 9mm)
• May associated with persistent Rt umbilical vein
• Between abdominal insertion site and inferior
  liver
• May be large
• UA aneurysm
• May have A-V fistula to UV
• Associated with multiple anomalies (T18)
• Near placental origin
• More rare than UV varix wall may be calcified

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Umbilical Cord Aneurysm (UCA)

• Careful research for other anomalies
• UV varix may be first manifestation of ? vein
  pressure
• Monitor impending hydrops
• Monitor for anemia
• Use color Doppler for checking
• D/D
• Normal fluid-filled structures
• Abdominal cysts (choledochal cyst, meconium
  pseudocyst, ovarian cyst, urachal cyst)
• UC cysts

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Meconium pseudocyst
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Vasa Previa

• Submembranous fetal vessels cross cervical os
• Doppler shows fixed fetal vessels overlying cx os
• From succenturiate lobe most common etiology
• Best imagine tool TVS color Doppler PW
• D/D
• Marginal sinus previa
• Cord presentation
• Uterine vessel near cervix

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Vasa Previa

• Pathology 1 in 3500 deliveries
• 6080 fetal mortality if diagnosis missed.
• C/S before onset of labor

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Nuchal Cord

• One or more complete loops of UC around fetal
  neck.
• Malesgtfemales 29 at 42wks
• Single loop 10.6, double 2.5
• Diagnosis best by Doppler US and 3D ultrasound
• Recommendations
• Look for vascular compromise (S/D ratio)
• Fetal growth and movement, amniotic fluid
• D/D
• Cord adjacent to neck
• Cystic hygroma

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Special Topic

• Cord Index

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OBGYN 2006
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• Under coiling is associates with (umbilical
  coiling index below the 10th percentile)
• fetal death
• spontaneous preterm delivery
• trisomies
• low Apgar score at 5 minutes
• velamentous cord insertion
• single umbilical artery

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There was an inverse relationship between the
umbilical coiling index and the birth weight
percentile.

• Over coiling (umbilical coiling index above the
  90th percentile)
• asphyxia
• umbilical arterial pH lt 7.05
• small for gestational age infants
• trisomies
• single umbilical artery

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• Under-coiling may give way to kinking and
  compression, whereas over-coiling may give way to
  occlusion in cases with cord entanglement.
• Early second-trimester low umbilical coiling
  index predicts small-for-gestational-age
  fetuses.(J Ultrasound Med 2011831188, 2001)

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It appears that umbilical cord coiling modulates
noticeably blood flow through the umbilical cord.
We speculate that more prominent
umbilicalcoiling (higher antenatal UCI values)
has a protective effect on blood flow in terms of
decreased arterial resistance and higher blood
flow velocities, as well as increased venous
blood flow.
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Abnormal Cord Doppler Clinical Significance
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The DV blood flow that was corrected for fetal
weight was increased significantly in
intrauterine growth-restricted fetuses compared
with control fetuses (P0).In 23 of 30 IUGR,
the percentage of umbilical blood flow that was
shunted through the ductus wasgt90th percentile of
control fetuses.DV diameters were significantly
greater in growth-restricted fetuses than in
control fetuses (P.0001).
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• IVC, DV, and UV Doppler parameters correctly
  predict acid-base status in a significant
  proportion of IUGR neonates. Combination, rather
  than single vessel assessment provides the best
  predictive accuracy.

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We studied 97 gravidas with the diagnosis IUGR
and confirmed 61 cases of IUGR with acidemia. The
demographic data showed that 24 gravidas had a
diagnosis of preeclampsia, and 37 had pregnancies
superimposed with chronic hypertension.
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Results

• Based on the PI of the umbilical artery and PI
  for the vein of the ductus venosus, the areas
  under the receiver operating characteristic
  curves were 0.7992 and 0.6749, respectively, for
  predicting growth-restricted neonates with
  acidemia.
• With a combination of the PIs of the umbilical
  artery and the PIs for the vein of the ductus
  venosus, the predictive accuracy of the
  growth-restricted neonates with acidemia
  increased, with sensitivity of 0.79 and
  specificity of 0.79 and an area under the
  receiver operating characteristic curve of 0.8441.

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Conclusions

• Compared with single-vessel assessment, combining
  the PIs of the umbilical artery and the PIs for
  the vein of the ductus venosus provides the
  greatest accuracy in predicting growth-restricted
  neonates with acidemia.

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Train up a child in the way he should go and
when he is old, he will not depart from it.
(Proverb 226)

• Thanks for attention!