Umbilical Cord Hematoma

Unexpected stillbirth from umbilical cord hematoma

Background

Umbilical cord hematomas (UCHs) can cause life-threatening outcomes, although extremely uncommon. They can lead to fetal distress and stillbirth. They have been observed in about 1:5500 pregnancies; they are associated with poor outcome in about the 50% of all cases. UCHs commonly occur due to rupture/lesion of umbilical vein's walls, or less frequently of umbilical arteries' ones.

Case Report

We present a case of a fetal demise which acutely and unexpectedly occurred in the last phases of labor. In this fetus, the identification of the cause of death was made only after post-mortem examination. The present report depicts the uncommon eventuality of umbilical cord hematomas which can cause unexpected fetal demise.

Conclusion

This case points out that in these cases careful examination of umbilical cord's macroscopic/microscopic examination is fundamental to clarify the natural cause of fetal death for statistical purposes; to close parents' mourning process; to ascertain medical malpractice claims.

Clinically Relevant Prenatal Ultrasound Diagnosis of Umbilical Cord Pathology

Umbilical cord abnormalities are not rare, and are often associated with structural or chromosomal abnormalities, fetal intrauterine growth restriction, and poor pregnancy outcomes; the latter can be a result of prematurity, placentation deficiency or, implicitly, an increased index of cesarean delivery due to the presence of fetal distress, higher admission to neonatal intensive care, and increased prenatal mortality rates. Even if the incidence of velamentous insertion, vasa praevia and umbilical knots is low, these pathologies increase the fetal morbidity and mortality prenatally and intrapartum. There is a vast heterogeneity among societies’ guidelines regarding the umbilical cord examination. We consider the mandatory introduction of placental cord insertion examination in the first and second trimester to practice guidelines for fetal ultrasound scans. Moreover, during the mid-trimester scan, we recommend a transvaginal ultrasound and color Doppler assessment of the internal cervical os for low-lying placentas, marginal or velamentous cord insertion, and the evaluation of umbilical cord entanglement between the insertion sites whenever it is incidentally found. Based on the pathological description and the neonatal outcome reported for each entity, we conclude our descriptive review by establishing a new, clinically relevant classification of these umbilical cord anomalies.

Current Perspectives of Prenatal Sonography of Umbilical Cord Morphology

The umbilical cord constitutes a continuation of the fetal cardiovascular system anatomically bridging between the placenta and the fetus. This structure, critical in human development, enables mobility of the developing fetus within the gestational sac in contrast to the placenta, which is anchored to the uterine wall. The umbilical cord is protected by unique, robust anatomical features, which include: length of the umbilical cord, Wharton’s jelly, two umbilical arteries, coiling, and suspension in amniotic fluid. These features all contribute to protect and buffer this essential structure from potential detrimental twisting, shearing, torsion, and compression forces throughout gestation, and specifically during labor and delivery. The arterial components of the umbilical cord are further protected by the presence of Hyrtl’s anastomosis between the two respective umbilical arteries. Abnormalities of the umbilical cord are uncommon yet include excessively long or short cords, hyper or hypocoiling, cysts, single umbilical artery, supernumerary vessels, rarely an absent umbilical cord, stricture, furcate and velamentous insertions (including vasa previa), umbilical vein and arterial thrombosis, umbilical artery aneurysm, hematomas, and tumors (including hemangioma angiomyxoma and teratoma). This commentary will address current perspectives of prenatal sonography of the umbilical cord, including structural anomalies and the potential impact of future imaging technologies.

Risk factors for spontaneous hematoma of the umbilical cord: A case-control study

BACKGROUND

Spontaneous hematomas of the umbilical cord are rare and often fatal to the fetus. Little is known about their mechanism or their risk factors. In view of their rarity, the series are limited. No comparative study enabling the identification of factors associated with these hematomas has been published.

MATERIAL AND METHODS

This retrospective case-control study of 13 spontaneous histologically confirmed hematomas of the umbilical cord over a consecutive 16-year period compared the characteristics of the case mothers and fetuses to those of a group of 39 control mothers who gave birth the same day as the case mothers.

RESULTS

In utero death was high in the case group (46.2% vs 0.0%, P < 0.001). Third-trimester oligohydramnios (30.8 vs 2.6%, OR = 16.9, P = 0.01), second-trimester amniocentesis (33.3 vs 5.1%, OR = 9.3, P = 0.02), and a reduction in fetal movements as perceived by the mother (35.7 vs 7.7%, P = 0.02) were significantly associated with spontaneous umbilical cord hematomas.

CONCLUSION

Third-trimester oligohydramnios and second-trimester amniocentesis appear to be associated with the occurrence of a spontaneous hematoma of the umbilical cord.