Intrauterine thrombosis of umbilical artery - case report

Clinical significance of the large fetal vessel lesions of placental fetal vascular malperfusion

Fetal vascular malperfusion (FVM) is an important pattern of placental injury. While the significance of distal villous FVM (clusters of sclerotic and/or mineralized chorionic villi) is well documented, the clinical significance of proximal (large vessel) lesions of FVM is less clear, which is the aim of this retrospective analysis. To evaluate the clinical significance and placental associations of single and co-existing categories of lesions of large vessel FVM, 24 clinical and 44 placental phenotypes of 804 consecutive placentas with at least 1 lesion of proximal vessel FVM from the 2nd half of pregnancy, divided according to the type/category of the individual FVM lesion (fetal vascular ectasia, fetal vascular thrombi, intramural fibrin deposition, stem vessel obliteration): 689, 341, 286, 267 placentas, respectively (first analysis), and single or coexisting large fetal vessel lesions: 1, 2, 3, and 4 coexisting categories of lesions: 276, 321, 162, and 45 placentas, respectively, were statistically compared (analysis of variance, Chi-square, univariate analysis). Because of multiple comparisons, p Bonferroni <0.001 was used as a threshold of statistical significance. In this population of high-risk pregnancies dominated by fetal congenital anomalies, single individual or 1-2 coexisting categories of lesions of the large vessel FVM, including fetal vascular thrombi, did not consistently correlate with clinical or placental variables and were not prognostically useful, but the coexistence of 3 or 4 lesions was associated with the most advanced gestational age, fetal congenital anomalies, distal villous FVM, particularly high grade, chorangioma/chorangiomatosis, hyper coiled umbilical cord, perivascular stem edema, and marginate/vallate placenta. Therefore, the finding of multiple lesions of the large vessel FVM not only merits a diligent search for the distal villous lesions, but also by CD34 immunostaining but justifies putting the large vessel (global) FVM on the final placental diagnosis line which in the case of up to only two lesions may not be justified.

Umbilical artery Thrombosis: A case report of prenatal diagnosis and systematic review of the literature

Umbilical Artery Thrombosis (UAT) is an extremely rare complication of pregnancy strongly associated with severe fetal distress and death. The pathogenesis is still unclear but it is often associated with anatomical cord abnormalities that leads to blood stasis and thrombosis formation. Other possible risk factors are maternal thrombophilia, autoimmune disease, gestational diabetes, hypertension disorders of pregnancy and Rh-alloimmunization. The most common clinical symptom is the reduction of fetal movements. The diagnosis is histopathological, but it can be suspected by clinical and prenatal ultrasound findings. Generally, the first choice therapy is the immediate delivery with cesarean section. This study reported a case of a spontaneous intrauterine UAT in a low-risk pregnancy and a systematic review of the literature on clinical, ultrasound and histopathological findings of UAT, in order to help clinicians in the diagnostic process and management of this rare complication.

Ultrasound blood flow characteristics changes in fetal umbilical artery thrombosis: A retrospective analysis

BACKGROUND

Umbilical artery thrombosis (UAT) is extremely uncommon and leads to adverse perinatal outcomes. Hypercoagulation of blood in pregnant women is suspected to be an important risk for UAT. Ultrasound is an effective way to detect thrombosis. The mother can monitor her own fetal health using ultrasound, which enables her to take preventative action in case of emergency.

AIM

To investigate ultrasonic blood signal after UAT in the umbilical artery, and evaluate the relationship between hypercoagulability and UAT.

METHODS

We described a case of a newly formed UAT with markedly altered ultrasonic indices of umbilical artery blood flow, and retrospectively studied it with 18 UAT patients confirmed by histopathology from October 2019 and March 2023 in Xiamen Women and Children's Hospital. Patients' information was collected from medical archives, including maternal clinical data, neonatal outcomes, pathological findings and ultrasonic indices of umbilical artery blood flow, such as systolic-diastolic duration ratio (S/D), resistance index (RI), pulsatility index (PI) and peak systolic velocity (PSV). Ultrasound and coagulation indices were analyzed with matched samples t-test and Wilcoxon rank sum test using the statistical packages in R (version 4.2.1) including car (version 3.1-0) and stats (version 4.2.1), and visualized by ggplot2 package (version 3.3.6).

RESULTS

A patient with normal findings in second and third-trimester routine ultrasound scan developed UAT with severe changes in ultrasonic indices of umbilical artery blood flow (within 2.5th of reference ranges) in a short period of time. Statistical analysis of umbilical artery blood flow ultrasound indices for 19 patients with UAT showed that the decrease in S/D, RI, and PI and increase of PSV during the disease process was greater than that of non-UAT. All 18 patients delivered in our hospital showed characteristic manifestations of UAT on histological examination after delivery, most of which (16/18) showed umbilical cord abnormalities, with 15 umbilical cord torsion and 1 pseudoknot. Coagulation parameters were not significantly changed in UAT patients compared with normal pregnancy women.

CONCLUSION

Significant changes in ultrasound indicators after UAT were demonstrated. PSV can play important roles in the diagnosis of UAT. Hypercoagulability alone is not sufficient for the occurrence of UAT.

Case Report of Umbilical Artery Thrombosis in a Patient With a History of Heparin-Induced Thrombocytopenia

Women are at increased risk of thromboembolism during pregnancy because of hypercoagulability associated with pregnancy. Heparin-induced thrombocytopenia (HIT) is an uncommon complication of heparin therapy, and patients with histories of HIT cannot receive any heparin-derived medications. Limited data exist regarding the clinical management of pregnant women with histories of HIT. Umbilical artery thrombosis (UAT) is a rare fetal complication with significant fetal morbidity and mortality. Using the CARE guidelines, we report a case of a woman previously diagnosed with HIT who received long-term anticoagulation therapy and whose fetus developed UAT at 27 weeks gestation. The purpose of this case report is to share our successful expectant management plan of care, which centered on the woman, involved multidisciplinary collaboration, and led to a term cesarean birth.

Expectant management for umbilical artery thrombosis in monochorionic diamniotic twin pregnancies: a case report

BACKGROUND

Thrombosis of one of the umbilical arteries is a rare complication of pregnancy and is associated with adverse pregnancy outcomes, including stillbirth and intrauterine growth restriction. Although extremely rare, umbilical artery thrombosis (UAT) in monochorionic diamniotic twins is difficult to diagnose prenatally and manage. UAT has a poor prognosis and is associated with an increased perinatal mortality rate. In most previous cases, emergency cesarean section was performed or intrauterine fetal death occurred at the time of UAT diagnosis.

CASE PRESENTATION

Herein, we report an extremely rare case of sequential UAT in monochorionic diamniotic twins diagnosed via ultrasound at 29^+ 5 weeks of gestation in a 34-year-old woman. Following expectant management with intensive monitoring for 16 days, two healthy infants were delivered through an emergency cesarean section. UAT in both fetuses was confirmed by pathological examination. The mother and twins described in this case underwent long-term follow-up and are currently in good health without any complications.

CONCLUSIONS

Based on our experience, we suggest that expectant management should be undertaken as long as the mother and infants are stable on ultrasonographic scans and are closely monitored. When UAT is suspected, we believe that the best delivery time should be determined by considering complaints of unusual fetal movements, non-stress test evidence, gestational age, amniotic fluid volume, and blood flow in the umbilical artery, middle cerebral artery, and ductus venosus. Obstetricians should ensure that the patients and their families are clearly informed about all potential risks of expectant management for UAT.

Fetal umbilical artery thrombosis: prenatal diagnosis, treatment and follow-up

BACKGROUND

To analyze the ultrasound imaging and clinical characteristics of fetuses with umbilical artery thrombosis (UAT), explore the potential causes of UAT and construct a prognostic prediction model to guide clinical practice.

METHODS

This was a retrospective cohort study of fetal UAT cases examined at two academic tertiary referral care centers from 2014 to 2020. The basic information of the participants was obtained by interview during follow-up, and data on clinical treatment, delivery conditions, diagnosis and confirmation were obtained through medical records. Probable causes of thrombosis were explored by comparative analysis of the UAT group to the control group and by further regression analysis. Multivariable logistic regression models were used to evaluate risk factors for adverse pregnancy outcomes. Receiver operating characteristic (ROC) curves were constructed to evaluate the diagnostic value of the prognostic prediction model.

RESULTS

Thirty fetuses with UAT were included in this study. UAT occurred mostly in the third trimester of pregnancy, and there was an obvious predominance of right UAT. An abnormal pregnancy history (53.3%) was the most common comorbidity, followed by gestational diabetes mellitus (GDM) (20.0%). GDM and umbilical cord (UC) abnormalities were found to be independent risk factors for the development of UAT. After comprehensive decision-making, over two-thirds of the patients with UAT received urgent treatment, and less than one-third received expectant management. Surprisingly, there were no significant differences in fetal outcomes between the urgent treatment and expectant management groups. Multivariate logistic regression analysis showed that gestational age (GA) at clinical diagnosis and UC abnormalities were independent risk factors for adverse pregnancy outcomes (OR 0.781, p = 0.042; OR 16.779, p = 0.023, respectively). Based on this, we constructed a comprehensive prognostic prediction model. The area under the ROC curve (AUC) was 0.877 (95% CI 0.698-0.970; p < 0.001), which suggested that the combination of GA and UC abnormalities was a better predictor for fetal outcomes in our setting.

CONCLUSION

In summary, maternal GDM and fetal UC abnormalities are independent risk factors for UAT. UAT is more frequently observed on the right side. Moreover, poor clinical outcomes for fetuses with UAT are ascribed mainly to GA and UC abnormalities, which should be comprehensively evaluated to choose the appropriate treatment.

Umbilical artery thrombosis diagnosed at different gestational ages and fetal outcomes: a case series

BACKGROUND

Umbilical artery thrombosis is a rare complication of pregnancy strongly associated with poor fetal and perinatal outcomes, such as intrauterine asphyxia, fetal growth restriction, and stillbirth. Its pathogenesis remains unclear, and there is the added challenge of selecting an appropriate delivery time to achieve excellent neonatal outcomes.

METHODS

Our Hospital is a critical maternal rescue center with approximately 7000 births annually. We present a series of 8 cases of umbilical artery thrombosis diagnosed at the hospital between Apr 1, 2018, and Jan 31, 2020. We identified the cases through a keyword search of the maternity and pathology information management systems.

RESULTS

Three patients were diagnosed with a transabdominal ultrasound scan and hypoxia on fetal heart monitoring. All three patients had emergency cesarean section delivery. Four patients were observed closely for 5 to 13 weeks from initial detection by an ultrasound scan to delivery. Only one patient was diagnosed after vaginal delivery by Hematoxylin-eosin staining of umbilical cord sections. Seven patients had deliveries by cesarean section, and one patient had a vaginal delivery. All infants were born alive.

CONCLUSIONS

Umbilical artery thrombosis is a challenging and rare condition that can occur at different gestational ages, especially when diagnosed in the third trimester and accompanied by fetal growth restriction. Consequently, these patients require close monitoring of umbilical blood flow and fetal growth and intervention at the appropriate time to achieve an optimal outcome.

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.

Thrombosis of Both Umbilical Arteries of a Female Fetus in a Twin Gestation Causing Fetal Demise

Thrombosis of both umbilical arteries is a rare condition, less common than venous thrombosis. They cause a lot of complications during and after delivery. Umbilical artery thrombosis is associated with both maternal predisposing factors and cord abnormalities and is commonly seen in male fetuses. Presenting symptoms are those of intrauterine growth retardation. Ultrasound abdomen and Doppler flow studies are useful in diagnosing this condition. The prognosis is very poor. Histopathological examination is helpful for confirmation. We present a case of both umbilical arteries thrombosis of a female fetus in a twin gestation causing fetal demise.

10 cases of umbilical cord thrombosis in the third trimester

BACKGROUND

Thrombosis of umbilical vessels is a rare occurrence that is difficult to detect during routine antenatal examinations but can lead to poor perinatal outcomes.

OBJECTIVE

The aim of this study is to examine the association between meaningful clinical manifestations and features associated with thrombosis of umbilical vessels, and to evaluate optimal management options.

METHODS

A retrospective study of umbilical cord thrombi cases enrolled between 2015-2019 was carried out. Data were analyzed from the medical archives where the diagnosis of all cases was established by histopathology.

RESULTS

Gross examination reported additional cord abnormalities (7/10), including the irregular length of the umbilical cord, narrowed cord with hyper-coiling, swollen cord with deficiency of Wharton's jelly, placenta velamentous and umbilical infarction. Pathological examination accounted for 10 cases of umbilical cord thrombosis including umbilical artery embolism (3/10), umbilical vein thrombi (5/10) and funisitis (2/10). Clinical findings depicted that the chief complaint was decreased fetal movement companied by nonreactive NST tests (5/10). With the exception of two stillbirths, the remaining pregnancies (8/10) were terminated by cesarean section. All neonates are alive, including one VLBW and three LBW cases.

CONCLUSION

We have observed that umbilical structural dysplasia, maternal coagulation disorder, vascular endothelial injury and elevated blood glucose may lead to the formation of thrombosis. Focus on specific signs during a prenatal ultrasound, EFM monitoring and counting fetal movements can help in early identification of umbilical cord thrombi. Our results support the more effective approach of emergency cesarean section during the third trimester.

Umbilical artery thrombosis: Two case reports

RATIONALE

The umbilical cord is the way to exchange gas, supply nutrients, excrete metabolized. Thrombosis of the umbilical cord leads to fetal hypoxia, which jeopardizes fetal health and can cause fetal death. Umbilical vessel thrombosis, which is rarely reported, is difficult to detect prenatally.

PATIENT CONCERNS

Both pregnant women had an unremarkable pregnancy course until a routine ultrasound scan in the third trimester showed a single umbilical artery. However, one umbilical vein and 2 umbilical arteries were seen during an ultrasound examination at 32 weeks. Case 2 had a better pregnancy outcome because of the timely discovery of this complication.

DIAGNOSIS

Both cases were diagnosed as umbilical artery thrombosis.

INTERVENTIONS

The first patient received no interventions until they reported decreased fetal movements and gradually disappear. The second patient underwent an emergency cesarean section.

OUTCOMES

In Case 1, an emergency ultrasound examination showed intrauterine fetal death, and the patient vaginally delivered a stillborn child weighing 3300 g in a day. In Case 2, a female neonate weighing 2860 g was delivered by cesarean section, and exhibited Apgar scores of 10 and 10 at 1 and 5 minutes.

CONCLUSION

In the late-term abortions, obstetricians should be vigilant if ultrasound imaging shows suspected umbilical vascular thrombosis or shows 1 umbilical artery when there had previously been 2. The fetus should be closely monitored and interventions implemented as early as possible to improve the prenatal detection rate of umbilical vessel thrombosis and avoid adverse pregnancy outcomes.

Umbilical Artery Thrombosis with Associated Acute and Severe Fetal Growth Restriction and Transient Severe Protein S Deficiency: Report of a Case with Prenatal Ultrasound Diagnosis Allowing for Timely Intervention and Good Outcome

Background

Thrombosis of one of the umbilical arteries can be associated with adverse pregnancy outcomes such as stillbirth and severe intrauterine growth restriction (IUGR).

Case

A 21-year-old gravida 1 patient, with a history of 3-vessel cord at 20 weeks, presented at 29 weeks with a single umbilical artery. The estimated fetal weight measurements at 26 weeks, 29 weeks, and 31 weeks were at the 27th percentile, the 26th percentile, and less than the 5th percentile, respectively. At 33 weeks, amniotic fluid index became abnormal at 2.3 cm and fetal heart tracing revealed spontaneous prolonged decelerations, and a cesarean delivery was performed. Placental pathology showed thrombosis of one of the umbilical arteries. At birth, a transient protein S deficiency was detected (activity 13%) and resolved at two months of age (activity 66%). The baby had an uneventful clinical course since birth.

Conclusion

The recognition of reduction of umbilical arteries from two to one allowed for timely intervention with good outcome in this case. Thrombosis of umbilical vessels may be associated with a deficiency in coagulation proteins such as protein S.