Clinical associations to abnormal umbilical cord length in Latin American newborns

Umbilical cord length and neurodevelopmental disorders, a national cohort study

INTRODUCTION

Adversities in fetal life are known risk factors for neurodevelopmental disorders (NDD). Despite the pivotal role of the umbilical cord, little is known about its associations to later NDD.

OBJECTIVE

To estimate the associations between umbilical cord length and NDD (Attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), intellectual disability (ID), cerebral palsy (CP), epilepsy, impaired vision or hearing), and whether associations differed by sex.

MATERIALS AND METHODS

A prospective population-based cohort study including all liveborn singletons in Norway from 1999, through 2013 and followed up through 2019. Data were retrieved from The Medical Birth Registry of Norway and linked with other national health and administrative registries. Exposures were extreme umbilical cord length (empirical percentile <5th or ≥ 95th percentiles). Main outcome measures were NDD (ADHD, ASD, ID, CP, epilepsy, impaired vision or hearing). Associations with umbilical cord length were assessed using logistic regression.

RESULTS

The cohort consisted of 858,397 births (51.3% boys). We identified 33,370 persons with ADHD (69.8% boys), 10,818 had ASD (76.0% boys), 5538 ID (61.4% boys), 2152 with CP (59.9% boys), 8233 epilepsy (55.0% boys), 900 impaired vision (boys 55.0%), and 11,441 impaired hearing (boys 52.8%). Cord length was positively associated with ADHD (OR 1.15; 95%CI 1.09-1.22), i.e., the risk increased with long cord and decreased with short cord, regardless of sex. A short cord was positively associated with ID (OR 2.42; 95%CI 2.17-2.69), impaired hearing (OR 1.41; 95%CI 1.29-1.54), and epilepsy (OR 1.31; 95%CI 1.18-1.46). CP was associated with both short and long cord (OR 1.31; 95% CI 1.07-1.61 and 1.34, 95%CI 1.13-1.60, respectively). There was no association between cord length and impaired vision.

CONCLUSIONS

This first population study finds that umbilical cord length is associated with NDD. The findings support the hypothesis that neurodevelopment and development of the umbilical cord share pathways.

Correlation of the umbilical cord coiling pattern and fetal outcome: A single-center observational analytical study

INTRODUCTION

The umbilical cord (UC) anatomically embodies the feto-placental bridge with a major role in fetal development due to the vascular structures embedded in Wharthon's jelly. The helical coiling of the umbilical cord may be counterclockwise, viewed from the fetus, defined as sinistral coiling, while the opposite as dextral coiling. This study aimed to determine any associations between UC coiling patterns and medical disorders of pregnancy.

MATERIAL AND METHODS

An observational analytical study was conducted at the Clinical Emergency Hospital of Targu-Mures, Romania between January 2023-December 2023. Consecutive singleton placentas with attached UC submitted to the Pathology Department for various feto-maternal conditions were considered for appropriate measurements. The coiling number and direction (sinistral or dextral) of the umbilical cord were assessed per first 10 cm measured at the placental end.

RESULTS

Of 187 cases this study included, 57.21 % (97) had sinistral and 42.79 % (90) had dextral UC coiling. The minimum and maximum maternal age group was 12-44 years old. Sinistral UC coiling was associated with an increased risk of spontaneous abortion and stillbirth (25.77 %, p = 0.028). Sinistral coiling was also associated with extreme prematurity (p = 0.013), smaller birth weight (p = 0.040) and lower placental weight (p = 0.029). A lower 1 min (p = 0.045) and 5 min Apgar score (p = 0.017) were associated with sinistral coiling. No relevant risk of premature rupture of membranes (PROM) was observed (p = 0.324). No significant association of sinistral coiling and metabolic or blood-related maternal diseases was observed (p = 0.385 and p = 0.725).

CONCLUSION

According to the literature approximately 25 % of all pregnancies have a dextral UC coiling direction. In contrast, in our study a significantly higher percentage was found (slightly higher than 42 %) to have dextral coiling of the UC. Data from our selected group indicated that certain neonatal pathologies (extreme prematurity, stillbirth, smaller birth weight, and lower Apgar score) were more associated with sinistral coiling as compared to dextral. More extensive studies are necessary to ascertain the clinical relevance of these data, particularly concerning high-risk pregnancies.

Protein and genetic expression of CDKN1C and IGF2 and clinical features related to human umbilical cord length

BACKGROUND

Umbilical cord (UC) abnormalities are related to neurological outcome and death; specific molecular factors that might be involved are, as yet, unknown; however, protein-coding genes insulin-like growth factor 2 (IGF2) and cyclin-dependent kinase inhibitor 1C (CDKN1C) have been identified as potential candidates.

METHODS

An analytical observational study was carried out. Newborn UCs were collected, along with their clinical and morphological features. Immunohistochemical analysis was made on paraffin-embedded sections and quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed in fresh UC tissue for the assessment of gene expression.

RESULTS

A total of 100 newborns were included. A significant association was found between long UC and prematurity [odds ratio (OR) 9] and long UC and respiratory distress (OR 4.04). Gestational diabetes (OR 8.55) and hypertensive disorders of pregnancy (HDP) (OR 4.71) were found to be related to short UCs. The frequency for abnormal UC length was higher than expected. UC length was positively correlated with maternal, newborn and placental weight. No statistical association was found between IGF2 and CDKN1C (p57) expression and UC length; however, there was a tendency for higher CDKN1C expression in short UCs, while, on the contrary, higher IGF2 expression for long UCs.

CONCLUSION

UC length was observed to be associated with maternal and newborn complications. Protein expression, messenger RNA (mRNA) activity and the activity of said genes seem to be related to UC length.

Umbilical cord characteristics and their association with adverse pregnancy outcomes: A systematic review and meta-analysis

OBJECTIVE

Current data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes.

METHODS

MEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks' gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA.

RESULTS

This review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37).

CONCLUSIONS

True umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.

Effect of umbilical cord length on early fetal biomechanics

The umbilical cord suspends the fetus within the amniotic cavity, where fetal dynamics is one of its many functions. Hence, the umbilical cord is a viable index in determining fetal activity. Fetal movements result in mechanical loads that are fundamental for fetal growth. At present, mechanical environment during early human fetal development is still largely unknown. To determine early fetal movement dynamics at given physiological (0.060 m) and pathological umbilical cord lengths (0.030 m, 0.020 m, 0.017 m and 0.014 m) a 2D computational model was created to simulate dynamic movement conditions. Main findings of this computational model revealed the shortest umbilical cord length (0.014 m) with a 6(10-6)N, twitch force amplitude had a two-fold increase on linear velocity (0.12 m/s) in comparison with other lengths (0.05m/s). Moreover, umbilical cord length effect presented an increasing exponential tension on the fetus body wall from longest to shortest, from 0 N in the control length to 0.05 N for the shortest umbilical cord. Last, tension was always present over a period of time for the shortest cord (0.03 N to 0.08 N). Collectively, for all variables evaluated the shortest umbilical cord (0.014 m) presented remarkable differences with other lengths in particular with the second shortest umbilical cord (0.017 m), suggesting a 0.003 m difference represents a greater biomechanical effect. In conclusion, this computational model brings new insights required by clinicians, where the magnitude of these loads could be associated with different pathologies found in the clinic.

Implantation and pregnancy outcome of Sprague-Dawley rats exposed to pirimiphos-methyl

OBJECTIVE

This study was designed to investigate the effect of sublethal doses (10, 60, and 120 mg/kg of pirimiphos-methyl on implantation and pregnancy in female Sprague-Dawley rats. Pirimiphos-methyl is a pesticide widely used worldwide, especially in Africa to protect food against pests and has gained widespread acceptance.

METHODS

Pregnant Sprague-Dawley rats used for this study had access to food and water ad libitum and were divided into a control group and three experimental groups based on dose of chemical given. The pregnant rats were given pirimiphos-methyl orally on days 1-5, 1-7, 7-18th day of gestation and from day 1 to term. Implantation studies were carried out on days 6 and 8 of pregnancy, while the fetal parameters were ascertained on day 19 of pregnancy and at term. Serum levels of progesterone and estradiol were measured on days 6, 8 and 19 of pregnancy.

RESULTS

Sublethal administration of pirimiphos-methyl showed decreased number of implantation sites on days 6 and 8, fetal weight, crown-to-rump length, length of umbilical cord and placenta weight (day 19), birth weight, litter size and total number (at term) in rats administered with pirimiphos-methyl when compared with control.

CONCLUSION

Administration of pirimiphos-methyl resulted in a reduced implantation rate due to decreased uterine receptivity caused by an imbalance in the level of estradiol and progesterone and impaired reproductive outcome during pregnancy.

Role of VEGF in the differential growth between the fetal and placental ends of the umbilical cord

INTRODUCTION

The umbilical cord (UC) is a vital structure; its alterations affect the newborn and neurological impact can be permanent. Paradoxically, factors that determine it remain unknown. We explore the differential VEGF protein expression in the UC's proximal and distal portions in relation to the hypothesis that the UC has differential growth and that VEGF plays a role in it.

METHODS

An observational analytical study was performed. One UC segment was taken proximal to fetus and another distal; both were randomly processed; VEGF immunohistochemical analysis was performed; two blinded pathologists read results.

RESULTS

Forty-eight newborns were included. Protein expression between the two edges of the umbilical cord, in any kind of cells, was interpreted. Endothelium, amnion, and stromal cells expressed VEGF; the first two were not different between opposite ends. Stromal cells had differential expression: higher in the proximal to the fetus portion.

CONCLUSION

Knowledge of molecular factors is necessary. UC cells widely expressed VEGF, possibly contributing to UC growth. Even though stromal cell expression was different, the interaction with activity close to the fetus must be explored.

The umbilical cord, preeclampsia and the VEGF family

Introduction

The VEGF family has been identified as abnormal in preeclampsia (PE). Hypertensive disorders of pregnancy (HDP) are major contributors to maternal and neonatal morbidity and mortality worldwide; likewise, umbilical cord anatomical abnormalities (UCAA) are linked to poor neonatal outcomes. Based on the relationship described between PE and UCAA and the role of the VEGF family in PE, this study explored VEGF expression in placental and UC tissued from patients with PE and with UCAA.

Methods

We performed an observational, analytical study on placentas, comparing protein and mRNA expression in four groups: patients with PE, patients with UC abnormalities, patients with both, and patients with none of them. Using immunohistochemistry, we studied VEGF A, VEGF R1 (FLT1), MMP1, and PLGF. With quantitative reverse transcription polymerase chain reaction we described mRNA expression of PLGF, VEGF and sFLT1, and sFLT1/PLGF ratio.

Results

Forty newborns were included. Sixty-seven percent of mothers and 45% of newborns developed no complications. Immunohistochemistry was performed on UC and placental disc paraffin-embedded tissue; in the latter, the mRNA of the VEGF family was also measured. Statistically significant differences were observed among different expressions in both HDP and UCAA groups. Interestingly, the UCAA group exhibited lower levels of sFLT1 and VEGF-A in comparison with other groups, with significant P-value for sFLT1 (P=0000.1).

Conclusion

The origin of UCAA abnormalities and their relation with HDP are still unknown. VEGF family alterations could be involved in both. This study provides the first approach related to molecules linked to UCAA.

Prenatal measurement of umbilical cord length using magnetic resonance imaging

OBJECTIVE

This study aimed to evaluate the feasibility of prenatal measurement of umbilical cord length using magnetic resonance imaging (MRI) in comparison with that of postnatal visual measurement.

STUDY DESIGN

Patients who underwent MRI pelvimetry to rule out cephalopelvic disproportion were recruited. We compared the umbilical cord length measured prenatally using the three-dimensional image of the umbilical cord constructed by AZE virtual place system (AZE^®, Japan) on MRI (M-length) and measured postnatally using the actual length (R-length). The time interval between MRI scan and birth was set within 4 weeks. Patients were divided into normal, long (>90th centile), and short (<10th centile) groups based on the umbilical cord length.

RESULTS

A total of 106 pregnancies were analyzed. MRI was performed at a mean gestational age of 37.4 (34.1-41.7) weeks; the mean gestational age at delivery was 39.4 (36.0-41.8) weeks. M-length and R-length were 67.9 ± 13.6 [mean ± standard deviation] and 57.2 ± 12.7 cm, respectively. The correlation coefficient was larger in the long and short groups than in the normal group. The intraclass correlation coefficient showed high agreement, and Pearson's correlation coefficient revealed correlation inspection as r = 0.702. Bland-Altman analysis indicated non-agreement, and the bias and upper and lower limits of agreement were 10.6 cm and -6.0 and 27.3 cm, respectively.

CONCLUSIONS

Short and long umbilical cord lengths are associated with perinatal mortality and morbidity. Prenatal measurement of umbilical cord length using MRI is feasible for daily clinical use to distinguish short or long umbilical cords. Further research is needed for more precise clinical application and technical reduction of overestimation errors.

Are Short Umbilical Cords Seen in Pathology Really Short?

PURPOSE

Short umbilical cords are associated with adverse perinatal outcomes. Clinicians may rely on measurements made by pathologists, which do not include portions of the cord remaining n the child or sent for blood gasses.

METHODS

This was a retrospective chart review of term placentas. Sequential cases from January through August 2017 were reviewed from the Pathology archive.

RESULTS

198 placentas were recorded as either third trimester of mature, of which 146 were 37 or greater weeks of gestation. Of these 146, 142 had cords measuring less than 35 cm, the definition of short. Mean cord length was 19.6 cm. Of the 146 placentas, 50(34%) had had blood gases submitted.

CONCLUSIONS

34% of short cords by Pathology measurement had had blood gases sent. The fact that 142 out of 146 sequential placentas were recorded as "short" suggests an additional unmeasured loss of length due to cord attached to the infant. Pathology laboratory measurements should not be interpreted as truly short without clinical correlation.

Anatomical Pathology of the Umbilical Cord and Its Maternal and Fetal Clinical Associations in 434 Newborns

Introduction Umbilical cord (UC) abnormalities and their clinical relations in 434 newborns were analyzed. We had previously reported on clinical associations of long and short UCs with any kind of malformation. This study focuses on other UC features (insertion, vessels, entanglements, coiling, and knots) and their associations with clinical characteristics and neonatal prognosis. Methods An observational analytic study was performed on placentas from consecutive deliveries. Ordered logistic regression with bivariate and multivariate analysis was performed to evaluate the relationship between variables of interest concerning UC abnormalities. Results A total of 434 placentas made up the study. UC abnormalities were abnormal insertion, 82 (18.86%); coiling (hypo and hypercoiled), 177 (40.78%); single umbilical artery (SUA), 4 (0.92%); entanglements, 8 (1.84%); true knots, 3 (0.69%); webs in UC base, 9 (2.07%); and right twist, 68 (15.67%). After analyzing maternal and fetal complications during pregnancy, multivariate analysis confirmed the recognized association between malformations and SUA and male gender; further confirmation was also made between hypertensive disorders of pregnancy and true knots. Discussion UC abnormalities associated with undesirable outcomes are varied and should be recognized and described. Clinical factors associated with anatomical UC abnormalities are not completely understood and justify forthcoming studies.

Extreme umbilical cord lengths, cord knot and entanglement: Risk factors and risk of adverse outcomes, a population-based study

Objectives

To determine risk factors for short and long umbilical cord, entanglement and knot. Explore their associated risks of adverse maternal and perinatal outcome, including risk of recurrence in a subsequent pregnancy. To provide population based gestational age and sex and parity specific reference ranges for cord length.

Design

Population based registry study.

Setting

Medical Birth Registry of Norway 1999–2013.

Population

All singleton births (gestational age>22weeks<45 weeks) (n = 856 300).

Methods

Descriptive statistics and odds ratios of risk factors for extreme cord length and adverse outcomes based on logistic regression adjusted for confounders.

Main outcome measures

Short or long cord (<10^th or >90^th percentile), cord knot and entanglement, adverse pregnancy outcomes including perinatal and intrauterine death.

Results

Increasing parity, maternal height and body mass index, and diabetes were associated with increased risk of a long cord. Large placental and birth weight, and fetal male sex were factors for a long cord, which again was associated with a doubled risk of intrauterine and perinatal death, and increased risk of adverse neonatal outcome. Anomalous cord insertion, female sex, and a small placenta were associated with a short cord, which was associated with increased risk of fetal malformations, placental complications, caesarean delivery, non-cephalic presentation, perinatal and intrauterine death. At term, cord knot was associated with a quadrupled risk of perinatal death. The combination of a cord knot and entanglement had a more than additive effect to the association to perinatal death. There was a more than doubled risk of recurrence of a long or short cord, knot and entanglement in a subsequent pregnancy of the same woman.

Conclusion

Cord length is influenced both by maternal and fetal factors, and there is increased risk of recurrence. Extreme cord length, entanglement and cord knot are associated with increased risk of adverse outcomes including perinatal death. We provide population based reference ranges for umbilical cord length.