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Al Qasem M, Meyyazhagan A, Tsibizova V, Clerici G, Arduini M, Khader M, M Alkarabsheh A, Di Renzo GC. Knots of the umbilical cord: Incidence, diagnosis, and management. Int J Gynaecol Obstet 2024. [PMID: 38264935 DOI: 10.1002/ijgo.15373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
Knot(s) of the umbilical cord have received emphasis because the clinical assessments and sonographic literature show a crucial role in fetal outcomes. The true umbilical cord knot could be a knot in a singleton pregnancy or an entanglement of two umbilical cords in monoamniotic twins. Clinical manifestations are almost silent, which can raise clinical challenges. They worsen outcomes, and the pathology can be easily missed during prenatal visits because ultrasonographers do not pay attention to the cord during an obstetric ultrasound scan. However, most medical centers now have ultrasound machines that improve fetal assessment. The umbilical cord should be routinely evaluated during a fetal assessment, and suspicion of an umbilical cord knot can be more frequently diagnosed and is detected only incidentally. Clinical outcome is usually good but depends on the knot's characteristics and if it is tight or loose. In this review, we discuss pathophysiology, the theories on formation, the main risk factors, ultrasound signs and findings, different opinions in the management, and features of pregnancy outcomes feature.
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Affiliation(s)
- Malek Al Qasem
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Arun Meyyazhagan
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- Department of Life Sciences, CHRIST (Deemed to be University), Bengaluru, Karnataka, India
- PREIS International School, Firenze, Italy
| | - Valentina Tsibizova
- PREIS International School, Firenze, Italy
- CEMER, European Centre for Medical Research, Perugia, Italy
| | - Graziano Clerici
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- CEMER, European Centre for Medical Research, Perugia, Italy
| | - Maurizio Arduini
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Mohammed Khader
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Ahlam M Alkarabsheh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Gian Carlo Di Renzo
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
- PREIS International School, Firenze, Italy
- Department of Obstetrics, Gynecology and Perinatology, IE Sechenov First State University, Moscow, Russian Federation
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Houri O, Bercovich O, Wertheimer A, Pardo A, Berezowsky A, Hadar E, Hochberg A. Clinical significance of true umbilical cord knot: a propensity score matching study. BMC Pregnancy Childbirth 2024; 24:59. [PMID: 38216863 PMCID: PMC10785496 DOI: 10.1186/s12884-024-06249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE True umbilical cord knot (TUCK) is a rare finding that often leads to intensified surveillance and patient anxiety. This study sought to evaluate the incidence, risk factors, and obstetric and neonatal outcomes of TUCK. METHODS A retrospective cohort study was conducted at a tertiary university medical center in 2007-2019. Patients with singleton pregnancies diagnosed postnatally with TUCK were identified and compared to women without TUCK for obstetric and neonatal outcomes using propensity score matching (PSM). RESULTS TUCK was diagnosed in 780 of the 96,766 deliveries (0.8%). Women with TUCK were older than those without TUCK (32.57 vs. 31.06 years, P < 0.001) and had higher gravidity (3 vs. 2, P < 001) and a higher rate of prior stillbirth (1.76% vs. 0.43%, P < 0.01). Following covariate adjustment, 732 women with TUCK were compared to 7320 matched controls. TUCK was associated with emergency cesarean delivery due to non-reassuring fetal heart rate (2.54% vs. 4.35%, P = 0.008, OR 1.71, 95%CI 1.14-2.56) and intrapartum meconium-stained amniotic fluid (19.26% vs. 15.41%, P = 0.022, OR 1.31, 95%CI 1.04-1.65). Neonatal outcomes were comparable except for higher rates of 1-min Apgar score < 7 and neonatal seizures in the TUCK group. The stillbirth rate was higher in the TUCK group, but the difference was not statistically significant (1.23% vs 0.62%, P = 0.06, OR 1.96, 95%CI 0.96-4.03). CONCLUSIONS TUCK has several identifiable risk factors. Pregnant women with TUCK may cautiously be informed of the relatively low risks of major obstetric or perinatal complications. The lower occurrence of stillbirth in the TUCK group warrants further study.
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Affiliation(s)
- Ohad Houri
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel.
| | - Or Bercovich
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
| | - Avital Wertheimer
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
| | - Anat Pardo
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
| | - Alexandra Berezowsky
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
| | - Alyssa Hochberg
- Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky Street, 4941492, Petach Tikva, Israel
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Tonni G, Lituania M, Cecchi A, Carboni E, Resta S, Bonasoni MP, Ruano R. Umbilical Cord Diseases Affecting Obstetric and Perinatal Outcomes. Healthcare (Basel) 2023; 11:2634. [PMID: 37830671 PMCID: PMC10572758 DOI: 10.3390/healthcare11192634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND (1) The aim of this article is to describe the physiopathology underlying umbilical cord diseases and their relationship with obstetric and perinatal outcomes. (2) Methods: Multicenter case series of umbilical cord diseases with illustrations from contributing institutions are presented. (3) Results: Clinical presentations of prenatal ultrasound findings, clinical prenatal features and postnatal outcomes are described. (4) Conclusions: Analysis of our series presents and discusses how umbilical cord diseases are associated with a wide variety of obstetric complications leading to a higher risk of poor perinatal outcomes in pregnancies. Knowing the physiopathology, prenatal clinical presentations and outcomes related to umbilical diseases allow for better prenatal counseling and management to potentially avoid severe obstetric and perinatal complications.
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Affiliation(s)
- Gabriele Tonni
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, 42100 Reggio Emilia, Italy
| | - Mario Lituania
- Preconceptional and Prenatal Pathophysiology, Department of Obstetrics and Gynecology, E.O. Ospedali Galliera, 16128 Genoa, Italy;
| | - Alessandro Cecchi
- Department of Obstetrics and Gynecology, Regional Prenatal Diagnostic 2 Level Center, ASUR Loreto Hospital, 60025 Loreto, Italy; (A.C.); (E.C.)
| | - Elisa Carboni
- Department of Obstetrics and Gynecology, Regional Prenatal Diagnostic 2 Level Center, ASUR Loreto Hospital, 60025 Loreto, Italy; (A.C.); (E.C.)
| | - Serena Resta
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, University of Tor Vegata, 00133 Rome, Italy;
| | - Maria Paola Bonasoni
- Department of Pathology, Santa Maria Nuova Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, 42100 Reggio Emilia, Italy;
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
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Ebbing C, Rasmussen S, Kessler J, Moster D. Association of placental and umbilical cord characteristics with cerebral palsy: national cohort study. Ultrasound Obstet Gynecol 2023; 61:224-230. [PMID: 36722428 PMCID: PMC10108292 DOI: 10.1002/uog.26047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Cerebral palsy (CP) is a group of movement disorders usually diagnosed in childhood. A substantial proportion are thought to be caused by antenatal events. Abnormalities of the umbilical cord and placenta are associated with an increased risk of adverse neonatal outcomes, but it is unclear whether these conditions also carry an increased risk of CP. We aimed to determine whether abnormalities of the umbilical cord or placenta are associated with CP and assess if these associations differ by sex of the child or gestational age at birth. METHODS We performed a national cohort study by linking data from The Medical Birth Registry of Norway with other national registries. All liveborn singletons born between 1999 and 2017 (n = 1 087 486) were included and followed up until the end of 2019. Diagnoses of CP were provided by the Norwegian National Insurance Scheme and the Norwegian Patient Register. We used generalized estimating equations and multilevel log binomial regression to calculate relative risks (RR), adjusted for year of birth, and stratified analyses were carried out based on sex and gestational age at birth. Exposures were abnormal umbilical cord (velamentous or marginal insertion, single umbilical artery (SUA), knots and entanglement), and placental abnormalities (retained placenta, placental abruption and previa). RESULTS A total of 2443 cases with CP (59.8% males) were identified. Velamentous cord insertion (adjusted RR (aRR), 2.11 (95% CI, 1.65-2.60)), cord knots (aRR, 1.53 (95% CI, 1.15-2.04)) and placental abnormalities (placenta previa (aRR, 3.03 (95% CI, 2.00-4.61)), placental abruption (aRR, 10.63 (95% CI, 8.57-13.18)) and retained placenta (aRR, 1.71 (95% CI, 1.32-2.22))) carried an increased risk of CP. Velamentous cord insertion was associated with CP regardless of gestational age or sex. A retained placenta was associated with a 2-fold increased risk for CP in males, while the associations of SUA and cord knot with CP were significant only among females. CONCLUSIONS The detection of placental and umbilical cord abnormalities may help identify children at increased risk of CP. The associations between placental or umbilical cord abnormalities and the risk of CP do not vary substantially with gestational age at birth or sex of the child. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Ebbing
- Department of Obstetrics and GynecologyHaukeland University HospitalBergenNorway
- Department of Clinical ScienceUniversity of BergenBergenNorway
| | - S. Rasmussen
- Department of Clinical ScienceUniversity of BergenBergenNorway
| | - J. Kessler
- Department of Obstetrics and GynecologyHaukeland University HospitalBergenNorway
- Department of Clinical ScienceUniversity of BergenBergenNorway
| | - D. Moster
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
- Department of PediatricsHaukeland University HospitalBergenNorway
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Laranjo M, Neves BM, Peixinho C. True double umbilical cord knot. BMJ Case Rep 2022; 15:15/8/e251388. [DOI: 10.1136/bcr-2022-251388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Weissmann-Brenner A, Domniz N, Weissbach T, Mazaki-Tovi S, Achiron R, Weisz B, Kassif E. Antenatal Detection of True Knot in the Umbilical Cord - How Accurate Can We Be? Ultraschall Med 2022; 43:298-303. [PMID: 32674187 DOI: 10.1055/a-1205-0411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Umbilical cord knot (UCK) is associated with increased risk of fetal death, but is usually diagnosed only after delivery. Our objective was to examine the accuracy of prenatal ultrasound in the diagnosis of UCK and the outcomes of these pregnancies. METHODS A prospective study was performed on 56 patients in which UCK was suspected during a routine level-II anatomical scan (study group). Data included demographics, pregnancy outcome, and short-term neonatal follow-up. The control group included pregnant women with normal pregnancy without UCK in a 4:1 ratio matched for gestational age at delivery. RESULTS True knot was observed postnatally in 54 out of 56 fetuses (detection rate of 96.4 %). Gestational age at diagnosis of UCK was 22.1 ± 3.1 weeks. The female to male ratio was 1:1 in both groups. Maternal age and parity were significantly higher in pregnancies with UCK compared to controls. The mean gestational age at delivery was 37.1 weeks of gestation in the UCK group. There was no difference in the birthweight percentile. 47 patients (87 %) underwent induction of labor. There were no differences in the rate of cesarean section or Apgar scores. No neonate with UCK needed ventilation. None suffered from seizures and none needed brain imaging. There were no cases of fetal or neonatal death in the pregnancies with UCK. CONCLUSION There is a high detection rate of UCK during targeted scan of the umbilical cord performed during the level-II anatomical scan. Careful pregnancy follow-up and early term delivery may result in excellent obstetrical outcomes.
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Affiliation(s)
- Alina Weissmann-Brenner
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Domniz
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Weissbach
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shalev Mazaki-Tovi
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reuven Achiron
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Weisz
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Kassif
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Weissmann-Brenner A, Meyer R, Domniz N, Levin G, Hendin N, Yoeli-Ullman R, Mazaki-Tovi S, Weissbach T, Kassif E. The perils of true knot of the umbilical cord: antepartum, intrapartum and postpartum complications and clinical implications. Arch Gynecol Obstet 2021; 305:573-579. [PMID: 34405285 DOI: 10.1007/s00404-021-06168-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 07/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND True knot of the umbilical cord (TKUC) is found in 0.3-2.1% of pregnancies and is associated with an increased risk of adverse perinatal outcomes. METHODS A retrospective cohort study including all singleton pregnancies delivered from 2011 to 2019 was performed. Diagnosis of TKUC was made postnatally, immediately after delivery of the baby. Comparison was made between pregnancies with and without TKUC regarding maternal, fetal and neonatal adverse outcome. RESULTS Overall, 867/85,541 (1%) pregnancies were diagnosed with TKUC. Maternal age, BMI, gravidity and parity were significantly higher in pregnancies with TKUC as well as higher rate of induction of labor, meconium-stained amniotic fluid, and delivery prior to 37 weeks. The rate of cesarean deliveries due to non-reassuring-fetal monitor was significantly higher in pregnancies with TKUC. Overall, there were 2.5% IUFD in pregnancies with TKUC vs. 1% in pregnancies without TKUC (p < 0.001). Importantly, the rate of IUFD prior to 37 weeks of gestation was not significantly higher in the group with TKUC, however, the rate of IUFD after 37 weeks of gestation was 10 folds higher in fetuses with TKUC, 0.9% vs. 0.08% (p < 0.001). Significantly, more neonates with TKUC needed phototherapy or suffered from hypoglycemia. There were no differences in the 5 min Apgar scores, admission to the NICU and number of days of hospitalization. CONCLUSION Pregnancies complicated with TKUC are associated with a tenfold higher risk of IUFD beyond 37 weeks of gestation. To the results of this study suggest that it would be prudent to induce labor around 37 weeks of gestation in pregnancies with prenatal diagnosis of TKUC. It may be warranted to use continuous fetal monitoring during labor and delivery in those cases were antenatal diagnosis of TKUC is made.
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Affiliation(s)
- Alina Weissmann-Brenner
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel.
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Noam Domniz
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Levin
- The Department Gynecologic Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Natav Hendin
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Rakefet Yoeli-Ullman
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Shali Mazaki-Tovi
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Tal Weissbach
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Eran Kassif
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
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Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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Lichtman Y, Wainstock T, Walfisch A, Sheiner E. The Significance of True Knot of the Umbilical Cord in Long-Term Offspring Neurological Health. J Clin Med 2020; 10:jcm10010123. [PMID: 33396487 PMCID: PMC7796317 DOI: 10.3390/jcm10010123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/26/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022] Open
Abstract
We aimed to study both the short- and long-term neurological implications in offspring born with confirmed knotting of the umbilical cord-"true knot of cord". In this population based cohort study, a comparison of perinatal outcome and long-term neurological hospitalizations was performed on the basis of presence or absence of true knot of cord. A Kaplan-Meier survival curve was constructed to compare the cumulative incidence of neurological hospitalizations between the study groups. Multivariable regression models were used to assess the independent association between true knot of cord, perinatal mortality and long term neurological related hospitalizations, while controlling for potential confounders. The study included 243,639 newborns, of them 1.1% (n = 2606) were diagnosed with true knot of the umbilical cord. Higher rates of intrauterine fetal demise (IUFD) were noted in the exposed group, a finding which remained significant in the multivariable generalized estimation equation, while controlling for confounders. The cumulative incidences of neurological hospitalizations over time were comparable between the groups. The Cox regression confirmed a lack of association between true knot of cord and total long term neurological related hospitalizations. While presence of true knot of the umbilical cord is associated with higher IUFD rates, in our population, however, its presence does not appear to impact the long term neurological health of exposed offspring.
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Affiliation(s)
- Yael Lichtman
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
- Correspondence: (Y.L.); (E.S.); Tel.: +972-526-803-609 (Y.L.); Fax: +972-732-049-297 (Y.L.)
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel;
| | - Asnat Walfisch
- Department of Obstetrics and Gynecology, Hadassah Mt. Scopus Medical Center, Jerusalem 9112001, Israel;
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
- Correspondence: (Y.L.); (E.S.); Tel.: +972-526-803-609 (Y.L.); Fax: +972-732-049-297 (Y.L.)
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Hayes DJL, Warland J, Parast MM, Bendon RW, Hasegawa J, Banks J, Clapham L, Heazell AEP. Umbilical cord characteristics and their association with adverse pregnancy outcomes: A systematic review and meta-analysis. PLoS One 2020; 15:e0239630. [PMID: 32970750 PMCID: PMC7514048 DOI: 10.1371/journal.pone.0239630] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/09/2020] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Dexter J. L. Hayes
- Tommy’s Stillbirth Research Centre, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Jane Warland
- University of South Australia, Adelaide, Australia
| | - Mana M. Parast
- University of California, San Diego, CL, United States of America
| | - Robert W. Bendon
- Retired from Norton Children’s Hospital, Louisville, Kentucky, United States of America
| | | | - Julia Banks
- Tommy’s Stillbirth Research Centre, University of Manchester, Manchester, United Kingdom
| | - Laura Clapham
- Tommy’s Stillbirth Research Centre, University of Manchester, Manchester, United Kingdom
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Haghighi L, Jahanshahi F, Dini P. Two knots in an umbilical cord with seventy centimeter length: A case report. Clin Case Rep 2020; 8:1579-1581. [PMID: 32884799 PMCID: PMC7455404 DOI: 10.1002/ccr3.2919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 12/02/2022] Open
Abstract
Our case was a newborn with two umbilical knots that delivered 39 weeks gastation and did not experience any developmental disruptions. The risk factors of fetus for true knot formation in the umbilical cord were gender and the umbilical cord size.
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Affiliation(s)
- Ladan Haghighi
- Department of Obstetrics and GynecologySchool of MedicinesIran University of Medical SciencesTehranIran
| | - Fatemeh Jahanshahi
- Student Research Committee, Faculty of MedicineIran University of Medical SciencesTehranIran
| | - Parisa Dini
- Department of Obstetrics and GynecologySchool of MedicinesIran University of Medical SciencesTehranIran
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Lee SM, Kim DY, Cho S, Noh SM, Park HL, Lee G. Correlations between the Status of the Umbilical Cord and Neonatal Health Status. Child Health Nurs Res 2020; 26:348-356. [PMID: 35004478 PMCID: PMC8650973 DOI: 10.4094/chnr.2020.26.3.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 11/06/2022] Open
Abstract
Purpose: This study aimed to identify correlations between the status of the umbilical cord and neonatal health status.Methods: In total, 172 newborns were enrolled who were admitted to the newborn nursery with a gestational age of 35 weeks or older and a body weight of 2 kg or above. Data were collected on the basic personal information of the newborns, the diameter and soft tissue status of the umbilical cord, and neonatal health status after birth. Analyses were performed using t-test, analysis of variance, <i>x</i><sup>2</sup> test, and Fisher exact test.Results: Umbilical cord diameter exhibited a statistically significant difference by sex (t=2.71, <i>p</i>=.007). A thin umbilical cord diameter was associated with a 1-minute Apgar score less than 8 points (t=2.47, <i>p</i>=.015) and with being transferred to the intensive care unit (t=2.45, p=.015). Poor soft tissue status of the umbilical cord was associated with a 1-minute Apgar score of less than 8 points (<i>x</i><sup>2</sup>=16.68, <i>p</i><.001) and with oxygen being supplied (<i>x</i><sup>2</sup>=4.81, <i>p</i>=.028).Conclusion: Assessing the umbilical cord diameter and status in newborns is an important tool for evaluating neonatal health status after birth, and this point also underscores the importance of professionals' careful observations in the newborn nursery.
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Affiliation(s)
- Sun Min Lee
- Registered Nurse, Newborn Nursery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Yeon Kim
- Unit Manager, Neonatal Intensive Care Unit, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Corresponding author Dong Yeon Kim https://orcid.org/0000-0001-9500-5792 Neonatal Intensive Care Unit, Seoul St. Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea TEL +82-2-2258-3044 FAX +82-2-2258-2958 E-MAIL
| | - Seongmin Cho
- Registered Nurse, Newborn Nursery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sun Mi Noh
- Registered Nurse, Newborn Nursery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hye Ly Park
- Registered Nurse, Newborn Nursery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Gyungjoo Lee
- Associate Professor, College of Nursing, The Catholic University of Korea, Seoul, Korea
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Sherer DM, Amoabeng O, Dryer AM, Dalloul M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of True Knot of the Umbilical Cord. Int J Womens Health 2020; 12:221-233. [PMID: 32273778 PMCID: PMC7115211 DOI: 10.2147/ijwh.s192260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/23/2020] [Indexed: 11/23/2022] Open
Abstract
Umbilical cord accidents preceding labor are rare. Single and multiple nuchal cords, and true knot(s) of the umbilical cord, are often incidental findings noted at delivery of non-hypoxic non-acidotic newborns without any evidence of subsequent adverse neonatal outcome. In contrast to single nuchal cords, true knots of the umbilical cord, which occur in between 0.04% and 3% of all deliveries, have been associated with a reported 4 to 10 fold increased risk of stillbirth. First reported with real-time ultrasound, current widespread application of color Doppler, power Doppler and three-dimension sonography, has enabled increasingly more accurate prenatal sonographic diagnoses of true knot(s) of the umbilical cord. Reflecting the inability to visualize the entire umbilical cord at prenatal ultrasound assessment, despite detailed second and third-trimester scanning, many occurrences of incidental true knot of the umbilical cord remain undetected and are noted only at delivery. Although prenatal sonographic diagnostic accuracy is increasing, false positive sonographic diagnosis of true knot of the umbilical cord cannot be ruled out with certainty, and must continue to be considered clinically. Notwithstanding the inability to diagnose all true knots, currently there is a clear absence of clinical management guidelines by governing bodies regarding patients in whom prenatal sonographic diagnosis of true knot(s) of the umbilical cord is / are suspected. As a result, in many prenatal ultrasound units, suspected sonographic findings suggestive of or consistent with true knot of the umbilical cord are often disregarded, not documented, and patients are not uniformly informed of this potentially life-threatening condition, which carries an associated considerable risk of stillbirth. This commentary will address current perspectives of prenatal sonographic diagnostic and management challenges associated with true knot(s) of the umbilical cord in singleton pregnancies.
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Affiliation(s)
- David M Sherer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Opokua Amoabeng
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Alexandra M Dryer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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Díaz de la Noval B, Porcel Llaneza I, Rueda Sepúlveda M, Ferrer Barriendos FJ, Fernández Blanco C. True umbilical cord knot, an emergency during labor. Clin Case Rep 2019; 7:2242-2244. [PMID: 31788288 PMCID: PMC6878209 DOI: 10.1002/ccr3.2441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/29/2019] [Accepted: 08/11/2019] [Indexed: 11/12/2022] Open
Abstract
An umbilical cord knot is an unexpected event that should not change obstetric approach for delivery.
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Affiliation(s)
- Begoña Díaz de la Noval
- Department of Gynaecology and ObstetricsHospital Universitario Central de AsturiasOviedoSpain
| | - Iris Porcel Llaneza
- Department of Gynaecology and ObstetricsHospital Universitario Central de AsturiasOviedoSpain
| | - Manuel Rueda Sepúlveda
- Department of Gynaecology and ObstetricsHospital Universitario Central de AsturiasOviedoSpain
| | | | - Carmen Fernández Blanco
- Department of Gynaecology and ObstetricsHospital Universitario Central de AsturiasOviedoSpain
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Affiliation(s)
- Chanchal Singh
- Fetal Medicine, BirthRight by Rainbow Hospitals, New Delhi, India.
| | - Kavita Kotoch
- Obstetrics and Gynecology, BirthRight by Rainbow Hospitals, New Delhi, India
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Singh C, Kotoch K. Diagnostic prénatal d'un vrai nœud du cordon ombilical. J Obstet Gynaecol Can 2019; 42:1067-1068. [PMID: 31402272 DOI: 10.1016/j.jogc.2019.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Chanchal Singh
- Fetal Medicine, BirthRight by Rainbow Hospitals, New Delhi, Inde
| | - Kavita Kotoch
- Obstetrics and Gynecology, BirthRight by Rainbow Hospitals, New Delhi, Inde
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Carter EB, Chu CS, Thompson Z, Tuuli MG, Macones GA, Cahill AG. True knot at the time of delivery: electronic fetal monitoring characteristics and neonatal outcomes. J Perinatol 2018; 38:1620-4. [PMID: 30323323 DOI: 10.1038/s41372-018-0250-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/24/2018] [Accepted: 10/02/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Determine the association between electronic fetal monitoring and neonatal outcomes in the setting of a true knot at delivery. STUDY DESIGN This was a planned secondary analysis of a prospective cohort of 8580 women. Patients with and without a true knot were compared and the primary outcome was repetitive late decelerations occurring with at least 50% of contractions. Confounders were adjusted for using logistic regression. RESULTS A total of 8580 patients met inclusion criteria and 49 (0.57%) had a TK. There was no significant difference in the rate of repetitive late decelerations in patients with TK (aOR 1.04; 95% confidence interval [CI] 0.25-4.40),other electronic fetal monitoring parameters, or neonatal outcomes. CONCLUSION Neonates with true knots who are delivered at term have similar electronic fetal monitoring characteristics compared to those without true knots and no detectable difference in neonatal morbidity; thus, calling into question the clinical significance of a true knot at term.
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Linde LE, Rasmussen S, Kessler J, Ebbing C. Extreme umbilical cord lengths, cord knot and entanglement: Risk factors and risk of adverse outcomes, a population-based study. PLoS One 2018; 13:e0194814. [PMID: 29584790 DOI: 10.1371/journal.pone.0194814] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/09/2018] [Indexed: 01/17/2023] Open
Abstract
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 (<10th or >90th 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.
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Sherer DM, Dalloul M, Ward K, Nakagawa J, Joseph I, Grube S, Abulafia O. Coexisting true umbilical cord knot and nuchal cord: possible cumulative increased risk of adverse perinatal outcome. Ultrasound Obstet Gynecol 2017; 50:404-405. [PMID: 27997052 DOI: 10.1002/uog.17389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/18/2016] [Accepted: 12/13/2016] [Indexed: 06/06/2023]
Affiliation(s)
- D M Sherer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - M Dalloul
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - K Ward
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - J Nakagawa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - I Joseph
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - S Grube
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
| | - O Abulafia
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USA
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da Cunha AC, da Silveira Betat R, Dal Pai TKV, Arcolini CP, Gobatto AM, de Holleben Bicca AM, Zen PRG, Rosa RFM. Prenatal diagnosis of a true umbilical cord knot in a fetus with intrauterine growth restriction and placenta accreta. Taiwan J Obstet Gynecol 2017; 55:616-7. [PMID: 27590396 DOI: 10.1016/j.tjog.2015.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- André Campos da Cunha
- Fetal Medicine, Hospital Materno Infantil Presidente Vargas (HMIPV), Porto Alegre, RS, Brazil
| | | | | | | | | | | | - Paulo Ricardo Gazzola Zen
- Graduate Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Clinical Genetics, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) and Complexo Hospitalar Santa Casa de Porto Alegre (CHSCPA), Porto Alegre, RS, Brazil
| | - Rafael Fabiano Machado Rosa
- Fetal Medicine, Hospital Materno Infantil Presidente Vargas (HMIPV), Porto Alegre, RS, Brazil; Graduate Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Clinical Genetics, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) and Complexo Hospitalar Santa Casa de Porto Alegre (CHSCPA), Porto Alegre, RS, Brazil; Clinical Genetics, Hospital Materno Infantil Presidente Vargas (HMIPV), Porto Alegre, RS, Brazil.
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Abstract
Purpose: To define and describe the processes underlying the successful neonatal transition to extrauterine life and methods to assess the transition. Method: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, and Google Scholar were searched using a combination of the key words neonate, neonatal, newborn, transition, respiratory OR pulmonary, cardiac, metabolic, pH, umbilical cord, and assessment. Articles in English and German were reviewed. The final sample of articles consisted of one randomized controlled trial, 30 observational studies using human neonates, one observational study using rabbit pups, one secondary analysis, three systematic reviews, and 23 review articles. Major Findings: The pertinent findings in regard to normal events in the respiratory, cardiovascular, and metabolic transitions are reviewed and summarized. We address the underlying factors necessary for the transition to extrauterine life, specify the consequences of a successful transition, and review common assessment approaches. Conclusion: Available evidence indicates that the successful immediate transition to extrauterine life should be completed within 1–3 hr after birth, though some adaptive processes can fail as late as 24–48 hr after birth. Further research is necessary to identify a feasible, easily used, noninvasive method to assess the status of a neonate’s transition to extrauterine life.
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Affiliation(s)
| | - Nancy K. Lowe
- College of Nursing, University of Colorado, Denver, CO, USA
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