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Placenta and umbilical cord measurements and frequencies of placental and umbilical cord abnormalities stratified by umbilical cord insertion site between 9 and 13 weeks' gestation
Source publication
To assess the usefulness for predicting vasa previa by detecting a cord insertion site in the lower third of the uterus between 9 and 13 weeks' gestation.
The positional relationship between the uterine cavity and the cord insertion site was examined in consecutive subjects prospectively using ultrasonography at 9-13 weeks' gestation. The distance...
Context in source publication
Context 1
... placenta and umbilical cord measurements and the frequencies of placental and umbilical cord abnor- malities as stratified by the umbilical cord insertion site between 9 and 13 weeks' gestation are shown in Table 3. We calculated the estimated unadjusted univariate relative risks for those outcomes that were statistically associated with a lower cord insertion. ...
Similar publications
Type 3 vasa previa is a new concept. Herein, a case is reported of a 35-year-old woman, pregnant following in vitro fertilization, in whom vasa previa was detected on color Doppler ultrasound at 26 weeks, with no finding of a low-lying placenta. A cesarean section was performed at 34 weeks and 3 days. Gross examination of the placenta showed Type 3...
Citations
... In addition, this study found a higher incidence of low insertion sites progressing to furcate cord insertion than normal insertion sites. It has been proposed that inadequate blood supply is more likely to occur in the lower uterine segment [16], marginal cord insertion in the lower uterine segment is more likely to develop into velamentous cord insertion [12], and velamentous cord insertion is more likely to create vasa previa [17]. Furthermore, this study found 3 cases of low insertion sites in the first trimester, showing that the cord insertion site was located at the edge of the placenta in the second trimester, but it was not possible to distinguish whether the cord insertion site was in the placental parenchyma or the amniotic membranes, and velamentous cord insertion was confirmed after birth. ...
Objectives
To evaluate the potential connections between marginal cord insertion during the first trimester and furcate cord insertion later in pregnancy.
Methods
This is a prospective study of screening data on the cord insertion site in 3178 singleton pregnancies. The cord insertion site was examined in two stages. The first stage was screening for the cord insertion site between 10–13 weeks of gestation, the purpose is to determine the category of umbilical cord insertion. The second stage, performed at 22–28 weeks of gestation, was to follow up on the relationship between the cord insertion site and the placenta and to identify any changes in the category of umbilical cord insertion. This was performed to diagnose or exclude furcate cord insertion by identifying whether the umbilical cord trunk separated or branched before it reached the placenta. Factors influencing progression to furcate cord insertion and perinatal complications were assessed.
Results
Fourteen cases (0.44%) with progression to furcate cord insertion, all of which showed marginal cord insertion on ultrasound in the first trimester (p < 0.001). without progression to furcate cord insertion, there were no changes in the category of umbilical cord insertion in 3050 cases (96.40%) compared to the early pregnancy. 114 cases (3.60%) with changes in the category of umbilical cord insertion that was not consistent with furcate cord insertion. A total of 14 cases progressed to furcate cord insertion, all showed the cord insertion site were in close proximity, and 11 (78.57%) cases showed a low insertion site (p < 0.001). Regarding the choice of mode of delivery, elective caesarean delivery was done in 8/14 (57.14%). The incidences of spontaneous vaginal delivery were 5/14 (35.71%) (p < 0.001). One (7.14%) case of progression to furcate cord insertion due to haematoma at the root of the umbilical cord ended with an emergency caesarean section. In terms of perinatal complications, marginal cord insertion that progressed to furcate cord insertion had higher incidences of SGA infants, abnormal placental morphology, retention of the placenta, and cord-related adverse pregnancy outcomes than not progressed to furcate cord insertion (p < 0.05).
Conclusions
Marginal cord insertion in the first trimester has the potential to progress to furcate cord insertion. We suggest that ultrasound-diagnosed marginal cord insertion in the first trimester should be watched carefully in the second trimester, which is clinically useful to accurately determine the category of cord insertion and to improve the rate of prenatal diagnosis of furcate cord insertion.
... The included cohort studies scored low or moderate for risk of bias except the short report ofHasegawa et al. (2012) due to missing information and including a cohort overlapping with the two other included studies ofHasegawa et al. (2006Hasegawa et al. ( , 2011. ...
... The incidence of vasa previa in the studies ofHasegawa (2006Hasegawa ( , 2011Hasegawa ( , 2012 andDerisbourg et al. (2021) was almost three times higher than in the series byZhang et al. (2020). ...
Vasa previa is a rare disorder in which fetal blood vessels are left unprotected in the membranes and cross the internal os of the cervix. The risk of vessel tearing causing antepartum bleeding and fetal death due to exsanguination is highly increased. Prenatal detection drastically improves fetal outcome. The aim of this study is to scrutinize the recent evidence for the use of first trimester prenatal ultrasonography to improve the detection of vasa previa. We conducted a systematic literature review in the computerized databases Pubmed, Embase, CINAHL and Web of Science from inception to September 2022. Two first trimester sonographic markers are associated with vasa previa later in pregnancy: umbilical cord insertion in the lower one-third of the uterine cavity and a velamentous insertion. We conclude the evaluation of the umbilical cord insertion in the first trimester is feasible, not time-consuming and may identify the population at increased risk for vasa previa.
... Pregnancies with cord insertions located in the lower third of the uterine cavity in the first trimester were more likely to be found with abnormal placental forms and with complications such as placenta previa, velamentous cord insertion, and vasa previa. 22 However, differentiating between maternal and fetal vessels can be challenging in some cases. Heart rate measurement may help to differentiate maternal vessels from fetal arterial vessels. ...
Vasa previa is a rare condition. However, since the increase in assisted reproductive technologies (ARTs), clinicians are more frequently confronted with this complication. In this study, we present five cases of vasa previa prenatally diagnosed from a tertiary referral hospital with approximately 2000 births yearly. Accurate prenatal diagnosis and sufficient management before the onset of labor improve the outcome of pregnancies complicated with vasa previa.
... Only one study from Japan and one from Romania reported VCI incidence in cohorts that included all pregnancies. The studies found that VCI occurred in 21/ 1311 (1.6%) (Japan) and in 43/18,500 (0.23%) (Romania) of all cord insertions [39,40]. The other studies reported an overall incidence in singleton pregnancies only, or in specific pregnancy sub-groups, e.g. ...
... However, regardless of the strength of the association found (in terms of the OR of VCI in pregnancies with vs without each characteristic), the overall concurrence of these factors with VCI in absolute terms remains relatively low (Fig. 2). VCI was reported to have a strong association with low cord insertion [39], a variable (weak to strong) association with in vitro fertilisation (IVF) [4,7,8,41], a moderate association with placenta praevia [4,7,8] and a weak to moderate association with nulliparity [3,8] (Fig. 2). Limited evidence from one small study (n = 24) suggests an association between VCI and a placenta defined as "lobed"; however, considering the sample size and width of confidence intervals, the strength of this evidence is low (Fig. 2) [8]. ...
Background:
Velamentous cord insertion (VCI) is an umbilical cord attachment to the membranes surrounding the placenta instead of the central mass. VCI is strongly associated with vasa praevia (VP), where umbilical vessels lie in close proximity to the internal cervical os. VP leaves the vessels vulnerable to rupture, which can lead to fatal fetal exsanguination. Screening for VP using second-trimester transabdominal sonography (TAS) to detect VCI has been proposed. We conducted a rapid review investigating the quality, quantity and direction of evidence available on the epidemiology, screening test accuracy and post-screening management pathways for VCI.
Methods:
MEDLINE, Embase and the Cochrane Library were searched on 5 July 2016 and again on 11 October 2019, using general search terms for VP and VCI. Only peer-reviewed articles reporting on the epidemiology of VCI, the accuracy of the screening test and/or downstream management pathways for VCI pregnancies were included. Quality and risk of bias of each included study were assessed using pre-specified tools.
Results:
Forty-one relevant publications were identified; all but one were based on non-UK pregnancy cohorts, and most included relatively few VCI cases. The estimated incidence of VCI was 0.4-11% in singleton pregnancies, with higher incidence in twin pregnancies (1.6-40%). VCI incidence was also increased among pregnancies with one or more other risk factors, including in vitro fertilisation pregnancies or nulliparity. VCI incidence among women without any known risk factors was unclear. VCI was associated with adverse perinatal outcomes, most notably pre-term birth and emergency caesarean section in singleton pregnancies, and perinatal mortality in twins; however, associations varied across studies and the increased risk was typically low or moderate compared with pregnancies without VCI. In studies on limited numbers of cases, screening for VCI using TAS had good overall accuracy, driven by high specificity. No studies on post-screening management of VCI were identified.
Conclusions:
Literature on VCI epidemiology and outcomes is limited and low-quality. The accuracy of second-trimester TAS and the benefits and harms of screening cannot be determined without prospective studies in large cohorts. Modelling studies may indicate the feasibility and value of studying the epidemiology of VCI and the potential impact of detecting VCI as part of a population screening programme for VP.
... [3][4][5] Velamentous umbilical cord insertion is also related to the occurrence of vasa previa. 2 Therefore, in patients with velamentous umbilical cord insertion, low-lying placenta, or abnormal placental morphology, the diagnosis of vasa previa must be considered. [6][7][8] The American College of Obstetricians and Gynecologists also recommends the use of color Doppler in patients who are at a high risk for vasa previa. 9 However, in some cases, it is difficult to determine the cord insertion and abnormal placental morphology. ...
Vasa previa can occur even in cases without placental malposition and the precise diagnosis of vasa previa, and the course of the cord vessels contributes to a safe delivery. The color Doppler is a useful and easy‐to‐use device to confirm the presence of vasa previa. Vasa previa can occur even in cases without placental malposition and the precise diagnosis of vasa previa, and the course of the cord vessels contributes to a safe delivery. The color Doppler is a useful and easy‐to‐use device to confirm the presence of vasa previa.
... Despite two emergency caesarean sections, due to premature abruption of the placenta and increased vaginal bleeding with placenta praevia, there was no foetal death and no foetal blood transfusion in any of our individually managed cases. The feasibility of prenatal screening for umbilical cord insertion, which enables the detection of vasa praevia during first trimester screening, has already been demonstrated [8,9]. In the mid-trimester, detection is also possible with a high overall predictive reliability (sensitivity 100%, specificity 99.8%), as reported previously [10]. ...
... In the mid-trimester, detection is also possible with a high overall predictive reliability (sensitivity 100%, specificity 99.8%), as reported previously [10]. Recently, Hasegawa et al. suggested that sonographic screening in the late first or early second trimester, with follow-up examinations in cases with a low cord insertion in the second trimester, would be a useful way to detect vasa praevia [8]. Although the benefits of prenatal diagnosis have been suggested [8][9][10], there are no data from randomized trials that would provide highly reliable data upon which to base recommendations. ...
... Recently, Hasegawa et al. suggested that sonographic screening in the late first or early second trimester, with follow-up examinations in cases with a low cord insertion in the second trimester, would be a useful way to detect vasa praevia [8]. Although the benefits of prenatal diagnosis have been suggested [8][9][10], there are no data from randomized trials that would provide highly reliable data upon which to base recommendations. Therefore, it is not surprising that there is a lack of consensus concerning the management of pregnancies with vasa praevia. ...
Purpose
Vasa praevia is a rare condition with high foetal mortality if not detected prenatally. There is limited evidence available to determine the ideal timing of delivery and management recommendations. The aim of this study was to critically review our experience with vasa praevia, with a focus on diagnosis and management.
Methods
In a retrospective analysis, all cases of vasa praevia identified in our department from January 2003 to December 2017 were included. All cases were diagnosed antenatally during sonographic inspection of the placenta, and individualized management for each patient was performed based on individual risk factors. 19 cases of vasa praevia were identified (15 singletons, four twins). 13 patients (79%) presented placental anomalies. In patients at high risk for preterm birth, caesarean delivery was performed between 34–35 weeks after early hospitalization and administration of corticosteroids, whereas in patients at low risk for preterm birth, caesarean section could be delayed to 35–37 weeks of gestation. Administration of corticosteroids was not obligatory in the latter cases.
Results
There were two acute caesarean sections, due to premature abruption of the placenta and vaginal bleeding. There was no maternal or foetal/neonatal death. None of the neonates required blood transfusion. There is limited evidence available with which to determine the ideal timing of delivery.
Conclusion
However, our individualized, risk-adapted management, which attempts to delay the timing of caesarean section up to two weeks beyond the standard recommendation, seems feasible, with just two emergency caesarean sections and no case of foetal or maternal death.
... When should we screen? Three large studies examined the possibility of early diagnosis of the cord insertion in the late first trimester during the nuchal translucency scan [13][14][15]. The placental cord insertion was visualized in 93.5 -100% of cases and they found a high risk for complications later in pregnancy in those cases in which the cord was inserted into the lower third of the uterus in the first trimester. ...
... [30,31]. Hasegawa et al. have shown that pregnancies at risk of vasa previa could be identified as early as 9 weeks of gestation [32]. However, as the definitive placenta is only fully formed by 10-11 weeks of gestation making it impossible in many cases to predict the final position of the umbilical cord and to identify placental anomalies such as bilobed placenta, there appears to be little benefit in attempting to identify vasa previa during the first trimester. ...
Purpose of review:
Vasa previa is a rare disorder of placentation associated with a high rate of perinatal morbidity and mortality when undetected before delivery. We have evaluated the recent evidence for prenatal diagnosis and management of vasa previa.
Recent findings:
Around 85% of cases of vasa previa have one or more identifiable risk factors including in-vitro fertilization, multiple gestations, bilobed, succenturiate or low-lying placentas, and velamentous cord insertion. The development of standardized prenatal targeted scanning protocols may improve perinatal outcomes. There is no clear consensus on the optimal surveillance strategy including the need for hospitalization, timing of corticosteroids administration and the value of transvaginal cervical length measurements. Outpatient management is possible if there is no evidence of cervical shortening on ultrasound and there are no symptoms of bleeding or uterine contractions. Recent national guidelines and expert reviews have recommended scheduled cesarean section of all asymptomatic women presenting with vasa previa between 34 and 36 weeks' gestation.
Summary:
Prenatal diagnosis of vasa previa is pivotal to prevent intrapartum fetal death. Although there is insufficient evidence to support the universal mid-gestation ultrasound screening for vasa previa, recent evidence indicates the need for standardized prenatal targeted screening protocols of pregnancies at high-risk of vasa previa.
... 5 Currently, the majority of pregnant women undergo several scans during pregnancy. It has been proposed to include a standard evaluation of the umbilical cord insertion site in the second-trimester scan in an attempt to increase the prenatal detection of VP. 3,6,7 However, at present, targeted transvaginal ultrasound screening with colour Doppler has not been routinely included in prenatal care, due to a lack of critical data on the incidence and the efficacy of screening. For the purpose of potential screening for VP it might be helpful to identify women at high risk by establishing identifiable risk indicators for VP. ...
... 12 One cohort was described twice and therefore one study was excluded. 7,13 Two studies were (conference) abstracts of articles not yet published, one author was reached but no more data were obtained. 14,15 Two studies only reported on associations between velamentous cord insertion and low serum pregnancy-associated plasma protein A or cord insertion in the lower part of the uterus in the first trimester; associations with VP itself were not investigated and therefore these studies were excluded. ...
(BJOG . 2016;123:1278–1287)
Vasa previa (VP) is a rare but serious condition of fetal blood vessels lying over the cervical os. As the presenting part descends, the vessels can be compressed leading to fetal heart rate abnormalities. There is also the potential for rupture of the vessels and fetal hemorrhage with rupture of membranes. Thus, there is increased risk for neonatal morbidity or mortality in the setting of VP. Prenatal identification of VP via ultrasound could prevent neonatal death and morbidity by prompting elective cesarean delivery, thereby avoiding rupture of the fetal vessels. However, ultrasound examination of the umbilical cord insertion site is not routine. This meta-analysis was undertaken to determine the occurrence and risk indicators of VP with the goal of identifying the at-risk population that should receive ultrasound screening.
... These risk factors are represented by: the placenta inserted low, bipartita and multilobulate, aberrant cotyledon and the velamentous cord insertion (Carbonnel et al., 2007;Chmait et al., 2010;Gagnon et al., 2010). Indeed, in the presence of a velamentous y insertion of the cord associated with a placenta praevia, the incidence of vasa praevia is estimated at 1/50 (Hasegawa et al., 2011;Nishtar and Wood, 2012). Moreover, in many authors, in vitro fertilization (IVF) would be a risk factor, since it multiplies the risk by ten (Baulies et al., 2007;Chmait et al., 2010;Cipriano et al., 2010;Gagnon et al., 2010;Hasegawa et al., 2011;Nishtar and Wood, 2012). ...
... Indeed, in the presence of a velamentous y insertion of the cord associated with a placenta praevia, the incidence of vasa praevia is estimated at 1/50 (Hasegawa et al., 2011;Nishtar and Wood, 2012). Moreover, in many authors, in vitro fertilization (IVF) would be a risk factor, since it multiplies the risk by ten (Baulies et al., 2007;Chmait et al., 2010;Cipriano et al., 2010;Gagnon et al., 2010;Hasegawa et al., 2011;Nishtar and Wood, 2012). Of these, it would be desirable to carry out systematic screening in patients with risk factors. ...
... Giannopoulos (Giannopoulos and Carver, 1987) reported for the first time the ultrasound diagnosis of a preavia vessel and since this examination was proposed as a diagnostic element. Ultrasound allows the detection of vessels passing between the presentation and the internal orifice of the neck (Baulies et al., 2007;Carbonnel et al., 2007;Chmait et al., 2010;Cipriano et al., 2010;Hasegawa et al., 2011). Later it was shown that this method is not reproducible because of the difficulties of visualizing small diameter vessels buried in the bottom of the pelvis. ...
