UMBILICAL CORD PARAMETERS IN ILORIN: CORRELATES AND FOETAL OUTCOME

Abstract

Background:
The anthropometric parameters of the umbilical cord have clinical significance. Current parameters of the cord, its correlates and related foetal outcome are lacking in our parturients.

Objectives:
To describe the anthropometric parameters and abnormalities of the umbilical cord; and determine their maternal correlates and foetal outcome.

Design:
A cross sectional analytical study.

Setting:
The Obstetric and Gynaecology Department of the Universityof Ilorin Teaching Hospital, between September 2012 and June 2013.

Subjects:
Healthy pregnant women with singleton pregnancies.

Results:
Four hundred and twenty-eight (428) singleton deliveries were studied. The respective mean values of the cord length and width were 526.87 ± 115.5mm and 19.56 ± 11.12mm.Short cord (< 40cm) occurred in 7.2% while long cord (> 69cm) was found in 9.3% of the parturient. The incidences of single umbilical artery, cord round the body and knots were 7%, 8.4% and 14.5% respectively. Nuchal cord was the most common (91.4%). Only gestational age had significant statistical relationship with cord length abnormalities (P = 0.0093). The cord length was an important correlate of cord helices, knots and vessels (P < 0.05).Parity had correlations with the number of vessels (R = 0.099, P = 0.042). The cord coiling index was statistically related to the presence of congenital abnormalities (P = 0.011). Other perinatal events were not related to umbilical cord parameters. Perinatal asphyxia was the most common indication for NICU admission (3.5%) but there was no significant statistical difference between NICU admission and cord parameters.

Conclusion:
The umbilical cord parameters in apparently healthy parturients in Ilorin were comparable with others elsewhere. The cord length and helix are important correlates of gestational age and congenital abnormalities. Parity may be related to abnormal umbilical vessels. Cord length, coils, coil index and umbilical vessels should be examined post-natally.

Full text

274 East african MEdical Journal August 2014
East African Medical Journal Vol. 91 No. 8 August 2014
UMBILICAL CORD PARAMETERS IN ILORIN: CORRELATES AND FOETAL OUTCOME
K. T. Adesina, FWACS, FMCOG, O. O. Ogunlaja, FWACS, FMCOG, A. P. Aboyeji, FWACS, O. A. Olarinoye, FWACS,
A. S. Adeniran, FWACS, FMCOG, A. A. Fawole, FWACS, FICS, Department of Obstetrics and Gynaecology and H. J.
Akande, FMCR, Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
Request for reprint to: K. T. Adesina, Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College
of Health Sciences, University of Ilorin and University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria.
UMBILICAL CORD PARAMETERS IN ILORIN: CORRELATES AND FOETAL
OUTCOME
K. T. ADESINA, O. O. OGUNLAJA, A. P. ABOYEJI, O. A.OLARINOYE, A. S. ADENIRAN, A. A. FAWOLE
and H. J. AKANDE
ABSTRACT
Background: The anthropometric parameters of the umbilical cord have clinical
signicance. Current parameters of the cord, its correlates and related foetal outcome
are lacking in our parturients.
Objectives: To describe the anthropometric parameters and abnormalities of the
umbilical cord; and determine their maternal correlates and foetal outcome.
Design: A cross sectional analytical study.
Setting: The Obstetric and Gynaecology Department of the University of Ilorin Teaching
Hospital, between September 2012 and June 2013.
Subjects: Healthy pregnant women with singleton pregnancies.
Results: Four hundred and twenty- eight (428) singleton deliveries were studied.
The respective mean values of the cord length and width were526.87±115.5mm and
19.56±11.12mm.Short cord (< 40cm) occurred in 7.2% while long cord (> 69cm) was
found in9.3% of the parturient. The incidences of single umbilical artery, cord round
the body and knots were 7%, 8.4% and 14.5% respectively. Nuchal cord was the
most common (91.4%). Only gestational age had signicant statistical relationship with
cord length abnormalities (P = 0.0093). The cord length was an important correlate of
cord helices, knots and vessels (P< 0.05).Parity had correlations with the number of
vessels(R= 0.099, P=0.042).
The cord coiling index was statistically related to the presence of congenital
abnormalities (P=0.011). Other perinatal events were not related to umbilical cord
parameters. Perinatal asphyxia was the most common indication for NICU admission
(3.5%) but there was no signicant statistical dierence between NICU admission
and cord parameters.
Conclusion: The umbilical cord parameters in apparently healthy parturients in Ilorin
were comparable with others elsewhere. The cord length and helix are important
correlates of gestational age and congenital abnormalities. Parity may be related to
abnormal umbilical vessels. Cord length,coils, coil index and umbilical vessels should
be examined post-natally.
INTRODUCTION
The umbilical cord, also called the “the birth cord”,
is the connection between the developing foetus
and the placenta (1). It normally contains three
vessels, two arteries and one vein surrounded
by a connective tissue known “Wharton’s
jelly”. Physiologically, the umbilical vein carries
oxygenated blood to the foetus and the umbilical
artery carries de-oxygenated blood to the mother
from the foetus (1,2).
The anthropometric parameters of the
umbilical cord such as length, width, number
of vessels and coils (helices), have been linked
with clinical signicance in various reports. An
earlier study in Nigeria, found a correlation
between cord lengths, infant and placental
weight (3). An Indonesian study found a linear
correlation between umbilical cord length and
perinatal asphyxia and cord entanglement (4). Also,
authors have varying definitions of the mean
values for these parameters based on the study

August 2014 East african MEdical Journal 275
population and therefore, dierent denitions of
its abnormalities.
Abnormalities of the umbilical cord range from
single umbilical artery, short cord, velamentous
insertion to true knots.Knots often result from
the foetus as a whole or in parts, passing through
a loop of the cord in utero. These abnormalities
have been associated with congenital anomalies
and adverse perinatal outcome. True knot was
associated with advanced maternal age, multiparity,
previous miscarriages, obesity, prolonged gravidity,
male foetus, long cord, and maternal anaemia in a
retrospective review of singleton pregnancies (5).
Past studies in our environment have
documented various anthropometric parameters of
the umbilical cord and their correlates (3,6). These
studies were retrospective and perhaps the utilisation
of modern antenatal services by our women may have
inuence on these parameters. Hence, recent trends
in perinatal outcome relative to such measurements
are important.
To the best of our knowledge, this is the rst
study on the characteristics and abnormalities of
the umbilical cord and their outcome in Ilorin.
Early identication of such abnormalities and their
correlates could hasten measures needed to improve
neonatal survival. An observed abnormality found at
postnatal examination of the umbilical cord may have
signicant maternal or foetal correlates. This will form
a basis for antenatal screening for this abnormality
which may help predict foetal outcome.
The umbilical cord can easily be assessed with
real- time ultrasound and its blood ow by the Doppler
ultrasound, thereby assessing its functionality and
morphology. This may give more information on the
placenta and foetal well being (7,8). Unfortunately,
most abnormalities are incidental ndings and not
routine contents of obstetric scans (9).
In addition, with recent advances in the
ultrasound imaging techniques, sonographic
evidences of these abnormalities may need to be
demonstrated based on postnatal features and
correlated with earlier examinations of aected
foetuses.
This study describes the anthropometric
parameters of the umbilical cord at delivery, cord
abnormalities and their correlates among parturient
in the University of Ilorin Teaching Hospital, Ilorin
Nigeria. It is hoped that ndings from this study
will corroborate the need for prenatal ultrasound
evaluation of the umbilical cord in pregnancies at
risks of unfavourable outcome.
MATERIALS AND METHODS
This was a cross sectional, analytical study conducted
in the Department of Obstetrics and Gynaecology,
University of Ilorin Teaching Hospital, (U.I.T.H),
Ilorin. Pregnant women who presented for delivery
in the labour ward were randomly selected based
on the inclusion criteria. Apparently healthy
pregnant women at 28 weeks gestation or more with
singleton pregnancies were included while multiple
pregnancies were excluded.
Patients who met the criteria for this study were
informed and counseled and ethical approval was
obtained from the Research and Ethics Committee
of the University of Ilorin Teaching Hospital.
Socio-demographic characteristics, relevant
history of past and index pregnancies were noted.
Immediately after delivery, the umbilical cord was
clamped at the foetal end and cut with a sterile
scissors taking care not to milk the cord. At the foetal
end, the cord was cut ve centimeters from the foetal
insertion. The remaining length of the cord from the
cut end to the placental insertion was then measured
in centimetres. Five centimeters was added to the
length of the measured cord. Next, the number of
coils/ helices of the entire cord were counted and
a coil was taken as one complete 360-degree spiral
course of the umbilical vessels. Other features such as
vasculature, knotting, cord round the neck, thickness
of the umbilical cord, width and circumference were
examined.
The degree of the umbilical cord coiling was
determined by the umbilical coiling index (UCI),
dened as the number of complete coils/helices per
centimeter length of cord (10). The percentiles of the
umbilical measurements were calculated and values
less than 10th centile were taken as low, values greater
than 90th centile as high and values between 10th and
90th centiles as normal. The gross examination was
done within ve minutes of delivery of the placenta
in the second stage room.
The foetal outcomes were assessed by APGAR
scores, birth weight, admission to neonatal intensive
care unit (NICU), presence of congenital abnormalities
and indications for admission.
RESULTS
A total of four hundred and twenty eight (428)
singleton deliveries were studied. The mean values,
ranges, percentiles of the umbilical cord parameters
of the babies. Table1.

276 East african MEdical Journal August 2014
Table 1
Anthropometric parameters of the postpartum umbilical cord in the study population
Variable Mean ± SD Range Percentiles
5th 10th 50th 90th 95th
Umbilical cord
length (mm) 526.87 ± 115.15 101.00 – 1010.00 360.00 400.00 520.00 690.00 720.00
Umbilical cord
width (mm) 19.56 ± 11.12 4.00 – 200.00 10.00 10.00 20.00 26.4 30.00
Number of Helices 10.86 ± 5.12 2 – 46 5.00 6.00 10.00 16.00 20.00
Number of knots 3.24 ± 5.49 1 – 25 1.00 1.00 1.00 10.70 20.95
Number of Artery 1.93 ± 0.26 1 – 2 1 2.00 2.00 2.00 2.00
Number of Veins 1.07 ± 0.26 1 – 2 1 1.00 1.00 1.00 2.00
Umbilical cord
circumference(mm) 4.73 ± 5.75 0.4 – 61.00 1.81 2.00 4.00 6.00 6.00
Umbilical cord
coil index 0.02 ± 0.01 0.00 – 0.10 0.0097 0.0125 0.0195 0.0308 0.0370
Maternal age ranged between 17 and 49 years with
an average of 29.24 years ± 4.92 and parity was from
0-9 with a mean value of 2.The gestational age at
delivery was between 30 and 44 weeks and the mean
birth weight was 3.14Kg.
The pattern of foetal outcomes is displayed in Table 2.
The most common indication for Neonatal Intensive
Care Unit (NICU) admission among the babies was
perinatal asphyxia in 3.5% of the study population.
Other indications are shown in Figure 1.
Table 2
Pattern of foetal outcome of study population
Foetal Outcome GA at delivery(weeks)
Mean ± SD 38.80 ± 1.95
Range 30 – 44
Birth weight(Kg)
Mean ± SD 3.14 ± 0.44
Range 1.5 – 4.8
Apgar score at 1 minute
Mean ± SD 6.49 ± 1.84
Range 0 – 9
Apgar score at 5 minutes
Mean ± SD 8.00 ± 1.88
Range 0 – 10
Sex
Male 223 (52.1%)
Female 205 (47.9%)
Congenital Anomaly
Yes 7 (1.6%)
No 421 (98.4%)
Need for NICU admission
Yes 47 (11.0%)
No 381 (89.0%)
SD- standard deviation

August 2014 East african MEdical Journal 277
Figure 1
Indications for NICU admission
August 2014 EAST A FRICAN M E DICAL JOURNAL 89
Figure 1
The umbilical parameters were compared with various foetal outcomes. There was no statistical relationship
between the parameters and the need for NICU admission. Comparison with occurrence of congenital
abnormalities is shown in table 3 and there was a significant relationship between the mean umbilical coil
index and the presence of congenital abnormalities among the babies (P= 0.011). The various congenital
abnormalities seen were hydraencephaly, spina bifida,talipes, congenital hydrocele, achondroplasia, choanal
atresia.
In addition, there was no statistical correlation between the umbilical cord parameters and perinatal
events such as Apgar scores and birth weight.
Table 3
The comparison between the umbilical cord parameters and occurrence of congenital abnormalities.
Umbilical cord Parameter Congenital abnormality T P value
Yes No
Umbilical cord length
Mean ± SD 521.86 ± 96.21 527.10 ± 115.52 -0.324 0.746
Umbilical cord width
Mean ± SD 15.43 ± 8.23 19.62 ± 11.16 -0.990 0.323
Number of helices
Mean ± SD 15.14 ± 7.40 10.79 ± 5.05 2.241 0.021
Number of knots
Mean ± SD 1.50 ± 0.71 3.30 ± 5.58 -0.453 0.652
Umbilical cord circumference
Mean ± SD 3.60 ± 1.31 4.74 ± 5.80 -0.523 0.602
Umbilical coil index
Mean ± SD 0.0305 ± 0.0154 0.0210 ± 0.0098 2.542 0.011*
Number of Artery
Mean ± SD 1.86 ± 0.378 1.93 ± 0.254 -0.751 0.453
Number of Vein
Mean ± SD 1.14 ± 0.38 1.07 ± 0.255 0.746 0.456
t – Independent samples T test
SD – standard deviation
* P value < 0.05
The umbilical parameters were compared with
various foetal outcomes. There was no statistical
relationship between the parameters and the need
for NICU admission. Comparison with occurrence
of congenital abnormalities is shown in Table 3
and there was a signicant relationship between
the mean umbilical coil index and the presence
of congenital abnormalities among the babies (P=
0.011). The various congenital abnormalities seen
were hydraencephaly, spina bida,talipes, congenital
hydrocele, achondroplasia, choanal atresia.
In addition, there was no statistical correlation
between the umbilical cord parameters and perinatal
events such as Apgar scores and birth weight.
Table 3
The comparison between the umbilical cord parameters and occurrence of congenital abnormalities.
Umbilical cord Parameter Congenital abnormality T P-value
Yes No
Umbilical cord length
Mean ± SD 521.86 ± 96.21 527.10 ± 115.52 -0.324 0.746
Umbilical cord width
Mean ± SD 15.43 ± 8.23 19.62 ± 11.16 -0.990 0.323
Number of helices
Mean ± SD 15.14 ± 7.40 10.79 ± 5.05 2.241 0.021
Number of knots
Mean ± SD 1.50 ± 0.71 3.30 ± 5.58 -0.453 0.652
Umbilical cord circumference
Mean ± SD 3.60 ± 1.31 4.74 ± 5.80 -0.523 0.602
Umbilical coil index
Mean ± SD 0.0305 ± 0.0154 0.0210 ± 0.0098 2.542 0.011*
Number of Artery
Mean ± SD 1.86 ± 0.378 1.93 ± 0.254 -0.751 0.453
Number of Vein
Mean ± SD 1.14 ± 0.38 1.07 ± 0.255 0.746 0.456
t – Independent samples T-test
SD – standard deviation
* P-value < 0.05

278 East african MEdical Journal August 2014
Table 4
Correlations between cord parameters, parity and gestational age
Umbilical cord Parameters R P-value
Parity
Number of artery -0.099 0.042*
Number of veins 0.099 0.042*
Gestational Age at Delivery
Umbilical cord length 0.143 0.003*
Umbilical coil index -0.097 0.048*
R – Correlation coecient * - P value < 0.05
The signicant correlations between cord length and
coil index, and gestational age at delivery are shown
in Table 4.There was positive correlation between
number of veins and parity and a negative correlation
between the number of arteries and parity. There was
a positive correlation between apgar scores at 5th
minute and maternal age ( R = 0.161 P = 0.002) but
no statistical correlation between other umbilical
cord parameters and maternal age. The occurrence
of congenital abnormalities was also not signicantly
related to maternal age and parity in this study ( P
=0.268, 0.799 ).
The cord winding around some parts of the
body was found in 8.4% and the most common type
was nuchal cord in 91.6% of the cases. The cord was
inserted centrally in 67.8%,marginally in 31.3% and
a velamentous insertion was observed in 0.9% of the
study population. The umbilical cord abnormalities
identied in this study are displayed in Table 5.
Table 5
Umbilical cord Abnormalities in the study population
Abnormalities Value N Percentage (%)
Short cord < 400 mm 31 7.2
Long cord > 690 mm 40 9.3
Thin cord < 10 mm 17 4.0
Thick cord >25.4 mm 42 9.8
Single artery ≤ 1 30 7.0
Cord round the body - 36 8.4
Cord knots - 62 14.5
Hypocoiled cord < 0.01 42 9.8
Hypercoiled cord > 0.03 41 9.6
Abnormalities were dened by the 10th and 90th percentiles.
When the abnormalities dened in Table 5 were compared with foetal outcome, only gestational age was
statistically related to cord length abnormalities ( P= 0.0093). Other abnormalities were not related to foetal
outcome statistically. However, the cord length had correlation with some other parameters as shown in
Table 6.

August 2014 East african MEdical Journal 279
Table 6
correlation between umbilical cord length and other parameters
Other Umbilical Parameters Umbilical Cord Length P-value
Number of Helices 0.308 < 0.001*
Number of Knots 0.277 0.029*
Number of Arteries 0.116 0.016*
Number of Veins -0.118 0.016*
Umbilical cord coil index -0.237 <0.001*
R: Pearson correlation coecient
DISCUSSION
The range of cord length in this study was wider
than the ndings of Adinma and Balkawade et al
in a series of 1,000 patients in Eastern Nigeria and
India respectively. While the average cord length in
our study and Igbo parturient were similar (52.68 cm
and 51.5 cm), a mean value of 63.86 cm was reported
in India. It is likely that the observed dierence is
due to racial variation even though, the ndings are
comparable. The wide ranges of the lengths in these
studies support the variable nature of cord length
in humans (6,11). Umbilical cord length showed a
weak positive correlation with gestational age at
delivery which was signicant. That is an increase in
gestational age will lead to an increase in umbilical
cord length, suggesting that the cord grows as the
foetus does. The increase in cord length with the
increase in gestational length (R = 0.143, P = 0.003) is
similar to ndings in earlier studies (6,11,12). The usual
assumption that the cord stops growing after 28 weeks
of gestation is not supported by this study.
Studies have shown the linear correlation
between cord length and foetal complications (11,13).
Our study included apparently healthy women with
no observed signicant adverse maternal conditions.
This may explain the low incidence of adverse foetal
outcome in the study population.
The incidence of umbilical knots was14.5% in this
study and it is much higher than 1.25% as reported
by Airas et al in a population based analysis of 288
singleton pregnancies. Their report included only
true knots. In addition, the incidence of true knot was
associated with advanced maternal age, multiparity,
male foetus and long cord whereas, no similar
associations were observed in this study. However,
the length of the cord was an important correlate of
cord knots in this study. We therefore opined that the
occurrence of umbilical knots may be determined by
various independent characteristics of the foetus or
mother.
Although there was no association between
congenital abnormalities, maternal age and parity in
this study, there was a correlation between number of
umbilical vessels and parity. The negative correlation
of single umbilical artery with parity is comparable
to ndings of Lilja in Sweden (14).
Single umbilical artery is associated with low
birth weight babies and preterm deliveries. It was
also more common in women above 40 years and those
with three or more parous experiences (14). Neonates
with single artery have increased risks of congenital
and chromosomal abnormalities as well as adverse
perinatal outcome (2,15). This probably explains the
association of single umbilical artery with advanced
maternal age and increased parity as seen in this
study. In addition, a limitation in our design was that
no chromosomal studies were carried out on these
infants and some might have occurred without being
reported.
This study has further evaluated the association
between single umbilical artery and high parity. We
therefore recommend the identication of single
umbilical artery as a criterion for chromosomal and
congenital anomalies screening especially in a low
resource setting. The determination of the cord coil
index in addition, may also be informative, as this
parameter was also signicantly related to occurrence
of congenital anomalies in the study population. The
cord length, vessels and coil index are important
parameters with clinical signicance in this study.
Their documentation as part of routine postnatal
examination like birth and placental weights may
provide more information on foetal well being and
neonatal outcome. The prenatal assessment of the
umbilical cord is therefore desirable.
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