TWISTING OF THE UMBILICAL CORD CAUSING INTRAUTERINE FETAL DEATH

Abstract

Umbilical cord accident (UCA) is an emergency situation, as it threatens fetal wellbeing and or results into fetal jeopardy. Cord prolapse, cord compression, cord entanglement, true knot formation, thrombosis and rupture of cord blood vessels are some of the known cord related causes of stillbirths .Twisting of the umbilical cord occurs less often than above mentioned cord accidents. Twisting of the umbilical cord leads to obstruction in the flow of blood in umbilical cord vessels leading to acute placental insufficiency and sudden fetal death. A rare case of full term pregnancy with multiple twists of the umbilical cord, leading to intrauterine fetal death is presented in this case report .The antenatal diagnosis, predisposing factors and preventive measures are discussed in the end.

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International Journal of Biomedical and Advance Research 656
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TWISTING OF THE UMBILICAL CORD CAUSING INTRAUTERINE FETAL
DEATH
Bangal V B*, Shinde K K , Gavhane S P , Borawake S K , Chandaliya R M
*Dept. of Obstetrics and Gynaecology, Rural Medical College & Pravara Rural Hospital Pravara
Institute of Medical Sciences (Deemed University), Loni, Dist. Ahmednagar, Maharashtra, India
E-mail of Corresponding Author: vbb217@rediffmail.com
Abstract
Umbilical cord accident (UCA) is an emergency situation, as it threatens fetal wellbeing and or results
into fetal jeopardy. Cord prolapse, cord compression, cord entanglement, true knot formation,
thrombosis and rupture of cord blood vessels are some of the known cord related causes of stillbirths
.Twisting of the umbilical cord occurs less often than above mentioned cord accidents. Twisting of the
umbilical cord leads to obstruction in the flow of blood in umbilical cord vessels leading to acute
placental insufficiency and sudden fetal death. A rare case of full term pregnancy with multiple twists
of the umbilical cord, leading to intrauterine fetal death is presented in this case report .The antenatal
diagnosis, predisposing factors and preventive measures are discussed in the end.
Keywords: Twisting of umbilical cord, Intrauterine fetal death,Umbilical cord accidents, Stillbirths
1. Introduction
Umbilical Cord Accidents (UCA) are
responsible for sudden antenatal death syndrome
(SADS). Meticulously performed ultrasound in
prenatal period can identify most of the
umbilical cord accident. An Umbilical Cord
Accident (UCA) occurs, when umbilical venous
or arterial blood flow is compromised to a
degree that it leads to fetal injury or death.1,2 The
human umbilical cord is vulnerable to a variety
of malformations, lesions, infections,
mechanical and iatrogenic events throughout
pregnancy, labor and delivery. Medical literature
on UCA has accumulated since the
Collaborative Perinatal Project (CPP).3,4,5 Two
reviews of UCA from the CPP study including;
multiple twists ,true knot, nuchal coils, and body
loops suggests an association with extremes of
umbilical cord length as a fetal risk factor for
fetal malformation, injury and stillbirth.6,7 A
review of stillbirths from the CPP suggests that
UCA's have at least an incidence of 1.5
stillbirths/1000 births.8
2. Case report
Twenty three year old, unbooked second gravida
presented with history of nine months of
amenorrhoea with loss of fetal movements since
five days of admission .She had undergone
emergency caesarean section in her first
pregnancy for cephalo pelvic disproportion three
years back in private hospital. Her intra and post
operative period following caesarean section
was uneventful .In the present pregnancy, she
had undergone anomaly scan at 18 weeks of
gestation. There was no history of leaking or
bleeding per vaginum in present pregnancy .She
had only two antenatal visits in the present
pregnancy .She did not receive hematinic
tablets. She did not suffer from any major
medical or surgical illness in the past. On
examination, she had moderate degree anaemia.
Her other vital parameters were within normal
limits .Per abdominal examination revealed full
term gestation with fetus in transverse lie .Fetal
heart was absent. Uterus was relaxed and liquor
volume was less. Estimated weight of the baby
was three kilograms. There was no scar
tenderness and the abdominal scar was healthy.
Pelvic assessment revealed contracted pelvis.
Laboratory investigations showed evidence of
iron deficiency anemia (Hb-6.9 grams
percent).Other hematological and biochemical
investigations were within normal limits.
Obstetric ultrasound showed single intrauterine
dead fetus in transverse lie of 36 weeks
gestation. Expected fetal weight was 2.9
kilograms. Amniotic fluid index was
3centimeters. Placenta was situated at fundus
and there was no demonstrable fetal, placental or
cord abnormality She was transfused with two
pints of fresh whole blood. She underwent
elective caesarean section under general
anesthesia. A full term dead, male baby
weighing 3.1 kilograms was delivered by
caesarean section. Placenta and cord was
delivered. There were no fetal abnormalities
except for the early evidence of maceration in
the form of skin peeling. Placenta was normal in
morphology. There was no evidence of
abruption or gross calcification. Umbilical cord
was 55centimeters long. It was edematous,

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congested and had three twists at its fetal
attachment near umbilicus. (Photograph 1 and
2) The twisted portion of the cord was pale
white in color and had thinned out. Clinical
autopsy of the baby could not be performed due
to lack of parental consent. The post operative
period was uneventful. She was discharged on
tenth postoperative day. She was given dietary
and contraceptive advice and was asked to come
for postnatal visit. She along with her relatives
was counseled about the cause of stillbirth and
the precautions to be taken in future
pregnancies.
3. Discussion
The umbilical cord serves as a critical lifeline to
the developing fetus. The umbilical cord is the
principal connection between the fetus and the
placenta, providing the nutrients, oxygen and
fluids necessary for life in utero. On occasion, a
variety of intrinsic or accidental processes
involving the umbilical cord can result in
intrauterine fetal death. The umbilical cord is
vulnerable to a number of insults which may
alter cord morphology, diminish cord blood flow
and ultimately compromise fetal nutrition. The
cord and its constituent tissues, an outer layer of
amnion, porous Wharton's jelly, two arteries and
one vein, are designed to provide and maintain
the blood flow to the developing fetus.9 Some of
the morphological aspects of the umbilical cord,
such as its length, knots, insertion to the
placenta, number of vessels and twisting have
been associated with pathological outcomes10-14.
At term, the typical umbilical cord length is 55
to 60 cm12. Adverse outcomes have been
reported with both abnormally long (70 to 80
cm) and abnormally short cords (30 to 40 cm) 15.
Long or short cords can be the cause of
hematomas and thrombosis of cord vessels and
the surface of the placenta thus causing fetal
hypoxia, damage of the central nervous system
or even fetal death16.
Umbilical cord torsion has been reported to be
an uncommon cause of intrauterine fetal
demise.17 Although initially described more
than 300 years ago, relatively few cases have
been de- scribed in the literature in the last 50
years.18 It may result from fetal movement
during which the cord normally become twisted.
But recent reports have shown familial
clustering. Such intra familial clustering
suggests that a genetic predisposition for
umbilical cord torsion may exist19.Umbilical
cord torsion has usually been regarded as
secondary to fetal death or cord con-striction or
due to lack or abnormality of Wharton’s jelly 20.
Umbilical cord torsion, in the absence of
predisposing constriction or abnormality of
Wharton’s jelly, can obstruct the umbilical blood
vessels and cause intrauterine death 21. Prenatal
ultrasonography can recognize torsion of the
umbilical cord. If the vein-to-vein pitch is <2
cm, torsion may be associated 22. Cardiac failure
can occur with umbilical cord torsion and can
present as nonimmune hydrops. Results of the
studies suggest that non genetic factors affect the
twisting of the cord, with shared and non-shared
environmental factors explaining most of the
variation. Previous research has debated over
whether twisting is genetically determined,
inherent to the cord itself or the result of
external/extrinsic forces. Fletcher23 reported
about a mechanical rotation in which the cord
twists as a result of fetal movement or rotation in
early gestation. On the other hand, alternative
theories have suggested that twisting is the result
of factors inherent to the cord itself. Malpas and
Symonds11 have suggested that the helical
structure of the cord results from genetic
differences in the direction of the fibres in vessel
walls and that a reciprocal action between the
vessels walls and flow rate of the fetal blood
result in the umbilical cord twist. Cord twisting
may occur either 1) clockwise, 2) mixed/
undefined and 3) counter- clockwise.The
literature on umbilical cord knots and twisting
suggests that more adverse outcomes are
associated with real knots24 or clockwise
twisting25,26, while the frequency of problems
diminish in the other categories.
In the present case, woman experienced loss of
fetal movements 8 days before coming to the
hospital. Due to lack of awareness regarding
need for reporting this symptom and for many
other reasons, she continued to stay at home.
Fetal demise was diagnosed during her
subsequent antenatal visit. There was no
evidence of growth restriction. As she was a
case of previous caesarean section with full term
baby in transverse position with
oligohydramnios, external cephalic version was
not attempted. The cause of fetal demise was
thought to be related to umbilical cord. Twisting
of the cord was not diagnosed by ultra
sonologist. The cause was confirmed after the
delivery of the baby by elective caesarean
section.
Conclusion
Twisting of the umbilical cord is a rare but
important cause of intrauterine death. The

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torsion or the twist can be diagnosed during
antenatal period by meticulously performed
obstetric sonography. Woman complaining of
either increased or decreased fetal movements or
with growth restriction must be carefully
evaluated for cord related causes of fetal
distress. Sonologist must make an attempt to
visualize entire length of cord and should rule
out cord related conditions which are
responsible for fetal jeopardy.
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Twisting of The Cord –Photograph - 1 Twisting of The Cord -Photograph - 2
CLINICAL PHOTOGRAPHS OF TWISTING OF UMBILICAL CORD