Management of Nuchal CordWith Multiple Loops

Yan Wang, MD, MSc, Camille Le Ray, MD, MSc,François Audibert, MD, MSc, andMarie-Soleil Wagner, MD, MSc, FRCSC

BACKGROUND: Nuchal cords are rarely associated withsignificant neonatal morbidity or mortality.

CASE: A primigravida with a normal term pregnancy pre-sented for diminished fetal movement. Several nuchal cordloops were found on the ultrasound imaging, with normalDoppler findings. Abnormal fetal heart rate pattern ap-peared after 6 hours of labor. A cesarean delivery wasperformed. A healthy baby was born with eight nuchal cordloops.

CONCLUSION: The management of nuchal cord with asingle loop, suspected before delivery, seems clear: itshould not influence the clinical management. However, inthis case, the previous knowledge of multiple nuchal loopsmay have influenced our decision to perform a cesareandelivery.(Obstet Gynecol 2008;112:460–1)

It is well known that the fetal umbilical cord canbecome coiled around the fetal body parts, especially

around the neck. From 1,007 consecutive deliveries,Shui et al report an incidence of nuchal cord that rangedfrom a single loop in 21% of cases to three loops in 0.2%of cases.1 Many retrospective studies conclude thatnuchal cords are rarely associated with significant neo-natal morbidity or mortality.2,3 We report a case of ahealthy term baby born with eight nuchal cord loops.

CASE

A 36-year-old primigravida presented for diminished fetalmovement at 40 weeks of gestation. Her pregnancy hadbeen normal, including normal ultrasound examinations at12 weeks and 20 weeks. A nonstress test was done and wasnonreactive. A fetal biophysical profile then was performedwith a score of 6/10 (nonreactive nonstress test, abnormal

fetal breathing, normal fetal movements, normal fetal tone,and normal volume of amniotic fluid). Multiple nuchal cordloops (at least three to four loops) were identified during theultrasound examination with Doppler (Fig. 1A and B).Labor induction was discussed with the patient, and sheagreed with the decision, knowing that the risk of cesareandelivery was increased. An endocervical two-way 18French Foley catheter (Silkolatex Rusch Gold, Rusch Inc,Cinnamonson. NJ) with a 50-mL balloon was used forcervical preparation concomitantly with an intravenousoxytocin infusion. Six hours later, abnormal fetal heart ratepattern was identified, consisting of moderate to severevariable decelerations, which became gradually late andprolonged. The cervical dilation was 5 cm, and, because ofa high cephalic fetal presentation, it was impossible toperform an amniotomy. It was decided to perform a cesar-ean delivery, and the patient’s consent was obtained. Atransverse lower segment cesarean delivery was performedunder epidural anesthesia with no complications. The

From the Department of Obstetrics and Gynecology, University of Montreal, St.Justine Hospital, Montreal, Quebec, Canada.

Corresponding author: Marie-Soleil Wagner, MD, MSc, FRCSC AssistantClinical Professor, Department of Obstetrics and Gynecology, University ofMontreal, St. Justine Hospital, 3175 Chemin Cote-Ste-Catherine, Montreal,Quebec, Canada, H3T 1N4; e-mail: marie-soleil.wagner.hsj@ssss.gouv.qc.ca.

Financial DisclosureThe authors have no potential conflicts of interest to disclose.

© 2008 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/08

Fig. 1. A. Ultrasound examination identified at least three tofour loops (the bubbly image indicated by the white arrow).B. Doppler images showed cord with multiple loops aroundthe fetal neck. Colored blood flow is indicated by the whitearrow.Wang. Nuchal Cord With Multiple Loops. Obstet Gynecol 2008.

460 Wang et al Nuchal Cord With Multiple Loops OBSTETRICS & GYNECOLOGY

amniotic fluid was clear. Eight tight nuchal cord loops wereobserved (type A, unlocked pattern). The newborn wasmale with a weight of 2,650 grams and Apgar scores of9-9-9 at 1, 5, and 10 minutes, respectively. The cord bloodgas values were 7.29 for the arterial pH, 44.1 for the PCO 2,and -5.3 for the base excess. The umbilical cord wasnormally structured with one vein and two arteries; how-ever, the length was increased (106 cm reported by the finalpathology). Both the patient and her baby had a goodevolution and were discharged on postoperative day four,as usual in our institution.

COMMENTThe obstetrical management of nuchal cord with asingle loop, suspected before delivery, seems clear: itshould not influence the clinical management. How-ever, the management of nuchal cord with multipleloops is more controversial.

In the literature, the detection rate of nuchal cordbefore labor varies according to the different studies,with a sensitivity of ultrasound and color Dopplerimaging to detect a nuchal cord between 38% and79%.4,5 Using color Doppler ultrasound imaging im-proved the prenatal detection of nuchal cord.5 How-ever, the sensitivity was higher when there was morethan one loop present.4 In a large retrospective studyincluding 8,565 deliveries, the presence of nuchalcord was associated with more abnormal fetal heartrate pattern (moderate or severe variable decelera-tions), more meconium staining, a lower birth weight,more umbilical artery pH 7.10 or less, lower 1-minute Apgar scores, and more forceps deliveries.6

Also, in the subgroup with four loops, there was morevariable and late decelerations, more meconiumstaining, and more forceps deliveries or cesareandeliveries compared with the subgroup with two tothree loops. In the same way, a retrospective case-control study including 550 fetuses with a nuchal cordat delivery showed a significantly higher incidence of1-minute Apgar score of less than 7, meconium-stained amniotic fluid, emergency cesarean delivery,need for neonatal resuscitation, and admission toneonatal intensive care unit in the nuchal cord groupcompared with the control group.7 Nuchal cord with

multiple loops was the main factor accounting for thehigher incidence of these complications. The pres-ence of a nuchal cord and the number of loops werenot associated with a significant difference in perinatalmortality. However, in the case of the three perinataldeaths that occurred in the multiple loops group, thepresence of nuchal cord was the only explanationfound for these deaths. Also, the three deaths oc-curred in women reporting reduced fetal movementat term. Moreover, another study suggests that sometypes of nuchal cord, such as those that are extremelytight or have multiple loops, may be associated with asubclinical deficit neurodevelopmental performanceat 1 year of age.8

Retrospectively in our case, where the diagnosisof multiple loops (at least three or four) was nearlycertain, one could argue that an elective cesareandelivery would have been appropriate. However, thefinal outcome of this case probably would not havebeen different. It is likely that the previous knowledgeof multiple nuchal loops influenced our decision toperform a cesarean delivery.

REFERENCES1. Shui KP, Eastman NJ. Coiling of the umbilical cord around the

foetal neck. J Obstet Gynaecol Br Emp 1957;64:227–8.2. Mastrobattista JM, Hollier LM, Yeomans ER, Ramin SM, Day

MC, Sosa A, et al. Effects of nuchal cord on birthweight andimmediate neonatal outcomes. Am J Perinatol 2005;22:83–5.

3. Hankins GD, Snyder RR, Hauth JC, Gilstrap LC 3rd, HammondT. Nuchal cords and neonatal outcome. Obstet Gynecol1987;70:687–91.

4. Jauniaux E, Mawissa C, Peellaerts C, Rodesch F. Nuchal cordin normal third-trimester pregnancy: a color Doppler imagingstudy. Ultrasound Obstet Gynecol 1992;2:417–9.

5. Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection ofnuchal cord prior to labor induction and the risk of Cesareansection. Ultrasound Obstet Gynecol 2005;25:160–4.

6. Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiplenuchal cord entanglements and intrapartum complications.Am J Obstet Gynecol 1995;173:1228–31.

7. Jauniaux E, Ramsay B, Peelaerts C, Scholler Y. Perinatalfeatures of pregnancies complicated by nuchal cord. Am JPerinatol 1995;12:255–8.

8. Clapp JF 3rd, Lopez B, Simonean S. Nuchal cord and neuro-developmental performance at 1 year of age. J Soc GynecolInvestig 1999;6:268–72.

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