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The Umbilical Cord
Umbilical Cord
Two umbilical arteries+ one umbilical vein
Surrounded by Wharton’s jellygelatinous mucopolysaccharidesprotect umbilical vessels
Outer amniotic layer Inner sub-amniotic layer
rich source of mesenchymalstem cells
Diagram umb cordUmbilical vein carriesoxygen & nutrients
from placenta to fetus
Umbilical arteries carry wasteproducts from fetus to placenta
Umbilical Cord
Umbilicalarteries Umbilical
vein
Umbilical Cord
Ultrasound of normal umbilical cord
3 vessels — 2 arteries & 1 vein
Surrounded by small amount of
Wharton’s jelly
Coiled/helical configuration
Inserts into central part of placenta
Abnormalities of Umbilical Cord
2 vessels, 1 artery & 1 vein
Anomalous venous return
Masses or cysts
Nuchal cord
Abnormal placental cord insertion
velamentous
marginal
Cord presenting/prolapse
Umbilical Cord
Are there really 3 vessels?
No Disclosures
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Zuckerman 3VC by bladder clip & Renta
Single umbilical artery
0.2 – 1% of pregnancies
Whites > Blacks, Asians
Multiple > Singleton gestations
incidence in monozygotic twinsoften discordant
incidence of fetal anomalies
2-Vessel Umbilical Cord
Ultrasound findings
2-vessel cord
Color Doppler
2-vessel cord
Single vessel by bladder
2-Vessel Umbilical Cord
Diomede &Caldwell 2vc
Outcome at birth
31% congenital anomalies*(4% aneuploidy)
69% normal
*Most identified by prenatal ultrasound
2-Vessel Umbilical Cord
Associated anomalies
Cardiovascular (51%)
Gastrointestinal (38%)
Central nervous system (24%)
Genitourinary (16%)
Pulmonary (11%)
Musculoskeletal (8%)
2-Vessel Umbilical Cord
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Trott, 2VC TOF
2-vessel cordTetralogyof Fallot
Isolated 2-Vessel Cord on Prenatal Ultrasound
Outcome at birth
7% Congenital anomalies
93% Normal
Structural anomalies at birthnot diagnosed at prenatal ultrasound
Ventricular septal defect
Tracheoesophageal fistula
Ambiguous genitalia
Clubfoot
Isolated 2-Vessel Cord on Prenatal Ultrasound
Powe misDx of 2vc
17 weeks 30 weeks
Misdiagnosis of 3-vessel cord
A
V
Krueger misDx of 2vc
Misdiagnosis of 3-vessel cord
Freeman misDx of 2vc
Misdiagnosis of 3-vessel cord
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Anomalous Umbilical Venous Return
Drainage of umbilical vein
through channels other than
ductus venosus in liver
Alters flow to and through heart
May lead to hydrops
Associated with anomalies &
aneuploidy
Anomalous Umbilical Venous Return
Persistent right umbilical veinAbsent ductus venosusDirect into systemic circulationDuctus venosus to systemic
circulation Intrahepatic porto-systemic shuntExtrahepatic porto-systemic shunt
Pena right UV
Right umbilical vein
*
*Gallbladder
Scola anom UV return
Umbilical vein drainsinto infrahepatic
inferior vena cava
Zwick absent DV poly
Absent ductus venosus, Polyhydramnios
Ortiz absent DV
Absent ductus venosusUmbilical vein drains into left hepatic vein
Normalhepatic
veinwaveform
Normalportal vein
waveform
Abnormalhepatic
veinwaveform
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Scola anom UV return
Umbilical vein drains into iliac vein
Scola anom UV return
Umbilical vein drains into iliac veinDilated inferior vena cava, cardiomegaly
Philogene intrahepportosystemic shunt
Intrahepatic portosystemic shunt
Lesions of Umbilical Cord
Cyst - allantoic duct
Focal thickening of Wharton’s jelly
Venous varix
Mass — teratoma, hemangioma
Associated with adverse outcomefetal distress, intrauterine growthrestriction, demise, anomalies
Umbilical Cord Cysts
1st Trimester
Prevalence ~ 0.4 – 3.4%
Usually detected at 8 – 9 weeks
Typically resolve before2nd trimester & normal outcome
If persist into 2nd trimester anomalies & aneuploidy
Umbilical Cord Cysts
2nd Trimester
Cysts associated withomphalocelepatent urachusurinary anomalies
Pseudocyst associated withaneuploidyanomalies
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Boothroyd UC cyst
Cyst of the umbilical cord – 9 weeks
Lymon UC cyst
Cyst of the umbilical cord – 17 weeks
Vazquez UC cyst & omphal
Umbilical cord cyst13 weeks
Vazquez UC cyst & omphal
Umbilical cord cyst13 weeks
↓Omphalocele
20 weeks
Garney UC cystpatent urachus
19 weeksUmbilical
cordcysts
26 weeks 30 weeks
Garney UC cystpatent urachus
34 weeksUmbilical
cordthickening
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Garney UC cystpatent urachus
Placenta
Delivery:Umbilical
cordthickening
Garney Baby UC cystpatent urachus
Neonate: Patent urachusOpening from bladder to umbilical cord
BL
UC
Placental Cord Insertion
Required element of 2nd & 3rd
trimester scan
Assess for abnormal insertionVelamentousMarginal
Locate for percutaneous umbilicalblood sampling (PUBS)
Color Dopplerfollow umbilical vessels to placenta
Diaz PUBS
Marginal and VelamentousUmbilical Cord Insertions
Abnormal insertion of cord into placenta
Marginal: < 1cm from placental edge
Velamentous: vessels travel unprotected
beneath membranes before insertion
At risk for rupture, thrombosis
Risk higher for velamentous
Predisposing factorsMultiple gestationLow-lying placenta or previaUterine scarringUterine anomalies
Singletons TwinsMarginal 7% 20%Velamentous 1% 12%
Marginal and VelamentousUmbilical Cord Insertions
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Lin marginal CI
Marginal cord insertion
MangioneVelamentous CI
Velamentous cord insertion
OrtizVelamentous CI
Velamentous cord insertion
GreenleafVelamentous CIbetw succ lobes
Velamentouscord
insertionbetween
succenturiatelobes
P
P
P
P
Santos intertwin membVelamentous CI
Velamentouscord insertionOn intertwinmembrane
23 weeks31 weeks
Vasa Previa
Velamentous cord insertion in
lower uterine segment with
fetal vessels crossing cervix
Associated with high perinatal
mortality
May develop from prior
low-lying placenta
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Vasa Previa
Ultrasound and Color Doppler findings
Vessels lying across the cervix
Spectral Doppler findings
Umbilical arterial & venous
waveforms
Charbit vasaprevia
Vasa Previa
McGrath vasaprevia
Vasa Previa
Rueda vasa previafrom lowlying pl*
*
Vasa PreviaPrevia19w
Vasa Previa26w
*
*30w
Cord (Funic) Presentation
Associated with abnormalfetal heart rate patterns
Obstetrical emergency
Risk of cord prolapse
Color Dopplerumbilical vessels between fetus and cervix
Collin cord presenting
Page 10
Rodriquez cord prolapse
Zuo obligatecord presenting
Obligate cordpresentation
Umbilical Vein Varix
Focal dilatation of umbilical vein
Associated withFetal anomalies & normal karyotype
(12%)Aneuploidy (10%)Fetal demise (10%)Anemia (6%)
Garang UV varix
Umbilical Vein Varix
Godfrey UV varixoutside fetus
Umbilical Vein Varix
Banik UV varixfalse knot
False knotUmbilical Vein Varix
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Umbilical Artery Doppler
Assess fetal well-being
Absent or reversed end diastolic flow
Associated with
morbidity
mortality
Umbilical Artery Doppler
Assess fetal well-beingConcerning findings:
Diminished end diastolic flowelevated systolic/diastolic (S/D)
Absent or reversedend diastolic flow
Associated with
morbidity
mortality
Brewer Nl UA Doppler
Normal
Ahir diminisheddiastolic flow
DiminishedEnd Diastolic
Flow
Buccafusca Reversed diastolic flow
ReversedEnd Diastolic
FlowUmbilical Cord Vessels
Unusual cases
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Holiday 3 to 2 vessel cord clip
3 -vesselcord?
Or 2 -vesselcord?
Steed 3 to 2 vc
22 weeks 32 weeks
Magalhaes hypoplUA & TOF
Hypoplastic Tetralogy of FallotUmbilical Artery
A
A V
Pilgrimthrombosed UA
Thrombosed umbilical artery
Khalifa 6 vessel cord1
234
5
6
6 -VesselCord
How manyvessels?
Khalifaconjoined twins
Page 13
Hall 3D face&UC
The end