Int J Gynecol Obstet,
1991, 35: 165-167
165
International Federation of Gynecology and Obstetrics
Extremely large number of twists of the umbilical cord causing torsion and intrauterine fetal death A. Herman, P. Zabow,
M. Segal, R. Ron-El,
Departments of Obstetrics and Gynaecology Tel Aviv University, Tel Aviv (Israel)
and Pathology,
Y. Bukovsky
and E. Caspi
Assaf Harofeh Medical Center, Zerifin and Sackler School of Medicine,
(Received December l8th, 1989) (Revised and accepted May 15th, 1990)
Abstract Extremely large number of twists of the umbilical cord causing torsion of the entire length of the umbilical cord was found in two cases of intrauterine fetal death. It was twistd in one case 35 times and in the other 20 times. No additional pathology, such as stricture or abnormality of the WhartonS jeIly, was found. The two mothers complained of decreased fetal movements and both newborns were found later to be growth retarded. A long cord of 120 cm was present in one case and normal length of 70 cm in the other. Close antenatal care in cases with growth retarded fetuses or decreased fetal movements may help in avoiding fetal demise in such rare cases.
Keywords:
Umbilical
cord;
Torsion;
Fetal
death. Introduction Umbilical cord abnormalities causing fetal death in pregnancy or complications in labor were generally attributed to true knot of cord, long or short cord and cord entanglement [3,8,9]. Torsion of the cord, as an etiology of intrauterine fetal death, was mentioned in association with constriction of the cord 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
and/or segmental abnormality of the Wharton’s jelly [4,7,10]. Torsion of a short segment of the cord, as an isolated finding in a case of fetal death, was described recently by Glanfield and Watson [5], mentioning that it is a rare event of unknown incidence. Reported herein are two cases of intrauterine fetal death caused by an extremely large number of twists of the umbilical cord that caused torsion of its entire length. Case report During the years 1987-1988 there were 9276 deliveries in Assaf Harofeh Medical Center, Zeritin. Out of the 53 mortality cases (birthweight L 1000 g) 35 were stillbirths (3.8 per 1000) and the remaining 18 were early neonatal deaths (1.9 per 1000). Of the former there were two cases attributed to torsion of the cord. In both cases the cord was twisted throughout its length, the first being twisted 35 times and the second 20 times. Case I
The first mother was 29 years old in her first pregnancy and pregnancy followup was satisfactory. Ultrasound (US) examinations performed at 11, 19 and 28 weeks of gestation were normal. At 35 weeks of gestational age she mentioned decreased fetal movements and Case Report
166
Herman et al.
was referred immediately to the hospital but only arrived a day later. A dead fetus in a breech presentation was found and she delivered spontaneously, 3 days later, a male stillborn of 1750 g which was small for dates. The only abnormal finding (macroscopic and histological sections) was a cord twisted 35 times throughout its entire length with its vessels compressed. The length of the cord was 70 cm with two arteries and one vein without any constriction, thrombosis or other abnormality. Case 2 The second mother was 31 years old in her third pregnancy after two normal deliveries. Her pregnancy followup was unsatisfactory and the first examination was in the sixth month as the date of last menstrual period was unknown. The results of her first US examination, which corresponded to 29 weeks, served as a landmark for calculation ,of the gestational age. She did not attend even following a repeated US at 35 weeks which revealed a growth retarded fetus with a weight estimation of 1800 g. The mother arrived at the hospital at 40 weeks of gestation because of diminished fetal movements in the last 24 h. The fundal height corresponded to 34 weeks and US revealed a dead fetus in a vertex position Induction of labor was performed and she delivered a dead female, weighing 2000 g which was also small for dates. The only abnormal finding was torsion of the entire length of the cord (20 times around the long axis). The cord was 120 cm long and its three vessels compressed. Both macroscopic and histologic examinations did not disclose any additional pathology. Discussion Torsion of apparently normal umbilical cord throughout the entire length, has been very rarely documented in the literature. Weber [lo] reviewed the literature and found that Ruysch was the first to describe a case of torsion of the cord in 1691 and that Dohrn. in Int J Gynecol Obstet 35
a review of the literature in 1861, found 85 cases of torsion of the cord. In the last three decades live cases were reported by Weber [lo], three by Riley et al. [7], one by Gilbert and Zugibe [4] and one by Glanlield and Watson [5]. It seems that three different pathological entities, that may occur separately or concomitantly, are gathered under this heading. One is a constriction of the cord, the second is a segmental abnormality of the Wharton’s jelly and the third is a true torsion. Weber [lo] mentioned that according to Schauta the torsion, as well as the constriction or the disappearance of Wharton’s jelly, occurred only after fetal death. Edmonds and Washington [2] favored this view since in most cases the findings were confined to the fetal end of the cord which is supposed to be more macerated due to less oxygenation. Nevertheless, in his description of five cases Weber [lo] stated that constriction occurred before fetal demise. In one case it was located at the placental end and in another one there were two constrictions. Gilbert and Zugibe [4] believed that abnormalities of the cord were the modus operandi during fetal life and that in some cases they were described with normal live births. Moreover, Glantield and Watson [5] described a case of a segmental torsion in the placental end in a recently dead fetus. The two torsions presented by us seem to have occurred before fetal demise since it is hard to believe that the cord may twist 35 or 20 times after fetal demise. Also, both newborns were found to be growth retarded which suggests that the problem began quite a long time before fetal death. The causes that invoke torsion of the cord are unknown but it seems that excessive fetal movements plays an important role. It was suggested that male fetuses and multiparity are more common and that abnormally long cord is a predisposing factor. Accurate antenatal diagnosis of such cases seems to be impossible. In a recent review of Hill et al. [6] concerning US view of the umbilical cord, they mentioned that antenatal diagnosis of stricture and torsion has not as yet been
Torsion of umbilical cord
made. They recommend careful examination especially near the fetal end in cases with sudden decreased fetal movements or changes in fetal heart rate. Brans et al. [l] reported that placental and cord pathologies constituted a leading cause out of 320 stillbirths investigated. Although, in their relatively large series, torsion of the cord was not diagnosed, its true incidence might be higher than is reflected from the few cases reported in the literature in the last decades. More attention and meticulous examination of the umbilical cord may disclose more cases. Awareness and close antenatal care may aid in the prevention of death. References Brans YW, Escobedo MB, Hayashi RH et al: Perinatal mortality in a large perinatal center: five-year review of 31,000 births. Am J Obstet Gynecol 148: 284, 1984. Edmonds HW, Washington DC: The spiral twist of the normal umbilical cord in twins and in singletons. Am J Obstet Gynecol 67: 102, 1954. Ghosh A, Woo JSK, MacHenry C et al: Fetal loss from
161
umbilical cord abnormalities-a difftcult case for prevention. Eur J Obstet Gynecol Reprod Biol 18: 183, 1984. Gilbert EF, Zugibe MFT: Torsion and constriction of the umbilical cord, a cause of fetal death. Arch Pathol 97: 58, 1974. Glantield PA, Watson R: Intrauterine fetal death due to umbilical cord torsion. Arch Pathol Lab Med 110: 357, 1986. Hill LM, Kislak S and Runco C: An ultrasonic view of the umbilical cord. Obstet Gynecol Surv 42; 82, 1987. Kiley KC, Perkins CS, Penney LL: Umbilical cord stricture associated with intra-uterine fetal demise. A report of two cases. J Reprod Med 31: 154, 1986. Naeye RL: Functionally important disorders of the placenta, umbilical cord, and fetal membranes. Hum Pathol 18: 680, 1987. Spellacy WN, Graven H, Fisch RO: The umbilical cord complications of true knots, nuchal coils, and cords around the body. Am J Obstet Gynecol 94: 1136, 1986. Weber J: Constriction of the umbilical cord as a cause of fetal death. Acta Obstet Gynecol Stand 42: 259, 1963.
Address for reprints: A. Herman Department of Obstetrics and Gynaecology Assaf Harofeh Medical Center Zerifin, 70300, Israel
Case Report
1991, 35: 165-167
165
International Federation of Gynecology and Obstetrics
Extremely large number of twists of the umbilical cord causing torsion and intrauterine fetal death A. Herman, P. Zabow,
M. Segal, R. Ron-El,
Departments of Obstetrics and Gynaecology Tel Aviv University, Tel Aviv (Israel)
and Pathology,
Y. Bukovsky
and E. Caspi
Assaf Harofeh Medical Center, Zerifin and Sackler School of Medicine,
(Received December l8th, 1989) (Revised and accepted May 15th, 1990)
Abstract Extremely large number of twists of the umbilical cord causing torsion of the entire length of the umbilical cord was found in two cases of intrauterine fetal death. It was twistd in one case 35 times and in the other 20 times. No additional pathology, such as stricture or abnormality of the WhartonS jeIly, was found. The two mothers complained of decreased fetal movements and both newborns were found later to be growth retarded. A long cord of 120 cm was present in one case and normal length of 70 cm in the other. Close antenatal care in cases with growth retarded fetuses or decreased fetal movements may help in avoiding fetal demise in such rare cases.
Keywords:
Umbilical
cord;
Torsion;
Fetal
death. Introduction Umbilical cord abnormalities causing fetal death in pregnancy or complications in labor were generally attributed to true knot of cord, long or short cord and cord entanglement [3,8,9]. Torsion of the cord, as an etiology of intrauterine fetal death, was mentioned in association with constriction of the cord 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
and/or segmental abnormality of the Wharton’s jelly [4,7,10]. Torsion of a short segment of the cord, as an isolated finding in a case of fetal death, was described recently by Glanfield and Watson [5], mentioning that it is a rare event of unknown incidence. Reported herein are two cases of intrauterine fetal death caused by an extremely large number of twists of the umbilical cord that caused torsion of its entire length. Case report During the years 1987-1988 there were 9276 deliveries in Assaf Harofeh Medical Center, Zeritin. Out of the 53 mortality cases (birthweight L 1000 g) 35 were stillbirths (3.8 per 1000) and the remaining 18 were early neonatal deaths (1.9 per 1000). Of the former there were two cases attributed to torsion of the cord. In both cases the cord was twisted throughout its length, the first being twisted 35 times and the second 20 times. Case I
The first mother was 29 years old in her first pregnancy and pregnancy followup was satisfactory. Ultrasound (US) examinations performed at 11, 19 and 28 weeks of gestation were normal. At 35 weeks of gestational age she mentioned decreased fetal movements and Case Report
166
Herman et al.
was referred immediately to the hospital but only arrived a day later. A dead fetus in a breech presentation was found and she delivered spontaneously, 3 days later, a male stillborn of 1750 g which was small for dates. The only abnormal finding (macroscopic and histological sections) was a cord twisted 35 times throughout its entire length with its vessels compressed. The length of the cord was 70 cm with two arteries and one vein without any constriction, thrombosis or other abnormality. Case 2 The second mother was 31 years old in her third pregnancy after two normal deliveries. Her pregnancy followup was unsatisfactory and the first examination was in the sixth month as the date of last menstrual period was unknown. The results of her first US examination, which corresponded to 29 weeks, served as a landmark for calculation ,of the gestational age. She did not attend even following a repeated US at 35 weeks which revealed a growth retarded fetus with a weight estimation of 1800 g. The mother arrived at the hospital at 40 weeks of gestation because of diminished fetal movements in the last 24 h. The fundal height corresponded to 34 weeks and US revealed a dead fetus in a vertex position Induction of labor was performed and she delivered a dead female, weighing 2000 g which was also small for dates. The only abnormal finding was torsion of the entire length of the cord (20 times around the long axis). The cord was 120 cm long and its three vessels compressed. Both macroscopic and histologic examinations did not disclose any additional pathology. Discussion Torsion of apparently normal umbilical cord throughout the entire length, has been very rarely documented in the literature. Weber [lo] reviewed the literature and found that Ruysch was the first to describe a case of torsion of the cord in 1691 and that Dohrn. in Int J Gynecol Obstet 35
a review of the literature in 1861, found 85 cases of torsion of the cord. In the last three decades live cases were reported by Weber [lo], three by Riley et al. [7], one by Gilbert and Zugibe [4] and one by Glanlield and Watson [5]. It seems that three different pathological entities, that may occur separately or concomitantly, are gathered under this heading. One is a constriction of the cord, the second is a segmental abnormality of the Wharton’s jelly and the third is a true torsion. Weber [lo] mentioned that according to Schauta the torsion, as well as the constriction or the disappearance of Wharton’s jelly, occurred only after fetal death. Edmonds and Washington [2] favored this view since in most cases the findings were confined to the fetal end of the cord which is supposed to be more macerated due to less oxygenation. Nevertheless, in his description of five cases Weber [lo] stated that constriction occurred before fetal demise. In one case it was located at the placental end and in another one there were two constrictions. Gilbert and Zugibe [4] believed that abnormalities of the cord were the modus operandi during fetal life and that in some cases they were described with normal live births. Moreover, Glantield and Watson [5] described a case of a segmental torsion in the placental end in a recently dead fetus. The two torsions presented by us seem to have occurred before fetal demise since it is hard to believe that the cord may twist 35 or 20 times after fetal demise. Also, both newborns were found to be growth retarded which suggests that the problem began quite a long time before fetal death. The causes that invoke torsion of the cord are unknown but it seems that excessive fetal movements plays an important role. It was suggested that male fetuses and multiparity are more common and that abnormally long cord is a predisposing factor. Accurate antenatal diagnosis of such cases seems to be impossible. In a recent review of Hill et al. [6] concerning US view of the umbilical cord, they mentioned that antenatal diagnosis of stricture and torsion has not as yet been
Torsion of umbilical cord
made. They recommend careful examination especially near the fetal end in cases with sudden decreased fetal movements or changes in fetal heart rate. Brans et al. [l] reported that placental and cord pathologies constituted a leading cause out of 320 stillbirths investigated. Although, in their relatively large series, torsion of the cord was not diagnosed, its true incidence might be higher than is reflected from the few cases reported in the literature in the last decades. More attention and meticulous examination of the umbilical cord may disclose more cases. Awareness and close antenatal care may aid in the prevention of death. References Brans YW, Escobedo MB, Hayashi RH et al: Perinatal mortality in a large perinatal center: five-year review of 31,000 births. Am J Obstet Gynecol 148: 284, 1984. Edmonds HW, Washington DC: The spiral twist of the normal umbilical cord in twins and in singletons. Am J Obstet Gynecol 67: 102, 1954. Ghosh A, Woo JSK, MacHenry C et al: Fetal loss from
161
umbilical cord abnormalities-a difftcult case for prevention. Eur J Obstet Gynecol Reprod Biol 18: 183, 1984. Gilbert EF, Zugibe MFT: Torsion and constriction of the umbilical cord, a cause of fetal death. Arch Pathol 97: 58, 1974. Glantield PA, Watson R: Intrauterine fetal death due to umbilical cord torsion. Arch Pathol Lab Med 110: 357, 1986. Hill LM, Kislak S and Runco C: An ultrasonic view of the umbilical cord. Obstet Gynecol Surv 42; 82, 1987. Kiley KC, Perkins CS, Penney LL: Umbilical cord stricture associated with intra-uterine fetal demise. A report of two cases. J Reprod Med 31: 154, 1986. Naeye RL: Functionally important disorders of the placenta, umbilical cord, and fetal membranes. Hum Pathol 18: 680, 1987. Spellacy WN, Graven H, Fisch RO: The umbilical cord complications of true knots, nuchal coils, and cords around the body. Am J Obstet Gynecol 94: 1136, 1986. Weber J: Constriction of the umbilical cord as a cause of fetal death. Acta Obstet Gynecol Stand 42: 259, 1963.
Address for reprints: A. Herman Department of Obstetrics and Gynaecology Assaf Harofeh Medical Center Zerifin, 70300, Israel
Case Report
