Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 70
Table. Previously reported cases of nuchal cord entanglement
Reference
number
First
author
Year of
publication
Number of cases
Study design
Frequency
Study outcome
1
Lipitz S
1993
1016 newborns
Retrospective
+ prospective
8%
No effect on term birth weight
2
Larson JD
1995
326 newborns
Retrospective
4%
No effect on neonatal outcome. Increased risk of abnormal fetal
heart rate pattern, operative vaginal delivery
3
Larson JD
1997
4029 newborns
Retrospective
29%
4
Singh V
2003
1 intrauterine fetal
death (IUFD)
Prospective
5
Ghi T
2007
5 newborns
Prospective
3%
6
Tepper R
2009
64 fetuses
Prospective
43%
7
Gambhir PS
2011
3 cord entanglements
Case report
—
Died (3), one due to nuchal cord
8
Dodds M
2012
3 nuchal cord
entanglements
Case report
—
Died (1)
generally support that nuchal cord is a common finding in
fetal life, with decreasing rates in the newborn (1, 2, 5, 6).
However, rather than showing decreasing rates, one study
showed that nuchal cord rates increased linearly from 6% in
the 20th gestational week to 29% in the 42nd gestational week,
regardless of whether the entanglement involved a single loop
or multiple loops (3).
The presence of nuchal cord seems to have no effect on the
outcome of pregnancy in terms of birth weight, rate of stillbirth,
or rate of vaginal delivery after induction (1–3, 5). Compared to
no entanglement or only one cord entanglement, two or more
cord entanglements have been associated with an abnormal fetal
heart rate pattern, requiring more low or midforceps application with a lower 1-minute Apgar score and an umbilical artery
pH ≤ 7.10 without any adverse neonatal outcome (2). Umbilical cord abnormalities, mainly umbilical cord constriction and
coiling, have been shown to be related to 11% of intrauterine
fetal deaths within 16 gestational weeks (4). Fetal demise due
to nuchal cord entanglement has been reported to occur in the
first or second trimester in two case reports (7, 8).
A decreasing incidence of cord entanglement around the
neck seems to be a normal phenomenon during fetal uterine
development, but rare instances result in fetal demise. An autopsy study of 139 mostly second-trimester fetuses that died
due to umbilical cord stricture and overcoiling revealed the
absence of Wharton’s jelly as an intrinsic cord pathology (9).
Likewise, a not-yet-clarified intrinsic umbilical cord anomaly
associated with the physical compression of entanglement may
144
8%
No effect on stillbirth rate
Cord constriction, coiling, hemorrhage, thrombosis, amniotic
bands as frequent causes of IUFD
No effect on rate of vaginal delivery after induction
A 63% rate of any cord entanglement in early fetal life
explain why some rare cases of nuchal cord end in fetal demise.
To date, nuchal cords have been shown to have significantly
lower vascular coiling than ones without nuchal entanglement
(10). The relevance of this finding in terms of fetal demise is
not yet known.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Lipitz S, Seidman DS, Gale R, Stevenson DK, Alcalay M, Menczer J,
Barkai G. Is fetal growth affected by cord entanglement? J Perinatol
1993;13(5):385–388.
Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord
entanglements and intrapartum complications. Am J Obstet Gynecol
1995;173(4):1228–1231.
Larson JD, Rayburn WF, Harlan VL. Nuchal cord entanglements and
gestational age. Am J Perinatol 1997;14(9):555–557.
Singh V, Khanum S, Singh M. Umbilical cord lesions in early intrauterine
fetal demise. Arch Pathol Lab Med 2003;127(7):850–853.
Ghi T, D’Emidio L, Morandi R, Casadio P, Pilu G, Pelusi G. Nuchal
cord entanglement and outcome of labour induction. J Prenat Med
2007;1(4):57–60.
Tepper R, Kidron D, Aviram R, Markovitch O, Hershkovitz R. High
incidence of cord entanglement during early pregnancy detected by
three-dimensional sonography. Am J Perinatol 2009;26(5):379–382.
Gambhir PS, Gupte S, Kamat AD, Patankar A, Kulkarni VD, Phadke MA.
Chronic umbilical cord entanglements causing intrauterine fetal demise
in the second trimester. Pediatr Dev Pathol 2011;14(3):252–254.
Dodds M, Windrim R, Kingdom J. Complex umbilical cord entanglement.
J Matern Fetal Neonatal Med 2012;25(9):1827–1829.
Peng HQ, Levitin-Smith M, Rochelson B, Kahn E. Umbilica l cord
stricture and overcoiling are common causes of fetal demise. Pediatr
Dev Pathol 2006;9(1):14–19.
Strong TH Jr, Manriquez-Gilpin MP, Gilpin BG. Umbilical vascular coiling
and nuchal entanglement. J Matern Fetal Med 1996;5(6):359–361.
Baylor University Medical Center Proceedings
Volume 27, Number 2