13-umblical cord imaging Dr Ahmed Esawy

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

Dr. Ahmed Esawy
MBBS M.Sc
MD
Dr/AHMED ESAWY

Umblical
cord
imagingDr/AHMED ESAWY

Vitelline duct.
Dr/AHMED ESAWY

Early coiled umbilical cord.
Dr/AHMED ESAWY

• Cord daimeter cross section (outer to outer)
• Short cord less than 40 cm
• long cord more than 70 cm
• Vessel diameter inner to inner up to 4 mm
Dr/AHMED ESAWY

I. Abnormal number of vessels
single umblical artery
two vessels cords
four vessels cords
Two veins & two arteries
One vein & 3 arteries
One vein, two arteries and a duct
five and more vessels cords
Cords with unequal numbers of vessels at
the fetal and placental ends
Dr/AHMED ESAWY

II-Abnormal course or connection of vessels
Velamentous insertion of the cord
vasa previa
Ductus venosus agenesis
Replaced umbilical artery to the superior mesenteric
artery
Coronary sinus drainage to the umbilical portion of
the left portal vein
Persistent right umbilical vein
Arteriovenous fistula Dr/AHMED ESAWY

III-Abnormal structure or configuration of vessels
Hypoplastic umbilical artery
Umbilical artery stenosis
Thrombosis
Segmental thinning of umbilical cord vessels
Umbilical cord constriction
Nuchal cord loops
Type A - nuchal loop that encircles the neck in a freely sliding pattern
Type B - nuchal loop that encircles the neck in a locked pattern
Other locations are also frequent, such as the abdomen or the lower limbs.
Multiple cord loops are also a frequent event. This is a rare case of quintuple
nuchal cord entanglement.
Some cords seem entangled but they are not, and they are called
draped around the neck.
Dr/AHMED ESAWY

III-Abnormal structure or configuration of vessels
Cord-to-cord entanglement in twin gestations
Umbilical vein varix
Abnormal cord coiling
Non-coiled cords and poorly coiled cords
Hyper-coiled cords
Abnormal cord length.
Short cords (
Defined as total length of 40 cm or less
)
Long cords (defined as total length over 70 cm)
Abnormal cord width
Dr/AHMED ESAWY

UC Position
Normally:
• anterior to the fetal abdominal wall and adjacent to the
limbs.
Malposition
• Nucal: around fetal neck
• Around limbs
• Between the fetal presentation part and the lower
uterine segment (funic presentation). more common
with malpresentations such as breech or transverse lie.
• Prolapse
Dr/AHMED ESAWY

umbilical cord prolapse .
Dr/AHMED ESAWY

umbilical cord prolapse
Dr/AHMED ESAWY

Cord presentation.
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Abnormal number of vessels
Dr/AHMED ESAWY

Single Umbilical Artery
= 2 Vessel Cord
• In isolation, not significant risk of aneuploidy
• Associated with other anomalies 20-50% of cases
• UA anastomosis may normally occur at placental end –
• avoid diagnosing 2V cord there
• Useful view: 2 UAs at the level of the bladder
Dr/AHMED ESAWY

shows all the reported structural anomalies
associated with single umbilical artery
Dr/AHMED ESAWY

The normal umbilical cord with three vessels
Dr/AHMED ESAWY

Single umbilical artery.
Dr/AHMED ESAWY

SIJA, nuchal cord, and omphalocele.
Dr/AHMED ESAWY

SUA and multicystic dysplastic kidney.
Dr/AHMED ESAWY

one umbilical artery and an umbilical vein within this cord.
Dr/AHMED ESAWY

SUA multiple other anomalies, and an allantoic cyst.
Dr/AHMED ESAWY

Single umbilical artery (SUA) or 2
vessel umbilical cord:
Dr/AHMED ESAWY

Normal 3 vessel umbilical cord:
Dr/AHMED ESAWY

One vein & 3 arteries
Dr/AHMED ESAWY

One vein, two arteries and a duct While an
allantoic (2/3) or omphalomesenteric (1/3) duct
remnant is not a true vessel
Dr/AHMED ESAWY

omphalomesenteric duct
Dr/AHMED ESAWY

Artifacts
Occasionally the incidence of the ultrasound
beam gives exquisite view of the vessels walls
and gives the impression of extra vessels.
Dr/AHMED ESAWY

Abnormal cord insertion
vasa previa
Dr/AHMED ESAWY

Vasa Previa
• Submembranous fetal vessels cross cervical os
• Doppler shows fixed fetal vessels overlying cx os
• From succenturiate lobe: most common etiology
• Best imagine tool: TVS + color Doppler
• D/D
– Marginal sinus previa
– Cord presentation
– Uterine vessel near cervix
Dr/AHMED ESAWY

Associated anomalies :
• Esophageal atresia.
• Obstructive uropathies.
• Congenital hip dislocation.
• Asymmetrical head shape.
• Spina bifida.
• Ventricular septal defects.
• Single umbilical artery.
• Bilobate placenta.
• Trisomy 21.
Dr/AHMED ESAWY

Be aware that flash artifacts resulting from fluid
motion from the fetus may mimic the presence of
vasa previa
Dr/AHMED ESAWY

Marginal cord insertion.
Dr/AHMED ESAWY

II-Abnormal course or connection of vessels
Dr/AHMED ESAWY

Although absence of the ductus arteriosus is very rare
absence of the venosus is occasionally seen. The return of
the umbilical flow is via various vicarious ways
• a suprahepatic connection to the inferior vena cava or
• rarely to the right atrium directly
• an infrahepatic connection to the inferior vena cava
• cutaneous anastomosis with formation of a caput medusa
• left or right iliac connection.
Dr/AHMED ESAWY

3 ductal agenesis, with the
umbilical vein joining directly to
the inferior vena cava
Dr/AHMED ESAWY

type 6 ductal agenesis, with the umbilical vein
joining directly into the right atrium
Dr/AHMED ESAWY

Persistent right umbilical vein
Dr/AHMED ESAWY

Replaced umbilical artery to the superior
mesenteric artery
Dr/AHMED ESAWY

III-Abnormal structure or
configuration of vessels
Dr/AHMED ESAWY

Hypoplastic umbilical artery
Placental pathology .
Polyhydramnios.
Congenital heart disease.
Fetal growth restriction.
Stillbirth.
Trisomies
Dr/AHMED ESAWY

Segmental thinning of umbilical cord vessels
Dr/AHMED ESAWY

Umbilical cord constriction
Amniotic bands.
Nuchal loops.
True knots .
Fetal grasping
Entanglement in monoamniotic twins
Cord presentation and occult prolapse
Dr/AHMED ESAWY

Umbilical Cord Aneurysm (UCA)
• UV varix (UV > 9mm)
• UA aneurysm
Dr/AHMED ESAWY

Umbilical Cord Aneurysm (UCA)
• Careful research for other anomalies
• UV varix may be first manifestation of  vein
pressure
• Monitor impending hydrops
• Monitor for anemia
• Use color Doppler for checking
• D/D
– Normal fluid-filled structures
– Abdominal cysts (choledochal cyst, meconium
pseudocyst, ovarian cyst, urachal cyst)
– UC cysts
Dr/AHMED ESAWY

Meconium pseudocyst
Dr/AHMED ESAWY

Umbilical vein varix
Dr/AHMED ESAWY

Umbilical Vein Varix
• Normal Umbilical Vein
• 3mm at 15wks  8mm at term
• Varix usually incidental finding
• In isolation, prognosis is good
• If large:
• follow-up is suggested
• look for intraluminal thrombus formation
Dr/AHMED ESAWY

Focal varices of the umbilical cord simulating a knot (false knot).
Dr/AHMED ESAWY

Umbilical Vein Varix (small)
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intra-abdominal umbilical vein varix
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Fetal intra-abdominal umbilical vein varix
Dr/AHMED ESAWY

Abnormal cord coiling
Dr/AHMED ESAWY

Normal coiling of the umbilical cord
Dr/AHMED ESAWY

Umbilical cord coiling.
(a)normally coiled umbilical cord
(b)(b) noncoiled umbilical cord.
Dr/AHMED ESAWY

Under coiling is associates
fetal death
spontaneous preterm delivery
Operative delivery for fetal distress.
Meconium staining.
trisomies
low Apgar score at 5 minutes
velamentous cord insertion
single umbilical artery
Repetitive intrapartum fetal heart rate decelerations.
Aneuploidy .
IUGR
Dr/AHMED ESAWY

• Under-coiling may give way to kinking and
compression
• over-coiling may give way to occlusion in cases
with cord entanglement
• Early second-trimester low umbilical coiling
index predicts small-for-gestational-age fetuses.
Dr/AHMED ESAWY

Non-coiled cords and poorly coiled cords
Dr/AHMED ESAWY

Hypocoiled umbilical cord
Dr/AHMED ESAWY

hypocoiling of umbilical cord
Dr/AHMED ESAWY

• Over coiling (umbilical coiling index above the 90th
percentile).
– asphyxia
– umbilical arterial pH < 7.05
– small for gestational age infants
– trisomies
– single umbilical artery
Associations include :
Fetal demise.
• Fetal intrapartum distress.
• IUGR.
• Chorioamnionitis. Nuchal cord loops
Dr/AHMED ESAWY

Hyper-coiled cords
Dr/AHMED ESAWY

Abnormal cord length
Dr/AHMED ESAWY

Cord Length (50~70 cm)
• Short cord
– Akinesia sequence
– Trisomy 21
– Body stalk anomalies
• Long cord
– Hyperactivity
– Increased likelihood of true cord knot
Dr/AHMED ESAWY

Short cords
• Defined as total length of 40 cm or less, short
umbilical cords are uncommon.
Dr/AHMED ESAWY

• Fetal Akinesia Deformation Sequence (FADS) or Pena-
Shokeir Sequence,
• Spinal muscular atrophy (SMA)
• Body-stalk anomaly (also known as short cord umbilical
cord syndrome).
• Lateral meningocele syndrome (also known as "familial
osteosclerosis).
• Neu-Laxova syndromeDr/AHMED ESAWY
Short cords

Long cords
• Long umbilical cords, defined as total length over
70 cm, have been significantly associated with:
Maternal factors:
• Systemic diseases.
• Delivery complications.
• Increased maternal age.
Fetal factors:
• Non-reassuring fetal status during labor.
• Respiratory distress.
Dr/AHMED ESAWY

• Vertex presentation
• Cord entanglement.
• Fetal anomalies.
• Male sex.
• Increased birth weight.
• Placental features:
• Increased placental weight.
• Right-twisted cords.
• Hyper-coiled cords.
• True knots.
Dr/AHMED ESAWY

Abnormal cord width
Thin ("lean") cords
Defined as the cross-sectional area of the cord,
measured in a plane adjacent to the insertion into
the fetal abdomen, below the 10th centile for
gestational age. Lean cords have been associated
with
Dr/AHMED ESAWY

Umbilical Cord Cyst (UCC)
• D/D
– Normal yolk sac
– UC aneurysm
– Resolving UC hematoma (rare)
– UC supernumerary vessels (very rare, conjoined twins)
Dr/AHMED ESAWY

Cysts and pseudocysts
•
Umbilical cord cysts
• Pseudocysts are localized edema of Wharton"s
jelly or liquefaction of hematomas or thrombus
within the cord.
Dr/AHMED ESAWY

examples of first
trimester cord cysts
Dr/AHMED ESAWY

Patent urachus
It has been associated to structural anomalies are:
Anterior abdominal wall defects,
Bladder exstrophy and
Other lesions of the cord :hemangioma, varix, true knot, allantoic or
omphalomesenteric cysts.
Dr/AHMED ESAWY

Angiomyxoma
heterogeneous masses
Dr/AHMED ESAWY

True cord knots are associated with
• Advanced maternal age.
• Multiparity.
• Previous miscarriages.
• Obesity.
• Prolonged gravidity.
• Male fetus.
• Long cord.
• Maternal anemia.
• Maternal chronic hypertension.
• Hydramnios. Dr/AHMED ESAWY

Ocasionally, a bunch of cord loops make the false
impression of a cord knot like in this following
case with 3D reconstruction
Dr/AHMED ESAWY

Cord bleeding associates
• Cysts and pseudocysts
• Patent urachus
• Hematoma
• Aneurysm
• Hemangioma
• Teratoma
• Angiomyxoma
• Intestinal polyp
Dr/AHMED ESAWY

Nuchal cord loops
Type A - nuchal loop that encircles the neck in a freely sliding
pattern
Type B - nuchal loop that encircles the neck in a locked pattern
Dr/AHMED ESAWY

Nuchal Cord
• One or more complete loops of UC around fetal neck.
• Diagnosis best by: Doppler US and 3D ultrasound
• Recommendations~
– Look for vascular compromise (S/D ratio)
– Fetal growth and movement, amniotic fluid
• D/D
– Cord adjacent to neck
– Cystic hygroma
Dr/AHMED ESAWY

Pathogenesis of Nuchal Cords
• Unclear.
• fetal movements .
• Excessive fetal movement and long umbilical cords .
Dr/AHMED ESAWY

Incidence of Nuchal Cords
• Ranges between 15.8% and 30%.
• Nuchal cords may reduce spontaneously.
Dr/AHMED ESAWY

Perinatal Outcome
• Fetal bradycardia and variable decelerations
• Umbilical artery acidemia
• Metabolic acidemia was infrequent
Dr/AHMED ESAWY

Perinatal Outcome
multiple nuchal cords were more likely to have
– Meconium-stained amniotic fluid
– Intrapartum fetal heart rate changes
– Operative vaginal delivery
– Low 1 minute Apgar scores
– Mild umbilical artery acidosis at birth
Dr/AHMED ESAWY

Ultrasonography of the
Umbilical Cord
• Traditionally not performed uniformly
Dr/AHMED ESAWY

Ultrasonography of nuchal cords
• Requires a high-degree of suspicion.
• fixed point.
• high-resolution ultrasound with the “divot” sign representing
circular indentations of the fetal nuchal.
• D.D :
posterior cystic masses, folds of skin or amniotic fluid pockets,
with the “divot” sign.
Dr/AHMED ESAWY

Ultrasonography of Nuchal Cords
• color Doppler imaging.
• Both sagittal and axial
• .
• Doppler flow velocimetry may be applied to confirm
diagnosis.
• 3D ultrasound may improve prenatal diagnosis.
Dr/AHMED ESAWY

Nuchal cord or Umbilical cord
around fetal neck
Dr/AHMED ESAWY

nuchal cord entanglement
Dr/AHMED ESAWY

abdomen or the lower lims
Dr/AHMED ESAWY

Multiple cord loops are also a frequent event.
quintuple nuchal cord entanglement.
Dr/AHMED ESAWY

Some cords seem entangled but they are not,
and they are called draped around the neck
Dr/AHMED ESAWY

Single Nuchal Cord
(sagittal view)
Dr/AHMED ESAWY

Single Nuchal Cord
(color Doppler, sagittal view)
Dr/AHMED ESAWY

Single Nuchal Cord
(color Doppler, axial view)
Dr/AHMED ESAWY

Double Nuchal Cord
(sagittal view)
Dr/AHMED ESAWY

Double Nuchal Cord
(color Doppler, sagittal view)
Dr/AHMED ESAWY

Double Nuchal Cord
(color Doppler, axial view)
Dr/AHMED ESAWY

Doppler Flow Velocimetry of
Nuchal Cord
• Potential waveform abnormalities include:
– systolic notching of the umbilical artery waveform.
– poststenotic acceleration of umbilical vein flow.
– absent end diastolic flow (reported with nuchal cord).
Dr/AHMED ESAWY

Doppler Velocimetry of
Nuchal Cord
Dr/AHMED ESAWY

3D Ultrasound
Single Nuchal Cord
Dr/AHMED ESAWY

3D Ultrasound
Double Nuchal Cord
Dr/AHMED ESAWY

3D Ultrasound
Triple Nuchal Cord
Dr/AHMED ESAWY

Persistent RT Umbilical Vein
• May replace the L UV,
or coexist with L UV
• Lateral to GB
• Curves towards ST
• Mixed accounts of prognosis
• Look for anatomic abnormalities
• In isolation, prognosis good
Dr/AHMED ESAWY

Umbilical Cord Problems
Cord Cyst Nuchal Cord
Dr/AHMED ESAWY

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Dr/AHMED ESAWY

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Dr/AHMED ESAWY

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