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Case 301

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Primigravid patient, 35 years old, at 35 weeks’ gestation with normal pregnancy course, did a obstetric ultrasound examination, which is represented by images 1 and 2. Two weeks later, with 37 weeks’ gestation, a new obstetric ultrasonography was made, which its images showed in images 3 and 4. Fetal heartbeats were present at a regular frequency.

According to the clinical case and the images available, the correct diagnosis and its management are:

a) Multiple umbilical cord loops, with no indication for cesarean delivery

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b) Umbilical cord procidency, which constitutes an indication for labor induction

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c) Velamentous cord insertion with medical indication for urgent cesarean delivery

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d) Multiple umbilical cord loops, with indication for cesarean delivery

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Image Analysis

Image 1: Fetal ultrasonography, axial section, at 35 weeks’ gestation, with color Doppler, showing a double vascular contour (green arrow). The yellow arrow shows a cervical portion of fetal spinal canal.

 

Image 2: Fetal ultrasonography, longitudinal section, at 35 weeks’ gestation, with color Doppler, showing a double vascular contour (green arrow), below the skull base (yellow arrow).

 

Image 3: Fetal ultrasonography, axial section, at 37 weeks’ gestation, with color Doppler, showing a triple vascular contour (green arrow) at cervical level (yellow arrow).

 

Image 4: Fetal ultrasonography, longitudinal section, at 37 weeks’ gestation, with color Doppler, showing a triple vascular contour (green arrow), below the skull base (yellow arrow).

Highlights

- Umbilical cord loops can be single or multiple around the neck (nuchal cord) and its can be loose or tight (i.e. compressing the fetal neck)

- A nuchal cord be can be of two types: type I (a)- can spontaneously unwind; and type II (b) which cannot spontaneously unwind (locking type), with the first most related with spontaneous resolution.

- The umbilical cord loops seems to be a random event, most commonly happening in fetus with excessive movements and a long cord.

- The loops can be done at any gestational age, but it seems to be more common at term;

- Its incidence at term varies between 15-34% of births, 90% of which are single;

- The prenatal diagnosis is ultrasonograhic, showing that at least 75% of cervical region is involved by the umbilical cord.

References

- Schaffer L, Zimmermann R. Nuchal cord. UpToDate 2017. [Acesso em dezembro de 2017]. Available from: https://www.uptodate.com/contents/nuchal-cord.

- Rezende J, Montenegro CAB. Obstetrícia fundamental. 11ª ed. Rio de Janeiro: Guanabara Koogan, 2008.

- Hutchon DJR. Management of the Nuchal Cord at Birth. J Midwifery Reprod Health 1: 4-6, 2013.

Author

Wellerson Mayrink de Paula Junior, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: wmpjr110196[at]gmail.com

Supervisor

Drª Raquel Waleska dos Santos, specialized in Fetal Medicine and coordinator of its Residence Service and of the Ultrasonography Sector in Gynecology and Obstetrics of Hospital das Clínicas da UFMG.

E-mail: wsraquel[at]gmail.com

Reviewers

Ricardo Mazilão, Lucas Raso, Thiago Ruiz, Rafael Valério, Profa. Viviane Parisotto Marino

Translated by

Eduardo José Paolinelli Vaz de Oliveira, 6th year medical student at Universidade Federal de Minas Gerais.

Email: eduardopaolinelli[at]gmail.com

Test question

(Public tender for Administrative Technical Servants - 2011 - Obstetrical Physician Position - Lauro Wanderley University Hospital / ADAPTED) Caesarean is still frequently practiced in an abusive manner, while the forceps have been less used. Regarding cesarean operation and forceps, it is INCORRECT to state that:

a) The main maternal indications for the use of forceps are: heart disease, pulmonary involvement, some neurological conditions, exhaustion, failure to progress and prolonged delivery.

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b) There are several indications of cesarean section. Among them, we can mention: umbilical cord prolapse, uterine rupture imminence, functional dystocia, anomalous presentations, placenta previa total center and circular cord diagnosed by ultrasonography.

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c) Although the cesarean section is considered a low risk and safe procedure, it is not risk free, since it can cause from urological lesions, infections, to maternal death.

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d) Placental acretism, placenta previa, chronic pelvic pain are possible complications in pregnant women with previous cesarean sections.

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e) The maternal conditions for applicability of the forceps include: completely dilated cervix, purse of the route water, and the middle and lower narrows compatible with cephalic volume. The fetal conditions are: alive concept, insinuated head and normal cephalic volume.

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