T IP A RAŞTIRMALARI A RŞİVİ

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C A S E R E P O R T

T ^IP A RAŞTIRMALARI A ^RŞİVİ

VOLUME 2 • NUMBER 1 • SEPTEMBER 2017

A B S T R A C T

True knot of the umbilical cord is a rare event. Prenatal identification of a true knot is rare and challenging. Although it is a rare event, it may lead to fetal demise, in this case report we present a case with a 39^th week fetal demise because of a true umbilical cord knot. 35-year old woman G2P1, at 39^th week of her pregnancy, admitted to emergency service. She had the complaint of not feeling the baby kicks for two days. After the vaginal birth of 3120 gr ex male fetus, it was discovered that the ex-baby did not have any gross anomalies other than having a true umbilical cord knot that did not let the blood flow beyond the knot. True knot of the umbilical cord occurs rarely, but it is important to diagnose it prenatally that may lead to fetal demise which occurs also rarely.

Key Words: Umbilical cord, fetal demişe, true knot

Ö Z E T

Umblikal korddaki gerçek düğüm nadir bir vakadır. Gerçek düğümün prenatal tespiti nadir ve zorludur. Nadir bir vaka olmasına karşın fetal kayıba yol açabilir. Bu olgu sunumunda gebeliğin 39. haftasında gerçek umbilikal kord düğümüne bağlı fetal kayıp anlatıldı. 35 yaşında G2P1, 39 haftalık gebe acil servise başvurdu. 2 gündür bebek hareketlerini hissedememe ile başvurdu.

Fetal kayıp tanısı sonrası, doğumhanede 3120 gr ex-erkek bebek doğumu gerçekleşti. Doğum sonrası kan akışını engelleyen umbilikal korddaki gerçek düğüm dışında ek anomali saptanmadı.

Umbilikal korddaki gerçek düğüm ender gözlenir, ancak gebelik kaybına yol açabileceğinden prenatal tespiti önem arz eder.

Anahtar Kelimeler: Umbilikal kord, gerçek düğüm, fetal kayıp

INTRODUCTION

True knot of the umbilical cord is a rare event (0.3-2.1%) [1,2]. It is a difficult situation to diagnose antenatally, even with the help of the ultrasound [3].

Prenatal identification of a true knot of the umbilical cord is rare and challenging [3-6].

The ultrasonographic appearance has been described as similar to a four-leaf clover, but this pattern is nonspecific and can be seen with false knots or closely apposed loops of umbilical

cord [3]. Use of color Doppler ultrasound, particularly three-dimensional power Doppler imaging [7], may support the suspected diagnosis.

Although true knot of the umbilical cord is a rare event it may lead to fetal demise, in this case report we present a case with a 39th week fetal demise because of a true umbilical cord knot.

Case report

A 35-year old woman G2P1, at 39th week of her pregnancy, admitted to emergency service.

She had the complaint of not feeling the baby

True Knot of the Umbilical Cord Leading to Third Trimester Fetal Demise

Üçüncü Trimester Fetal Kayıba Yol Açan Umbilikal Korddaki Gerçek Düğüm

Görker Sel

Bartın Devlet Hastanesi, Kadın Doğum Kliniği, Bartın, Türkiye

Email: [email protected]

Geliş Tarihi / Received: 04.09.2017, Kabul Tarihi/Accepted: 30.09.2017 Doi: 10.5799/10.5799/ahinjs.03.2017.01.010

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True Knot of the Umbilical Cord

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kicks for two days. Obstetric ultrasound performed and diagnosed the fetal demise, amniotic fluid index (AFI) was at normal range.

Her pregnancy records were investigated, which were uneventful, such as normal triple test, normal oral glucose tolerance test 50 gr, normal ultrasound findings with normal AFI, reactive non- stress test which was recorded 1 week ago, and vital signs were normal at her previous visits.

After the vaginal birth of 3120 gr ex male fetus, it was discovered that the ex-baby did not have any gross anomalies other than having a true umbilical cord knot that did not let the blood flow beyond the knot (Fig.1). The length of the umbilical cord was 52 cm, which was at normal range. Placenta and fetus were examined by the pathologist and did not reveal any other pathology other than the true umbilical cord knot, also thrombosis and ischemia were detected at that umbilical cord level.

Figure 1. True umbilical knot

DISCUSSION

True knots occur in 1 percent of births and are generally single and loose [1]. However, tight (Figure 1) or multiple true knots and knots associated with coiling or twisting of the cord, increase the risk of intrauterine demise, if the cord is long and during the second trimester when the fetus has a lot of room to move. The medical record should document the presence of a true knot, which is hard to discover prenatally, the tightness or laxity of the knot, the presence of unilateral edema of the cord relative to the knot, and whether there are thrombi in the vessels.

It is believed that true knots of the cord are formed between 9–12 weeks’ gestation, a period with relatively large amount of

amniotic fluid but on the other hand some evidence for knot formation during labor also exists [8].

In this case although the patient’s medical records were uneventful, intrauterin fetal demise was occurred, because of the true knot of the umbilical cord, which was not discovered prenatally. When she admitted to emergency service, after we found that it was the case of a fetal demise, we could not find out the umbilical cord knot with the ultrasound, since it was not at first importance at that time after detecting the fetal demise.

True knot of the umbilical cord occurs rarely, but it is important to diagnose it prenatally that may lead to fetal demise which occurs also rarely.

We present this case because, fetal demise at the third trimester of pregnancy because of true knot of the umbilical cord is a rare event

Conflict of Interests: The authors declare that they have no conflict of interest.

Financial Disclosure: No financial support was received.

REFERENCES

1. Spellacy WN, Fisch GRO. The umbilical cord complications of true knots, nuchal coils, and cord around the body. Am J Obstet Gynecol.1966;94:1136–42.

2. Blickstein I, Schwatz ZS. Lancet Predisposing factors in the formation of the umbilical cord-analysis of morphometric and perinatal data. Int J Gynaecol Obstet. 1987;25:395–8.

3. Sepulveda WAH, Bower SS, Nicolaides P, Fisk NM. True knots of the umbilical cord: a difficult prenatal ultrasonographic diagnosis Ultrasound Obstet Gynecol. 1995;5:106–8.

4. Cajal RY, Martínez RO. Prenatal diagnosis of true knot of the umbilical cord. Ultrasound Obstet Gynecol. (2004);23:99.

5. Gembruch U, Baschat AA. True knot of the umbilical cord: transient constrictive effect to umbilical venous blood flow demonstrated by Doppler sonography. Ultrasound Obstet Gynecol. 1996;8:53.

6. Collins JH. First report: prenatal diagnosis of a true knot. Am J Obstet Gynecol 1991;165:1898.

7. Hasbun J, Alcalde JL, Sepulveda W. Three-dimensional power Doppler sonography in the prenatal diagnosis of a true knot of the umbilical cord:

value and limitations. J Ultrasound Med. 2007;26:1215.

8. Maher JT, Conti JA. A comparison of umbilical cord blood gas values between newborns with and without true knots. Obstet Gynecol.

1996;88:863–6.