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13-umblical cord imaging Dr Ahmed Esawy

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13 umblical cord imaging dr ahmed esawy
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
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
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.
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

Veröffentlicht in: Gesundheit & Medizin
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13-umblical cord imaging Dr Ahmed Esawy

  1. 1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
  2. 2. Dr. Ahmed Esawy MBBS M.Sc MD Dr/AHMED ESAWY
  3. 3. Umblical cord imagingDr/AHMED ESAWY
  4. 4. Double bleb. Dr/AHMED ESAWY
  5. 5. Vitelline duct. Dr/AHMED ESAWY
  6. 6. Early coiled umbilical cord. Dr/AHMED ESAWY
  7. 7. • 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. umbilical cord prolapse . Dr/AHMED ESAWY
  14. 14. umbilical cord prolapse Dr/AHMED ESAWY
  15. 15. cord prolapse Dr/AHMED ESAWY
  16. 16. Cord presentation. Dr/AHMED ESAWY
  17. 17. Abnormal number of vessels Dr/AHMED ESAWY
  18. 18. 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
  19. 19. shows all the reported structural anomalies associated with single umbilical artery Dr/AHMED ESAWY
  20. 20. Dr/AHMED ESAWY
  21. 21. The normal umbilical cord with three vessels Dr/AHMED ESAWY
  22. 22. Dr/AHMED ESAWY
  23. 23. Single umbilical artery. Dr/AHMED ESAWY
  24. 24. SIJA, nuchal cord, and omphalocele. Dr/AHMED ESAWY
  25. 25. SUA and multicystic dysplastic kidney. Dr/AHMED ESAWY
  26. 26. one umbilical artery and an umbilical vein within this cord. Dr/AHMED ESAWY
  27. 27. SUA multiple other anomalies, and an allantoic cyst. Dr/AHMED ESAWY
  28. 28. Single umbilical artery (SUA) or 2 vessel umbilical cord: Dr/AHMED ESAWY
  29. 29. Single umbilical artery (SUA) or 2 vessel umbilical cord: Dr/AHMED ESAWY
  30. 30. Normal 3 vessel umbilical cord: Dr/AHMED ESAWY
  31. 31. One vein & 3 arteries Dr/AHMED ESAWY
  32. 32. 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
  33. 33. omphalomesenteric duct Dr/AHMED ESAWY
  34. 34. 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
  35. 35. Abnormal cord insertion Velamentous insertion of the cord vasa previa Dr/AHMED ESAWY
  36. 36. 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
  37. 37. Dr/AHMED ESAWY
  38. 38. Dr/AHMED ESAWY
  39. 39. Dr/AHMED ESAWY
  40. 40. Velamentous insertion of the cord 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
  41. 41. Dr/AHMED ESAWY
  42. 42. Dr/AHMED ESAWY
  43. 43. Be aware that flash artifacts resulting from fluid motion from the fetus may mimic the presence of vasa previa Dr/AHMED ESAWY
  44. 44. Marginal cord insertion. Dr/AHMED ESAWY
  45. 45. II-Abnormal course or connection of vessels Ductus venosus agenesis Dr/AHMED ESAWY
  46. 46. Ductus venosus agenesis 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
  47. 47. Dr/AHMED ESAWY
  48. 48. 3 ductal agenesis, with the umbilical vein joining directly to the inferior vena cava Dr/AHMED ESAWY
  49. 49. type 6 ductal agenesis, with the umbilical vein joining directly into the right atrium Dr/AHMED ESAWY
  50. 50. Persistent right umbilical vein Dr/AHMED ESAWY
  51. 51. Replaced umbilical artery to the superior mesenteric artery Dr/AHMED ESAWY
  52. 52. III-Abnormal structure or configuration of vessels Dr/AHMED ESAWY
  53. 53. Hypoplastic umbilical artery Placental pathology . Polyhydramnios. Congenital heart disease. Fetal growth restriction. Stillbirth. Trisomies Dr/AHMED ESAWY
  54. 54. Segmental thinning of umbilical cord vessels Dr/AHMED ESAWY
  55. 55. Umbilical cord constriction Amniotic bands. Nuchal loops. True knots . Fetal grasping Entanglement in monoamniotic twins Cord presentation and occult prolapse Dr/AHMED ESAWY
  56. 56. Umbilical Cord Aneurysm (UCA) • UV varix (UV > 9mm) • UA aneurysm Dr/AHMED ESAWY
  57. 57. Dr/AHMED ESAWY
  58. 58. Dr/AHMED ESAWY
  59. 59. 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
  60. 60. Meconium pseudocyst Dr/AHMED ESAWY
  61. 61. Umbilical vein varix Dr/AHMED ESAWY
  62. 62. 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
  63. 63. Umbilical vein varix Dr/AHMED ESAWY
  64. 64. Umbilical vein varix Dr/AHMED ESAWY
  65. 65. Focal varices of the umbilical cord simulating a knot (false knot). Dr/AHMED ESAWY
  66. 66. Umbilical Vein Varix (small) Dr/AHMED ESAWY
  67. 67. intra-abdominal umbilical vein varix Dr/AHMED ESAWY
  68. 68. Fetal intra-abdominal umbilical vein varix Dr/AHMED ESAWY
  69. 69. Umbilical vein varix Dr/AHMED ESAWY
  70. 70. Abnormal cord coiling Dr/AHMED ESAWY
  71. 71. Normal coiling of the umbilical cord Dr/AHMED ESAWY
  72. 72. Umbilical cord coiling. (a)normally coiled umbilical cord (b)(b) noncoiled umbilical cord. Dr/AHMED ESAWY
  73. 73. 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
  74. 74. • 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
  75. 75. Non-coiled cords and poorly coiled cords Dr/AHMED ESAWY
  76. 76. Hypocoiled umbilical cord Dr/AHMED ESAWY
  77. 77. hypocoiling of umbilical cord Dr/AHMED ESAWY
  78. 78. • 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
  79. 79. Hyper-coiled cords Dr/AHMED ESAWY
  80. 80. Abnormal cord length Dr/AHMED ESAWY
  81. 81. 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
  82. 82. Short cords • Defined as total length of 40 cm or less, short umbilical cords are uncommon. Dr/AHMED ESAWY
  83. 83. • 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
  84. 84. 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
  85. 85. • 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
  86. 86. 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
  87. 87. 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
  88. 88. 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
  89. 89. examples of first trimester cord cysts Dr/AHMED ESAWY
  90. 90. 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
  91. 91. Angiomyxoma heterogeneous masses Dr/AHMED ESAWY
  92. 92. 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
  93. 93. 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
  94. 94. Dr/AHMED ESAWY
  95. 95. Cord bleeding associates • Cysts and pseudocysts • Patent urachus • Hematoma • Aneurysm • Hemangioma • Teratoma • Angiomyxoma • Intestinal polyp Dr/AHMED ESAWY
  96. 96. Nuchal Cords Dr/AHMED ESAWY
  97. 97. 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
  98. 98. 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
  99. 99. Pathogenesis of Nuchal Cords • Unclear. • fetal movements . • Excessive fetal movement and long umbilical cords . Dr/AHMED ESAWY
  100. 100. Incidence of Nuchal Cords • Ranges between 15.8% and 30%. • Nuchal cords may reduce spontaneously. Dr/AHMED ESAWY
  101. 101. Perinatal Outcome • Fetal bradycardia and variable decelerations • Umbilical artery acidemia • Metabolic acidemia was infrequent Dr/AHMED ESAWY
  102. 102. 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
  103. 103. Ultrasonography of the Umbilical Cord • Traditionally not performed uniformly Dr/AHMED ESAWY
  104. 104. 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
  105. 105. 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
  106. 106. Dr/AHMED ESAWY
  107. 107. Nuchal cord. Dr/AHMED ESAWY
  108. 108. Nuchal cord or Umbilical cord around fetal neck Dr/AHMED ESAWY
  109. 109. nuchal cord entanglement Dr/AHMED ESAWY
  110. 110. abdomen or the lower lims Dr/AHMED ESAWY
  111. 111. Multiple cord loops are also a frequent event. quintuple nuchal cord entanglement. Dr/AHMED ESAWY
  112. 112. Some cords seem entangled but they are not, and they are called draped around the neck Dr/AHMED ESAWY
  113. 113. Single Nuchal Cord (sagittal view) Dr/AHMED ESAWY
  114. 114. Single Nuchal Cord (color Doppler, sagittal view) Dr/AHMED ESAWY
  115. 115. Single Nuchal Cord (color Doppler, axial view) Dr/AHMED ESAWY
  116. 116. Single Nuchal Cord (color Doppler, axial view) Dr/AHMED ESAWY
  117. 117. Single Nuchal Cord (color Doppler, axial view) Dr/AHMED ESAWY
  118. 118. Double Nuchal Cord (sagittal view) Dr/AHMED ESAWY
  119. 119. Double Nuchal Cord (color Doppler, sagittal view) Dr/AHMED ESAWY
  120. 120. Double Nuchal Cord (color Doppler, axial view) Dr/AHMED ESAWY
  121. 121. Double Nuchal Cord (color Doppler, axial view) Dr/AHMED ESAWY
  122. 122. 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
  123. 123. Doppler Velocimetry of Nuchal Cord Dr/AHMED ESAWY
  124. 124. Doppler Velocimetry of Nuchal Cord Dr/AHMED ESAWY
  125. 125. Doppler Velocimetry of Nuchal Cord Dr/AHMED ESAWY
  126. 126. 3D Ultrasound Single Nuchal Cord Dr/AHMED ESAWY
  127. 127. 3D Ultrasound Double Nuchal Cord Dr/AHMED ESAWY
  128. 128. 3D Ultrasound Triple Nuchal Cord Dr/AHMED ESAWY
  129. 129. 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
  130. 130. Umbilical Cord Problems Cord Cyst Nuchal Cord Dr/AHMED ESAWY
  131. 131. • References • 1 Fox H. Pathology of the Placenta. London: W.B. Saunders 1978, pp.426-57. 2 Blazer S, Sujov P, Escholi Z, Itai BH, Bronshtein M. Single umbilical artery--right or left? does it matter? Prenat Diagn 1997 Jan;17(1):5-8. 3 Benirschke K, BourneGL. The incidence and prognostic implication of congenital absence of one umbilical artery. Am J Obstet Gynecol 1960; 79: 251-3. 4 Heifetz SA. Single Umbilical Artery. A statistical analyses of 237 autopsy cases and review of the kiterature. Perspect Pediatr Pathol 1984; 8: 345-78. 5 Lilja M. Infants with single umbilical artery studied in a national registry: general epidemiological characteristics. Paediatr Perinat Epidemiol 1991; 5: 27-36. 6 Saller DN Jr, Keen CL, Sun CC, Schwartz S. The association of single umbilical artery with cytogenetically abnormal pregnancies. 7 Clausen I. Umbilical cord anomalies and antenatal fetal demise. Obstet Gynecol Surv.1989; 44: 841-5. 8 Chow JS, Benson CB, Doubilet PM. Frequency and nature of structural anomalies in fetuses with single umbilical arteries. J Ultrasound Med 1998 Dec;17(12):765-8. 9 Thumala MR, Raju TN, Langemberg P. Isolated single artery anomaly and the risk of congenital malformations: a metaanalysis. J Pediatr Surg 1998; 33: 580-5. 10 Weissman A, Drugan A. Sonographic findings of the umbilical cord: implications for the risk of fetal chromosomal anomalies. Ultrasound Obstet Gynecol 2001 Jun;17(6):536-41. 11 Pavlopoulos PM, Konstantinidou AE, Agapitos E, Christodoulou CN, Davaris P. Association of single umbilical artery with congenital malformations of vascular etiology. Pediatr Dev Pathol 1998 Nov-Dec;1(6):487-93. 12 Scalercio F, Ferraro M, Mastrantonio P, Scalercio A. Single umbilical artery (SUA) and congenital eye abnormalities. 2 case reports. Minerva Pediatr 1998 Apr;50(4):141-4. 13 Meizner I, Sherizly I, Mashiach R, Shalev J, Kedron D, Ben-Rafael Z. Prenatal sonographic diagnosis of laryngeal atresia in association with single umbilical artery. J Clin Ultrasound 2000 Oct;28(8):435-8. Dr/AHMED ESAWY
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