Management of nuchal cord with multiple loops.

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Management of nuchal cord with multiple loops.

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Management of nuchal cord with multiple loops.

  1. 1. Management of Nuchal Cord fetal breathing, normal fetal movements, normal fetal tone, and normal volume of amniotic fluid). Multiple nuchal cordWith Multiple Loops loops (at least three to four loops) were identified during the ultrasound examination with Doppler (Fig. 1A and B). Labor induction was discussed with the patient, and sheYan Wang, MD, MSc, Camille Le Ray, MD, MSc, agreed with the decision, knowing that the risk of cesareanFrançois Audibert, MD, MSc, and delivery was increased. An endocervical two-way 18Marie-Soleil Wagner, MD, MSc, FRCSC French Foley catheter (Silkolatex Rusch Gold, Rusch Inc, Cinnamonson. NJ) with a 50-mL balloon was used forBACKGROUND: Nuchal cords are rarely associated with cervical preparation concomitantly with an intravenoussignificant neonatal morbidity or mortality. oxytocin infusion. Six hours later, abnormal fetal heart rate pattern was identified, consisting of moderate to severeCASE: A primigravida with a normal term pregnancy pre- variable decelerations, which became gradually late andsented for diminished fetal movement. Several nuchal cord prolonged. The cervical dilation was 5 cm, and, because ofloops were found on the ultrasound imaging, with normal a high cephalic fetal presentation, it was impossible toDoppler findings. Abnormal fetal heart rate pattern ap- perform an amniotomy. It was decided to perform a cesar-peared after 6 hours of labor. A cesarean delivery was ean delivery, and the patient’s consent was obtained. Aperformed. A healthy baby was born with eight nuchal cord transverse lower segment cesarean delivery was performedloops. under epidural anesthesia with no complications. TheCONCLUSION: The management of nuchal cord with asingle loop, suspected before delivery, seems clear: itshould not influence the clinical management. However, inthis case, the previous knowledge of multiple nuchal loopsmay have influenced our decision to perform a cesareandelivery.(Obstet Gynecol 2008;112:460–1)I t is well known that the fetal umbilical cord can become coiled around the fetal body parts, especiallyaround the neck. From 1,007 consecutive deliveries,Shui et al report an incidence of nuchal cord that rangedfrom a single loop in 21% of cases to three loops in 0.2%of cases.1 Many retrospective studies conclude thatnuchal cords are rarely associated with significant neo-natal morbidity or mortality.2,3 We report a case of ahealthy term baby born with eight nuchal cord loops.CASEA 36-year-old primigravida presented for diminished fetalmovement at 40 weeks of gestation. Her pregnancy hadbeen normal, including normal ultrasound examinations at12 weeks and 20 weeks. A nonstress test was done and wasnonreactive. A fetal biophysical profile then was performedwith a score of 6/10 (nonreactive nonstress test, abnormalFrom the Department of Obstetrics and Gynecology, University of Montreal, St. ´Justine Hospital, Montreal, Quebec, Canada. ´ ´Corresponding author: Marie-Soleil Wagner, MD, MSc, FRCSC AssistantClinical Professor, Department of Obstetrics and Gynecology, University ofMontreal, St. Justine Hospital, 3175 Chemin Cote-Ste-Catherine, Montreal, ´ ˆ ´Quebec, Canada, H3T 1N4; e-mail: marie-soleil.wagner.hsj@ssss.gouv.qc.ca. ´ Fig. 1. A. Ultrasound examination identified at least three toFinancial Disclosure four loops (the bubbly image indicated by the white arrow).The authors have no potential conflicts of interest to disclose. B. Doppler images showed cord with multiple loops around© 2008 by The American College of Obstetricians and Gynecologists. Published the fetal neck. Colored blood flow is indicated by the whiteby Lippincott Williams & Wilkins. arrow.ISSN: 0029-7844/08 Wang. Nuchal Cord With Multiple Loops. Obstet Gynecol 2008.460 Wang et al Nuchal Cord With Multiple Loops OBSTETRICS & GYNECOLOGY
  2. 2. amniotic fluid was clear. Eight tight nuchal cord loops were multiple loops was the main factor accounting for theobserved (type A, unlocked pattern). The newborn was higher incidence of these complications. The pres-male with a weight of 2,650 grams and Apgar scores of ence of a nuchal cord and the number of loops were9-9-9 at 1, 5, and 10 minutes, respectively. The cord blood not associated with a significant difference in perinatalgas values were 7.29 for the arterial pH, 44.1 for the PCO 2, mortality. However, in the case of the three perinataland -5.3 for the base excess. The umbilical cord wasnormally structured with one vein and two arteries; how- deaths that occurred in the multiple loops group, theever, the length was increased (106 cm reported by the final presence of nuchal cord was the only explanationpathology). Both the patient and her baby had a good found for these deaths. Also, the three deaths oc-evolution and were discharged on postoperative day four, curred in women reporting reduced fetal movementas usual in our institution. at term. Moreover, another study suggests that some types of nuchal cord, such as those that are extremelyCOMMENT tight or have multiple loops, may be associated with aThe obstetrical management of nuchal cord with a subclinical deficit neurodevelopmental performancesingle loop, suspected before delivery, seems clear: it at 1 year of age.8 Retrospectively in our case, where the diagnosisshould not influence the clinical management. How- of multiple loops (at least three or four) was nearlyever, the management of nuchal cord with multiple certain, one could argue that an elective cesareanloops is more controversial. delivery would have been appropriate. However, the In the literature, the detection rate of nuchal cord final outcome of this case probably would not havebefore labor varies according to the different studies, been different. It is likely that the previous knowledgewith a sensitivity of ultrasound and color Doppler of multiple nuchal loops influenced our decision toimaging to detect a nuchal cord between 38% and perform a cesarean delivery.79%.4,5 Using color Doppler ultrasound imaging im-proved the prenatal detection of nuchal cord.5 How-ever, the sensitivity was higher when there was more REFERENCES 1. Shui KP, Eastman NJ. Coiling of the umbilical cord around thethan one loop present.4 In a large retrospective study foetal neck. J Obstet Gynaecol Br Emp 1957;64:227–8.including 8,565 deliveries, the presence of nuchal 2. Mastrobattista JM, Hollier LM, Yeomans ER, Ramin SM, Daycord was associated with more abnormal fetal heart MC, Sosa A, et al. Effects of nuchal cord on birthweight andrate pattern (moderate or severe variable decelera- immediate neonatal outcomes. Am J Perinatol 2005;22:83–5.tions), more meconium staining, a lower birth weight, 3. Hankins GD, Snyder RR, Hauth JC, Gilstrap LC 3rd, Hammond T. Nuchal cords and neonatal outcome. Obstet Gynecolmore umbilical artery pH 7.10 or less, lower 1- 1987;70:687–91.minute Apgar scores, and more forceps deliveries.6 4. Jauniaux E, Mawissa C, Peellaerts C, Rodesch F. Nuchal cordAlso, in the subgroup with four loops, there was more in normal third-trimester pregnancy: a color Doppler imagingvariable and late decelerations, more meconium study. Ultrasound Obstet Gynecol 1992;2:417–9.staining, and more forceps deliveries or cesarean 5. Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection ofdeliveries compared with the subgroup with two to nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005;25:160–4.three loops. In the same way, a retrospective case- 6. Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiplecontrol study including 550 fetuses with a nuchal cord nuchal cord entanglements and intrapartum complications.at delivery showed a significantly higher incidence of Am J Obstet Gynecol 1995;173:1228–31.1-minute Apgar score of less than 7, meconium- 7. Jauniaux E, Ramsay B, Peelaerts C, Scholler Y. Perinatalstained amniotic fluid, emergency cesarean delivery, features of pregnancies complicated by nuchal cord. Am J Perinatol 1995;12:255–8.need for neonatal resuscitation, and admission to 8. Clapp JF 3rd, Lopez B, Simonean S. Nuchal cord and neuro-neonatal intensive care unit in the nuchal cord group developmental performance at 1 year of age. J Soc Gynecolcompared with the control group.7 Nuchal cord with Investig 1999;6:268–72.VOL. 112, NO. 2, PART 2, AUGUST 2008 Wang et al Nuchal Cord With Multiple Loops 461

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