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The West London Medical Journal 2014 Vol 6 No 1 pp 45-50

PLACENTAL CORD INSERTION ABNORMALITY, A


CAUSE FOR ASSYMETRICAL IUGR WITH PIH
Ravpreet Kaur

Uttam Sapkal

ABSTRACT
The incidence of velamentous insertion of the umbilical cord is about 1%
in singleton pregnancies. Prevalence of velamentous insertion of the umbilical
cord is approx 0.22% worldwide.
Prenatal diagnosis of velamentous insertion of the umbilical cord is of
practical importance since unsupported vessels in the amnion may be
lacerated at the time of membrane rupture. Failure to diagnose ruptured
vessels can lead to fetal death. This mode of insertion occurs much more
frequently with multi-foetal pregnancies.
We present a case of 32 yrs old women who presented with amennorrhoea
for 8 months. With history of previous first trimester abortion, she was found
to be of 34 weeks gestational age, clinically. USG revealed fundo-posterior
right lateral grade 3 placenta with no retroplacental clot or infarction.
Biophysical profile score was 6-8 and Doppler showed uteroplacental &
foetoplacental insufficiency. Emergency caesarean section was done on
2/5/2013, which revealed placenta-cord to be thin with normal length but
cord insertion was 5cm away from placental margin. Female baby of 2kg
weight was delivered by vertex who cried immediately. APGAR score was 7
at birth and 8 after 5minutes. Newborn had no congenital anomalies.

KEYWORDS
Placental abnormality, IUGR, Gestational hypertension

CASE REPORT
A 32 yrs old lady presented to our unit with amenorrhea for 8 months,
appreciating fetal movements well. She was originally registered with her
family physician and had an USG done at 11 weeks .She did not have any
follow up ultrasound. Her obstetric history revealed past history of first
trimester spontaneous abortion at 12 weeks gestation followed by surgical
evacuation a little more than year ago. She had conceived 6 months post

Ravpreet Kaur, Resident year III, Dept of Obstetrics and Gynaecology, Peoples
Medical College and Hospital, Bhanpur, Bhopal, India.
Email: dr.ravpreet@gmail.com

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abortion. Pt was diagnosed to be a case of PIH and had been started on


methyldopa 2 weeks before her presentation to our unit. She also complained
of pedal oedema for last two weeks. On further evaluation of her menstrual
history, she had regular painless menstrual cycles 3-4 days every 30 days with
average flow. Her menstrual age from history was 35 weeks and 6 days,
On clinical examination, she was found to be normal weight for height
with mild pedal oedema. Her BP was 130/90 mmHg, fundus was normal. Per
abdomen uterus was 34 wks, relaxed, Vertex right occipito anterior head was
fixed. Liquor was less for period of gestation. Fetal heart rate was 146 beats
per minute, regular. Clinical gestational age was 34 weeks. Symphasis fundal
height was 34 cms.
Biophysical Profile score was 6-8. On local examination there was no
vulval edema or varicosities, no leak or pv bleed. On per vaginum
examination cervix was soft, in mid position and os was closed, un-effaced
with head high up and floating. Pelvis was adequate with bishop score <6.
She was hospitalized and regular monitoring was started with strict input
output charting. She was instructed to rest in left lateral position & keep the
kick count. Counseling regarding diet & hygiene was done and warning signs
were explained in detail.
She was started on tablet methyldopa 500 mg three times a day & tablet
labetelol 100mg twice a day. Betamethasone 12 mg injection, total of two
doses were administered to the patient. IV antibiotics were also started.
Most of her blood investigations were normal with HIV, HBsAg and
VDRL being non reactive. FBC, U&E, LFT and Coagulation profile was all
within normal range
As per the ultrasound done at 11weeks by her family practitioner, her
gestational age was calculated as 35 weeks which was corresponding with
menstrual age. She had an USS done on admission which reported her mean
gestational age to be 33 weeks, expected fetal weight to be 2248 gms,
amniotic fluid index to be 7.8cm. Placenta was found to be fundo posterior
right lateral, grade 3 with no evidence of retroplacental clots or infarction.
Compared to findings of first USS, most recent showed a 3 week lag. There
was evidence of Uteroplacental & fetoplacental insufficiency in her Doppler
blood flow study, which showed end diastolic notch in uterine artery.
Reversal of flow was seen in umbilical artery. Resistive index & pulsatality
index value of umbilical artery and MCA was 0.48 & 0.66 and 0.56 & 0.79
respectively .
Based on the workup, in summary patient was 2nd gravida with first
abortion at 36wks of pregnancy, with mild Pregnancy induced hypertension,
unfavourable cervix, asymmetrical intra uterine growth retardation, mild
oligoamnois, abnormal biophysical profile & doppler blood flow study in
umbilical artery end diastolic notch.
Emergency LSCS under spinal anesthesia was done.

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PLACENTAL CORD INSERTION ABNORMALITY, A CAUSE FOR ASSYMETRICAL


IUGR WITH PIH

Intraoperatively Lower uterine segment not well formed.50-60 ml clear


liquor was there. Female Baby of 2kg weight was delivered by vertex who
cried immediately. APGAR SCORE was 7 at birth and 8 after 5minutes.
Newborn had no congenital anomalies. Placenta & membranes completely
delivered & were not adherent. Placenta was posterior on right side on body
of uterus. Cord was thin, normal length, cord insertion 5cm away from
placental margin. Placenta was Small size, 400gms with evidences of
Infarction. No retroplacental clot was seen. Subserous sessile posterior
3x3cm fibroid on left cornu was found showing no degenerative changes.
There was Evidence of endometriosis on posterior uterus & Bilateral ovarian
surface. Uterus was sutured in two layers. Confirming complete mop &
instrument counts, abdomen was closed in layers taking care of hemostasis.
There was average blood loss in procedure.
Breast feeding was established in 2hours of procedure. Postoperative day
one was uneventful. Day two, for complaint of dyspnoea, chest physician
reference was done & chest physiotherapy was given. Post operative days
3,4,&5 were uneventful. Oral antibiotics were given and tab amlovas 2.5 mg
twice daily was administered & BP monitoring was done for her. Stitch
removal was done on day7 & patient was discharged to stay along with baby
in Paediatric ward for 15days.

DISCUSSION
Early prenatal identification of velamentous insertion of the umbilical
cord is a desirable clinical goal since these pregnancies are at greater risk for
adverse perinatal outcome including FGR, preterm birth, congenital
anomalies, fetal distress and fetal bleeding.[1-7]
In approximately 99% of singleton pregnancies the umbilical cord inserts
either directly into the placental tissue or marginally on the placental edge.[1]
In the remaining 1% of cases the umbilical cord insertion is located away
from the placental mass, allowing a variable segment of umbilical vessels to
run between the membranes unsupported by Wharton's jelly. This condition,
known as velamentous insertion, has been associated with several obstetric
complications including fetal growth restriction (FGR), PIH, prematurity,
congenital anomalies, low Apgar scores, abortion, low birth weight,
premature delivery, fetal malformation, fetal hypoxia and intrauterine fetal
death and retained placenta[1-7]
In spite of the obvious importance of prenatal detection of velamentous
insertion of the umbilical cord in obstetric practice, only a few studies have
focused on the systematic identification of the placental cord insertion site
during prenatal ultrasound.[9-11]
It was noted that the use of color Doppler ultrasound enhanced umbilical
cord visualization even in difficult cases and, therefore, should be the
modality of choice to image the placental cord insertion site at routine
obstetric ultrasound. Nevertheless, we consider that ultrasound identification
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of the placental cord insertion site does not require additional skills, but it
should be performed in a systematic fashion in order to be useful for
screening velamentous insertion.

CONCLUSION
Placental Abnormalities are associated with reduced placental efficiency
but has been rarely reported day to day. Placental abnormalities are
associated with adverse pregnancy outcomes fetal growth restriction
(FGR),PIH, prematurity, congenital anomalies, low Apgar scores, abortion,
low birth weight, premature delivery, fetal malformation, fetal hypoxia and
intrauterine fetal death and retained placenta .[8] Timely diagnosis with
Transvaginal color Doppler imaging and serial scans were needed to identify
vasa previa routine sonography in the mid-trimester.
Or it can reliably be detected prenatally by gray-scale and color Doppler
ultrasound.

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IUGR WITH PIH

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