29/09/2021, 22:52 Anatomy, Abdomen and Pelvis, Umbilical Cord - StatPearls - NCBI Bookshelf

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Anatomy, Abdomen and Pelvis, Umbilical Cord

Marina Basta; Brody J. Lipsett.

Author Information
Last Update: July 31, 2021.

Introduction
The umbilical cord is considered both the physical and emotional attachment between mother
and fetus. This structure allows for the transfer of oxygen and nutrients from the maternal
circulation into fetal circulation while simultaneously removing waste products from fetal
circulation to be eliminated maternally. On the other hand, mothers associate an emotional
connection to the fetus through the cord. It may merit consideration as the route of love and care
during pregnancy. Thus, some poets call it the string of life. 

The umbilical cord is a bundle of blood vessels that develops during the early stages of
embryological development. It is enclosed inside a tubular sheath of amnion and consists of two
paired umbilical arteries and one umbilical vein. During development, the umbilical arteries have
a vital function of carrying deoxygenated blood away from the fetus to the placenta.[1] However,
after birth, a significant distal portion of the umbilical artery degenerates. These remnants later
obliterate, forming the medial umbilical ligament.[2] At the same time, the proximal portion of
each umbilical artery serves as a branching point for the development of the anterior internal iliac
arteries. The internal iliac arteries later give rise to the superior vesical arteries that supply the
urinary bladder and ureters as well as the ductus deferens and seminal vesicles in males.[3]
[4] The umbilical cord is a vital structure for the entire period of development since it functions
to tether the fetus to the placenta and the uterine wall while also acting as the primary route to
enable blood to circulate between the fetus and placenta.[5]

Structure and Function

Anatomical Features of an Umbilical Cord

The umbilical cord is a soft, tortuous cord with a smooth outer covering of amnion. It extends
from the umbilicus of the fetus to the center of the placenta. Its length ranges from 50 cm to 60
cm, with a diameter of about 1 cm.[6] The umbilical cord is composed of a gelatinous ground
substance called Wharton's jelly or substantia gelatinea funiculi umbilicalis. It is composed of
mucopolysaccharides from the conjugation of hyaluronic acid and chondroitin sulfate. As
previously mentioned, three vessels comprise the umbilical cord: two umbilical arteries and one
umbilical vein. It also encloses the urachus (a remnant of allantois).[7] The urachus is a fibrous
remnant of the allantois that extends through the umbilical cord and is located in the space of
Retzius between the peritoneum posteriorly and the transverse fascia anteriorly. The urachus
serves as a drainage canal for the urinary bladder of the fetus.[8]

Function

The umbilical arteries carry deoxygenated blood from fetal circulation to the placenta. The two
umbilical arteries converge together about at 5 mm from the insertion of the cord, forming a type
of vascular connection called the Hyrtl's anastomosis.[9] The primary function of Hartl's
anastomosis is to equalize blood flow and pressure between the umbilical and placental arteries.
[10] As the arteries enter the placenta, each bifurcates into smaller branches called the chorionic
vessels.

Embryology

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During the early stages of embryonic development, gastrulation occurs and

differentiates germinal tissues into three distinct layers: outer ectoderm, intra-embryonic
mesoderm, and inner endoderm.[11] The formation of the umbilical cord occurs over three stages
and coincides with the gastrulation process. 

I. Formation of the Primitive Umbilical Ring

This developmental stage happens together with the folding of the embryonic disc. During this
stage, the embryonic disc bulges into the amniotic cavity as a result of folding. At the same time,
the amnio-ectodermal junction, which is the tight connection between the embryonic amnion and
the ectodermal layer, becomes the ventral aspect of the embryo. Then, the line of reflection
between the amnion and the ectoderm acquires an oval outline called the primitive umbilical
ring.

II. Formation of the Primitive Umbilical Cord

This stage of development starts in the fifth week of pregnancy, during which the primitive
umbilical ring constricts to form a tubular sheath. The tubular sheath is called the primitive
umbilical cord. It encloses the body stalk, the yolk sac, and its vessels, as well as a part of the
allantois. 

III. Formation of the Definitive Umbilical Cord

During this stage, the umbilical cord elongates, and its fundamental structures undergo primary
changes. For instance, The extraembryonic mesoderm of the body stalk starts to differentiate into
a mucoid substance called Wharton's jelly. Wharton's jelly develops gradually and forms the
main bulk of the umbilical cord. The remnants of the extraembryonic coelom inside the umbilical
cord progressively degenerate. The yolk sac becomes obliterated together with the
vitellointestinal duct that connects the yolk sac with the midgut. Similarly, the distal part of the
allantois becomes obliterated. However, the allantoic vessels persist and elongate to form the
umbilical vessels. Finally, during the sixth week, a part of the midgut loop enters the umbilical
cord developing a physiological hernia. That physiological hernia is usually corrected when that
part of the midgut returns to the abdominal cavity after the tenth week of pregnancy.[12]

Blood Supply and Lymphatics

The umbilical cord, together with the placenta, contributes to the flow and regulation of fetal
circulation. The two umbilical arteries arise from the internal iliac arteries of the fetus and enter
the umbilical cord before further branching at the level of the placenta. At the placental level,
each umbilical artery bifurcates into smaller arterioles that continue to branch further to
distribute blood to the chorionic villi. The capillaries of the villi fuse to form venules that
converge to form the umbilical vein. The umbilical vein carries oxygenated blood and nutrients
from the mother to the fetus.[13]

As fetal growth ensues, both placental intervillous circulation and umbilical circulation develop
gradually, until maturation is complete at the end of the first trimester. At midgestation, the
percentage of umbilical blood in fetal circulation is about 30% of the fetal cardiac output. During
the last trimester of pregnancy, umbilical blood flow declines significantly as it becomes
inversely proportional to the fetal weight measured in kilograms. That percentage decreases
considerably during the last trimester till it reaches less than 20%. The umbilical vein enters the
abdominal region of the fetus. It carries the oxygenated blood with nutrients to the fetal liver
parenchyma and ductus venosus. Then, blood flows to the inferior vena cava and foramen ovale
of the fetal heart.[14]

On the other hand, the role and distribution of lymphatic drainage for the placenta, as well as the
umbilical cord, has been scarcely discussed in scientific resources. However, recent research has
shown D2-40 expression at the level of placental stromal has a vital role in the fetal lymphatic
drainage. This expression links to podoplanin-expressing cells whose function is related to

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forming a lymphatic-like reticular network. The thinking is that those cells are responsible for
providing lymphatic drainage for the umbilical cord and the placenta.[15]

Nerves
The umbilical cord lacks intrinsic and extrinsic innervations during all stages of embryonic
development. Vasoactive substances secreted locally within the umbilical vessels wall or carried
through the fetal circulation are responsible for regulating the smooth muscle tension within the
umbilical vasculature. For instance, nitrous oxide and prostacyclin play an essential role in
maintaining the low vascular resistance within the umbilical and placental circulation.
Furthermore, catecholamines are primary contributors for vasoconstriction of the umbilical
vessels immediately after parturition.[16]

Muscles
The bulk of the umbilical cord consists of Wharton's jelly since it does not have any voluntary
skeletal muscles. However, the umbilical vasculature has several smooth muscle layers of
various compositions and thicknesses. The walls of umbilical vessels consist mainly of three
layers: tunica externa, tunica media, and tunica interna.

Tunica externa

Also referred to as the tunica adventitia, it is the outermost layer of the umbilical vessels that
consists of fibrous and elastic connective tissue with varying amounts of collagen and elastic
fibers. The connective tissue of this layer is quite dense near the tunica media. It transitions to
loose connective tissue as it extends toward the periphery of the umbilical vessels. The umbilical
arteries have denser connective tissue in their tunica externa compared to that of the umbilical
vein.[17]

Tunica media

This section is the intermediate layer within the wall of the umbilical vessels. It represents the
muscular bulk of the vessels and consists mainly of smooth muscle. It provides structural support
for the vessels. It is also responsible for changing the diameter of the umbilical vessels. Thus, it
contributes primarily to regulate blood flow and blood pressure. It is commonly the thickest layer
within the vascular wall. It is much thicker in the umbilical arteries compared to the umbilical
vein. Moreover, tunica media of the umbilical arteries contain well-defined internal and external
elastic membranes that may be less defined or absent in the umbilical vein wall.[18]

Tunica interna

Also called the tunica intima, it is the innermost layer of the umbilical vasculature. It is
composed of simple squamous epithelium resting on a basement membrane consists of
connective tissue rich in elastic fibers. Those layers together form the endothelium of the
umbilical vessels. The tunica interna of the umbilical vein contains valves that direct the blood
flow in one direction and prevent its regurgitation in the opposite direction. Those valves are
absent in the wall of the umbilical arteries.[19] 

Physiologic Variants
Umbilical Cord Coiling Patterns

One of the most common morphological variations of the umbilical cord is its different helical
coiling patterns. The degree of coiling is measured by the umbilical cord index (UCI).
Commonly, the umbilical cord coiling pattern has a UCI of 0.2 coil/cm. The rope model is
considered the most common pattern of umbilical cord coiling. On the other hand, hyper-coiling
of the umbilical cord is defined as having a UCI greater than 0.3 coil/cm and a relatively high
incidence of about 6% to 21% of all pregnancies.[20] Also, the umbilical cord can coil in an
undulating pattern that has a relatively high incidence compared to other coiling patterns, such as
segmented or linked coiling of the umbilical cord. It was found clinically that abnormal coiling

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of the umbilical cord is closely associated with the fetal vascular obstruction, which in its role
can eventually lead to fetal thrombi,  avascular villi or villous stromal vascular karyorrhexis that
commonly occur with segmented coiling pattern of the umbilical cord [21].

False Knots of the Umbilical Cord

False knots are bulging masses located on the surface of the umbilical cord. Sometimes,
excessive torsion of the umbilical cord inside the uterus can cause these bulging masses to appear
as knots on uterine ultrasonography grossly. The knot appearance of this condition forms via the
excessive accumulation of Wharton's Jelly bulks alternating with areas with relatively less
amount of jelly composing constrictions after each bulging. Hence, they were identified as false
knots of the umbilical cord. This physiologic variation does not affect the stability of the fetal
position, nor does it affect umbilical blood flow and pressure. Thus, false knots do not represent
a considerable risk to the fetus.[22]

Single Umbilical Artery

The incidence of having a single umbilical artery is very low overall. However, It is known to be
more common in multiparous females compared to nulliparous ones. Many studies have reported
that the left umbilical artery is more often absent than the right.[23] The side of umbilical artery
absence has very minimal significance with the exception that one study concluded that infants
with a single umbilical artery identified by ultrasound in utero had reported the presence of
congenital abnormalities, including cardiac, renal, intestinal, and skeletal anomalies when the left
umbilical artery was absent.[23][24][25][26][27] Also, it is noted that the incidence of urinary
tract infection is higher in infants with a single umbilical artery.[28]

Surgical Considerations
Anesthetic Considerations

Placental and umbilical blood flow impact fetal oxygen delivery. Myometrial tone and maternal
blood pressure have a direct correlation with uterine artery blood flow. Volatile anesthetics
usually decrease myometrial tone and tend to reduce maternal blood pressure. Subsequently,
there is a decrease in fetal oxygenation due to a reduction in placental blood flow. Maintenance
of patent umbilical arteries and baseline maternal arterial blood pressure is essential for
maintaining sound cardiac output for the fetus. For example, maternal hypercapnia leads to fetal
hypoxia and metabolic acidosis as a result of umbilical venous flow reduction. Similarly,
maternal hypocapnia should be avoided during all maternal or fetal procedures since it has a
direct correlation with fetal hypoxia. Consequently, inhalation anesthesia is the best option for
fetal and intrauterine procedures. Moreover, epidural anesthesia plays a critical role in the
prevention of premature labor during the postoperative period of maternal surgeries.[29]

Intravenous Administration/Catheterization 

The umbilical vein is considered the primary site for cannulation. The umbilical vein remains
open for approximately one week after labor, and it can be useful for administering intravenous
fluids and medications for newborns requiring more aggressive resuscitation efforts. The
umbilical vein has a larger lumen than the umbilical arteries due to its thinner tunica media—
catheterization through the umbilical vein to the ductus venosus. Finally, the catheter arrives at
the inferior vena cava below the right atrium.[30] Furthermore, umbilical artery lines may also
be used for resuscitative efforts during the first week after delivery. Umbilical artery
catheterization is routinely used for direct access to monitor arterial blood gas, arterial blood
pressure, and angiography. In the neonatal intensive care, umbilical artery catheterization is
typically used to provide blood samples for laboratory testings.[31]

Clinical Significance
Different types of umbilical cord abnormalities may be potentially fatal or pose a severe threat to
fetal health. Thus, it is of great clinical significance to have early detection of these

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malformations to be able to provide a proper diagnosis and plan of care. 

Velamentous Insertion

The incidence of velamentous insertion of the umbilical cord is significantly high for in vitro
fertilization(IVF)-induced pregnancies compared to naturally-conceived pregnancies. It happens
in about 10% of pregnancies and 20% of IVF pregnancies.[32] Velamentous insertion of the
umbilical cord occurs when the placental end of the umbilical cord consists of umbilical arteries
and vein surrounded by fetal membranes without Wharton's jelly. The exact reason for this
condition is still unclear. However, the most current hypothesis suggests that during IVF
pregnancy, half of the placenta undergoes excessive proliferation making the site of the insertion
of the umbilical cord move peripherally away from its center. Conversely, the other pole of the
placenta involutes and the umbilical cord becomes unable to follow the migration of the placenta.
This condition casts risk for the fetus during delivery.[33]

Four-Vessel Umbilical Cord

Normal umbilical cord anatomy consists of three vessels represented by two umbilical arteries
and one umbilical vein. By the seventh week of gestation, the right umbilical vein usually
obliterates, leaving a single (left) umbilical vein patent. However, there have been documented
cases of umbilical cords containing four-vessels. The persistence of two umbilical veins and two
umbilical arteries within the umbilical cord is associated with multiple cardiovascular and
gastrointestinal anomalies.[34] When both the right and left umbilical veins remain open, a
condition called persistent right umbilical vein (PRUV). This condition usually happens due to a
deficiency in folic acid during the first trimester of pregnancy. This condition may cause
teratogenic effects for the fetus and act as a risk factor for its overall physical health.[35]

True Knots of the Umbilical Cord

These are real tangling nodules of the umbilical vessels along the length of the umbilical cord.
They usually occur early in pregnancy as a result of various predisposing factors. Most
commonly, the development of true knots is associated with the presence of excessive amniotic
fluid, causing high pressure on the umbilical cord vessels, increasing their torsional force,
causing deep knots of those vessels. Also, an increase in the movement of the fetus in utero plays
a vital role in creating that teratogenic deformity as supercoils of the umbilical cord can cause it
to knot over itself. True knot deformities of the umbilical cord are very dangerous because they
may obstruct the blood flow in the umbilical vessels, which may eventually lead to fetal demise.
[36]

Very Short Umbilical Cord

An umbilical cord is considered significantly short when its length is less than approximately 40
cm. A short umbilical cord can lead to premature separation from the placenta resulting in
an interruption in fetal circulation and, as a result, intrauterine bleeding followed by fetal death.
[37]

Very Long Umbilical Cord

If an umbilical cord is longer than 65 to 70 cm, it is clinically considered long. An abnormally

long umbilical cord has the greater potential wind around the neck of the fetus multiple times
contribute to fetal death, or it may also protrude from the mother's cervix.[37]

Omphalocele

Also referred to as exomphalos, an omphalocele is an abdominal wall defect that causes the
herniation of bowel and sometimes other organs into the umbilical cord. The pathophysiology
behind this condition is due to the failure of the reduction of the physiological umbilical hernia.
[38] Surgical correction is considered for such conditions to prevent intestinal obstruction of the
neonate. 

Abnormal attachment of the umbilical cord to the placenta

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Sometimes, the umbilical cord may have an abnormal attachment site on the placenta. For
example, the umbilical cord may attach to the placenta significantly off-center, giving rise to
eccentric attachment deformity. The placenta may take a deformed shape called battledore
placenta. This deformity results from the marginal attachment of the umbilical cord to the
placenta.[39] It closely correlates with abnormal hyper-coiling of the umbilical cord in most
cases. 

Delayed Umbilical Cord Separation

Normal separation of the umbilical cord can occur anytime after delivery with no reliable,
constant timeline. However, generally speaking, separation of the umbilical cord is considered
delayed if it happens later than the first three weeks after delivery. There are many factors and
pathological conditions associated with the incidence of delayed cord separation. For instance,
the topical application of antibiotics, alcohol, and triple dye after delivery has a significant
contribution to delayed cord separation. Moreover, pathological conditions such as; infections,
immune disorders, and the presence of urachal remnants can also delay umbilical cord
separation. Interestingly, researchers found a correlation between each low birth weight, cesarian
delivery, and prematurity and the increased risk of delayed umbilical cord separation. It is
clinically significant to consider further workup in newborns with delayed umbilical cord
separation and skin infections or those with persistent urachal remnants. These infants most
likely have an underlying immunologic disorder.[40]

Umbilical Cysts

Cysts classify into two main categories: true cysts and pseudocysts. They usually occur near or
around the insertion of the cord into the fetal umbilicus. Umbilical cord cysts generally develop
during the first trimester with a standard resolution by the end of the twelfth week of gestation.
Umbilical cysts have an incidence of 3.4% of all pregnancies. The exact etiology of umbilical
cysts is not defined clinically. However, they appear to be closely related to chromosomal
abnormalities, including trisomies of chromosomes 13 and 18, imperforate anus, and
angiomyxoma of the cord.[41] The most frequently encountered type of cyst is a pseudocyst.
Pseudocysts are also known as Wharton's jelly cysts. They lack epithelial tissue and occur
commonly as a result of focal edema of Wharton's jelly. Also, they can develop as a result of
mucoid degeneration inside the cord. It is not uncommon to see single cysts or multiple
focal lesions. The diameter of these lesions is less than 2 cm approximately.

On the contrary, true cysts of the umbilical cord develop commonly from the omphalomesenteric
duct or other primitive embryonic structures, including the allantois. True cysts have a distinct
epithelial lining; hence they are known as true cysts.[42] In general, umbilical cysts are
considered clinically significant. They serve as an early indicator of chromosomal abnormalities,
especially if cysts persist during the second and third trimester of pregnancy. Thus, fetal
karyotyping and amniocentesis are useful diagnostic procedures to determine any underlying
conditions associated with them.

Umbilical Granuloma

An umbilical granuloma is a red nodule that may develop after the umbilical cord has separated
from the naval of a newborn. On average, the diameter of a granuloma is about five mm.
[40] The development of this lesion involves an abnormal proliferation of fibroblasts at the
umbilicus forming thick layers of granulation tissue and endothelium. The vessels enclosed
within the lesion have a dotted or strawberry-like appearance.[43] The mainstay of treatment
is chemical cauterization with silver nitrate. Extra caution is needed to avoid injury or chemical
burns of the surrounding skin. However, it is of great clinical significance to provide further
evaluation of persistent umbilical granulomas as they can be mistaken for polyps that may
require surgical removal. 

Review Questions

Access free multiple choice questions on this topic.

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Comment on this article.

Figure

Development of the Fetal membrane and the Placenta,

Diagram illustrating a later stage in the development of the
umbilical cord, Placental villi, Umbilical cord, Allantois,
Heart, Embryo. Contributed by Gray's Anatomy Plates

Figure

Development of Fetal Membranes and Placenta, Fetus in

utero; between fifth and sixth months, Umbilical cord, Cervix
uteri. Contributed by Gray's Anatomy Plates

Figure

The Branchial Region, Embryo of about six weeks, Umbilical

cord, Embryology. Contributed by Gray's Anatomy Plates

Figure

Umbilical cord. Image courtesy S Bhimji MD

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