The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20

Perinatal outcomes of cases with umbilical

hypocoiled cord: a study at a single perinatal
center

Hiroko Takita , Mayumi Tokunaka , Tatsuya Arakaki , Minako Goto , Mizue

Saito , Shoko Hamada , Tomohiro Oba , Masamitsu Nakamura , Ryu
Matsuoka & Akihiko Sekizawa

To cite this article: Hiroko Takita , Mayumi Tokunaka , Tatsuya Arakaki , Minako Goto , Mizue
Saito , Shoko Hamada , Tomohiro Oba , Masamitsu Nakamura , Ryu Matsuoka & Akihiko Sekizawa
(2020): Perinatal outcomes of cases with umbilical hypocoiled cord: a study at a single perinatal
center, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1808613

To link to this article: https://doi.org/10.1080/14767058.2020.1808613

Published online: 26 Aug 2020.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2020.1808613

ORIGINAL ARTICLE

Perinatal outcomes of cases with umbilical hypocoiled cord: a study at a

single perinatal center
Hiroko Takita, Mayumi Tokunaka, Tatsuya Arakaki, Minako Goto, Mizue Saito, Shoko Hamada, Tomohiro
Oba, Masamitsu Nakamura, Ryu Matsuoka and Akihiko Sekizawa
Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan

ABSTRACT ARTICLE HISTORY

Objectives: To evaluate the perinatal outcomes of hypocoiled cord. Received 20 November 2019
Methods: This retrospective study was carried out in the Department of Obstetrics and Accepted 7 August 2020
Gynecology at Showa University Hospital between 2011 and 2017. Umbilical cord index (UCI)
KEYWORDS
was calculated by dividing the total number of coils by the total length of umbilical cord. All
Hypocoiled cord; umbilical
umbilical cords were measured and calculated coiling index by obstetrician after delivery. cord index;
Perinatal outcomes like non-reassuring fetal status (NRFS), emergency cesarean sections, and perinatal outcome
other perinatal complications were compared.
Results: From January 2011 to December 2017, a total of 4047 fetuses were born at our hos-
pital after 28 weeks’ gestation. After excluding 100 fetuses of hypercoiled cord, a total of 3947
fetuses were included in this study, of which 71 fetuses were hypocoiled cord and 3876 fetuses
were normal coiled cord. There were no association between maternal background and both
UCI group. NRFS during labor was significantly associated with hypocoiled cord compared with
normal cord (p ¼ .02). Additionally, the rates of emergency cesarean section were raised in cases
of hypocoiled cord (p ¼ .02).
Conclusion: In this study, it was found that hypocoiled cord is related to NRFS and emergency
cesarean section. In addition, hypocoiled cord was not associated with any maternal factors.
However, in previous studies, no opinion has been reported on the timing of diagnosis of hypo-
coiled cord during pregnancy. It is difficult to evaluate hypocoiled cord correctly in third trimes-
ter. It is a task to find the hypocoiled cord correctly before birth.

Introduction Similar to hypercoiled cords, abnormal hypocoiled

Umbilical cords have Wharton’s jelly that provide sup-
port when they are stretched, compressed and twisted
[1]. In 1521, Berengarius et al. reported that the umbil-
ical cord was susceptible to forming torsion [1]. A coil
was defined as having completed a 360 spiral course
of the umbilical vessels around the Wharton’s jelly [1].
For quantification of cord coiling, the ratio of twists to
the length of the cord was named “the umbilical cord
coiling index” by Strong et al. [2].
Abnormal umbilical coiling index has been reported
to be associated with adverse perinatal outcomes [3].
In previous studies, hypercoiled cords have been
reported to cause an increased risk of fetal distress,
fetal growth restriction, or intrauterine fetal death [4].
Extremely hypercoiled vessels are prone to kinking
and torsion during labor and cause non-reassuring
fetal status (NRFS) and fetal hypoxia [4].
cords are also associated with poor perinatal and neo-
natal outcomes [5]. Interruptions in the vascular flow
to the fetus with compression of hypocoiled umbilical
cords can cause severe fetal distress or intrauterine
death; incidents caused by abnormal coiling of the
cords are most likely to occur in the second or third
trimesters. However, there are few reports of perinatal
outcomes of hypocoiled cords. The objective of this
study was to evaluate the perinatal outcomes of hypo-
coiled cords.
Material and methods
This retrospective study was carried out in the
Department of Obstetrics and Gynecology at Showa
University Hospital. Patients in this study were women
with singleton pregnancies delivered after 28 weeks

CONTACT Mayumi Tokunaka mayumi.k.0415@gmail.com Department of Obstetrics and Gynecology, Showa University School of Medicine,
Tokyo, Japan
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 H. TAKITA ET AL.

Table 1. Maternal outcomes.

Characteristic Case (n ¼ 71) Control (n ¼ 3876) p-value
Gravida 0 (0–8) 0 (0–5) .08
Parity 0 (0–4) 0 (0–3) .05
Maternal age 37 (21–43) 36 (26–40) .23
Gestational weeks at delivery 38 (31–41) 38 (28–41) .52
Pregnancy after infertility care (IVF, ICSI) 8 (11.3%) 291 (7.5%) .25
Height 159.3 ± 4.7 159.0 ± 5.8 .56
Body mass index ( before pregnancy) 21.0 ± 3.8 20.9 ± 4.0 .42
The data are presented as the mean ± standard deviation, median (range) or frequency % (n).

Table 2. Perinatal outcomes.

Characteristic Case (n ¼ 71) Control (n ¼ 3876) p-value
NRFS 15 (21.1%) 452 (11.7%) .02
Operation delivery 11 (15.0%) 389 (10.0%) .16
Emergency cesarean section 10 (14.1%) 242 (6.2%) .02
A cord gas pH 7.30 ± 0.10 7.29 ± 0.07 .10
Apgar Score at 1 min 8 (4-9) 9 (6-10) .14
Apgar Score at 5 min 9 (8-9) 9 (9-10) .24
Birth weight 3013 ± 372 3042 ± 440 .29
Oligohydroamnios 7 (9.9%) 354 (9.1%) .92
Meconium staining 11 (15.5%) 562 (14.4%) .83
The data are presented as the mean ± standard deviation, median (range) or frequency % (n). p < .05 using an
analysis of variance.

gestation at our institution between January 2011 and
December 2017.
Umbilical cord index (UCI) was calculated by dividing
the total number of coils by the total length of the
umbilical cord. The coiling index of all umbilical cords
were measured and calculated by an obstetrician after
delivery. In the present study, hypocoiled cord was
defined as having a UCI less than 0.1 after delivery.
Moreover, normal coiled cord was defined as UCI of 0.1
or greater, up to a value of less than 0.3. In this
research, cases of hypercoiled cords with a UCI 0.3 or
greater were excluded. Medical records of all neonates
who were born at Showa University Hospital after
28 weeks gestation between 2011 and 2017 were retro-
spectively reviewed. Perinatal outcomes like NRFS,
emergency cesarean sections, and other perinatal com-
plications were compared. The data were entered into
a computerized data analysis program (Statistical
Package for Social Science (SPSS), Windows version
20.0 J; Chicago, IL, USA). Continuous variables are
reported as the mean ± standard deviation and were
compared using Student’s t-test. Categorical variables
are reported as percentages and were compared using
Fisher’s exact test. Statistical significance was defined as
a p value of less than .05. The study was approved by
the ethical committees of our institution, and patients
gave oral informed consent for all examinations.
Ethics
This research study was approved by the Ethics
Committee of our hospital. Informed consent was
obtained in writing from all patients before conduct-
ing ultrasound scanning. The confidentiality of the
patients was protected, and no personal data were
collected in the present study.
Result
From January 2011 to December 2017, 4047 fetuses
were born at our hospital after 28 weeks of gestation.
After excluding 100 fetuses with hypercoiled cords,
3947 fetuses were included in this study, of which 71
had hypocoiled cords and 3876 had normal
coiled cords.
The results of maternal background and neonatal
outcomes are presented in Tables 1 and 2. There was
no association between maternal background and
both UCI groups. Although there was a difference
between case and control with or without infertility
care, namely, in vitro fertilization (IVF) and intracyto-
plasmic sperm injection (ICSI), there was no statistical
difference. NRFS during labor was significantly associ-
ated with hypocoiled cords compared with normal
cords (p ¼ .02). Additionally, there was an increased
rate in emergency cesarean sections in cases of hypo-
coiled cords (p ¼ .02). In our study, there was no asso-
ciation between meconium staining and UCI.
Discussion
In this study, hypocoiled cords were significantly asso-
ciated with NRFS and emergency cesarean section,
which was similar to previous reports. Although there

was a difference between case and control with or
without infertility care (IVF and ICSI), there was no
statistical difference.
Regarding maternal background, our study showed
no association between hypocoiled and normal cords.
None of the other previous studies found age to be a
significant factor, which was similar to our results.
Pergialiotis et al. reported hypocoiled cords were sig-
nificantly associated with interventional delivery due
to fetal distress, meconium stained liquor, Apgar
scores < 7 at 5 min, small for gestational age (SGA)
neonates, fetal anomalies, need for admission in the
neonatal intensive care unit (NICU), fetal heart rate
abnormalities, and fetal death [6]. There was no signifi-
cant association between hypocoiled cords and grav-
ida, parity, or infertility care in previous studies [5].
One of the reasons may be associated with the
increasing incidence of assisted reproductive technol-
ogy (ART) pregnancy, since ART pregnancy has been
reported to adversely affect placental and umbilical
cord development [7,8]. However, our study did not
find any significant association between gravida, par-
ity, or infertility care. Although there was a difference
between hypocoiled cord cases and normal cord cases
with or without infertility care (IVF, ICSI), there was no
statistical difference. Therefore, it is difficult to assume
that hypocoiled cords are a result of mater-
nal background.
Conversely, hypocoiled cords were significantly
associated with NRFS and emergency cesarean sec-
tions in our study, which was similar to previous
reports. Neonatal outcomes were reported to have a
significant association with hypocoiled cords. The pres-
ence of hypocoiled and hypercoiled cords was associ-
ated with fetal death (21% and 37%, respectively),
fetal intolerance of labor (15% and 14%, respectively),
and intrauterine growth restriction (29% and 10%
respectively) [9]. These findings were confirmed by
previous reports and adverse fetal outcomes were
attributed to abnormal coiling that likely predisposed
umbilical cord vessels to thrombosis, constriction, or
both [9].
Our results revealed no difference between UCI and
oligohydramnios or meconium staining. These results
were different from previous reports stating that oligo-
hydramnios has been associated with an increased risk
of potentially life-threatening umbilical cord compres-
sion [10]. Moreover, Pergialiotis suggested that meco-
nium staining was significant in the group of neonates
with hypocoiled cords [6]. In our hospital, we per-
formed the screening of the placenta and umbilical
cord at 36 weeks for all patients, so as to predict NRFS
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
during labor [11]. In this screening, we check the UCI,
nuchal cord, and placenta. Furthermore, we classify
the risk of NRFS during labor to decide on the mode
of delivery. High-risk groups were carefully managed,
such as cases involving umbilical cord abnormalities
especially with hypercoiled cords and nuchal cord
entanglement at 36 weeks. Moreover, when NRFS
occurs, we referred to medical records of the patients
at 36 weeks of gestation. This 36-week antenatal
screening may result in no difference between meco-
nium staining, oligohydramnios, Apgar score, and cord
gas pH in our report [11]. Moreover, we have not
classified patients with a hypocoiled cord into the
high-risk group. The results of our study suggest the
classification of hypocoiled cords into the high-risk of
NRFS during labor.
Vascular coiling of the umbilical cord seems to
begin early in gestation and may reflect fetal move-
ment, unequal vascular growth rates, fetal hemo-
dynamic forces, and the umbilical vascular wall
mechanism [1,3,9,10]. Although the etiology of cord
coiling remains unclear, the process seems to facilitate
the turgidity, strength, and flexibility of the umbil-
ical unit.
In an attempt to prognosticate adverse fetal out-
comes, a sonographic evaluation of umbilical cord coil-
ing revealed a significant correlation regarding the
measurement between antenatal and postnatal UCI, but
these studies were limited to the third trimester or the
immediate postpartum period [5,8]. However, an
attempt to establish the correlation between the ante-
natal umbilical cord index obtained in the second tri-
mester and the umbilical cord index at delivery revealed
fewer compelling results. Under the assumption that
the umbilical coiling is fully developed by the end of
the first trimester and does not change thereafter but,
rather, that the cord lengthens between established
coils [9], the true umbilical cord index should be pre-
dictable from the sonographic assessment in the second
trimester [10]. Although the antenatal umbilical coiling
index was measured easily and reliably on second-tri-
mester sonography, it did not accurately reflect the true
index at term [10]. A discordance between the antenatal
index and the true index was attributed to the presence
of “mixed” coiling patterns or to the evolution of the
umbilical cord index at later gestation.
In conclusion, this study revealed that hypocoiled
cords are related to NRFS and emergency cesarean
sections. It is preferable to classify and manage the
hypocoiled cord at high-risk of NRFS before birth.
In addition, hypocoiled cords were not associated
with any maternal factors. However, in previous
4 H. TAKITA ET AL.
studies, no opinion has been reported on the timing
of diagnosis of hypocoiled cords during pregnancy. It
is difficult to evaluate hypocoiled cords correctly in
the third trimester. It is important to assess the hypo-
coiled cords correctly before birth.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
[1] Degani S, Mlewinsky R, Berger H, et al. Sonographic
estimation of umbilical coiling index and correlation
with Doppler flow characteristics. Obstet Gynecol.
1995;86(6):990–993.
[2] Strong TH, Jarles DL, Vega JS, Feldman, et al. The
umbilical coiling index. Am J Obst Gynecol Part I.
1994;170(1):29–32.
[3] Rana J, Ebert GA, Kappy KA. Adverse perinatal out-
come in patients with an abnormal umbilical coiling
index. Obst Gynaecol. 1995;85(4):573–577.
[4] Hasegawa J, Matsuoka R, Ichizuka K, et al. Ultrasound
diagnosis and management of umbilical cord abnor-
malities. Taiwan J Obstet Gynecol. 2009;48(1):23–27.
[5] Predanic M, Perni SC, Chervenak FA. Antenatal umbil-
ical coiling index and Doppler flow characteristics.
Ultrasound Obstet Gynecol. 2006;28(5):699–703.
[6] Pergialiotis V, Kotrogianni P, Koutaki D, et al.
Umbilical cord coiling index for the prediction of
adverse pregnancy outcomes: a meta-analysis and
sequential analysis. J Matern Fetal Neonatal Med.
2019;27:1–8.
[7] Qin J, Liu X, Sheng X, et al. Assisted reproductive
technology and the risk of pregnancy-related compli-
cations and adverse pregnancy outcomes in singleton
pregnancies: a meta-analysis of cohort studies. Fertil
Steril. 2016;105(1):73–85 e1–e6.
[8] Hasegawa J. Sonoembryological evaluations of the
development of placenta previa and velamentous
cord insertion. J Obstet Gynaecol Res. 2015;41(1):1–5.
[9] Devaru D, Thusoo M. Umbilical coiling index & the
perinatal outcome. J Obstet Gynecol India. 2012;62(1):
43–46.
[10] Otsubo Y, Yoneyama Y, Suzuki S, et al. Sonographic
evaluation of umbilical cord insertion with
umbilical coiling index. J Clin Ultrasound. 1999;27(6):
341–344.
[11] Takita H, Hasegawa J, Arakaki T, et al. Antenatal ultra-
sound screening using check list before delivery for
predicting a non-reassuring fetal status during labor.
J Matern Fetal Neonatal Med. 2018;31(1):1–6.