Original Research
Antenatal Diagnosis of Marginal and
Velamentous Placental Cord Insertion and
Pregnancy Outcomes
Candace O’Quinn, MD, FRCSC, Stephanie Cooper,
and Stephen Wood, MD, FRCSC
OBJECTIVE: To evaluate the association between ante-
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVLZFqv07kv790udtCTcCtoB2n3b++jFiO+CaWwYDahnbkj+q6iuivmM= on 04/11/2020
natal diagnosis of velamentous and marginal placental
cord insertions with adverse perinatal outcomes of
small-for-gestational-age (SGA) birth weight (less than
the 5th percentile), caesarean birth, and perinatal mor-
tality.
METHODS: Using a diagnostic imaging database, we
performed a cohort study of all consecutive singleton
pregnancies (35,391), including 1,427 cases of marginal
and 107 cases of velamentous cord insertion, delivered
after 24 6/7 weeks of gestation between January 1, 2012,
and December 31, 2015, at a single Canadian tertiary
care center. Cases with placenta previa, vasa previa, no
documented cord insertion, or fetal anomalies were
excluded.
RESULTS: In the overall cohort, the rate of birth weight
less than the 5th percentile was 5.2%, the rate of
cesarean delivery was 27.1%, and the rate of perinatal
From the Maternal Fetal Medicine Section, Department of Obstetrics & Gyne-
cology, and the Department of Obstetrics & Gynecology, University of Calgary,
and EFW Radiology, Calgary, Alberta, Canada.
A research grant from the DEAR fund (Department of Obstetrics and Gynecology,
University of Calgary, AB, Canada) provided funding for this project.
Presented at John Jarrell Research Day (Department of Obstetrics and Gynecology
Research Day), University of Calgary, May 11, 2018, Calgary, Alberta, Can-
ada.
The authors thank the Alberta Perinatal Health Program (APHP), especially Ms.
Susan Crawford, for her generous donation of time and support in matching the
data for this study. Ms. Susan Crawford also participated in the manuscript
review.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Candace O’Quinn, Maternal Fetal Medicine Section,
Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta,
Canada; email: candace.oquinn@ucalgary.ca.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
VOL. 135, NO. 4, APRIL 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD, FRCSC, Selphee Tang, BSc,
mortality was 0.24%. Velamentous cord insertion was
associated with SGA (relative risk [RR] 2.19, 95% CI 1.28–
3.74). This persisted after controlling for smoking during
pregnancy, diabetes, and hypertension (adjusted odds
ratio [aOR] 1.98, 95% CI 1.03–3.84). Velamentous cord
insertion was also associated with an increased risk of
caesarean birth (RR51.38, 95% CI51.08–1,77) and peri-
natal death (1.87%, RR 8.15, 95% CI 2.02–32.8), a relation-
ship that persisted after controlling for smoking during
pregnancy, diabetes, and hypertension (aOR 1.53, 95% CI
1.01–2.32). Marginal cord insertion was not associated
with birth weight less than the 5th percentile (RR 1.23,
95% CI 1.00–1.51), cesarean delivery (RR 1.01, 95% CI
0.92–1.10), or perinatal death (RR 1.53, 95% CI 0.62–3.78).
CONCLUSION: Antenatal diagnosis of velamentous pla-
cental cord insertion is associated with birth weight less
than the 5th percentile.
(Obstet Gynecol 2020;135:953–9)
DOI: 10.1097/AOG.0000000000003753
M
arginal placental cord insertion is defined as the
insertion of the umbilical cord vessels at or
within 1–2 cm of the placental edge.1,2 Velamentous
insertion of the umbilical cord is defined as umbilical
vessels that insert into the fetal membranes before they
reach the placental margin.3 In singletons, the incidence
of velamentous cord insertion is reported to be 0.5–
2.4% and of marginal cord insertion 6.0–8.3%.1,3–5
Peripheral cord insertions (marginal or velamen-
tous cord insertions) have been associated with
placenta previa, placental abruption, preeclampsia,
preterm birth, low Apgar scores, neonatal intensive
care admission, low birth weight, and small for
gestational age (SGA).3,4,6–8 Increased rates of fetal
demise have also been reported for velamentous cord
insertion.1,3 An increase in caesarean birth rates for
cases of velamentous cord insertion has been reported
by some but not others.1,4,7,9,10
OBSTETRICS & GYNECOLOGY 953
 Many of the prior-mentioned studies1,3,4,8,9 are
based on pathologic review of the placenta after birth,
not an antenatal ultrasound diagnosis. Selection bias
may be a factor in these studies. Available evidence
linking antenatal diagnosis of peripheral cord inser-
tion and perinatal outcomes is limited. One study
has found an association between marginal cord inser-
tion and growth impairment11 and there are conflict-
ing results regarding an increase in preterm birth
with marginal cord insertion (Feldman D, Koning K,
Bobrowski R, Borgida A, Ingardia C. Clinical impli-
cations of prenatally diagnosed marginal placental
cord insertion [abstract]. Am J Obstet Gynecol
2004;191:S176; Carbone J, Feldman D, Lazarus S,
Borgida A. Clinical implications of prenatally diag-
nosed marginal placental cord insertion [abstract].
Am J Obstet Gynecol 2008;199:S187.).2,11
The objective of this large contemporary cohort
study was to evaluate the association between antena-
tally diagnosed velamentous and marginal cord in-
sertions with adverse perinatal outcomes of SGA at
birth, caesarean delivery, and perinatal death.
METHODS
A cohort study including all consecutive singleton
pregnancies delivered after 24 6/7 weeks of gestation
between January 1, 2012, and December 31, 2015,
was performed at the University of Calgary in
Calgary, Alberta. The University of Calgary Research
Ethics Board approved the study protocol (REB14-
2037).
Eligible pregnancies were identified using an
obstetric imaging database (Astraia) at the Calgary
Maternal Fetal Medicine Centre (EFW Radiology) in
Calgary, Alberta. Data are entered into the Astraia
database by the ultrasonographers and physicians.
This database is used to generate the examination
reports. Data were retrieved using the data query
function within the database. All singleton pregnan-
cies with completed anatomic surveys were included.
Those with placenta previa, vasa previa, no docu-
mented cord insertion type, or fetal anomalies were
excluded. Data for each pregnancy were captured
from the database and matched with data from the
Alberta Perinatal Health Program (http://aphp.dapa-
soft.com).
The Alberta Perinatal Health Program collects
data from the provincial delivery record for all
deliveries within the province of Alberta. The Alberta
Perinatal Health Program database contains informa-
tion on labor and delivery outcomes for births at all
Alberta hospitals and all home births and birthing
center births. Information on maternal demographics,
954 O’Quinn et al Antenatal Diagnosis of Placental Cord Insertion
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
comorbidities, pregnancy complications and delivery
outcomes is recorded in a standardized fashion from
the provincial delivery record. Data for this record are
recorded by the nursing team.
Available data included clinical variables includ-
ing gravidity, parity, type of conception, estimated
due date, and number of ultrasonographic examina-
tions in the pregnancy (completed at our center).
Placental location, number of vessels in the umbilical
cord, and nature of the placental cord insertion were
also obtained. A central cord insertion was defined as
a placental cord insertion greater than 2 cm from the
placental edge. Marginal cord insertion was defined as
placental cord insertion within 2 cm of the placental
edge and velamentous cord insertion was defined as
placental cord insertion into the edge of the placenta
through the fetal membranes.
The identified pregnancies were then matched
with delivery data from the Alberta Perinatal Health
Program. Data collected from the Alberta Perinatal
Health Program included maternal age at delivery,
gestational age at delivery, birth weight, newborn sex,
mode of delivery, type of labor (spontaneous or
induction), smoking (at any point in the pregnancy),
gestational hypertension, diabetes mellitus or gesta-
tional diabetes, perinatal death, neonatal intensive
care unit admission, placental cord insertion, and the
presence of congenital anomalies. All data were
returned to the authors in a de-identified fashion.
Small for gestational age birth weight was defined
as less than the 5th percentile for gestational age and
sex on the Canadian Perinatal Surveillance System
curves, which were developed based on Canadian
singleton newborns.12 A cut off of the 5th percentile
for SGA was chosen as more indicative of significant
fetal growth restriction. The primary outcome for the
study was to evaluate the association between antena-
tally diagnosed (diagnosed at the 18–21-week anat-
omy ultrasound scan) velamentous and marginal
cord insertions (as separate entities) with SGA. Sec-
ondary outcomes included cesarean birth, perinatal
mortality, SGA less than the 10th percentile, and pre-
term delivery before 37 weeks of gestation.
The time frame of 2012–2015 for the study was
chosen because assessment of the placental cord inser-
tion became a routine practice at the Calgary Mater-
nal Fetal Medicine Centre in 2012. An end date of
December 2015 allowed for complete pregnancy data
on the identified cases to be available. An estimated
60,000 pregnancies had anatomic surveys completed
during this time period. Assuming 5% of neonates will
be SGA, and approximately 1% of cases would have
a velamentous cord insertion, this study was powered
OBSTETRICS & GYNECOLOGY
to detect a 50% relative increase in SGA neonates (to
7.5%), with 75% power at a significance level of 0.05.
For maternal characteristics, means, SDs, fre-
quencies, and percentages were reported. T-tests, x2
tests, and Fisher exact tests were used to compare the
maternal characteristics of the marginal cord insertion
and velamentous cord insertion groups, separately,
against the central cord insertion group. Relative risks
and 95% CIs were calculated for the outcomes using
pregnancies with central cord insertion as the refer-
ence group. As numbers for perinatal mortality were
small, Fisher exact test was used to test for statistical
significance for this outcome.
An exploratory multivariate logistic regression
was performed separately for SGA (5th percentile),
SGA (10th percentile), and cesarean birth including
smoking status, diabetes mellitus (gestational or pre-
existing) and hypertension (gestational or pre-
existing), as confounders as these factors are known
to affect fetal growth. P,.05 was considered statisti-
cally significant. Statistical analyses were performed
using SAS 9.3.
RESULTS
The study cohort of 35,391 included unique pregnan-
cies, of which 32,771 were included for analysis (Fig. 1).
The women in the velamentous cord insertion group
were more likely to have gestational hypertension. The
women in the marginal cord insertion group were old-
er, had more assisted conceptions, and were more
likely to be primiparous than those in the central cord
insertion group. Women in both groups were more
likely to have more ultrasound examinations during
pregnancy compared with the central cord insertion
group. There was no difference in smoking rates, ges-
tational or pregestational diabetes mellitus, or pre-
existing hypertension between the groups (Table 1).
In the overall cohort, the rate of birth weight less
than the 5th percentile was 5.2%, the rate of cesarean
birth was 27.1%, and the rate of perinatal mortality
was 0.24%. Velamentous cord insertion was associ-
ated with an increased relative risk of SGA less than
the 5th percentile (Table 2). The relationship between
velamentous cord insertion and SGA persisted after
controlling for smoking during pregnancy, diabetes,
and hypertension (adjusted odds ratio [aOR] 1.98,
95% CI 1.03–3.84).
Velamentous cord insertion was also associated
with an increased risk of cesarean delivery, and this
association persisted after controlling for smoking,
diabetes, and hypertension (aOR 1.53, 95% CI 1.01–
2.32 (Table 2). Velamentous cord insertion was also
associated with an increased risk of perinatal death
with several different suspected reasons for perinatal
death (Tables 2 and 3).
An association between SGA less than the 5th
percentile was not found for marginal cord insertion
(Table 2) with or without adjustment for smoking, dia-
betes, and hypertension (aOR 1.24, 95% CI 0.981–
1.559). There was no association between marginal
cord insertion and cesarean birth or perinatal death.
In a secondary analysis examining marginal and
velamentous cord insertion and SGA at the 10th
percentile, we found a statistically significant association
between marginal cord insertion and SGA after adjust-
ing for smoking during pregnancy, diabetes, and

Fig. 1. Study outline.

O’Quinn. Antenatal Diagnosis of Placental Cord Insertion. Obstet Gynecol 2020.

VOL. 135, NO. 4, APRIL 2020 O’Quinn et al Antenatal Diagnosis of Placental Cord Insertion 955

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 1. Maternal Characteristics

Cord Insertion
Characteristic Central (n530,953) Marginal (n51,427) Velamentous (n5107)

Maternal age at delivery 31.464.7 32.064.9* 32.264.8

Conception
Spontaneous 23,843 (94.4) 1,066 (90.2)* 83 (94.3)
Assisted 1,403 (5.6) 116 (9.8) 5 (5.7)
Unknown 5,707 245 19
Smoking at any time during pregnancy
No 24,396 (91.2) 1,161 (92.1) 91 (93.8)
Yes, stopped 2,364 (8.8) 100 (7.9) 6 (6.2)
Unknown 4,193 166 10
Gravidity
1 9,899 (36.6) 524 (41.3)* 43 (43.9)
2 or more 17,138 (63.4) 745 (58.7) 55 (56.1)
Unknown 3,916 158 9
Parity
0 13,173 (49.9) 667 (53.1)* 54 (56.3)
1 or more 13,247 (50.1) 588 (46.9) 42 (43.8)
Unknown 4,533 172 11
Total examinations
1–5 27,874 (90.1) 1,158 (81.1)* 65 (60.7)*
6 or more 3,079 (9.9) 269 (18.9) 42 (39.3)
Placenta site (distance from internal os) (cm)
Less than 2 2,709 (8.8) 136 (9.5) 9 (8.4)
Greater than 2 28,244 (91.2) 1,291 (90.5) 98 (91.6)
Gestational diabetes
No 28,793 (93.4) 1,316 (92.5) 98 (91.6)
Yes 2,044 (6.6) 106 (7.5) 9 (8.4)
Unknown 116 5 0
Pre-existing diabetes
No 30,387 (98.5) 1,409 (99.1) 106 (99.1)
Yes 450 (1.5) 13 (0.9) 1 (0.9)
Unknown 116 5 0
Gestational hypertension
No 29,089 (94.3) 1,347 (94.7) 94 (87.9)*
Yes 1,748 (5.7) 75 (5.3) 13 (12.1)
Unknown 115 5 0
Pre-existing hypertension
No 30,508 (98.9) 1,402 (98.6) 106 (99.1)
Yes 329 (1.1) 20 (1.4) 1 (0.9)
Unknown 116 5 0
Data are mean6SD or n (%).
* Indicates P,.05 for pairwise comparison against central cord insertion group.

hypertension (aOR 1.46 (95% CI 1.25–1.70, Appendix
1, available online at http://links.lww.com/AOG/B779).
DISCUSSION
This study demonstrates a clear association with
antenatally diagnosed velamentous cord insertion
with growth restriction, cesarean delivery, and peri-
natal death. This is consistent with most prior
pathology based studies of velamentous cord inser-
tion.1,3,4,8,13 The strength of this large study is that
marginal and velamentous cord insertions were sepa-
rated in assessing the association on outcomes of
growth, caesarean delivery, and perinatal death.
Other authors have combined peripheral cord inser-
tions together, making the associations less clear.6,13,14
This large study provides additional information that
will allow for more specific patient counseling regard-
ing antenatally diagnosed placental cord insertion
type. An adjusted analysis to control for potential con-
founding factors was also performed. However, as
there were relatively few outcomes, the models were
all potentially overfitted and should not be interpreted
as highly reliable results. Additionally, it is possible
that placenta abnormalities may be on the causal

956 O’Quinn et al Antenatal Diagnosis of Placental Cord Insertion OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 2. Outcome Measures

Cord Insertion
Marginal Velamentous
Outcome Central (n530,953) (n51,427) (n5107)

Gestational age at delivery (wk)

25 0/7–31 6/7 199 (0.6) 12 (0.8) 2 (1.9)
32 0/7–36 6/7 1,602 (5.2) 101 (7.1) 12 (11.2)
37 0/7–42 6/7 29,152 (94.2) 1,314 (92.1) 93 (86.9)
Type of delivery
Term 29,152 (94.2) 1,314 (92.1) 93 (86.9)
Spontaneous before 37 wk* 1,287 (4.2%) 75 (5.3) 6 (5.6)
Indicated before 37 wk 514 (1.7) 38 (2.7) 8 (7.5)
RR of any preterm delivery before 37 wk (95% CI) Ref 1.36 (1.13–1.63) 2.25 (1.38–3.67)
uRR of spontaneous preterm delivery* before 37 weeks Ref 1.26 (1.01–1.59) 1.35 (0.62–2.94)
(95% CI)
uRR of indicated preterm delivery before 37 weeks Ref 1.60 (1.16–2.22) 4.50 (2.30–8.82)
(95% CI)
Sex
Female 15,185 (49.1) 748 (52.4) 51 (47.7)
Male 15,765 (50.9) 679 (47.6) 56 (52.3)
Unknown 3 0 0
Birth weight (g) 3,3036511 3,2046542 2,9886586
(missing529)
SGA less than the 5th percentile
SGA 1,585 (5.1) 90 (6.3) 12 (11.2)
Not SGA 29,336 (94.9) 1,337 (93.7) 95 (88.8)
Unknown 32 0 0
uRR of SGA less than the 5th percentile (95% CI) Ref 1.23 (1.00–1.51) 2.19 (1.28–3.74)
SGA less than the 10th percentile
SGA 3,518 (11.4) 219 (15.3) 21 (19.6)
Not SGA 27,403 (88.6) 1,208 (84.7) 86 (80.4)
Unknown 32 0 0
uRR of SGA 10th percentile (95% CI) Ref 1.35 (1.19–1.53) 1.73 (1.17–2.53)
Mode of delivery
Spontaneous vaginal 17,713 (57.2) 815 (57.1) 51 (47.7)
Operative vaginal 4,871 (15.7) 224 (15.7) 16 (15.0)
Cesarean 8,367 (27.0) 388 (27.2) 40 (37.4)
Unknown 2 0 0
uRR of cesarean delivery (95% CI) Ref 1.01 (0.92–1.10) 1.38 (1.08–1.77)
Perinatal death
No death 30,882 (99.8) 1,422 (99.7) 105 (98.1)
Antepartum stillbirth 54 (0.17) 4 (0.28) 2 (1.87)
Intrapartum stillbirth 10 (0.03) 1 (0.07) 0 (0.0)
Neonatal death 7 (0.02) 0 (0.0) 0 (0.0)
uRR of perinatal death (95% CI) Ref 1.53 (0.62–3.78) 8.15 (2.02–32.80)
P† Ref 0.390 0.026
RR, relative risk; uRR, unadjusted relative risk; SGA, small for gestational age.
Data are n (%) or mean6SD unless otherwise specified.
* Spontaneous preterm delivery defined as delivery at before 37 weeks where type of labor is spontaneous or induction reason is premature
rupture of membranes or membranes ruptured before 37 weeks.
†
Fisher exact test comparing with percentage of perinatal death to central cord insertion group.

pathway of adverse perinatal outcomes for some of
the risk factors for which we controlled. Therefore,
controlling for them in multivariate analysis may not
be appropriate. In any event, the adjusted analysis did
not change the point estimates for cord insertion to
any significant degree.
We also identified an association with velamen-
tous cord insertion and an increased rate of cesarean
birth rate, which is consistent with some prior studies
(Abu Subeih H, Slevin J, Burke G, Saunders J, Una F.
P14.06: the significance of umbilical cord insertion in
term singleton pregnancies [abstract]. Ultrasound

VOL. 135, NO. 4, APRIL 2020 O’Quinn et al Antenatal Diagnosis of Placental Cord Insertion 957

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 3. Perinatal Deaths
Type of Placental Timing of
Cord Insertion Perinatal Death
Marginal Antepartum
Marginal Antepartum
Marginal Antepartum
Marginal Antepartum
Marginal Intrapartum
Velamentous Antepartum
Velamentous Antepartum
Obstet Gynecol 2010;36:219.)4,8 and a recent meta-
analysis,9 but differs from other studies.1,13 Part of this
discrepancy may be explained by difference in base-
line cesarean birth rates between centers. Both Esakoff
et al and Ismail et al had lower cesarean birth rates for
their central cord insertion groups than was found at
our center (13.7% and 16.2%, respectively, vs our rate
of 27%). The lower rates may be explained by Esakoff
et al reporting only primary cesarean birth rates and
Ismail et al only emergency cesarean birth rates. We
included all cesarean births.
We found an association between velamentous
cord insertion and perinatal death. This has been
reported in prior studies1,5 and a recent meta-analy-
sis.15 It is important to mention that the overall number
of perinatal deaths in our cohort was small. This makes
it difficult to make recommendations for altering
patient care and counseling regarding this outcome.
The lack of association between marginal cord
insertion and SGA at the 5th percentile is consistent
with the prior studies in which marginal cord insertion
was diagnosed antenatally (Feldman et al. Am J
Obstet Gynecol 2004;191:S176.).2,14 Those studies
used less than the 10th percentile2,14 or 2,500 g (Feld-
man et al. Am J Obstet Gynecol 2004;191:S176.) as
markers of SGA or low birth weight. We did find an
association between marginal cord insertion and SGA
at the 10th percentile. This contradicts the previous
study by Lui et al, who did not find an association
between marginal cord insertion and SGA in 100
antenatally diagnosed cases. This may be explained
by differences in the comparison populations. Lui
et al compared the birth weights from marginal cord
insertion cases with previously published birth weight
data, whereas we compared birth weight with a cohort
from the same time period at the same center. The
present study also presents a much larger series of
marginal cord insertions (1,427 vs 100). An associa-
tion with SGA with pathology-based marginal cord
insertion diagnosis has been previously reported and
supports the present study’s findings.3,13
958 O’Quinn et al Antenatal Diagnosis of Placental Cord Insertion
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Gestational Age at Time Suspected Cause
of Perinatal Death (wk) of Perinatal Death
26 Fetal growth restriction
40 True knot
31 Infectious
37 Unknown
35 Fetomaternal hemorrhage
26 Umbilical cord stricture
36 Unexplained
This study found a lower rate of velamentous
cord insertion (0.3%) and marginal cord insertion
(4.5%) compared with previously published re-
ports.1,3–6 Cases of placenta previa and vasa previa
were excluded from this study. Both placenta previa
and vasa previa are associated with increased rates of
velamentous cord insertion,8 which may explain the
higher rates noted in previous studies. Given the
lower-than-expected marginal and velamentous cord
insertion rates detected in this study, our statistical
power to discern differences between groups in infre-
quent outcomes was limited.
A limitation of this study is that marginal and
velamentous cord insertions were not confirmed on
pathology specimens. Even so, it has been reported that
the placental cord insertion can be reliably visualized on
ultrasound scan in 91–100% of cases.11,16–19
Although the results of this study cannot be
generalized to cases of multiple pregnancy or placenta
or vasa previa, this contemporary cohort is generaliz-
able to singleton, nonanomalous fetuses. Given the
identified association with marginal and velamentous
cord insertion with the adverse fetal outcomes
described above, we recommend consideration of an
ultrasound scan for fetal growth in the third trimester
after earlier identification of a marginal or velamen-
tous cord insertion to attempt to identify at-risk
fetuses. Further studies are needed to clarify the value
and timing of additional antenatal imaging.
REFERENCES
1. Esakoff TF, Cheng YW, Snowden JM, Tran SH, Shaffer BL,
Caughey AB. Velamentous cord insertion: is it associated with
adverse perinatal outcomes? J Matern Fetal Neonatal 2015;28:
409–12.
2. Liu CC, Pretorius DH, Scioscia AL, Hull AD. Sonographic
prenatal diagnosis of marginal placental cord insertion: clinical
importance. J Ultrasound Med 2002;21:627–32.
3. Ebbing C, Kiserud T, Johnsen SL, Albrechtsen S, Rasmussen S.
Prevalence, risk factors and outcomes of velamentous and
marginal cord insertions: a population-based study of 634,741
pregnancies. PLoS One 2013;8:e70380.
OBSTETRICS & GYNECOLOGY
 4. Raisanen S, Georgiadis L, Harju M, Keski-Nisula L, Heinonen
S. Risk factors and adverse pregnancy outcomes among births
affected by velamentous umbilical cord insertion: a retrospec-
tive population-based register study. Eur J Obstet Gynecol Re-
prod Biol 2012;165:231–4.
5. Ebbing C, Kiserud T, Johnsen SL, Albrechtsen S, Rasmussen S.
Third stage of labor risks in velamentous and marginal cord
insertion: a population-based study. Acta Obstet Gynecol
Scand 2015;94:878–83.
6. Brouillet S, Dufour A, Prot F, Feige J, Equy V, Alfaidy N, et al.
Influence of the umbilical cord insertion site on the optimal
individual birth weight achievement. BioMed Res Int 2014;
2014:341251.
7. Heinonen S, Ryynanen M, Kirkinen P, Saarikoski S. Perinatal diag-
nostic evaluation of velamentous umbilical cord insertion: clinical,
Doppler, and ultrasonic findings. Obstet Gynecol 1996;87:112–7.
8. Suzuki S, Kato M. Clinical significance of pregnancies complicated
by velamentous umbilical cord insertion associated with other umbil-
ical cord/placental abnormalities. J Clin Med Res 2015;7:853–6.
9. Ismail KI, Hannigan A, O’Donoghue K, Cotter A. Abnormal
placental cord insertion and adverse pregnancy outcomes: a sys-
tematic review and meta-analysis. Syst Rev 2017;6:242.
10. Eddleman KA, Lockwood CJ, Berkowitz GS, Lapinski RH, Ber-
kowitz RL. Clinical significance and sonographic diagnosis of ve-
lamentous umbilical cord insertion. Am J Perinatol 1992;9:123–6.
11. Allaf MB, Andrikopoulou M, Crnosija N, Muscat J, Chavez
MR, Vintzileos AM. Second trimester marginal cord insertion
is associated with adverse perinatal outcomes. J Materal Fetal
Neonatal Med 2019;32:2979–84.
12. Kramer MS, Platt RW, Wen SW, Joseph KS, Allen A, Abraha-
mowicz A, et al. A new and improved population-based Cana-
dian reference for birth weight for gestational age. Pediatrics
2001;108:E35.
VOL. 135, NO. 4, APRIL 2020 O’Quinn et al
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
13. Ismail KI, Hannigan A, Kelehan P, O’Donoghue K, Cotter A.
Abnormal placental cord insertion and adverse pregnancy out-
comes: results from a prospective cohort study. Am J Perinatol
2017;34:1152–9.
14. Uyanwah-Akpom P, Fox H. The clinical significance of mar-
ginal and velamentous insertion of the cord. Br J Obstet
Gynaecol 1977;84:941–3.
15. Vahanian SA, Lavery JA, Ananth CV, Vintzileos A. Placental
implantation abnormalities and risk of preterm delivery: a sys-
tematic review and metaanalysis. Am J Obstet Gynecol 2015;
213:S78–90.
16. Sepulveda W, Rojas I, Robert JA, Schnapp C, Alcalde JL. Pre-
natal detection of velamentous insertion of the umbilical cord:
a prospective color Doppler ultrasound study. Ultrasound Ob-
stet Gynecol 2003;21:564–9.
17. Nomiyama M, Toyota Y, Kawano H. Antenatal diagnosis of
velamentous umbilical cord insertion and vasa previa with
color Doppler imaging. Ultrasound Obstet Gynecol 1998;12:
426–9.
18. Padula F, Lagana AS, Vitale SG, Mangiafico L, D’Emidio L,
Cignini P, et al. Ultrasonographic evaluation of placental cord
insertion at different gestational ages in low-risk singleton
pregnancies: a predictive algorithm. Facts Views Vis Obgyn
2016;8:3–7.
19. Di Salvo D, Benson CB, Laing FC, Brown DL, Frates MC,
Doubilet PM. Sonographic evaluation of the placental cord
insertion site. Am J Roentgenol 1998;170:1295–8.
PEER REVIEW HISTORY
Received October 20, 2019. Received in revised form December
20, 2019. Accepted January 2, 2020. Peer reviews and author cor-
respondence are available at http://links.lww.com/AOG/B780.
Antenatal Diagnosis of Placental Cord Insertion 959