Furcate Cord Insertions: A Comprehensive Review of Reported Cases, Outcomes, and Management Implications.

Our study aims to evaluate the umbilical vein (UV) hemodynamic change in the prenatal cohort of pregnancies diagnosed with abnormal placental cord insertion (aPCI). From January 2022 to December 2022, the fetal umbilical cord insertion site was sonographically examined in singleton fetuses, and umbilical cord blood flow was calculated. The umbilical artery and UV Doppler flow indexes were assessed in cases of normal and abnormal cord insertion. Among 570 singleton fetuses between 18 + 0 and 40 + 6weeks of gestation in the final study, the umbilical vein blood flow (UVBF) in the 3 groups of normal umbilical cord insertions, marginal umbilical cord insertions, and velamentous umbilical cord insertions was 145.39ml/min, 146.18ml/min, and 93.96ml/min, respectively. UVBF was significantly lower in the velamentous cord insertion (VCI) group than in the other groups (P < 0.05). Compared with the normal cord insertions group, lower birth weight (2820 ± 527g vs. 3144 ± 577g, P < 0.05), delivery at an earlier gestational age (38.0 ± 1.55weeks vs. 38.8 ± 2.34weeks, P < 0.05), higher bicarbonate (25.08 ± 1.72mmol/L vs. 22.66 ± 4.05mmol/L, P < 0.05), and higher standard base excess (-1.14 ± 1.50mmol/L vs. -3.30 ± 3.22mmol/L, P < 0.05) were found in the VCI group. We observed lower UVBF volume with aPCI. Hence, we propose UVBF analysis to evaluate fetal aPCI according to UV hemodynamics as an advisory in prenatal care. This would be useful and improve obstetricians' clinical explanation about the potential prenatal consequences so that parents can opt for future prenatal care during pregnancy.

Multiple pregnancy is associated with high perinatal mortality and morbidity. Abnormal cord insertions more common in twin pregnancies compared to singleton pregnancies and velamentous cord insertion is related with poor pregnancy outcomes. There is no definition of velamentous cord insertion into the intertwine membrane between two fetuses in the literature. In our single-center cross-sectional study, monochorionic-diamniotic and dichorionic-diamniotic twins who were admitted to our clinic between 18 + 0 and 23 + 6 weeks of pregnancy were enrolled in this study. We evaluated fetal, placental, and umbilical cord abnormalities in addition to fetal growth restrictions and weight discordance by ultrasonography. Although abnormal cord insertion frequency was significantly higher in monochorionic twins (p=0.003), intertwin membrane cord insertion could only occur in dichorionic twins. In cases with cord insertion anomaly; FGR and weight discordance was observed more frequently (p < 0.001 and p=0.003, respectively). Weight discordance, the presence of abnormal cord insertion and abnormal UAD were found as statistically significant predictors of FGR (p < 0.001, p=0.021, and p < 0.001, respectively). Intertwin membrane insertion is a novel umbilical cord insertion abnormality. The presence of abnormal umbilical cord insertion is a risk factor for poor pregnancy outcomes in twin pregnancies.

Abnormal placental cord insertion includes marginal and velamentous placental cord insertion. With the development of obstetric ultrasound, such abnormal placental cord insertion can be diagnosed prenatal, and the relationship between the abnormal placental cord insertion of prenatal diagnosis and the pregnancy outcome is to be investigated. We performed a prospective study of singleton and multiple pregnancies women undergoing obstetric ultrasonography between 20–24 weeks of gestation at Ewha Women's University Hospital from February 2019 to October 2020. For the characteristics of pregnant women and pregnancy outcome, continuous variables were expressed as mean ± standard deviation and were compared using Student's t-test, or median (IQR) using Mann-Whitney test. Abnormal placental cord insertion was confirmed in 23 cases (6.42%) after a total of 358 deliveries, which 18 cases (5.02%) of marginal cord insertion were found, and 5 cases (1.40%) of velamentous placental cord insertion. Preterm birth, pre-eclampsia, fetal anomaly, postpartum hemorrhage, SGA, and LBW were significantly increased. (P-value< 0.05). Delivery by primary Caesarean section, gestational diabetes mellitus, low APGAR score was not statistically significant, but showed a tendency to increase. The results are given in table 1. Abnormal placental cord insertion is associated with poor pregnancy outcomes. Detecting abnormalities in the placenta attachment area before delivery can improve the prognosis of pregnancy. More cohort study is needed to evaluate the effects of abnormal placental cord insertion and pregnancy outcome. VP44.13: Table 1. Association of abnormal placental cord insertion with pregnancy outcome Central cord insertion (n = 335) Abnormal cord insertion (n = 23)

IUGR in rats is associated with changes in placental expression of MTAs

Prevalence of velamentous and marginal umbilical cord insertions; a comparison of term singleton ART and non-ART pregnancies

Abnormal umbilical cord insertion has been associated with unequal sharing of the placental vasculature between twins. A higher prevalence has been reported in pregnancies complicated by selective growth restriction (sFGR), birth weight discordance (BWD). We aimed to investigate the association between cord insertion site and adverse pregnancy outcomes in twin pregnancies. A single-centre cohort study of twin pregnancies that had placental histology. Higher-order multiples, major fetal anomaly, aneuploidy and MCMA pregnancies were excluded. Cord insertion site was categorised into 3 groups: marginal (attachment <2cm to the placental margin), velamentous (attached to the membrane before reaching the placenta with vessels traversing the membranes), normal. Chorionicity, placental weight, number of cord vessels, examination of the membranes, ultrasound findings, maternal characteristics and pregnancy outcome were collected. 546 pregnancies were eligible; 497 (146 monochorionic; 351 dichorionic) were included in the analysis. Significant differences were found between the normal and abnormal cord insertion groups with regards to BWD (P=0.001), BWD>25% (P=0.001), and absolute Z-score differences (P=0.020). Velamentous, but not marginal, cord insertion was significantly associated with sFGR (OR 8.51,95%CI 2.09-34.58;P=0.03) and BWD>25% (OR 11.88,95%CI 3.54-39.79;P=0.04). In MCDA, but not DCDA pregnancies, the rate of composite adverse outcome was higher in those with abnormal cord insertion (70.0% vs 53.0%, p=0.04). Selective fetal growth restriction and birthweight discordance are more common in twin pregnancies with abnormal cord insertion. MCDA twins with velamentous cord insertion are at increased risk of sFGR, and composite adverse pregnancy outcome.

AimsThis study aimed to identify any microscopic features associated with abnormal (membranous/velamentous or marginal) placental cord insertions and to analyse their adverse neonatal outcomes.MethodsWe retrospectively analysed the records—including pathological findings,...

To investigate the association between abnormal cord insertion and the development of twin-specific complications, including birth-weight discordance, selective fetal growth restriction (sFGR) and twin-to-twin transfusion syndrome (TTTS). This was a single center retrospective cohort study of twin pregnancies. Abnormal cord insertion was defined as either marginal (umbilical cord attachment site less than 2 cm to the nearest margin of the placental disc) or velamentous (cord attached to the membrane before reaching the placental disc with clear evidence of vessels traversing the membranes to connect with the placental disc), as described in placental pathology reports. Twins with major structural or chromosomal abnormalities and monochorionic monoamniotic twins were not included in the study. Information on the pregnancies, ultrasound findings, prenatal investigations and interventions was obtained from the electronic ultrasound database, while data on placental histopathological findings, pregnancy outcome, mode of delivery, birth weight, gestational age at delivery and admission to the neonatal intensive care unit were obtained from maternity records. Categorical variables were compared using the chi-square or Fisher's exact test, while continuous variables were compared using the Student's t-test, ANOVA for multiple comparisons and the Kruskal-Wallis test. Of the 497 twin pregnancies included in the analysis, 351 (70.6%) were dichorionic and 146 (29.4%) were monochorionic. The incidence of birth-weight discordance of 25% or more was significantly higher in pregnancies with velamentous and those with marginal cord insertions compared to those with normal cord insertion (24.0%, 15.3% vs 7.6%, P< 0.001 and P= 0.020, respectively). In pregnancies with birth-weight discordance of 25% or more, the smaller twins had significantly higher prevalence of velamentous (13.8%) and marginal (34.2%) cord insertions compared with the larger twins (1.8% and 18.5%, respectively, P< 0.001). The smaller twins of the monochorionic diamniotic pregnancies showed an even higher prevalence of velamentous (29.5%) and marginal (40.9%) cord insertions compared with the larger twins (2.3% and 31.5%, respectively, P< 0.001). Compared with the normal cord insertion group, only velamentous insertion was associated significantly with the risk of sFGR (odds ratio (OR), 9.24 (95% CI, 2.05-58.84), P< 0.001) and birth-weight discordance of 20% or more (OR, 4.34 (95% CI, 1.36-14.61), P= 0.007) and 25% or more (OR, 6.81 (95% CI, 1.67-34.12), P= 0.003) in monochorionic twin pregnancies. There was no significant association between velamentous cord insertion and TTTS (P= 0.591), or between marginal cord insertion and the development of sFGR (P= 0.233), birth-weight discordance of 25% or more (P= 0.114) or TTTS (P= 0.487). Subgroup analysis of dichorionic twins showed that abnormal cord insertion was not associated with the risk of birth-weight discordance (P= 0.999), sFGR (P= 0.308), composite neonatal adverse outcome (P= 0.637) or intrauterine death (P= 0.349). Monochorionic twins with velamentous cord insertion are at increased risk of birth-weight discordance and sFGR. Sonographic delineation of placental cord insertion could be of value in the antenatal stratification of twin pregnancies. Prospective studies are required to assess the value and predictive accuracy of this potential screening marker. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

To investigate the relationship between abnormal umbilical cord insertion and birthweight discordance in monochorionic diamnionic (MCDA) twins. A total of 137 pairs of MCDAs were retrospectively analyzed who delivered and survived in Hangzhou Women’s Hospital from January 2016 to December 2021. According to different insertion methods, they were divided into normal cord insertion group (n = 57), marginal cord insertion (MCI) group (n = 34) and velamentous cord insertion (VCI) group (n = 46). The correlation was analyzed between different insertion methods of umbilical cord and the discordant birth weight of MCDAs. The gestational age of delivery with velamentous cord insertion was significantly earlier than those with normal and marginal insertion (P < .05). There were significant differences in birthweight between large fetus (F1) and small fetus (F2) with different umbilical insertion methods (P < .05). The birthweight of F1 and F2 in normal insertion group was significantly higher than those in MCI and VCI group (P < .05). Logistic regression analysis showed that VCI was significantly associated with birth weight in F1/F2, birthweight discordance ≥ 20%, and birthweight discordance ≥ 25%, however MCI and VCI were not an independent factor for discordance in birthweight of MCDAs (P > .05). Umbilical cord insertion method can lead to inconsistency in birthweight of MCDA twins, however they were not an independent factor for discordance in birthweight.

ObjectiveThis study aimed to evaluate the success rate of vaginal delivery, the reasons for unplanned caesarean delivery, the rate of umbilical cord prolapse and the risk of umbilical cord prolapse...

IntroductionTwin–twin transfusion syndrome (TTTS) complicates approximately 10%–15% of all monochorionic twin pregnancies. The aim of this review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success.Material and MethodsFive databases were searched from inception to August 2023. Studies detailing post‐delivery placental analysis within TTTS twins post‐laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post‐laser. Secondary outcomes included assessing residual anastomoses on post‐laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random‐effects meta‐analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875.ResultsTwenty‐six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12–0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per placenta. Post‐laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33–4.26]), neonatal death (OR, 3.37 [95% CI, 1.65–6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64–89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36–28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39–0.59), 27% (95% CI, 0.18–0.38), and 28% (95% CI, 0.21–0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) vs non‐TTTS monochorionic twins.ConclusionsTo the best of our knowledge, this is the first review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post‐laser.

We evaluated risk factors for birthweight discordance in monochorionic diamniotic (MCDA) twin pregnancies without twin-twin transfusion syndrome (TTTS). We investigated all MCDA twin placentas injected with colored dye at our institution between 2007 and 2015. We excluded pairs of twins with TTTS, fetal demise, or severe fetal malformation. All pairs of twins were assigned to the discordant group (birthweight discordance ≥ 25%) or the concordant group (birthweight discordance < 25%). In each pair of twins, we described vascular anastomoses as either arterioarterial, venovenous (VV), or arterial-venous, and abnormal umbilical cord insertion as either marginal or velamentous. We also recorded placental sharing discordance. A total of 150 placentas were analyzed. The incidence of VV anastomosis in the discordant group (40%) was significantly higher than that in the concordant group (12%, P = 0.005). Unilateral abnormal umbilical cord insertion was significantly more common in the discordant group (85%) than in the concordant group (38%, P < 0.001). Placental sharing discordance was seen more frequently in the discordant group than in the concordant group. Multiple logistic analysis revealed that VV anastomosis (odds ratio: 4.7; 95% confidence interval: 1.2-18.6, P < 0.01) and unilateral abnormal umbilical cord insertion of the smaller twin (odds ratio: 5.7; 95% confidence interval: 1.4-22.9, P < 0.01) were independent risk factors for birthweight discordance. VV anastomoses and unilateral abnormal umbilical cord insertion of the smaller twin are independent risk factors for birthweight discordance in MCDA twin pregnancies without TTTS.

Placental pathology in twin to twin transfusion syndrome twins after fetoscopic laser photocoagulation

To assess perinatal outcome in type II monochorionic (MC) diamniotic twin pregnancies (DA) affected by selective intrauterine growth restriction (sIUGR) and abnormal cord insertion managed expectantly. A prospective longitudinal study from June 2008 and July 2011 on 24 MCDA sIUGR twins. sIUGR was defined as estimated fetal weight below the 10th percentile in one twin and was classified into three groups based on umbilical artery (UA) Doppler diastolic flow (I: presence; II: constantly absent/reverse (AEDF/ARED); III: intermittently absent or reverse). Marginal cord insertion was defined as insertion within 2 cm of the placental disc edge, and velamentous insertion as a cord insertion into the fetal membranes. Expectant management was chosen in these twins, and absent or reverse A wave in the ductus venosus (DV) was a criterion for delivery. Neonatal outcome was available for all twins delivered. Pathological examination and vascular cast of placentas were performed in all cases. Fourteen twin pregnancies were type II sIUGR, and ten presented an abnormal umbilical cord insertion. Median gestational age (GA) at diagnosis of sIUGR was 18 weeks' gestation (range 16-20 weeks), and all sIUGR co-twins showed AEDF of UA at a median gestational age of 20 weeks (range 18-22 weeks). Median gestational age at delivery was 30 weeks (range 28-34 weeks) with a median birth weight of 1285 g (range 307-1725 g). pH at birth and base excess (BE) were normal in all IUGR co-twin (pH>7.10, median BE 5.5); Apgar score at 5 min was >7. Perinatal outcome was favorable in all cases. Placental pathological examination confirmed the marginal insertion of the umbilical cord and the absence of anastomosis between the two portions of umbilical insertion. This study highlights that expectant management for sIUGR type II twins with or without an abnormal cord insertion should be a valid option to time delivery for these fetuses as shown by the favorable neonatal outcome.

To investigate whether there is an association between congenital heart disease (CHD) and placental abnormalities. We conducted a case-control study that included cases of infants with CHD who underwent cardiac surgery within 6 months of life at the Johns Hopkins Medical Center from 2000 to 2013, and gestational age-matched normal pregnancy controls (200 neonates per group). Overall, abnormal placental cord insertion (ie, eccentric, marginal, or velamentous) was associated with CHD (odds ratio, 2.33-3.76). The main cardiac defects associated with abnormal cord insertion were conotruncal defects (relative risk, 3.08; 95% confidence interval [CI], 1.48-6.40; P = .003), left heart disease (relative risk, 2.40; 95% CI, 1.32-4.37; P = .004), and right heart disease (relative risk, 2.22; 95% CI, 1.21-4.07; P = .010). The Placenta-to-birth weight ratio was not associated with CHD. Intrauterine growth restriction was associated with CHD (odds ratio, 3.00; 95% CI, 1.41-6.39; P = .004). Abnormal cord insertion, as well as intrauterine growth restriction, was determined to be correlated with the presence of CHD. On the basis of our results, we conclude that cord insertion should be evaluated at routine obstetric sonography, and further fetal heart evaluation is warranted if abnormal cord insertion is detected.