Placental Insertion Site Research Articles

Prenatal Diagnosis of Umbilical Cord Angiomyxoma: Case Studies and Literature Review of 45 Cases.

We describe two cases of umbilical cord (UC) angiomyxoma diagnosed prenatally by sonography in the second trimester of pregnancy. In both cases, a complex mass was detected at the placental insertion site, characterized by an echoic nodule surrounding the umbilical vessels and distal edematous Wharton's jelly. Follow-up scans showed that the mass grew mainly at the expense of its edematous component, with normal uteroplacental Dopplers throughout the remaining of the pregnancy. However, late-onset fetal growth restriction complicated the progress of pregnancy, requiring delivery by Cesarean section at 37 weeks' gestation in both cases. Neonatal courses were unremarkable. An extensive review of the English literature was also performed, collecting 45 similar cases including ours. Our experience as well as the review of the literature confirms that UC angiomyxoma is an uncommon, sporadic condition that is usually detected incidentally during prenatal sonography and presents as an isolated finding. Nevertheless, it represents a high-risk condition for pregnancy complications including prematurity, fetal growth restriction, and fetal demise.

Double/Triple Intrauterine Blood Transfusion in Rh-isoimmunized Anemic Fetuses in Multiple Pregnancies with Favorable Outcome.

Multiple pregnancies have increased with the use of assisted reproduction, and we expect more women reporting with Rh isoimmunization among multiple gestation in near future. Intrauterine transfusion in singleton itself is technically difficult and requires a lot of skill and precision. Performing double/triple transfusion in twins/triplets is expected to be more demanding. To create awareness on the technical difficulties encountered in intrauterine transfusion in twins and triplets. We report a case series of four Rh-isoimmunized twins/triplets in 5years who presented with severe anemia requiring intrauterine transfusion. Each of the four sets of cases had their own intricacies that needed to be pondered before tackling them as not much was available in the literature. In Case 1, the first twin intrauterine transfusion in our 20-year-long experience, the difficulty in the approach to the first twin due to a posteriorly placed placenta has been highlighted. Case 2 was rare due to the concomitant presence of atypical antibodies in the mother in addition to Rh-D isoimmunization that made it difficult to cross match any donor blood for intrauterine transfusion. The third case was exclusive due to its monochorionic-diamniotic nature of the twins where the impact of inter-twin anastomosis on the transfusion was to be taken into consideration. Fourth case was a triplet gestation where the difficulty of which cord to be assigned to which fetus, the crowded space for intervention, as well as the risk of prolonged operative time and associated risk of preterm/premature rupture of membranes were our concern. Intrauterine transfusion (IUT) in twins/triplets is challenging. Difficulties encountered during IUT in multifetal gestation are due to different or uncertain chorionicity, intraplacental anastomosis between vessels, different degree of anemia in twins, difficult to ascertain cord-fetus relationship and difficulty to reach placental insertion site due to crowding by multiple fetal parts.

Use of compressive sutures in the control of obstetric hemorrhage as a conservative measure of the uterus, in naval medical center, from june 2017 to December 2020

Objective: To describe the results obtained in the use of compression sutures in the control of obstetric hemorrhage as an alternative measure that conserves the uterus. Materials and methods: Observational, cross-sectional, descriptive, and retrospective, carried out at the Naval Medical Center in Mexico City, from June 2017 to December 2020. Patients with a diagnosis of postpartum obstetric hemorrhage were included. In which advanced surgical techniques were applied, such as compression sutures with the Hayman and B-Lynch technique. The variables of 1) Amount of bleeding before and after applying the compression suture, 2) Procedure time, 3) Hemoglobin concentration on admission to the care unit, 1 hour after the bleeding and 24 hours after the procedure were analyzed. surgical intervention, 4) outcome of the techniques, 5) complications. SPSS version 22 was used for data analysis. Results: 72 patients were registered: 46 patients with application of the Hayman technique and 26 patients with the B Lynch technique. Blood loss after the application of the techniques was lower (p<0.001). The surgical time in the application of compression sutures was 85.8±17.6 minutes. The concentration at hospital admission and 1 hour after bleeding was significantly lower (p<0.01) versus 24 hours later (p<0.05). Among the causes of obstetric hemorrhage, we found uterine atony with 59 patients (81.94%), bleeding at the placental insertion site 8 (11.11%) and placenta previa 5 (6.94%). No maternal deaths associated with suturing techniques were reported. Conclusion: Uterine suture techniques represent a useful, fast and uncomplicated procedure for the control of obstetric hemorrhage and a uterine- conserving measure.

Umbilical Cord Abnormalities and Maternal and Perinatal Outcome: A Prospective Observational Study

Introduction: The umbilical cord is the vital extension of the fetal circulatory system which regulates blood flow in both directions, thus allowing mother-child communications viz., immunological, oxygenation, fetal nutrition, cardiac function. Umbilical cord abnormalities are associated with the adverse maternal and perinatal outcome.. Aim: To assess prevalence of various umbilical cord abnormalities and its association with maternal complications and perinatal outcome. Materials and Methods: This prospective observational study was conducted at Saraswathi Institute of Medical Sciences Pilkhuwa, Hapur, Uttar Pradesh, India from June 2019 till March 2020. The approval for the study was taken from the Institutional Ethical Committee. Total number of deliveries during this period were 1284. After satisfying exclusion criteria, total 600 deliveries of more than 37 weeks of gestation were included in the study at random. Examination of cord was done during delivery for presence of loops of cord around the neck or body, any knots, true or false. After the delivery, the cord was clamped 5 cm from the fetal end and the total length was measured from the cut end till the placental insertion site, and 5 cm added therein. Umbilical cord was examined for any abnormalities and numbers of coils recorded and Umbilical Coiling Index (UCI) measured. Apgar score and NICU admissions noted. Results: Out of 600 patients, umbilical cord abnormalities were seen in 194 (32.33%) patients, while in 406 (67.67%) no abnormality was detected. The mode of delivery was vaginal in 441 cases (73.5%) while 159 (26.5%) had Lower Segment Cesarian Section (LSCS). Out of 194 cases with umbilical cord abnormality, 89 (45.87%) had LSCS and out of 406 cases with no cord abnormality, only 70 cases (17.24%) had LSCS (p-value<0.0001). Mean UCI was 0.25±0.09. Total 269(44.83%) had maternal complications and 143 cases (53.16%) had umbilical cord abnormalities. While 126 (46.84%) cases with maternal complications did not show any cord abnormality. Apgar score of <7 at one minute was seen in 43 cases (22.16%) and 23 (11.86%) were admitted in Neonatal Intensive Care Unit (NICU) with umbilical cord abnormality. Conclusion: The umbilical cord abnormalities were associated with the adverse maternal and perinatal outcome and increased rate of LSCS (p-value <0.0001). The study shows the importance of knowledge of cord abnormalities. The cord abnormality should be looked for after each delivery, with the aim to reduce perinatal morbidity.

Conservative approach: Intentional retention of the placenta.

Intentional retention of the placenta (IRP), or 'conservative' treatment or management, entails opening the uterus, delivering the baby, tying and cutting the umbilical cord at its placental insertion site, leaving the placenta in the uterus and waiting for its complete spontaneous resorption in women with placenta accreta spectrum (PAS). The uterine preservation rate with this approach is about 78%, and severe maternal morbidity about 6%; these rates are respectively lower and higher in subgroups of women with placenta percreta. IRP has become a recommended option for women with PAS reluctant to undergo caesarean-hysterectomy and wanting to preserve their fertility, after appropriate information about the uterine preservation rate, but also the risk of a subsequent emergency hysterectomy due to unpredictable haemorrhage and/or infection, and the need for follow-up with regular visits for several months. Some authorities also recommend IRP when hysterectomy is at very high risk of surgical complications.

Modern Ultrasonography of the Umbilical Cord: Prenatal Diagnosis of Umbilical Cord Abnormalities and Assessement of Fetal Wellbeing.

The umbilical cord is the only connection between the mother and the fetus, through which it is possible to transport respiratory gases, nutrients, and metabolites. Thanks to the umbilical cord, the fetus has also the ability to move, which is necessary for its proper psychomotor development. The correct structure and function of umbilical vessels and the entire umbilical cord determine the possibility of proper development and survival of the fetus. Umbilical cord anatomy should be assessed in the ultrasound examination in the first trimester. It is of vital importance to confirm the correct number of umbilical vessels and their intra-abdominal course, as well as carefully assessing the abdominal and placental insertion sites. In the latter half of pregnancy, the use of the Doppler imaging enables assessment of the function of the fetal-placental vessels, thus providing valuable information about the condition of the fetus.

OP27.09: The utility of a routine screening for abnormal invasive placentation in women with previous Caesarean sections according to placental insertion site

To evaluate the utility of a routine screening for abnormal invasive placentation (AIP) in women with previous Caesarean sections (CS) according to the placental insertion site. Retrospective analysis of AIP and maternal outcomes of women evaluated between January 2014 and 2016 with a scoring system based on 5 sonographic criteria (i.e. placental lacunae, loss of the hypoechoic retro-placental space, bladder wall abnormalities, abnormal vascularisation at myometrial-bladder interface and placental thinning) which identified 2 risk classes (high: ≥2 criteria, low: ≤1 criteria). AIP was determined following surgery and/or pathological analysis. We enrolled 135 women, 97 women (71.9%) with history of ≥2 CS without placenta previa (PP) (CS group) and 38 women (28.1%) with PP (9/38 with a previous CS and 29/38 with no CS) (PP group). According to our score, 122 women (90.4%) were at low risk, 13 (9.6%) at high risk. AIP was confirmed in 14/135 (10.4%) cases. Hysterectomy was performed in 9 cases with confirmed AIP. All AIP cases were in the PP group (14/14, 100%). Women with PP had higher risk of AIP than those with multiple CS without PP (37.8% vs 0%, p<0.0001). Our score diagnosed 10/14 confirmed AIP with 71% of sensitivity (IC95%:48;94) and 98% of specificity (IC95%:96;100), PPV of 77% (IC95%:54;100) and NPV of 97%(IC95%:94;100). Placental lacunae alone had a sensitivity and a specificity of 86% and 93%. Logistic and multiple regression analyses, corrected for maternal age and BMI, gestational age and fetal weight at time of delivery, need of radiology assistance, suggested that only placental lacunae were significantly associated with AIP (CR 28.05; 95% CI 2.91 to 270.58; p < 0.01) and blood loss during CS (CR 0.553; r = 0.588; p < 0.001). Our data suggest that AIP prevalence is not increased in women with multiple previous CS without PP; only women with PP need a routine screening for AIP. Placenta lacunae are the most associated criterion for AIP and blood loss during CS.

Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare but serious and potentially deadly complication of pregnancy that is unpreventable and unpredictable. Most AFE events occur during labor; however, approximately one third happen during the immediate postpartum period. Presentation is abrupt and thought to be an abnormal response to fetal materials entering maternal circulation through the placental insertion site. Care providers must recognize the signs and symptoms of AFE and react quickly to treat potential complications. This can be challenging as there are no set diagnostic criteria or specific laboratory tests. Generally, the diagnosis is based on clinical status when the classic triad of hypoxia, hypotension, and subsequent coagulopathy are noted in a laboring woman or woman who just gave birth, and no other plausible explanation can be determined. Proper treatment of AFE requires a multidisciplinary approach to decrease maternal morbidity and mortality. Knowledge, simulation, and familiarization of a Massive Obstetric Transfusion protocol can help all members of the perinatal team recognize and respond to women with AFE in a timely and effective manner. A case study is presented of a woman with a seemingly normal obstetric course that became complicated rapidly following development of an AFE.

Umbilical cord abnormalities

Objective: Stillbirths and neonatal outcome after delivery has been associated with umbilical cord findings. Cord abnormalities may put the baby in higher risk of certain diseases or low birth weight. The etiology of the umbilical cord abnormalities are not clear diagnosis. Although the fetal mortality associated with umbilical cord abnormalities is very high, identification of the fetus at risk has remained a difficult problem. The aim of this academic work is to study the human umbilical cord (UC) congenital abnormalities including length, diameter, coiling pattern, and placental insertion site in full term Sudanese neonates. Materials and Methods: One thousand and twenty UC of full-term birth neonates of both sexes, single and twin, of normal vaginal delivery in 2013, were studied in the Department of Obstetrics and Gynecology, Omdurman Maternity Hospital. UC length was entirely measured in centimeters using flexible plastic meter and the diameter was measured by Vernier caliper. The number of UC coils, coils pattern, insertion site, knots, cysts, and the blood vessels were fully studied. Results: The average UC length was about 58 cm, with minimal difference between male to female, single to twin birth. In majority of the cases, true knots occur without any clinical significance, whereas the tight knot may impede the circulation and may lead to low birth or intrauterine death. Thin cord places fetus at risk during pregnancy and may result in restricted growth, low birth weight, and neonates which are small for gestational age. This appears to be a consequence of reduction in the area of Wharton's jelly or small cord diameter. Very helical designs may predispose the fetus to certain blood flow changes, and very straight designs may be susceptible to compression. In both these types of coils, the degree of coils vary depending on cord length, diameter, fetal gender, and number of pregnancy. Hypercoiled coils may predispose the fetus to certain blood flow changes and hypocoiled cords may lead to the fetus being susceptible to compression; however in both cases, the blood flow and fetal weight may be affected. These factors were considered regarding possible interactions and correlation to pregnancy and perinatal outcome. Conclusion: Average length of UC in Sudanese neonates about 55 cm, being long in males and single birth, and there is no big difference in the cord length measurement before and after birth, comparing the two methods (ultrasound and manual measurements). 20cm of the cord length is suitable for fetus to be delivered vaginally. Average UC diameter in Sudanese neonates about 1.5 cm, big in males and single birth, Maximum UC coils about 45 coils, more in males and single birth, eccentric insertion is more common than central or marginal false knots of the are also more common than true knots. Most of the cord true knots located near to the fetal end of the umbilical cord, and they were commonly coiled to the left side (anticlockwise direction) incidence of a SUA in Sudanese neonate about 1% more common in males

Is complete umbilical cord scanning possible at the second-trimester ultrasound scan?

To evaluate the feasibility of umbilical cord scanning during the second-trimester sonographic examination, we looked at the method of scanning, the findings, and the time spent. Five hundred forty-nine singleton pregnancies were evaluated at 18-23 weeks' menstrual age with two-dimensional sonography (US). Color Doppler US was used when needed. The umbilical cord was traced from the fetal insertion site to the placental insertion site. Fetal and placental sites of insertion; number of vessels; presence of knots, cysts, tumors, nuchal cords, or placental anomalies; time spent for scanning; and the use of color Doppler US were noted. The mean maternal age was 33.1 ± 4.1 years, and the mean menstrual age of the fetuses during scanning was 20.4 ± 2.4 weeks. The mean time spent for umbilical cord scanning was 41.5 ± 46.7 seconds. In one case (0.2%), the umbilical cord could not be scanned completely. Color Doppler US was needed in 125 (22.8%) of the scans. Scan results were positive in 153 (27.9%) cases. We observed six cases (1.1%) of a single umbilical artery, two (0.4%) umbilical cord knots, one (0.2%) umbilical cord hernia, and 104 (18.9%) nuchal cords. We also documented 27 (5.0%) marginal insertions, four placenta previa totalis (0.7%), four placenta previa marginalis (0.7%), and eight velamentous insertions (1.5%). Umbilical cord US scanning is feasible during the second trimester of pregnancy, and complete scanning can be performed in the majority of the cases. Color Doppler analysis may aid scanning when needed. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:249-253, 2015.

P15.01: Umbilical cord anomalies: detection and expectations

Fetal ultrasonographic screening has to include assessment of the umbilical cord for possible abnormalitiesthat can be: hypercoiled cord and nuchal cord, abnormal length and thickness of the cord, anomalies of the placental insertion site, vascular abnormalities and primary tumors of the cord. These conditions may be associated with fetal anomalies, chromosomal anomalies and intrauterine growth restriction. In our study we describe and analyze the ultrasound diagnosis and management of major umbilical cord abnormalities, considering the current knowledge on physiologic and pathologic aspects of each of them. A retrospective study was conducted in Universitary Emargency Hospital Bucharest over a 3-year period. We found 18 cases of single umbilical arteries, 6 cases of velamentous cord insertion, 3 of them associated with placental adherence abnormalities, partial placenta previa and one with vasa previa, 16 cases of more than 2 loops nuchal cord, 7 cases of true knot cord with 2 ultrasound undiagnosed cases, 5 true cord cysts and 3 cases of fetal intra-abdominal umbilical vein dilatation. A pregnancy with umbilical cord anomalies is more likely to be complicated with polyhydramnios, preterm delivery under 34 weeks, low birthweight, Caesarean delivery for fetal distress, perinatal death, admission to NICU and placental abnormalities compared with a pregnancy with a normal umbilical cord. We sustain that prenatal detection of umbilical cord abnormalities will decrease the number of emergent Caesarean sections and intrauterine fetal death. Safe fetal delivery, fetal echocardiography and karyotype analysis should be offered depending on risk associated to each umbilical cord abnormality. Doppler US is a critical tool for assessment and diagnosis of vascular cord abnormalities, whereas 3D/4D Doppler US of the fetal umbilical cord and abdominal vasculature allows a high accurate diagnosis of vascular abnormalities.

Comprehensive Imaging Review of Abnormalities of the Umbilical Cord

A complete fetal ultrasonographic (US) study includes assessment of the umbilical cord for possible abnormalities. Knowledge of the normal appearance of the umbilical cord is necessary for the radiologist to correctly diagnose pathologic conditions. Umbilical cord abnormalities can be related to cord coiling, length, and thickness; the placental insertion site; in utero distortion; vascular abnormalities; and primary tumors or masses. These conditions may be associated with other fetal anomalies and aneuploidies, and their discovery should prompt a thorough fetal US examination. Further workup and planning for a safe fetal delivery may include fetal echocardiography and karyotype analysis. Doppler US is a critical tool for assessment and diagnosis of vascular cord abnormalities. US also can be used for follow-up serial imaging evaluation of conditions that could result in fetal demise. Recent studies suggest that three- or four-dimensional Doppler US of the fetal umbilical cord and abdominal vasculature allows more accurate diagnosis of vascular abnormalities. Doppler US also is invaluable in assessment of fetal growth restriction since hemodynamic changes in the placenta or fetus would appear as a spectral pattern of increased resistance to forward flow in the fetal umbilical artery. Early detection of umbilical cord abnormalities and close follow-up can reduce the risk of morbidity and mortality and assist in decision making.

Klinefelter twins presenting with discordant aneuploidies, acardia, forked umbilical cord and with different gonadal sex despite monozygosity

A higher frequency of twin births in sibships of Klinefelter syndrome patients and also monozygotic or dizygotic twins, themselves being affected by Klinefelter syndrome have been noted repeatedly. To address this issue, we evaluated type and frequency of twinning among Klinefelter fetuses that we had received for autopsy within a 'Prenatal Diagnosis' program. We performed fetal autopsies, and genetic analyses on DNA extracted from stained histological slides. Among 41 prenatal diagnoses of a 47, XXY karyotype we observed four twin pairs. One was dizygotic with discordant Klinefelter and Down syndrome. Three twin pairs were monozygotic as concluded from monochorial placentation. In two monozygotic pairs one twin partner was an acardiac monster and in one of these the acardiac twin showed a female gonadal sex and missing Y-chromosomal SRY-sequences as confirmed by polymerase chain reaction. There is a high rate of twinning and twin reversed arterial perfusion sequence among our Klinefelter fetuses. Forked umbilical cords at the placental insertion site in one case allowed classification as conjoined twins in the sense of a 'funiculopagus'. Anaphase lagging or semidizygosity by second polar body twinning are proposed as explanations for the gonadal sex discordance and the excessive developmental disadvantage in the one acardiac. Problems may arise with regard to non-invasive prenatal diagnosis of aneuploidies in twin pregnancies.

Two placentas in singleton pregnancy with fused umbilical cord: A case report

Two placentas in singleton pregnancy with fused umbilical cord which has its own placental insertion site forming 3-vessel cord at fetal end is an extremely rare case. This present case describes two placentas with fused umbilical cord with an episode of vanishing twin syndrome and there seems to be a strong relationship between these two events. A 37-year-old woman, gravid 0, para 0, visited emergency room with an episode of vaginal bleeding without pelvic cramps at 8 weeks and 5 days of gestation and repeated ultrasonic exams revealed reabsorption of vanishing twin and two separate placentas on anterior and posterior body of uterus. At 40 weeks and 4 days, the patient delivered a viable female infant weighing 3,900 g via Cesarean section and postpartum examination of the placentas and membranes confirmed two placentas with fused umbilical cord. Two placentas were almost equal in size and there were 2 cord insertions, 1 into each placenta. The cord at each of the placental disc had marginal insertion site and main placental disc cord had 2 arteries with one vein (3 vessel-cord) whereas side placental disc cord had one artery with one vein (2 vessel-cord). Several hypothesis for this two placentas with fused umbilical cord in singleton pregnancy, were proposed including placenta abnormalities after in vitro fertilization-embryo transfer procedure, succenturiate lobes and fetus in fetus, however, further evaluation is need.

Midpregnancy cordocentesis training of maternal–fetal medicine fellows

To describe systematic cordocentesis training among maternal-fetal medicine (MFM) fellows. During their 2-year training period, five MFM fellows, who had completed systematic model training, performed 1116 midpregnancy diagnostic cordocentesis procedures (mean, 223 (range, 185-259) procedures each) under expert supervision. The details of the procedures were recorded prospectively. Multiple pregnancies and those with fetal chromosomal or structural anomalies were excluded from analysis. The outcome measures included success rate, duration of the procedure, fetal loss and complications. Of the 1116 procedures performed, 184 were excluded because of fetal abnormalities; the remaining 932 were available for analysis. Cordocentesis was performed on free-floating umbilical cord (79.3%) and at the placental insertion site (20.7%). There was an immediate complication of transient fetal bradycardia in 10% of cases. Individual success rates ranged from 98.1 to 100% and the mean cumulative success rate had plateaued by approximately 60 procedures. The overall fetal loss rate was 1.3%. The overall mean +/- SD duration of successful procedures was 4.4 +/- 4.7 min, individual mean durations ranging from 3.7 to 5.9 min. MFM fellows with systematic training are able to perform cordocentesis with very high success rates, and with an acceptable procedure-related fetal loss rate. An intensive course of preclinical training with the model, and more than 60 procedures on patients under supervision is recommended.

Blood flow volume of uterine arteries in human pregnancies determined using 3D and bi-dimensional imaging, angio-Doppler, and fluid-dynamic modeling

The primary aim of this pilot study was to study uterine artery (UtA) blood flow volume in uneventful human pregnancies delivered at term, at mid and late gestation by means of 3D and bi-dimensional ultrasound imaging with angio-Doppler combined with fluid-dynamic modeling. Secondary aims were to correlate flow volume to placental site and to UtA Pulsatility Index (PI).Women with singleton, low-risk pregnancies were examined at mid and late gestation. The structure and course of the uterine artery (UtA) was studied in each patient by means of 3D-angio-Doppler and included vessel diameter D, blood flow velocity and PI (measured along the UtA). Fetal weight estimation and placental insertion site were assessed by ultrasound. A robust fluid-dynamic modeling was applied to calculate absolute flow and flow per unit fetal weight.Mean UtA diameter and blood flow velocity increased significantly (p < 0.0001) from mid-gestation to late gestation from 2.6 mm and 67.5 cm/s, to 3.0 mm and 85.3 cm/s, respectively, yielding an increasing absolute flow troughout gestation. h coefficient, derived by fluid-dynamic modeling to calculate mean velocity, increased significantly from 0.52 at mid-gestation to 0.57 at late gestation. UtA blood flow volume ml/min/kg-fetal weight was significantly higher at mid-gestation than at late gestation (535 ml/min/kg vs 193 ml/min/kg; p < 0.0001). In cases with strictly lateral placentas the ipsilateral UtA accommodates at mid and late gestation 63% and 67% of the total UtA flow. In central placentas UtA flow was evenly distributed between the two vessels. An inverse correlation was observed between PI and blood flow volume ml/min/kg (Pearson's coefficient r = −0.54).Our work confirms the technological and methodological limitations in the measurement of uterine artery blood flow. However, Doppler measurements supported by three-dimensional angio imaging of the uterine vessel, high resolution imaging and diameter measurement, and a robust mathematical model of local circulation adds a genuine new area of investigation into human uterine circulation during pregnancy.

Trizygotic dichorionic triplets with 46,XX/46,XY chimerism in both fetuses of the monochorionic pair

Monochorionic fetuses are traditionally thought of as monozygotic (MZ), arising from a single embryo that splits during early embryogenesis. With rare exception, they typically exhibit the same genotype and the same gender. However, several recent reports have documented that monochorionicity does not always indicate monozygosity (Souter et al., 2003). At least 14 such cases have been reported (Ekelund et al., 2008). We report a trizygotic triplet pregnancy conceived by in vitro fertilization (IVF) in which triamniotic dichorionic placentation was identified in addition to hematopoietic chimerism in the monochorionic pair. A 29-year-old Caucasian, insulin-dependent diabetic woman gravida 2, para 1, conceived a triplet gestation with the assistance of IVF. Three embryos were transferred. An ultrasound performed at 7 weeks revealed three viable embryos in three gestational sacs. A thin membrane, with a direct, perpendicular insertion into a single placenta, was visualized between sacs B and C. There was no evidence of a lambda sign at the placental insertion site. These findings indicated monochorionicity between the B and C sacs. Fetus A was surrounded by a single amnion and a single chorion. The sonographic findings indicated a triamniotic, dichorionic triplet pregnancy. Genotypes of the B and C embryos were assumed to be identical due to the observed monochorionicity. At 12 weeks and 5 days, the ultrasound findings were confirmed. As part of a Down syndrome risk assessment, nuchal translucency measurements were 1.9, 1.3 and 2.2 mm, for triplets A, B and C, respectively. Ultrasound at 18 weeks revealed a gender discrepancy between the monochorionic fetuses, with triplet B demonstrating normal appearing female external genitalia and triplet C demonstrating normal appearing male external genitalia. Fetus A was noted to be female. Due to the gender discrepancy, amniocentesis was performed on all three gestational sacs. Separate needle insertions were performed for each fetus. Following withdrawal

Correlations of placental perfusion and PlGF protein expression in early human pregnancy

The purpose of this study was to investigate temporal correlations between maternal serum placenta growth factor levels and placental perfusion in early human pregnancies. Systolic umbilical artery Doppler blood flow velocity indices at fetal and placental insertion sites were measured between 7 and 22 weeks of gestation from normal singleton pregnancies. Maternal serum placenta growth factor levels were determined by enzyme-linked immunosorbent assay. Maternal serum placenta growth factor levels showed an exponential increase at approximately 14 weeks of gestation. Placenta perfusion, as estimated by systolic Doppler blood flow indices, significantly increased with gestational age (P < .0001). There was a close association between placenta growth factor expression levels and evidence of increased placenta perfusion (P < .033). The significant increase in serum placenta growth factor coincides with the increased perfusion of the maternal/fetal interface at approximately 12 to 14 weeks of gestation. Correlation of placenta growth factor expression and placental perfusion suggests that placenta growth factor may contribute to assuring adequate vascular development/function of the placenta early in gestation.

Myometrial thickness during human labor and immediately post partum

Objective: Morphologic studies suggest dramatic, asymmetric uterine growth during pregnancy that is caused by muscle cell hypertrophy. This growth is most marked at the fundus. Our objective was to evaluate sonographically the in vivo changes in myometrial thickness during active labor, second-stage labor, and after delivery. Study design: Abdominal ultrasound scans were performed on 52 term pregnant women to investigate the dynamic changes in myometrial thickness during the active and second stages of labor and immediately after delivery. Twenty-six women (mean ± SEM gestational age, 39.09 ± 0.3 weeks) were in active labor (cervical dilatation >4 cm with regular uterine contractions). An additional 26 nonlaboring women (gestational age, 39.8 ± 0.2 weeks) provided control measurements. The myometrium was defined sonographically as the echo homogeneous layer between the serosa and the decidua. Myometrial thickness was measured at the low segment and mid anterior, fundal, and posterior uterine walls by the same observer. Myometrial thickness was also measured during uterine contractions and after artificial rupture of the amniotic membranes. All laboring women had uncomplicated labor patterns when studied and were delivered spontaneously. Results: The myometrium was significantly thinner during active labor compared with nonlabor at each site studied: midanterior (mean [±SEM] myometrial thickness, 5.8 ± 0.27 vs 8.83 ± 0.51 mm; t test, P < .001), fundus (mean myometrial thickness, 6.78 ± 0.32 vs 8.49 ± 0.35 mm; P = .0015), and posterior (mean myometrial thickness, 6.22 ± 0.34 vs 8.12 ± 0.30 mm; P < .001). However, myometrial thickness did not differ among sites within the two groups. The thickness of the low segment was not affected by labor status (nonlabor, 4.68 ± 0.48 vs labor, 4.66 ± 0.37 mm; P = .97). Similarly, the myometrial thickness of the anterior uterine wall was unaffected by contractions (no contractions, 5.56 ± 0.2 vs contractions, 5.68 ± 0.22 mm; t test, P = .654). There was no change in myometrial thickness measured immediately before and after rupture of the amniotic membranes, despite a significant decrease of the amniotic fluid index. There was significant thickening of the anterior and fundal myometrium during the second stage of labor after the fetal head descended to +3 station by digital examination (anterior, 12.99 ± 0.60 vs 5.8 ± 0.27 mm; t test, P < .001; fundus, 10.61 ± 1.63 vs 6.78 ± 0.32 mm; t test, P = .04). Valsalva maneuver (pushing) during contractions did not affect myometrial thickness at the fundus (between contractions, 10.61 ± 1.63 vs pushing, 10.76 ± 1.95 mm; t test, P = .99). Immediately after delivery, the myometrial thickness at the placental insertion site was the thinnest. After completion of the third stage of labor, the uterine fundus remained significantly thinner than the anterior and posterior walls (fundus, 27.37 ± 3.5 mm vs anterior, 40.94 ± 3.5 vs posterior, 42.34 ± 2.44; one-way analysis of variance, P = .02). Conclusion: There is significant and widespread thinning of the myometrium during active labor. Descent of the fetal head during the second stage of labor is associated with a significant relative thickening of the anterior and fundal myometrium. After delivery, the relationship reverses. These findings suggest the directionality of the expulsive force vectors (fundal dominance) is not determined by asymmetric myometrial growth but, rather, may be a function of increased “myometrial mass” that results from increased surface area at the fundus. (Am J Obstet Gynecol 2003;188:553-9.)

The Role of Ultrasound in Diagnosing and Managing a Monochorionic-Monoamniotic Twin Gestation With an Anencephalic Twin

This report presents a case of a monoamnioticmonochorionic twin gestation with a marginal placental insertion site, adjacent umbilical cords, entangled umbilical cords, abnormally long cords, one fetus affected with anencephaly, and another twin with no apparent abnormalities.