OP-06 Umbilical cord torsion

Objective

Our aim was to present 3 cases of umbilical cord torsion during pregnancy. Methods: We detected 3 cases of umbilical cord torsion in the period covering 2022 and 2023 in our clinic. The data and information of these cases were obtained retrospectively from hard copy files and electronic records.

Cases

In all three cases, the main complaint was related to fetal movements.1st case: A 25-year-old gravida 1 woman at the 32nd week of gestation admitted to our clinic with the complaint of decreased fetal movements. Oligohydramnios and decelarations on nonstress test were the main findings. Fetal biophysical profile score was determined as 2 (only fetal tone was 2 points). As a result of emergency cesarean section, a fetus weighing 1850 grams was delivered with an Apgar score of 4 at the 1st minute. He was discharged in good health after 1 month in the neonatal intensive care unit.2nd case: A 30-year-old gravida 2 woman at the 36 weeks and 4 days of gestation, presented to our clinic with the complaint of decreased fetal movements. On ultrasonographic evaluation estimated fetal weight was consistent with 33 weeks and 2 days which led us to a diagnosis of fetal growth retardation. Oligohydramnios was present and the nonstress test was found to be non-reactive. Fetal biophysical profile score was getting 2 points only from fetal breathing movements. Emergency cesarean section was performed and a fetus weighing 1920 grams was delivered with an Apgar score of 8 at the 1st minute.3rd case: A 31-yearold gravida 1 woman at the 37 weeks and 3 days of gestation admitted to our clinic with the complaint of not feeling fetal movements. Estimated fetal weight was consistent with 37 weeks and 5 days and amniotic fluid index was normal on ultrasound examination, however intrauterine fetal death was detected. Nonstress test was reactive 1 week ago. 3300 gram ex fetus was delivered vaginally. 

Discussion

Umbilical cord torsion describes excessive twisting in any part of the cord. Cord torsion may cause fetal growth retardation, oligohydramnios and hypoxia by causing impaired blood flow, however sometimes it can cause fetal death by obstructing fetoplacental blood flow. [1, 2, 3]In line with the literature, we detected oligohydramnios in two cases, fetal growth retardation in one case and intrauterine fetal death in one case. Multiparity, longer umbilical cord and maternal age ≥ 35 years have been reported as risk factors for cord torsion. The incidences of fetal distress, fetal heart rate abnormalities during labor, meconium stained amniotic fluid, cesarean deliveries, instrumental vaginal deliveries and emergency cesarean deliveries were significantly higher in patients with cord torsion. [2] In accordance with the literature information, fetal distress findings were found in the nonstress test in two of our cases and their deliveries were performed by emergency cesarean section. Since cord torsion effects blood flow and abnormal coiling (hypocoiling is associated with decreased flow indices in the umbilical vein, while hypercoiling coiling is associated with a pulsatile pattern of the umbilical venous flow velocity waveforms) can result in fetal growth restriction and fetal demise, we think that Doppler evaluation of umbilical artery and middle cerebral artery blood flow and evaluation of umbilical coiling index in the third trimester may be effective in preventing adverse obstetric results. 

Conclusion

As seen in our case series, decreased or abscent fetal movements are the main symptoms of cord torsion, and fetal biophysical profile score is an useful and easy way of detecting a compromised fetus. In case of decreased fetal movements, the well-being of the fetus should be evaluated in detail and cord torsion should be considered.

Keywords

Fetal distress, fetal well-being umblical kord, torsion

1. Ben-Arie A, Weissman A, Steinberg Y, Levy R, Hagay Z. Oligohydramnios, intrauterine growth retardation and fetal death due to umbilical cord torsion. Arch Gynecol Obstet.  1995;256(3):159-61. 
2.  Chen R, Yan J, Han Q, Zheng L. Factors related to morbidity and maternal and perinatal outcomes of umbilical cord torsion. J Int Med Res. 2020 Mar;48(3):300060520905421.
3. Fleisch MC, Hoehn T. Intrauterine fetal death after multiple umbilical cord torsion-complication of a twin pregnancy following assisted reproduction. J Assist Reprod Genet. 2008 Jun;25(6):277-9.
4. de Laat MW, Franx A, van Alderen ED, Nikkels PG, Visser GH. The umbilical coiling index, a review of the literature. J Matern Fetal Neonatal Med. 2005 Feb;17(2):93-100. 

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