Obstet Gynecol Sci.  2016 Sep;59(5):388-392. 10.5468/ogs.2016.59.5.388.

Umbilical cord ulceration: An underdiagnosed entity

• Maheshwari B
• Roy M
• Agarwal S
• Devi S
• Singh A
• Khurana N
• Gupta S

• KMID: 2391689
• DOI: http://doi.org/10.5468/ogs.2016.59.5.388

Abstract

Umbilical cord ulceration is a rare condition presenting with sudden fetal bradycardia due to fetal hemorrhage and in most cases leading to intrauterine death. A strong association with intestinal atresia has been reported. Most cases present after 30 weeks of gestation, with preterm labor or rupture of membranes followed by sudden fetal bradycardia. We report two such cases of umbilical cord ulceration and review the available literature. One of the cases interestingly presented at 26 weeks, much earlier than what is reported in the world literature. In view of high perinatal mortality and morbidity, awareness of this condition is mandatory for timely and appropriate management to improve the fetal outcome.

Keyword

Intestinal atresia; Intrauterine hemorrhage; Umbilical cord ulcer; Whartson's jelly

MeSH Terms

Bradycardia
Female
Hemorrhage
Intestinal Atresia
Membranes
Obstetric Labor, Premature
Perinatal Mortality
Pregnancy
Rupture
Ulcer*
Umbilical Cord*

Figure

• 

  Fig. 1 Case 1. (A) Gross specimen showing surface ulceration of the umbilical cord with overlying hematoma. (B) Microscopic counterpart showing breach in the amniotic epithelium (H&E, ×100) (arrow). (C) Section showing umbilical vessel dilatation with focal rupture and hemorrhage into adjoining perivascular space (H&E, ×100). (D) Section at another level of the cord showing two uninvolved vessels (arrows). There is evidence of aneurysmal dilatation of the third vessel with marked loss of its muscular wall (H&E, ×100). Adjoining Wharton's jelly is showing hemorrhage and degeneration (inset; H&E, ×200) is noted.

• 

  Fig. 2 Case 2. (A) Section showing aneurysmal dilatation of two of the umbilical vessels (arrows) (H&E, ×100), dilatation and rupture of the umbilical vessel (inset; H&E, ×400). (B) Surface hemorrhage, an indirect evidence of focal breach in the amniotic epithelium (H&E, ×200).

Reference

1. Bendon RW, Tyson RW, Baldwin VJ, Cashner KA, Mimouni F, Miodovnik M. Umbilical cord ulceration and intestinal atresia: a new association? Am J Obstet Gynecol. 1991; 164:582–586.

2. Ohyama M, Itani Y, Ishikawa H, Tanaka Y. Is umbilical cord ulcer associated with congenital upper intestinal atresia so rare? Japanese case series and review of the literature. Fetal Diagn Ther. 2010; 28:236–237.

3. Yamanaka M, Ohyama M, Koresawa M, Kawataki M, Ohsaki I, Tanaka Y. Umbilical cord ulceration and intestinal atresia. Eur J Obstet Gynecol Reprod Biol. 1996; 70:209–212.

4. Shimizu S, Kawagishi R, Arimoto-Ishida E, Wada K, Shimoya K, Murata Y. Fetal hemorrhage associated with congenital intestinal atresia. J Obstet Gynaecol Res. 2003; 29:312–316.

5. Chan SS, Lau AP, To KF, Leung TY, Lau TK, Leung TN. Umbilical cord ulceration causing foetal haemorrhage and stillbirth. Hong Kong Med J. 2008; 14:148–151.

6. Altshuler G, Arizawa M, Molnar-Nadasdy G. Meconium-induced umbilical cord vascular necrosis and ulceration: a potential link between the placenta and poor pregnancy outcome. Obstet Gynecol. 1992; 79(5 Pt 1):760–766.

7. Anami A, Morokuma S, Tsukimori K, Kondo H, Nozaki M, Sueishi K, et al. Sudden fetal death associated with both duodenal atresia and umbilical cord ulcer: a case report and review. Am J Perinatol. 2006; 23:183–188.

8. Ohyama M, Itani Y, Yamanaka M, Imaizumi K, Nishi T, Ijiri R, et al. Umbilical cord ulcer: a serious in utero complication of intestinal atresia. Placenta. 2000; 21:432–435.

9. Ichinose M, Takemura T, Andoh K, Sugimoto M. Pathological analysis of umbilical cord ulceration associated with fetal duodenal and jejunal atresia. Placenta. 2010; 31:1015–1018.

10. Miyake H, Yamamoto A, Yamada T, Okazaki K, Morita K, Kondo M, et al. Umbilical cord ulceration after prenatal diagnosis of duodenal atresia with interstitial deletion of chromosome 13q: a case report. Fetal Diagn Ther. 2008; 24:115–118.

11. Nijagal A, Rand L, Goldstein R, Poder L, Miniati D. Intrauterine umbilical cord hemorrhage with associated jejunal atresia captured by real-time ultrasound. Am J Obstet Gynecol. 2009; 200:e5–e6.