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Objective To investigate the prevalence of single and multiple umbilical cord cysts in the first trimester and to assess whether there is a difference in the pregnancy outcome between them. Methods A targeted sonographic morphological and morphometric evaluation of the umbilical cord was performed in consecutive patients between 7 and 14 weeks of gestation. Crown–rump length and umbilical cord diameter were measured in all cases. Nuchal translucency thickness was measured between 11 and 14 weeks' gestation. In pregnancies at very early gestational ages (7–10 weeks) an additional scan was performed between 11 and 14 weeks. Results A total of 1159 patients was screened. The prevalence of umbilical cord cysts was 2.1% (24/1159). The cysts were single and multiple in 18 and six cases, respectively. The median (range) largest umbilical cord cyst diameter was no different between multiple and single umbilical cord cysts (3.8 (2.1–18) mm vs. 3.05 (2.0–7.8) mm; P = 0.386). All women with a single umbilical cord cyst delivered an infant without structural abnormalities and without features suggestive of chromosomal abnormalities. Among the women with multiple umbilical cord cysts, four had a missed miscarriage and one had a fetus with obstructive uropathy. Conclusion Single and multiple umbilical cord cysts in the first trimester of gestation represent two different entities. While single cysts in the first trimester are associated with a favorable pregnancy outcome, the presence of multiple umbilical cord cysts is associated with an increased risk of miscarriage and aneuploidy. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To compare the umbilical cord diameter at 10– 14 weeks of gestation of chromosomally normal and abnormal fetuses. Methods In a consecutive series of women, who were undergoing routine sonographic evaluation at 10–14 weeks of gestation, umbilical cord diameter and nuchal translucency were measured. Reference ranges for umbilical cord diameter according to gestational age and crown–rump length were constructed. Fetal karyotype was obtained at chorionic villus sampling, amniocentesis or at delivery in newborns with features suspicious for chromosomal abnormalities. Results During the study period, 784 patients met the inclusion criteria. Of these, a fetal or placental chromosomal abnormality was present in 17 cases. The mean umbilical cord diameter increased with gestational age (r = 0.41, P < 0.001). The proportion of fetuses with an umbilical cord diameter above the 95th centile was higher in the presence of fetal or placental chromosomal abnormalities than in normal fetuses (5/17 vs. 39/767, P < 0.01). Among fetuses with an abnormal fetal or placental karyotype, nuchal translucency was above the 95th centile for gestational age in 10 cases. When only fetal chromosomal abnormalities were considered (n = 14), the combined detection rate was 85.7% (12/14). Conclusions Sonographic assessment of the umbilical cord in early gestation appears to identify a subset of fetuses at increased risk of chromosomal abnormalities.

Objectives Experimental and clinical evidence have shown that the morphometry of the umbilical cord in the second half of gestation might be useful in predicting adverse perinatal outcome. The purposes of this study were to generate a nomogram for the umbilical cord diameter in the first trimester and, in an observational study, to investigate whether the sonographic measurement of the umbilical cord diameter early in gestation has the same clinical value as that late in gestation. Methods The sonographic umbilical cord diameter, crown–rump length and biparietal diameter were measured in 439 fetuses at between 8 and 15 weeks of gestation. The perinatal outcome was recorded for all patients. Results The umbilical cord diameter increased steadily from 8 to 15 weeks of gestation. A significant correlation was found between umbilical cord diameter and gestational age (r = 0.78; P < 0.001), umbilical cord diameter and crown–rump length (r = 0.75; P < 0.001) and umbilical cord diameter and biparietal diameter (r = 0.81; P < 0.001). No correlation was found between umbilical cord diameter values and either birth weight or placental weight. Among patients who had a miscarriage (n = 7) and pre-eclampsia (n = 8) the umbilical cord diameter was below 2 standard deviations from the mean in three cases (42.9%) and three cases (37.5%), respectively. Conclusion The measurement of the umbilical cord diameter in the first trimester is correlated with the growth of the embryo and may be a marker for identifying a subset of fetuses at risk of spontaneous miscarriage and pre-eclampsia. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

Objectives To generate a nomogram for the sonographic measurement of Wharton’s jelly area (WJA) during gestation and to investigate whether WJA is related to fetal biometric parameters. Method The sonographic cross-sectional area of the umbilical cord and of its vessels was measured in 659 fetuses between 15 and 42 weeks of gestation. The WJA was calculated by subtracting the vascular area from the umbilical cord area. The conventional biometric parameters were measured and correlated with the WJA. Polynomial regression analysis was utilized for statistical purposes. Results The WJA increased as a function of gestational age (r = 0.63, P < 0.001). The regression equation for the mean WJA (y) according to gestational age (x) was y = −114.7 + 4.142x – 0.01x 2 and for the standard deviation (y′) was y′ = –7.567 + 1.319x. There was a strong correlation between the WJA and the umbilical cord area (r = 0.97, P < 0.001). A significant correlation was also found between the WJA and fetal biometric parameters before 32 weeks of gestation (WJA and biparietal diameter: r = 0.82, P < 0.001; WJA and abdominal circumference: r = 0.79, P < 0.001; WJA and femur length: r = 0.81, P < 0.001) while after 32 weeks of gestation no correlations were found between WJA and fetal anthropometric parameters. Conclusion A nomogram for the WJA has been generated. The WJA increases as a function of gestational age and it is correlated with fetal size up to 32 weeks of gestation.

Objective To evaluate whether umbilical vascular coiling is correlated with the umbilical vein blood flow profile and to investigate if this is different between fetuses with a lean and those with a normal umbilical cord. Methods Consecutive women with a singleton gestation who delivered at term and who underwent an ultrasound examination within 24 h from delivery were studied. Umbilical cord and vessel areas were calculated. Umbilical vein blood flow parameters were obtained by digital color Doppler velocity profile integration. After delivery, the umbilical coiling index was calculated. Results One hundred and sixteen women were studied. Twelve (10.3%) had a lean umbilical cord (area < 10th centile). A significant correlation was found between the umbilical coiling index and the umbilical vein blood flow (r = 0.67, P < 0.001). A significant difference between fetuses with and without a lean cord was found in terms of: umbilical coiling index (0.18 ± 0.08 vs. 0.29 ± 0.09, P < 0.005), cord area (87.6 ± 5.1 mm 2 vs. 200.6 ± 34.6 mm 2 , P < 0.001), Wharton’s jelly amount (25.7 ± 10.3 mm 2 vs. 122.1 ± 33.4 mm 2 , P < 0.001), umbilical vein blood flow (93.7 ± 17.8 ml/kg per min vs. 126.0 ± 23.4 ml/kg per min, P < 0.001), and umbilical vein blood flow mean velocity (6.6 ± 2.7 cm/s vs. 9.0 ± 3.6 cm/s, P < 0.05). The proportion of fetuses with an umbilical vein blood flow < 80 ml/kg per min was higher when the cord was lean than when it was normal (25% vs. 1.9%, P < 0.01). Conclusions Lean umbilical cords differ from normal cords not only from a structural point of view but also in the umbilical vein blood flow characteristics. This could explain the increased incidence of intrapartum complications and fetal growth restriction among fetuses with a lean and/or hypocoiled cord.

Objective To investigate whether the amount of Wharton's jelly in non-malformed fetuses with a single umbilical artery is different from that of fetuses with a normal umbilical cord. Methods We evaluated patients with singleton pregnancies, non-malformed fetuses and single umbilical artery undergoing sonographic evaluation at a gestational age ranging from 19 to 41 weeks' gestation. The cross-sectional areas of the umbilical cord and of the umbilical vessels were measured. The amount of Wharton's jelly was calculated by subtracting from the total cross-sectional area of the umbilical cord the areas of the artery and of the vein. The umbilical cord cross-sectional area, the umbilical artery and vein areas as well as the amount of Wharton's jelly were plotted on previously published nomograms. Results Twenty-two patients met the inclusion criteria. The umbilical cord cross-sectional area was within the normal range in 20 (90.1%) cases. The umbilical artery and vein areas were above 2 standard deviations from the mean in 20 cases and in 11 cases (50%), respectively. The amount of Wharton's jelly was below 2 standard deviations from the mean in all cases. An abnormal insertion of the umbilical cord (marginal, velamentous) was present in five cases (22.7%). Conclusions A reduction of Wharton's jelly is frequently present in cases of single umbilical artery. The increased perinatal morbidity and mortality observed in cases of single umbilical artery, even in the absence of congenital or chromosomal abnormalities, could be in part the consequence of a reduced amount of Wharton's jelly. Copyright © 1999 International Society of Ultrasound in Obstetrics and Gynecology

Objective The purpose of this study was to investigate whether the prenatal diagnosis of a ‘lean’ umbilical cord in otherwise normal fetuses identifies fetuses at risk of being small for gestational age (SGA) at birth and of having distress in labor. The umbilical cord was defined as lean when its cross-sectional area on ultrasound examination was below the 10th centile for gestational age. Method Pregnant women undergoing routine sonographic examination were included in the study. Inclusion criteria were gestational age greater than 20 weeks, intact membranes, and singleton gestation. The sonographic cross-sectional area of the umbilical cord was measured in a plane adjacent to the insertion into the fetal abdomen. Umbilical artery Doppler waveforms were recorded during fetal apnea and fetal anthropometric parameters were measured. Results During the study period, 860 patients met the inclusion criteria, of whom 3.6% delivered a SGA infant. The proportion of SGA infants was higher among fetuses who had a lean umbilical cord on ultrasound examination than among those with a normal umbilical cord (11.5% vs. 2.6%, p < 0.05). Fetuses with a lean cord had a risk 4.4-fold higher of being SGA at birth than those with a normal umbilical cord. After 25 weeks of gestation, this risk was 12.4 times higher when the umbilical cord was lean than when it was of normal size. The proportion of fetuses with meconium-stained amniotic fluid at delivery was higher among fetuses with a lean cord than among those with a normal umbilical cord (14.6% vs. 3.1%, p < 0.001). The proportion of infants who had a 5-min Apgar score < 7 was higher among those who had a lean cord than among those with normal umbilical cord (5.2% vs. 1.3%, p < 0.05). Considering only patients admitted in labor with intact membranes and who delivered an appropriate-for-gestational-age infant, the proportion of fetuses who had oligohydramnios at the time of delivery was higher among those who had a lean cord than among those with a normal umbilical cord (17.6% versus 1.3%, p < 0.01).

were beneath the 3rd centile. The patient was counselled regarding the poor prognosis for this fetus. The patient elected to continue with the pregnancy. Repeated scans at 20, 21, 24, 26, and 27 weeks showed persistent oligohydramnios with the mean pool depth decreasing from 17 mm to 15 mm. From 20 weeks umbilical artery Doppler showed absent end-diastolic flow, although this never reversed. At 28 + 1 weeks’ gestation, the patient presented with antepartum haemorrhage, and uterine contractions. Ultrasound confirmed fetal viability. Labour progressed spontaneously, a female infant with a birthweight of 355 g was delivered with APGAR scores of 3 at 1 minute, and 8 at 5 minutes. The infants abdominal circumference was 24.5 cm and head circumference was 21.5 cm, both beneath the 3rd centile for gestation age and gender. The placenta was noted to be extremely small and gritty. The infant had an uneventful neonatal period with no evidence of respiratory distress, necrotising enterocolitis, intracranial damage or infection. Chromosomal analysis was normal. She was discharged at 95 days of age. Despite severe placental insufficiency as diagnosed by Doppler ultrasound this fetus survived to extra-uterine life. It is hypothesised that the second wave of trophoblastic invasion failed, leading to a period of chronic physiological stress in the fetus allowing it to survive.

combined with antibiotics given i.v. or orally. Successful treatment we defined as a patient in good health after 3 months, without clinical symptoms or laboratory signs of infection. Unsuccessful treatment we defined as relapse of TOA in less than 3 months or patients that had surgery in the form of laparoscopy or laparatomy for abscess/organ removal in less than 3 months. Results: The immediate success rate according to our definition was 94% for the whole material. If however, we compare the period 1986 to 1990 (5 years) with 2000 to 2002 (3 years) we see an improved success rate from 88 % to 97 %. The rate of success was not influenced by age, parity, earlier PID, size of abscess or universus bilateral abscess. As for the longterm outcome, 8% have had a new episode of TOA, which in almost all cases have been successfully treated in the same way as the first. In patients operated on more than 3 months after successful treatment, no rest of abscess was found. 25% of patients under 40 years have become pregnant after treatment. Conclusion: This method of treating TOA is simple, cheap and safe. We have had no major complications. With respect to the immediate success and longterm outcome, we recommend this as the method of choice for treatment of TOA.

manifestations of the underlying hemodynamic imbalance may be present as early as the first trimester of gestation and may have a profound impact on the development of the UC angioarchitecture. Methods: Twenty four consecutive monochorionic twins with TTTS were included into the study. The length of one complete umbilical vascular coil (distance between the right outer surface of consecutive arterial coils) was measured in a longitudinal section of the UC. The coiling index (CI), defined as the reciprocal value of that measurement, was calculated. The UC coiling pattern was classified as normal or abnormal [uncoiled, hypocoiled (CI 90th centile)] according to local reference ranges. Atypical (uncoordinated, supercoiling) coiling was classified according to Raio et al. (ISUOG 2003, OC 205). Results: Nine (37.5%) and 8 (33.3%) cases were treated with endoscopic laser coagulation and amnionreduction, respectively. In the remaining 7 (29.2%) cases, no treatment was undertaken. The surviving rate was 72.2%, 56.3%, and 21.4% in the laser, amnioreduction and no treatment group, respectively. The donor twin showed in 22 (91.7%) cases a less twisted UC than the recipient twin. Of these, 12 (54.5%) were uncoiled and 5 (22.7%) hypocoiled. On the other hand, the UCs of recipient twins were characterized by a high percentage of atypical [4 (16.7%) with supercoiling, and 8 (33.3%) with uncoordinated coiling], and abnormal coiling patterns [4 (16.7%) with hypercoiling, 2 (8.3%) hypocoiling]. Only 13 (27.1%) cases had a CI within normal ranges for gestational age. In one case informations on UC angioarchitecture was available from the first trimester and the UCs were uncoiled and atypical, respectively. Conclusions: Monochorionic twins with TTTS have different UC coiling patterns.

Objective: to evaluate the morbidity and mortality rate of IUGR fetuses correlated to Doppler velocimetry, FHR tracing, BPP and AFI. Methods: a multicenter prospective study of 246 fetuses with ultrasound diagnosis of IUGR. Among them 186 met the study entry criteria. The study group underwent Doppler velocimetry study of UA, MCA, DV and UV twice weekly, BPP and AFI twice weekly and FHR tracing daily. IUGR fetuses were divided into two groups: Group 1 IUGR fetuses with Doppler velocimetry abnormality; Group 2 with normal Doppler velocimetry. In Group 1 the type and time passing from Doppler alteration to birth were documented. Apgar score, pH at birth, need of intubation, RDS, IVH, PVL, days of NICU hospitalization were available and related to neonatal outcome. Results: Gestational age at time of admission ranged from 16.1 to 40 weeks. One hundred IUGR fetuses showed Doppler velocimetry alteration while sixty-eight fetuses did not show Doppler alteration (Group 2). In Group 1 morbidity and mortality rate were significantly correlated with the type of Doppler velocimetry abnormality and with time passing from the latter finding and delivery being higher in fetuses with AEDF, RF in UA with a time >72 hours from the Doppler abnormality and delivery. Conclusions: Doppler velocimetry should be performed in IUGR fetuses as its findings help to reduce morbidity and mortality rate. There is a significant correlation between the type of alteration and time passing from alteration to birth.

Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic aspects of the UC have usually been studied by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes, respectively. Of note, lean UC in the second and third trimester differs from normal UC not only from a structural point of view but also in the umbilical vein blood flow characteristics. On the other hand a thin UC in the first trimester seems to be a marker for identifying a subset of fetuses at risk for spontaneous abortion and pre-eclampsia. A Wharton's jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric and morphologic UC characteristics as well as UC arterial and venous blood flow parameters in normal and pathologic conditions will be presented and discussed.

Background Abnormalities of the umbilical cord size have been associated with the growth of the fetus (Raio et al. Ultrasound Obstet Gynecol 1999; 13: 176). Therefore, this study was undertaken to generate a nomogram for the amount of Wharton's jelly (WJA) during gestation and to investigate whether it is related to fetal biometric parameters. Method The sonographic cross-sectional area of the umbilical cord and of its vessels was measured in 627 healthy fetuses between 15 and 42 weeks of gestation. The WJA was calculated subtracting the vascular area from the umbilical cord area. The conventional biometric parameters were measured. Results The WJA increases as a function of gestational age (r = 0.63, P