Early prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies.
OBJECTIVE
Cord entanglement is a severe complication in monoamniotic multiple pregnancies. Three cases were reviewed to determine how early ultrasound diagnosis might improve counselling and management.


METHODS
In two monoamniotic twin and one dichorionic diamniotic triplet pregnancies, cord entanglement was detected between 10 and 18 gestational weeks by color Doppler and pulsed Doppler velocimetry. Pregnancies were followed up on a weekly basis with special observation of fetal behavior and use of color Doppler velocimetry.


RESULTS
In Case 1, a monoamniotic twin pregnancy with cord entanglement close to the umbilical insertions was diagnosed at 10 weeks. Longitudinal follow-up showed intrauterine death of both twins at 15 weeks. In Case 2, entanglement of the umbilical cords of two monoamniotic triplets within a dichorionic diamniotic triplet pregnancy was diagnosed at 10 weeks. The pregnancy continued uneventfully until 35 weeks when cord entanglement was confirmed at Cesarean section. All triplets have since developed normally. In Case 3, monoamniotic twins were diagnosed at 18 weeks. Color Doppler detected side-by-side insertion of the umbilical cords and Doppler velocimetry suggested an entanglement at the chorionic plate. The pregnancy was complicated by polyhydramnios. Cesarean section at 36 weeks confirmed cord entanglement at the chorionic plate. Postnatal computer angiography and morphological examination of the placenta showed the presence of superficial artery-to-artery and vein-to-vein anastomoses and of deep arteriovenous shunts. The development of the twins was uneventful.


CONCLUSIONS
Diagnosis of cord entanglement is feasible early in gestation. Future protocols are proposed to document the gestational age at detection, the location, and the Doppler flow patterns and to facilitate the assessment of short- and long-term development.
Arabin
B
B
Department of Perinatology, Isala Hospital, Zwolle, The Netherlands.
Laurini
R N
RN
van Eyck
J
J
D000328:Adult; D000650:Amnion / Q000000981:diagnostic imaging; D000792:Angiography; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging; D002585:Cesarean Section; D002823:Chorion / Q000000981:diagnostic imaging; D005260:Female; D005313:Fetal Death / Q000000981:diagnostic imaging; D005315:Fetal Diseases / Q000000981:diagnostic imaging*; D005500:Follow-Up Studies; D005865:Gestational Age; D006801:Humans; D010920:Placenta / Q000098:blood supply / Q000000981:diagnostic imaging; D011247:Pregnancy; D011272:Pregnancy, Multiple; D012212:Rheology; D014310:Triplets; D014427:Twins; D018615:Ultrasonography, Doppler, Color; D018617:Ultrasonography, Doppler, Pulsed; D016216:Ultrasonography, Prenatal; D014469:Umbilical Arteries / Q000000981:diagnostic imaging; D014470:Umbilical Cord / Q000000981:diagnostic imaging*; D014471:Umbilical Veins / Q000000981:diagnostic imaging