title: Cord insertion into the lower third of the uterus in the first trimester is associated with placental and umbilical cord abnormalities.
abstract: OBJECTIVE
  To assess the feasibility of detecting the cord insertion site during the late first trimester, and to investigate the possible association between perinatal complications and a cord insertion in the lower third of the uterus in the first trimester.
  
  
  METHODS
  This was a prospective cohort study in which the positional relationship between the uterus and the cord insertion site was examined using gray-scale transvaginal sonography at 9-11 weeks of gestation. The distance between the internal os and the fundus was divided equally into three parts. Cord insertions located in the upper or middle thirds were defined as normal (controls), and those located in the lower third were defined as cases, regardless of their relationship to the chorion villosum. Third-trimester sonography and pathological examination of the placenta and cord at delivery were performed to check for placental/cord abnormalities. The univariate association between the location of the cord insertion in the first trimester and placental and umbilical cord abnormalities and perinatal complications was assessed.
  
  
  RESULTS
  The cord insertion site was identified in 318/340 (93.5%) cases at 9-11 weeks of gestation and it was in the lower third of the uterus in 35 (11.0%) cases. Of these 35, the cord insertion was found at delivery to be low in nine cases (26%) and the placenta was low-lying at delivery in eight (23%). None of the 283 cases with a normal cord insertion in the first trimester was found to have a low-lying placenta at delivery (P < 0.0001). Ten (29%) of the cases with a low cord insertion and four (1.4%) with a normal cord insertion in the first trimester had a velamentous or marginal cord insertion at delivery (P < 0.0001). At delivery, five (14%) of the low cord insertion cases and four (1.4%) of the normal cord insertion cases (P < 0.0001) had some form of placental malformation, including accessory placenta and infarction of the placenta. An emergency Cesarean section was performed in four (11%) and six (2.1%) of the low and normal cord insertion cases, respectively (P = 0.003).
  
  
  CONCLUSIONS
  Developmental abnormalities of the placenta and umbilical cord occur frequently in cases in which the cord insertion is in the lower third of the uterus in the first trimester. We suggest that screening for the cord insertion site at 9-11 weeks of gestation may have clinical significance for predicting abnormalities of the cord and the placenta at delivery.
authors.affiliation: Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan. hasejun@oak.dti.ne.jp
authors.forename: J
authors.initials: J
authors.lastname: Hasegawa
authors.forename: R
authors.initials: R
authors.lastname: Matsuoka
authors.forename: K
authors.initials: K
authors.lastname: Ichizuka
authors.forename: K
authors.initials: K
authors.lastname: Otsuki
authors.forename: A
authors.initials: A
authors.lastname: Sekizawa
authors.forename: A
authors.initials: A
authors.lastname: Farina
authors.forename: T
authors.initials: T
authors.lastname: Okai
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D010922:Placenta Diseases / Q000000981:diagnostic imaging / Q000209:etiology*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011261:Pregnancy Trimester, First; D018566:Pregnancy, High-Risk; D011446:Prospective Studies; D016216:Ultrasonography, Prenatal / Q000379:methods / Q000592:standards*; D014470:Umbilical Cord / Q000002:abnormalities* / Q000000981:diagnostic imaging