A singleton pregnancy with five loops of nuchal cord and multiple fibroids
YY Liaw1, M Herreck1, M Elrabat1, A Mohamed1, 1The Royal Wolverhampton NHS Trust, UK
Objective
This case report describes the management of a
singleton pregnancy complicated by the presence
of high order nuchal cords and multiple large
uterine fibroids.
Case summary
Discussions
Higher-order nuchal cord
• Three or more loops around the neck, considered complex
umbilical cord entanglement (1).
Is operative delivery indicated?
• Nuchal cord alone is not an indication (2), but multiple tight
loops may cause fetal distress (3).
• Higher-order nuchal cords are associated with increased
intrapartum complications such as meconium staining, lower
Apgar scores, and a higher likelihood of requiring Caesarean
delivery (4-9).
A 31-year-old nulliparous with multiple fibroids,
including one measuring 20cm, was monitored
throughout her pregnancy.
At 35 weeks, a scan was done by fetal medicine
specialist for fibroid mapping.
Fibroids were clear of the cervical os.
However, there were five loops of cord around
fetal neck (Figure 1 and 2). Estimated fetal weight
was on the ninth centile.
A repeat scan two weeks later showed persistent
findings.
After multidisciplinary team meeting and careful
counselling, she underwent an elective caesarean
section and myomectomy (see Figure 3-6)
Figure 1 Two-dimensional cross-sectional
ultrasound images at 34 + 6 weeks' gestation,
showing five loops of umbilical cord around
fetal neck.
Figure 2 Two-dimensional colour Doppler
ultrasound images at 34 + 6 weeks' gestation,
showing five loops of umbilical cord around
fetal neck.
Conclusions
This case highlights the importance of a tailored approach when
managing pregnancies with nuchal cords and fibroids. Prenatal
diagnosis via ultrasound and expert management can prevent
adverse outcomes. Furthermore, with appropriate planning and
surgical expertise, caesarean myomectomy can be performed
safely, ensuring optimal maternal and fetal health outcomes.
Figure 3 Five loops of tight cord around fetal
neck was noted at delivery. Birthweight of the
baby was on 1.56th centile.
References
1. Sherer, D.; Roach, C.; Soyemi, S.; Dalloul, M. Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Complex
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2. Mahendra G et al., Sch. J. App. Med. Sci., 2015; 3(1C):175-177
3. AA Begum, H Sultana, R Hasan, M Ahmed; A Clinical Study of Fetal Outcome in Cases of Nuchal Cord. JAFMC Bangladesh. Vol 7, No 1 (June) 2011; 25-2
4. G Singh, K Sidhu, Nuchal Cord : A Retrospective Analysis, Medical Journal Armed Forces India, Volume 64, Issue 3, 2008, Pages 237-240, ISSN 0377-1237,
https://doi.org/10.1016/S0377-1237(08)80102-5.
5. Peesay, M. Nuchal cord and its implications. matern health, neonatol and perinatol 3, 28 (2017). https://doi.org/10.1186/s40748-017-0068-7
6. Schreiber, H., Daykan, Y., Arbib, N. et al. Adverse pregnancy outcomes and multiple nuchal cord loops. Arch Gynecol Obstet 300, 279–283 (2019).
https://doi.org/10.1007/s00404-019-05178-w
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Cohort Study. Pediatric Reports. 2022; 14(1):40-47. https://doi.org/10.3390/pediatric14010007
8. E. Assimakopoulos, M. Zafrakas, P. Garmiris, D.G. Goulis, A.P. Athanasiadis, K. Dragoumis, et al., Nuchal cord detected by ultrasound at term is associated
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doi: 10.18689/mjwh-1000110
Individualized approach
• Inconclusive literature regarding the association
between nuchal cords and adverse perinatal
outcomes, especially if more than three loops.
• In view of presence of both nuchal cords and large
fibroids, a multidisciplinary team meeting was held
to discuss the safest mode of delivery.
• The decision to proceed with elective caesarean
delivery in this case was influenced by several factors
• Small-for-gestational-age fetus - high likelihood of
acute fetal distress during labour requiring
emergency intervention.
• To avoid the potential delay in emergency delivery
of baby due to surgical difficulty posed by the large
fibroids
Figure 5
Figure 4 The largest fibroid (maternal left)
was as large as the gravid uterus (maternal
right). A midline skin incision was made to
allow adequate access.
Figure 5 and 6: After uterine closure,
myomectomy was performed. The
largest fibroid was a subserosal fibroid
extending up to liver and adhering to
the anterior abdominal wall. The
fibroid was cystic in nature and
ruptured while being separated from
the anterior abdominal wall.
All figures are obtained with consent from patient.