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Objective. The purpose of this study was to evaluate the sonographic accuracy to determine the
umbilical coiling index (UCI) during the routine fetal anatomic survey in the second trimester.
Methods. In 300 consecutive women with singleton pregnancies and absence of gross fetal anomalies who had a routine second-trimester fetal anatomic survey, a distance between 2 pairs of coils was
measured from the longitudinal images of the umbilical cord, and the antenatal UCI (aUCI) was calculated. The aUCI was compared with true UCI results obtained after birth. Results. Two hundred thirty-six patients had adequate sonographic umbilical cord images, and all required demographic,
antenatal, and labor data collection to meet the inclusion criteria. A statistically significant correlation
between aUCI and true UCI was found (P < .0001; r = 0.643). The mean aUCI was 0.402 (80% confidence interval, 0.382), and the true UCI at birth was 0.203 (80% confidence interval, 0.176). The
sonographic evaluation showed 12.3% and 8.9% of hypocoiled and hypercoiled cords, whereas evaluation at birth found 10.6% and 8.1% hypocoiled and hypercoiled umbilical cords, respectively. The
sensitivity values of sonography to predict hypocoiling and hypercoiling at birth were 78.9% and
25.4%, respectively. Conclusions. A sonographic evaluation of umbilical cord coiling in the second
trimester correlates with the true UCI at birth, although the sensitivity in predicting coiling patterns as
hypocoiled and hypercoiled cords is less accurate. A difference between the aUCI and matched UCI at
birth could be explained by a sonographic error in the sampling of different umbilical cord segments
with discordant coiling patterns or the possibility of a dynamically evolving UCI with advancing gestational age. Key words: coiling index; sonography; umbilical coiling.
Abbreviations
aUCI, antenatal umbilical coiling index; UCI, umbilical
coiling index
2005 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2005; 24:185191 0278-4297/04/$3.50
Predanic et al
Results
During the study period, a total of 331 pregnancies had fetal anatomic scans performed
between 18 and 23 weeks gestation. Thirty-one
patients were excluded on the basis of multifetal
pregnancy (21 patients), fetal anomalies (7
patients), and the presence of a 2-vessel umbilical cord (3 patients). From the remaining 300
consecutive patients who were initially included
in the study, only 236 had adequate sonographic
umbilical cord images and all demographic,
antenatal, and labor data to meet the inclusion
criteria. The mean gestational age SD was 20.4
0.9 weeks, and the mean maternal age was 31.8
5.1 years (range, 1447 years), with median parity of 0 (range, 05). Most patients gave birth at
Figure 1. Longitudinal (axial) sonogram of the umbilical cord
with the normal UCI (normally coiled). A distance of 22.6 mm
was measured between the 2 pairs of coils from the inner edge
of the artery to the outer edge of the same artery at the adjacent umbilical twist along the ipsilateral cord side.
187
90th percentile
Mean
10th percentile
Sonographic Examination
aUCI
Distance, cm
0.592
0.402
0.21
1.67
2.49
4.80
UCI
Delivery
Distance, cm
0.291
0.203
0.115
3.44
4.93
8.69
Discussion
The umbilical cord is the major fetomaternal
unit that provides communication between the
placenta and the fetus. However, it is a part of the
fetal anatomy and may be prone to compression,
tension, or torsion, with subsequent interruption
of blood flow. It is thought that coiling provides a
protective effect to these forces, therefore securing an interrupted blood supply to the fetus. The
true etiology of umbilical coiling is unclear, but it
is thought to result from fetal movement as well
as unequal vascular growth.10,11 It appears that
the umbilical coiling pattern is established in the
first trimester, although the presence of a mixed
coiling pattern and even reversal of the coiling
direction in third trimester have been shown.9
We observed a significant correlation between
the aUCI and true UCI at term. The provided
Figure 4. Sonogram of a hypocoiled umbilical cord with a
straight vein and sparsely coiled arteries.
Figure 3. Distribution of the normal and abnormal coiling patterns obtained by the sonographic evaluation and after delivery.
188
Predanic et al
Figure 5. Sonogram of a hypercoiled cord in which the umbilical vein and adjacent arteries are twisted as a single unit rather
than arteries twisting at a higher rate around the umbilical vein,
such as in Figure 1.
189
UCI at Birth
Hypocoiled Normally Coiled Hypercoiled
>90th percentile
10th90th percentiles
<10th percentile
Total
0
4
15
19
15
163
14
192
6
19
0
25
Total
21
186
29
236
Cutoff values for 10th and 90th percentiles are presented in Table 1.
cords. It is also possible that the error in measurement is more common if hypercoiling is present. In addition, poor sensitivity of sonography
for accurately describing cord coiling could be
found in differences between coiling patterns
at the different cord segments. Substantially
increased coiling was found at the fetal end of the
umbilical cord when compared with the middle
segment (free loop) and placental end.13 At the
same time, concordant hypocoiling and hypercoiling were found in only 4.4% and 6.3% of cases,
respectively, when the fetal versus placental cord
ends were compared. Nevertheless, the mean
sonographic UCI obtained in the middle of the
cord (free loop) would be the approximate arithmetic mean of the UCI at the fetal and placental
ends.9
In addition, we observed small proportions of
umbilical cords (4.2%) with twisting patterns in
which substantial coiling of the vein around the
straight or minimally coiled arteries was noted.
These cords were mainly labeled as hypercoiled
(6 of 10) and were likely a consequence of different growth rates between the vein and umbilical
arteries (the presumed case of false knots).
In conclusion, prenatal sonographic evaluation
of umbilical cord coiling during the secondtrimester fetal anatomic survey is accurate
enough to predict true coiling at birth if the aUCI
is obtained in an adequate and standardized
manner. The distance between the 2 pairs of coils
should be measured by placement of both
calipers along the ipsilateral side of the longitudinal umbilical cord image. The true accuracy of
the abnormal coiling determined by sonography
in the second trimester of gestation and its relationship with adverse pregnancy outcome are to
be determined in future studies.
References
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Predanic et al
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Rana J, Ebert GA, Kappy KA. Adverse perinatal outcome in patients with an abnormal umbilical coiling
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Ezimokhai M, Rizk DE, Thomas L. Maternal risk factors for abnormal vascular coiling of the umbilical
cord. Am J Perinatol 2000; 17:441445.
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Qin Y, Lau TK, Rogers MS. Second-trimester ultrasonographic assessment of the umbilical coiling
index. Ultrasound Obstet Gynecol 2002; 20:458
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