Spontaneous umbilical cord hematoma diagnosed antenatally with ultrasonography

Abstract

Umbilical cord abnormalities include aneurysms, true knots, false knots, hematoma, etc. Spontaneous umbilical cord hematoma is a rare anomaly, which has an estimated incidence of approximately 1 in 5000 deliveries (1, 2). The complications of this anomaly are uneventful pregnancy, fetal distress, or even intrauterine fetal death (1). We present the case of spontaneous umbilical cord hematoma diagnosed antenatally with ultrasonography, with the baby being successfully delivered vaginally. A female infant weighing 2440 g was born vaginally at 37 weeks of gestation to a healthy 22-year-old mother who had a history of previous cesarean section. The woman had no family history of congenital anomalies and had taken no medications during her pregnancy. During routine prenatal examinations, the woman had normal results in routine serum screenings, including β-HCG and αFP. The result of the ultrasonographic examinations at 30 weeks of gestational age (see Fig. 1) showed an abnormal hypoechoic mass 3.45 × 3.37 × 2.86 cm. The mass did not show any blood flow and pulsatility inside the umbilical cord adjacent to the fetus. Continuous follow ups of this mass with color Doppler ultrasonography was obtained every 2 weeks in the prenatal care clinic until delivery. The Apgar scores of the infant were 8 at 1 min and 9 at 5 min after birth. Ultrasound picture of the umbilical cord hematoma at 30 weeks of intrauterine life. We can see the mass adjacent to the fetus and placenta. At birth, the infant was noted to have a large umbilical cord mass (10 × 6 × 6 cm), which was 1 cm proximal to the infant. The length of the cord was 50 cm with two arteries and one vein. No true or false knots were noted in the cord (see Fig. 2). She was referred to our pediatric department for the assessment and removal of the umbilical cord. The infant was normal and fully developed in appearance except for being underweight for the gestational age. Infant with the umbilical cord hematoma a few minutes after delivery. We can see the dilated hemorrhagic cyst at approximately 1 cm from the cord insertion to the infant. The microscopic findings showed a picture of umbilical cord hematoma with fresh blood clots within the cystic lumen. Focal fibrin thrombus formation, dilatation, and destruction of the umbilical artery wall were seen in one microscopic field. The risk factors of having spontaneous umbilical cord rupture include infection, traction on a short umbilical cord, torsion of the cord, abdominal trauma in pregnancy, laceration of the umbilical cord during amniocentesis, venopuncture of the umbilical vein, post maturity pregnancy, congenital defect, and calcification after syphilitic infection (2, 3). In our case, the length of the cord was within normal range, and no histories of amniocentesis or abdominal trauma were noted during her pregnancy. The rupture hole was found in one of the two umbilical arteries. This finding is rarely reported in the literature. The possibility of chromosomal anomaly is remote. As our infant had normal appearance, we did not perform any chromosomal study. Interesting to note, Berg et al. reported a case of umbilical cord aneurysm in a fetus with trisomy 18 (4). We first discovered this hematoma at 30 weeks of gestation by an ultrasound examination, and had continuous follow up of the fetal condition and the hematoma with repeated color Doppler ultrasonographic examinations until birth. In the literature, umbilical cord hematomas may occur anywhere along the cord, with the most common location being near the umbilicus (2). In our case, the location of this hematoma was also near the umbilicus. Based on this case report and those described in the literature, obstetricians should be aware of the possible existence of spontaneous umbilical cord hematoma, so that careful measures can be taken to avoid fetal distress or intrauterine fetal death.