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Review
. 2024 Nov 28;24(1):801.
doi: 10.1186/s12884-024-06962-6.

Ultrasound diagnosis of first trimester umbilical cord entanglement in monochorionic monoamniotic twins - case report and review of the literature

Gad Liberty  1 , Sarit Mash Reyzer  2 , Simon Shenhav  2 , Eyal Y Anteby  2 , Sarah M Cohen  3 , Simcha Yagel  3
Affiliations
Review

Ultrasound diagnosis of first trimester umbilical cord entanglement in monochorionic monoamniotic twins - case report and review of the literature

Gad Liberty et al. BMC Pregnancy Childbirth. .

Abstract

Background: Diagnosis of umbilical cord entanglement (UCE) by ultrasound (US) in monochorionic monoamniotic (MCMA) twins in the second and third trimesters is common. However, only a few cases have been reported on the diagnosis of UCE as early as the first trimester. Herein, we report a case of the earliest-ever sonographic diagnosis of UCE and demonstrate the feasibility of its diagnosis by US.

Case presentation: A 32-year-old gravida 2 para 1 woman conceived after assisted reproductive technology (ART) treatment. In transvaginal US examination at 8.5 gestational weeks, two embryos with regular heartbeats in the same amniotic sac and with only one yolk sac were demonstrated. The fetal crown-rump lengths were 20 and 21 mm, appropriate for 8.4 and 8.5 gestational weeks, respectively. HD-flow power Doppler 2D and 3D US demonstrated two tightly entangled umbilical cords of the two fetuses. Spectral Doppler US showed two different heart rates (162 and 167 beats per minute) and blood flow in opposite directions from the point of entanglement of the two umbilical cords. This was consistent with a diagnosis of a first-trimester MCMA pregnancy with UCE. Missed abortion of the two embryos was diagnosed by US examination at 10.5 weeks, and the pregnancy was terminated by dilatation and curettage without further complications.

Conclusions: UCE in the first trimester may occur as early as eight gestational weeks, and its diagnosis by ultrasound is feasible. UCE diagnosed in the first trimester may be a poor prognostic factor.

Keywords: Entanglement; First trimester; Monochorionic-monoamniotic; Twin; Umbilical cord.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient for publication of this case report. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
2D US at 8.5 weeks demonstrates two fetuses in the same amniotic sac with only one yolk sac
Fig. 2
Fig. 2
Various ultrasound Doppler techniques demonstrate umbilical cord entanglement. A. 2D power Doppler shows the entangled cord point. B. 3D multiplanar power Doppler ultrasound displays the connection between the entangled point of the fetal umbilical cords and the two fetal hearts and circulations. C. 3D HD power Doppler flow highlights the bidirectional flow of the two entangled cords and the different fetal circulations. D. 3D HD-live power Doppler flow depicts the entanglement of two separate umbilical cords
Fig. 3
Fig. 3
Spectral Doppler demonstrating two different arterial heart rates with opposite blood flow directions (A) and simultaneous counter-arterial blood flow directions (B) at the point of entangled cords (white and yellow arrows)
Fig. 4
Fig. 4
Two sequential images demonstrate the distinct insertion site of the umbilical cord of each fetus to the placenta. A. the insertion site of one fetus’s umbilical cord using 2D Power Doppler mode (white arrow), while the other is shown without Doppler imaging (yellow arrow). B. The insertion site of the other fetus is displayed using Power Doppler (white arrows), with the corresponding site of the first fetus shown without Doppler (yellow arrow)
See this image and copyright information in PMC

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