Intrauterine fetal demise (nuchal cord accident)

Case contributed by Dennis Odhiambo Agolah
Diagnosis certain


Routine surveillance, one previous c-section scar.

Patient Data

Age: 30 years
Gender: Female

Fetal obstetrics assessment demonstrates a non-viable singleton intrauterine pregnancy in flexed breech presentation. A visible nuchal cord (appearing as a single twist), well applied and completely encircling the fetal neck, is evident with a Divot sign (in the sagittal plane) and an O-shaped appearance (on the axial probe orientation) consistent with type -B nuchal chord. There is no obvious Robert sign at the fetal heart, Spalding sign at the fetal head or subcutaneous tissue edema, or related hydrops fetalis changes. The parameters, including liquor amount, placental attachment, and the rest of the fetal anatomy, were unremarkable (save for the minimal casually chanced, unilateral left-sided simple fetal scrotal sac hydrocele seen).

Post operative- c-section findings

Non-viable singleton fetus in breech presentation. No macerations. No Spalding sign. Tight nuchal cord at the neck (x2) and umbilical cord tightly encircling the fetal wrist. Impression/conclusion: Umbilical cord accident.

Case Discussion

Intrauterine fetal death/demise (IUFD) refers to a situation where the fetus is no longer alive, the cervical ostia remains closed, and the uterus has not yet started to expel its contents 1. The average ultrasound age corresponds to 35 weeks of maturity in this presentation. The cervix is closed, whereas, during real-time scanning, the ornamental wrist cord or the double looped nuchal cord was not chanced (save for only one), initial ultrasound impression of the seen single loop possibly resulting in the fetal demise was clinically confirmed.

Again, maternal uterine arterial evaluation (despite the patient not presenting with pressure issues) was unremarkable with normal waveforms, pulsatility, and resistive indices. 

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