“Umbilical Cord Issues in Pregnancy” – with Dr. Simi Gupta

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Simi Gupta, welcome back to the podcast. How you doing?

Dr. Gupta: I’m doing good. Thanks for having me back.

Dr. Fox: You’re welcome. Thanks for agreeing to come on. So, we decided we’re gonna talk a little bit about the umbilical cord, and I guess specifically as it relates to ultrasound or things that we might see in the umbilical cord or notice about the umbilical cord during pregnancy. Not so much after delivery. That’s a different topic, I would say. You know, we had a podcast related to cord prolapse. We’re not gonna talk about that. How do you even explain to people, you know, when you’re doing an ultrasound, you’re talking to them about maybe an issue with the umbilical cord, what is the umbilical cord? Like, what are we talking about here? Real basic.

Dr. Gupta: Right. Yeah. So, in very basic terms, the umbilical cord is a cord that connects the baby. As we all know, it’s where the baby’s belly button ultimately forms. So, it connects the baby to the placenta. And the placenta is attached to mom’s uterus. So, it’s essentially how the baby gets nutrients from mom, and how the baby’s, kind of, waste products get back to mom to be processed.

Dr. Fox: Yeah. It’s really everything. Like, the baby “eats” through the cord, the baby “drinks” through the cord, the baby gets oxygen. I mean, the baby does drink amniotic fluid, but that’s not how the baby gets hydrated. Everything is really through the umbilical cord. And so, you would think it’s a pretty vital component of this whole system. The example I gave is, you know, old deep sea divers on the bottom of the ocean in the metal suits. They’ve got that hose that connects them to the boat with the oxygen that plugs into their helmet. Like, that’s the baby’s cord. Like, it really…it needs that thing. It’s important.

Dr. Gupta: Right. Exactly. It’s definitely the lifeline for the baby.

Dr. Fox: And when we look at the cord, there are things within it. So, like, what is it that runs through the cord that brings this stuff back and forth?

Dr. Gupta: Right. So, the cord, essentially, has three vessels in it. It usually has one umbilical vein, which essentially brings nutrients from mom through the placenta to the baby. And it has two umbilical arteries, which take waste products from the baby going back to the mom. And then, it’s kind of covered in this jelly-like substance that we call Wharton’s jelly.

Dr. Fox: And that, really, is just there to protect the blood vessels from getting compressed or squeezed.

Dr. Gupta: Right. Exactly.

Dr. Fox: Right. And what’s interesting is, when we’re looking at the cord, so we can see, sort of, the thickness of the cord, we can’t really tell the length of the cord because it’s all, like, curled up and coiled up and it’s a lot longer than just connecting the baby to the placenta. So, it sort of floats around there. But it’s sort of twisty like a rope. It’s sort of three things that are twisted together in sort of the same way. It’s got these, what we call coils. And there’s a lot of facts about the cord that we look at on ultrasound. So, I sort of divided it into how the cord inserts into the placenta, which we’re gonna talk about. And then also, looking at the cord itself, you know, within the cord. Because probably the two most common “abnormalities” or differences we see are related to those. So, how does the cord normally plunk into the placenta or insert into the placenta? Like, if you were to describe it to somebody?

Dr. Gupta: Yeah. In very basic terms, it should kind of enter into the center of the placenta, so somewhere in the middle. And if it inserts off to the side or into the membranes, then it’s considered abnormal. So, it should insert somewhere in the middle of the placenta.

Dr. Fox: Right. Almost like the middle of a bullseye, so to speak, if we’re thinking about it. Placentas aren’t always perfectly round, but somewhere in the middle. So, if it’s off to the side, you know, it’s inserting, let’s say, on the outer rim, what do we call that?

Dr. Gupta: So, if it’s off to the side of the placenta, then we call that a marginal-cord insertion. And, you know, we technically define it as within 2 centimeters of the edge of the placenta, but essentially it means off to the side. This is very common. It happens in, like, 6% of pregnancies. There’s not really good data that shows it’s associated with any pregnancy complications. So, we consider this, essentially, like a normal variant.

Dr. Fox: Yeah, I mean the fear, sort of, theoretically is if the cord’s all the way off to one side of the placenta, maybe it’s not grabbing nutrients from the entire placenta. Like, maybe it’s, sort of, you know, all the way on the other side of the placenta, it’s really not contributing. But that tends not to be the case because even though the cord inserts into one side, there’s a vast, sort of, network. you know, the blood vessels spread out and fan out over the whole placenta, so it tends to be fine. We don’t really do that much different in our unit if there’s a marginal cord insertion. Some people will maybe check a growth ultrasound later in pregnancy if they wouldn’t have otherwise. We usually do it routinely anyways, so it doesn’t have much of an impact. But I find this is something that tends to scare people more than is necessary because it’s pretty common and we really…I don’t wanna say we ignore it, but we really don’t do much different because of it because the risks are pretty low. Now, how do you differentiate that from when you said it inserts into the membranes of the placenta, or what we call a velamentous cord insertion?

Dr. Gupta: So, if the umbilical cord inserts into the membranes or the bag of water that the baby’s in, and then, kind of, runs in the membranes until it reaches the placenta, that is called a velamentous cord insertion. And that we take a little bit more seriously. So, it’s not uncommon. It happens in 1% to 2% of pregnancies. But the concern with velamentous cord insertion is the area where it’s, kind of, running in the membranes. It doesn’t have that Wharton’s jelly or that protective layer around the vessels. And so, a velamentous cord insertion has been associated with pregnancy complications such as growth restriction or lower birth weight babies. And it’s been associated with stillbirth.

Dr. Fox: It’s a little bit more scary, especially if you google it. I would only encourage googling it if you need to get a visual of what we’re talking about because it’s sometimes hard to explain to people in words. I mean, essentially, it’s like the cord missed the placenta, so inserted like a few inches to the side of the placenta, where there’s just like, you know, the membranes, it’s like a piece of saran wrap, so to speak. And so, if it missed the placenta, all those blood vessels in the cord have to, sort of, get to the placenta and, sort of, get to the very edge of the placenta. Again, if you can visualize it from that description, great, if not, good time to go to Google Images and take a look at velamentous cord insertion and find like, you know, an artist depiction of it to see what we mean. But yeah, it’s associated with stuff. And the question I guess I would ask you is, the complications that are listed to be associated with it like the baby not growing well or maybe stillbirth, do you think it’s because of the velamentous cord insertion or is it just something related to an abnormal placenta in general?

Dr. Gupta: I think we won’t know. I don’t think the data tells us which way those are. There’s definitely situations where there’s a velamentous cord insertion and other things that are seen on ultrasound. That would be a different situation from where there’s just an isolated velamentous cord insertion. But I don’t think we can tell from the data we have which one of those…like, which one’s causing the other thing to happen.

Dr. Fox: Yeah. It’s hard because anytime a placenta or cord develops differently, the question is, is it the difference itself that is causing the potential problem or is it just, well, it’s “a bad placenta” or an “unusual placenta?” And this is just one of the ways it manifests. And another way it manifests is that the baby may not be growing. Now, ultimately, it doesn’t matter because, you know, that risk is there no matter what the cause. But for people to, sort of, conceptualize this, some of the risks with velamentous cord are really directly related to these blood vessels.

Like, one of the risks that we didn’t mention, we’d mentioned in a prior podcast, is if those blood vessels that are, sort of, going from where the cord inserts to the placenta, those unprotected blood vessels, happen to coincidentally cover the cervix, we call that a vasa previa. And that is a whole set of its own issues. And so, it’s not really the velamentous cord insertion per se, but it’s that, plus the fact that, unluckily, it happens to cross the cervix. So, that would be like a direct problem related to the velamentous cord insertion. But how a baby, let’s say, wouldn’t grow so well from those blood vessels doing that, it’s really hard to tease out why that would be.

Dr. Gupta: Right. Exactly.

Dr. Fox: And then, what about in labor with velamentous cord insertion? Is there a concern that those blood vessels may get, sort of, compressed because they’re not protected in labor?

Dr. Gupta: Right. So, there is a concern. So, when women are in labor, we do monitor the baby’s heartbeat tracing. And sometimes women with a…or babies with a velamentous cord insertion will notice that the tracings are a little bit abnormal during labor. In some cases, that’s not serious. It can just be watched. In other cases, it may lead to needing a C-section to, kind of, expedite delivery.

Dr. Fox: Right. Now, if someone is having an ultrasound, how do we determine if there’s a velamentous cord insertion? Like, how would someone know if it was checked on their ultrasound?

Dr. Gupta: Right. So, it’s standard for the detailed anatomy scan, which is done around 20 weeks of pregnancy, to look at what we call the placental cord insertion site. And in that area, it should say normal or no anomaly seen, or it’ll say marginal, or it’ll say valemented. So, this is something that we clearly assess on every ultrasound and we document if it’s abnormal. And, of course, if it’s abnormal, we talk to our patients about it.

Dr. Fox: Yeah, sometimes we need to use color in order to visualize it well. And sometimes you can’t visualize it perfectly based on the position of the baby. But it is something we always try to identify on every anatomy ultrasound and see what’s going on there. Now, if you’re seeing someone around 20 weeks, and you’ve diagnosed a velamentous cord insertion, how does that conversation go? Like, what are you telling her about that and what the risks might be, and what we’re gonna do about it?

Dr. Gupta: Right. So, the conversation, you know, is first to say that it’s not so uncommon. Again, it happens in 1% to 2% of pregnancies. So, it’s a conversation that we’ve all had many times with patients. So, it’s not so unusual. And when we see it, you know, the first thing is that it’s not something that’s gonna be moved or fixed or treated. So, it’s not something you can change over the course of the pregnancy. So, when you see a velamentous cord insertion, really, the goal is just to monitor the baby and make sure that the baby’s doing well.

So, the first thing we do is we, of course, check the size at the ultrasound. And we check the baby’s size about every four weeks or so to make sure that the baby’s growing okay. And then, we also make sure that the baby’s, kind of, doing everything it’s supposed to be doing towards the end of the pregnancy. So, we call that type of ultrasound a biophysical profile, which looks for the baby’s movement and fluid level on these practiced breathing motions to make sure that the baby’s doing okay. If all of these things are fine, then we don’t really change anything over the course of the pregnancy or with delivery. But if anything, kind of, concerning comes up over the pregnancy, then we, kind of, address that separately.

I think the thing I try to reassure patients when I see a velamentous cord insertion is, yes, there is a little bit of an increased risk of these complications like growth restriction and stillbirth, but it is a small increased risk. So, this is something that, you know, I try to tell patients not to worry too much about. And the second thing I often get asked from patients, because I tell them, you know, that protective jelly isn’t there, they’re like, “Oh, should I not move very much? You know, do I need to try to keep the baby from moving?” And I try to reassure them they don’t need to change anything about their day-to-day activities. So, they can do their regular activities. They don’t have to worry if their baby’s moving too much. The baby’s not gonna cause any harm from this. And they’re not gonna any harm from this.

Dr. Fox: Yeah, I mean, my counseling, as you would imagine, is pretty much exactly the same or pretty similar to that. It’s more common than people think. This is definitely one of the examples where the Google is gonna make it sound worse than it is because, you know, all you see is velamentous, and then it’s associated with all these things. But, you know, often, it’s gonna be associated, potentially, with stillbirth. But usually, that’s if it’s preceded by severe growth restriction, right?

Dr. Gupta: Right.

Dr. Fox: So, if you’re following, and like you said, the baby’s growing well and moving well and doing everything in a healthy way, generally, the risks are very, very low and we don’t do much about it. We always double-check when we diagnose it that it’s just a velamentous cord insertion and not a vasa previa, either just based on where it is or if it’s close to the cervix. We’ll do a vaginal ultrasound to be sure. But, you know, that’s assuming that we haven’t additionally diagnosed a vasa previa, which again is a related but totally separate problem. And then, generally, that’s it.

You know, like you said, I don’t tell people they need to have a C-section because of this. They can labor, and if they’re unlucky enough that the baby’s heart rate’s dropping in labor and it’s concerning, we can switch to a C-section then. But it’s not common enough that we would normally recommend doing a C-section because of this. I don’t think that’s really a recommendation that’s out there by anyone.

Dr. Gupta: Right. I agree. I don’t think so by anyone either.

Dr. Fox: Now, in terms of the cord itself, there is a totally separate issue, but has very similar counseling, and that’s when the umbilical cord has two blood vessels instead of three. So, tell us about that. What do you call that and what’s going on there?

Dr. Gupta: Right. So, kind of, as we spoke about at the beginning, most babies have one umbilical vein that brings nutrients from the placenta and mom to the baby, and two umbilical arteries that take waste products from the baby back to the mom. For some babies, one of those umbilical arteries, kind of, goes away in the first trimester. And what we have left is one umbilical vein and one umbilical artery. So, we either call that a single umbilical artery or we call it a two-vessel cord.

Dr. Fox: Right. And those mean the exact same thing.

Dr. Gupta: Right.

Dr. Fox: Right. And then this is also something that, pretty similarly, not uncommon?

Dr. Gupta: Correct. Exactly. I think it happens in, like, 1 in every 100 or 200 pregnancies. So, not uncommon. And a conversation that we also have often with patients.

Dr. Fox: Right. And I think that, you know, a lot of the risks for velamentous cord are similar to the two-vessel cord. One of the things that sometimes gets confusing is, again, if you go on the Google, you’ll sometimes read that this is associated with genetic abnormalities as well. But we don’t typically worry so much about genetic abnormalities with this, and that’s really because we’re talking about a case when you find this and nothing else, right? In a normal-looking baby, having a two-vessel cord really does not have any genetic implications. But if I see a baby with nine abnormalities and a two-vessel cord, all right, fine, it’s associated with it. But it’s not the cord that’s the issue, it’s all the other things.

Dr. Gupta: Right. So, when we see this, the first thing we wanna do is exactly what you said, determine if this is an isolated finding or not. And we do that in two ways. One is by doing the full anatomy scan to make sure that the baby has no birth defects, so no heart conditions, brain conditions, etc. And then we also recommend a fetal echocardiogram, which is a special ultrasound of the baby’s heart, to ensure that the heart is also forming normally and that this is an isolated finding.

Dr. Fox: Right. And then, so assuming that it is an isolated finding, what risks do you typically tell them are associated with having a two-vessel cord? Is it the exact same as velamentous cord, basically?

Dr. Gupta: It basically is, so the small increased risk of growth restriction or what we call lower birth-weight babies, and a very, very slight increased risk of a stillbirth towards the end of the pregnancy. And so, we manage this in, essentially, the same way. We recommend growth ultrasounds about every four weeks and we recommend those weekly biophysical profiles or ultrasounds in the last month of the pregnancy to make sure the baby’s doing everything it’s supposed to be doing.

Dr. Fox: And again, this is not something that we would recommend a C-section for, for any reason. This does not typically have any issues in labor. It does not typically cause a higher chance of the heart rate dropping in labor, anything like that. And the other thing is, people are always worried that this is gonna be like a long-term problem for the baby. And I always reassure them all of these blood vessels and the cord are gone after the baby’s born. We clamp and cut the cord and it all goes, you know, to the pathologist, to medical waste, back home if you’re gonna take it and eat it. Whatever it might be, it’s leaving. And all the blood vessels internally on the baby where the cord is attached to actually all go away as well and turn into ligaments. Fascinating. They don’t stay as blood vessels in the baby.

Dr. Gupta: Right. And I should have also mentioned that about the velamentous cord insertion. So, all of these things, the diagnosis and the monitoring is just to make sure we get to delivery safely. And once the baby’s born and no longer needs its umbilical cord and placenta, these things really have no impact on the baby after delivery.

Dr. Fox: Right. So, those are pretty similar. One of the things that is out there, but we don’t spend a lot of time monitoring, is the coiling of the umbilical cord. As we mentioned earlier, the cord does have like a…it’s, like, twisted, sort of like a rope. And it can be…there’s, sort of, definitions for what is normal, and there’s cords that are what we call hyper-coiled, that they’re very twisted, and cords that are called hypo-coiled, which are, sort of, untwisted. And you can find stuff on them that says it might be associated with some issues. But I don’t think a lot of people are routinely measuring these in pregnancy. because we don’t really know how much of an issue it is or what to do about it, or whether they need to be followed any differently or not. I don’t know what your experience has been with coiling of the cord.

Dr. Gupta: Right. You know, it’s really difficult for…I mean, basically, the two reasons that you said. One is, there’s not really good standard ultrasound definitions for what is hyper-coiled or hypo-coiled cords. Most of the definitions really come from looking at the umbilical cord after delivery by the pathologist. So, it’s something that’s difficult to diagnose on ultrasound. And then, there’s also not any kind of standard management if you do suspect it because we really haven’t found that any kind of change in management changes the outcome in these situations because the vast majority of them are, kind of, normal variants. So, I think in the rare case where something significantly catches our eye or, of course, if we see other abnormalities, we might follow the babies a little bit more closely. But usually, this is something that’s, kind of, diagnosed after the baby’s born.

Dr. Fox: Yeah. Now, the last thing I wanted to talk about is two things more related to the location of the cord, right? So, the cord connects, as you said, the baby around the area of the belly button to the placenta, and there’s a lot of cord in between floating around. And one of the situations that we sometimes see is when the cord is, sort of, on the very bottom of the uterus, right above the cervix. And is that generally a concern for you during the course of pregnancy?

Dr. Gupta: No. So, as you know, what you’re referring to, we call a funic presentation. And that means that right in front of the cervix is the umbilical cord, which during most of the pregnancy means absolutely nothing because the baby and the umbilical cord are moving around so much during the pregnancy that really has no implications. The only time it matters, if that is happening when the patient’s getting close to the time of delivery. So, close to their due date and there’s a funic presentation, or if they break their bag of water or some case like that. And then it’s a concern because that could lead to what we call a cord prolapse. I think you said you spoke about this in a prior podcast where the baby’s umbilical cord comes out before the baby’s head comes out. And that is an emergency situation.

Dr. Fox: Yeah. So, when we see it in ultrasound, again, it’s rarely relevant, like you said, because unless you’re at the very end of pregnancy. And it’s also important because sometimes patients or even doctors get confused between this and the vasa previa, right? Having the cord near the cervix is not the same thing as having a blood vessel, you know, traveling through the membranes above the cervix. And so again, we don’t confuse those two because they’re totally different on ultrasound. But sometimes patients get confused. So, someone says, “Oh, there’s something related to the cord or a blood vessel near the cervix,” it’s important to differentiate, are they talking about a vasa previa, where it’s a single blood vessel in the membranes versus, well, the cord just happens to be sitting there, which is not a big deal in the middle of pregnancy?

Again, I’ve seen people come in because they think they have one and it’s the other. And usually, they think it’s the bad one and it’s not the bad one. But it could be in either direction. The last thing I wanna talk about, which is really, really a common question that I get from patients is, well, what if the baby’s cord is around its neck, or can you check if the cord is around the baby’s neck? How do you address that during pregnancy?

Dr. Gupta: Yeah. So, I also get that question a lot. And I think, as you would probably agree, patients are asking this question because they’ve all heard the scary stories where something bad has happened to a baby because of the cord around the neck. And so, that’s why the question comes up. The first thing I try to tell patients is, having a cord around the neck at the time and birth is really, really common. It happens in about 20% of pregnancies. So, that means one in five babies will have a cord around their neck when they’re born. And it doesn’t cause any issues during the pregnancy or delivery. We just, kind of, slip the cord off at delivery and the babies are completely fine. So, the first thing I try to say is that having a cord around the neck is very, very common.

And then, the next question, of course, is this something that we can look for during ultrasound? So, it’s not something that we usually look for, for a couple of reasons. The main one is, sometimes you see it, but then it could slip off the head, and then it could come back on. So, it’s not something that just because it’s there, it’s always there. And the second thing is, because it’s so common, it shouldn’t change our, kind of, management. Meaning we shouldn’t do anything differently or deliver the patient or do a C-section. And so, it’s honestly not something we look for because if we find it, it just makes everybody nervous and there’s nothing that we’re going to do to change anything about it.

Dr. Fox: Yeah. It is a tough one because, like you said, one in five babies has it. So, finding it really doesn’t mean much of anything. And it generally just scares people. And it’s, sort of, hard to undo that, telling someone…if somebody is, “Oh, my God. My doctor said the cord’s around the neck.” And they’re walking around like something horrible is going to happen. But one in every five babies. Very, very common. I do my very best not to look. And I also don’t think our diagnosis of it is particularly always accurate. I mean, sometimes it’s very clear, but sometimes it’s not. It’s hard to know that, for sure, that it’s actually completely around the neck versus just, let’s say, under the chin or something like that. So it’s tough, but it’s not recommended by anybody really to screen for this routinely or to do anything different about it, like you said, if it happens to be found incidentally. And so I generally discourage people from trying to seek this out during the course of pregnancy.

Again, during labor, some of the babies who have a cord around the neck will have the heart rate drop during labor, but even then, most of the time it’s a pattern that’s not concerning. And if it’s a pattern that is concerning, okay, we’ll do a C-section at that time. But if it’s not concerning, they just labor, and, you know, we deliver them vaginally like everyone else. That is a very common concern.

Dr. Gupta: And I will also just say in relation to that, because the baby’s essentially in this bag of water that’s like a balloon, the umbilical cord is gonna often be in the different pictures that we give patients of the baby. So, you’ll see the umbilical cord floating around, around the baby’s face, around the baby’s hands, around the baby’s neck. Just because it’s in the picture doesn’t mean it’s around the neck or causing any issues. We expect it to sometimes be in the picture just because it’s floating around.

Dr. Fox: Good point. All right. Simi, we covered the cord.

Dr. Gupta: All right. Sounds good.

Dr. Fox: Love it. Thanks for coming on. And we’ll see you again.

Dr. Gupta: Thanks. Take care.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you’d like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, it does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.