Early prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies

Objectives Cord entanglement is a severe complication in monoamniotic multi ple pregnancies. Three cases were reviewed to determine how early ultrasoun d diagnosis might improve counselling and management. Methods In two monoamniotic twin and one dichorionic diamniotic triplet pre gnancies, cord entanglement was detected between 10 and 18 gestational week s by color Doppler and pulsed Doppler velocimetry. Pregnancies were followe d up on a weekly basis with special observation of fetal behavior and use o f color Doppler velocimetry. Results In Case 1, a monoamniotic twin pregnancy with cord entanglement clo se to the umbilical insertions was diagnosed at 10 weeks. Longitudinal foll ow-up showed intrauterine death of both twins at 15 weeks. In Case 2, entanglement of the umbilical cords of two monoamniotic triplets within a dichorionic diamniotic triplet pregnancy was diagnosed at 10 week s. The pregnancy continued uneventfully until 35 weeks when cord entangleme nt was confirmed at Cesarean section. All triplets have since developed nor mally. In Case 3, monoamniotic twins were diagnosed at 18 weeks. Color Doppler det ected side-by-side insertion of the umbilical cords and Doppler velocimetry suggested an entanglement at the chorionic plate. The pregnancy was compli cated by polyhydramnios. Cesarean section at 36 weeks confirmed cord entang lement at the chorionic elate. Postnatal computer angiography and morpholog ical examination of the placenta showed the presence of superficial artery- to-artery and vein-to-vein anastomoses and of deep arteriovenous shunts. Th e development of the twins was uneventful. Conclusions Diagnosis of cord entanglement is feasible early in gestation. Future protocol's are proposed to document the gestational age at detection , the location, and the Doppler flow patterns and to facilitate the assessm ent of short- and long-term development.