Ultrasound Obstet Gynecol 2010; 35: 253–254Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.7543

Picture of the Month

Acute polyhydramnios in term pregnancy may be caused by multiple nuchal cord loops

Y. PERLITZ*†, I. BEN-SHLOMO* and M. BEN-AMI*†*Department of Obstetrics and Gynecology, The Baruch Padeh Medical Center, Poriya, Tiberias and †Rappaport Faculty of Medicine,Technion, Israeli Institute of Technology, Haifa, Israel

Acute severe polyhydramnios developing in the thirdtrimester or at term is a rare condition. Although thereare many possible fetal or maternal causes for thisphenomenon, in the majority of cases a specific etiologycannot be found. We describe our imaging findings andmanagement of a case of severe acute polyhydramniosdeveloping at the 40th gestational week.

A 24-year-old healthy mother of two children wasreferred to our obstetrics department at 41+2 gestationalweeks of her third pregnancy owing to very recentdistention of her uterus. Her pregnancy had beenuneventful, including a 22-week sonographic anomalyscan. No other screening tests were performed duringpregnancy. During a visit for a routine check-up1 week earlier, a sonogram revealed normal amnioticfluid volume and adequate gross body and breathingmovements. Current sonography at admission revealedsevere polyhydramnios, reaching an amniotic fluid indexof 40 cm. A Doppler examination of the umbilical corddiscovered multiple cord loops wrapped around thefetal neck (Figure 1). A healthy baby was delivered byCesarean section. The estimated amniotic fluid volumewas approximately 2.5 L. The umbilical cord was tightlywrapped three times around the fetal neck, forming abulk which limited the free movement of the neck, but nostrangulation marks were evident around the baby’s neck.

Third-trimester or term pregnancy acute onset polyhy-dramnios is rare, usually mild, and not associated withstructural defects1. However, in the severe polyhydram-nios state, in 75% of cases significant fetal abnormalitiesare found that predominantly involve the central nervoussystem, gastrointestinal tract, heart and genitourinarytract2. Esophageal atresia often leads to polyhydram-nios, usually early in the third trimester3. We found somecircumstantial evidence in the literature that impedimentto swallowing by goiters4, cervical teratomas5–7 or skinabnormalities8 is associated with polyhydramnios. In ourcase, the lack of any of these abnormalities in the newbornmakes it tempting to postulate that the bulky accumula-tion of cord loops around its neck may have limited the

Multiple nuchal cord loops

Fetal body

Fetal head

Figure 1 Doppler ultrasound image showing the fetus in thelongitudinal position, face down; multiple nuchal cord loops arewrapped around its neck.

in-utero ability to swallow amniotic fluid. This in turncould have led to accelerated, late-onset polyhydramnios.We propose that in any case of such sudden and late devel-opment of polyhydramnios, the fetal neck area should bescanned by ultrasonography, and the presence of nuchalcord loops should be considered as a possible cause of thepolyhydramnios.

References

1. Hill LM, Breckle R, Thomas ML, Fries JK. Polyhydramnios:Ultrasonically detected prevalence and neonatal outcome. ObstetGynecol 1987; 69: 21–25.

2. Barkin SZ, Pretorius DH, Beckett MK, Manchester DK, Nel-son TR, Manco-Johnson ML. Severe polyhydramnios: incidenceof anomalies. AJR Am J Roentgenol 1987; 148: 155–159.

3. Brantberg A, Blaas HG, Haugen SE, Eik-Nes SH. Esophagealobstruction – prenatal detection rate and outcome. UltrasoundObstet Gynecol 2007; 30: 180–187.

4. Perelman AH, Johnson RL, Clemons RD, Finberg HJ, ClewellWH, Trujillo L. Intrauterine diagnosis and treatment of fetalgoitrous hypothyroidism. J Clin Endocrinol Metab 1990; 71:618–621.

Correspondence to: Dr Y. Perlitz, Department of Obstetrics & Gynecology, The Baruch Padeh Medical Center, Poriya, MPO Lower Galillee15208, Tiberias, Israel (e-mail: yperlitz@poria.health.gov.il)

Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd. P ICTURE OF THE MONTH

254 Perlitz et al.

5. Langer JC, Tabb T, Thompson P, Paes BA, Caco CC. Manage-ment of prenatally diagnosed tracheal obstruction: access to theairway in utero prior to delivery. Fetal Diagn Ther 1992; 7:12–16.

6. Martino F, Avila LF, Encinas JL, Luis AL, Olivares P, Las-saletta L, Mistral M, Tovar JA. Teratomas of the neck andmediastinum in children. Pediatr Surg Int 2006; 22: 627–634.

7. Araujo Junior E, Guimaraes Filho HA, Saito M, Pires AB,Pontes AL, Nardozza LM, Moron AF. Prenatal diagnosis of alarge fetal cervical teratoma by three-dimensional ultrasonogra-phy: a case report. Arch Gynecol Obstet 2007; 275: 141–144.

8. Opitz JM. Pathogenetic analysis of certain developmental andgenetic ectodermal defects. Birth Defects Orig Artic Ser 1988;24: 75–102.

Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 253–254.