










































American Journal Of Biomedical Science & Pharmaceutical Innovation 9 https://theusajournals.com/index.php/ajbspi 

 
 

 VOLUME Vol.05 Issue08 2025 

PAGE NO. 9-12 

DOI 10.37547/ajbspi/Volume05Issue08-02 

 
 
 
 

Review of Literature on Epidemiology, Diagnostics, 

Complications of Umbilical Cord Pathology and 

Management Tactics 
 

Tojiyeva Nigina Iskandarovna 

Assistant, department of Obstetrics and gynecology #1, Samarkand State Medical University, Uzbekistan 

 

 

Received: 17 June 2025; Accepted: 13 July 2025; Published: 15 August 2025 

 

Abstract: This review systematizes current knowledge about umbilical cord abnormalities (UCAs) — a 
heterogeneous group of anomalies including length abnormalities, number of vessels, attachments, nodes, cysts, 
and vascular malformations. Based on the analysis of scientific literature (2000–2024), the epidemiological data 
are presented: UCAs occur in 15–35% of pregnancies, with single umbilical artery (SUA) — in 0.5–5%, velmen 
insertion — up to 50% in monochorionic twins, and true nodes — in 0.3–1.2%. The review details complications: 
fetal growth restriction (FGR), chronic and acute hypoxia, antenatal death, risks during childbirth (vascular rupture 
in vasa praevia, asphyxia). Particular attention is paid to early diagnostic methods: ultrasound with Doppler (blood 
flow assessment, EAP), color Doppler mapping (Velmen attachment), 3D/4D ultrasound in STIC mode (nodes, 
spatial anomalies), CTG monitoring. Differentiated management tactics are substantiated: from dynamic 
observation at low risk to planned cesarean section for vasa praevia or IUGR. It is emphasized that timely 
diagnostics and an individualized approach reduce perinatal mortality and improve outcomes. 

 

Keywords: Umbilical cord abnormalities; Single umbilical artery; Velamentous cord insertion; Vasa previa; True 
umbilical cord knot; Umbilical cord entanglement; Umbilical cord cysts; Umbilical artery Doppler; Prenatal 
diagnosis; Pregnancy complications; Perinatal outcomes; 3D/4D ultrasound; Fetal growth restriction (FGR); 
Pregnancy management; Cord structure pathology. 

 

Introduction: Umbilical cord abnormalities (UCAs) are 
a heterogeneous group of anomalies that include 
deviations in length, number of vessels, type of 
attachment, presence of nodes, cysts and vascular 
malformations. Despite the fact that many UCAs have 
no clinical consequences, some types are associated 
with an increased risk of fetal growth restriction (FGR), 
hypoxia, birth asphyxia, stillbirth and the need for 
emergency operative delivery [1, 2]. 

The prevalence of UCAs in the population varies, 
reaching significant numbers, which emphasizes the 
relevance of the problem for perinatology [3, 4]. 
Modern methods of prenatal diagnostics, primarily 
ultrasound, play a key role in early detection and 
determination of pregnancy and childbirth 
management tactics [5, 6]. 

The purpose of the review: to systematize modern 
data on the prevalence, diagnosis, complications and 

management tactics of pregnant women with various 
umbilical cord abnormalities. 

METHODS 

An analysis of scientific literature data published for the 
period 2000-2024 was conducted using the PubMed, 
MEDLINE, Scopus, Cochrane Library, and eLibrary 
databases. Key words: "umbilical cord pathologies", 
"umbilical cord anomalies", "umbilical cord 
entanglement", "true cord knot", "velmen insertion of 
the umbilical cord", "diagnosis of umbilical cord 
pathologies", "pregnancy complications with umbilical 
cord anomalies". Systematic reviews, meta-analyses, 
randomized controlled trials, large cohort studies, and 
clinical guidelines were selected. 

RESULTS 

The overall incidence of UCAs, according to ultrasound 
and pathological studies, ranges from 15% to 35% of all 

 

https://doi.org/10.37547/ajbspi/Volume05Issue08-02
https://doi.org/10.37547/ajbspi/Volume05Issue08-02
https://doi.org/10.37547/ajbspi/Volume05Issue08-02
https://doi.org/10.37547/ajbspi/Volume05Issue08-02


American Journal of Applied Science and Technology 10 https://theusajournals.com/index.php/ajast 

American Journal of Applied Science and Technology (ISSN: 2771-2745) 
 

 

pregnancies [3, 7]. Cord entanglement around the 
fetus's neck is the most common anomaly, occurring in 
21-34% of term births, with multiple entanglements 
recorded in 2-8% of cases [1, 8]. Single umbilical artery 
(SUA) occurs with a frequency of 0.5-1% in singleton 
pregnancies and up to 5% in multiple pregnancies [2, 
9]. In 20-30% of cases, SUA is combined with other 
congenital fetal anomalies (cardiovascular, 
genitourinary, gastrointestinal tract, central nervous 
system) or chromosomal pathologies (trisomy 18, 13) 
[2, 10, 11]. Velmen (membranous) insertion of the 
umbilical cord is observed in approximately 1% of 
singleton pregnancies, but its frequency increases to 
15% in multiple pregnancies and up to 50% in 
monochorionic twins [12, 13]. 

True umbilical cord knots are less common, occurring 
in approximately 0.3-1.2% of pregnancies, but their 
clinical significance is high [14]. 

Short umbilical cord (<35-40 cm) - 4-6%, long umbilical 
cord (>70-80 cm) - 5-7% [1, 15]. Umbilical cord cysts 
(true and false) are detected in 0.4-3.4% of cases [16]. 

Intrauterine growth retardation (especially with a 
single umbilical artery without associated anomalies, 
velmen attachment, thrombosis) is one of the common 
antenatal complications in umbilical cord pathologies 
[2, 9, 12]; chronic fetal hypoxia; spontaneous abortions 
(more often with early detection of SUA or multiple 
cysts) [16] also occur in various organic pathologies of 
the umbilical cord. Antenatal fetal death occurs with 
true knots, thrombosis, severe varicose veins, tight 
multiple entanglement [14, 17]. Acute fetal 
hypoxia/asphyxia during labor occurs with tension of a 
short umbilical cord, tightening of a true knot, tight 
entanglement, prolapse of the umbilical cord [1, 8, 14]; 
placental abruption is the most serious complication 
that occurs with a short umbilical cord or tension with 
a velmen insertion [12]; rupture of the umbilical vessels 
with fatal bleeding in the fetus is most typical for a 
velmen insertion, especially with vasa previa [12, 13]; a 
prolonged course of the second stage of labor occurs 
due to a short umbilical cord, which is expressed in the 
need for an emergency cesarean section [1, 8]. 

Children born with these pathologies have an increased 
risk of low scores on the Apgar scale, an increased need 
for neonatal resuscitation, and they can also develop 
hypoxic-ischemic encephalopathy and the worst - 
stillbirth [1, 14, 17]. The risk of perinatal mortality with 
a true umbilical cord knot increases by 4 times [14]. 

Modern methods of examination and early detection of 
umbilical cord pathologies are intended to prevent 
these complications. Standard 2D ultrasound (II 
trimester, 18-22 weeks) is the main screening method. 
It allows diagnosing vascular pathology (assessment of 

the number of vessels in the cross-section), cysts, 
attachment anomalies (especially with a thorough 
examination of the placental disk), length (indirectly by 
the presence of loops, their number), varicose veins [5, 
6, 9]. Color Doppler mapping (CDM) and power Doppler 
(PD) are new methods, especially in the conditions of 
Uzbekistan. These methods are critically important for 
confirming vascular anomalies, diagnosing Velmen 
attachment (visualization of vessels running in the 
membranes), assessing blood flow in the umbilical 
vessels and cysts, differentiating true and false nodes 
[5, 12, 13]. Doppler ultrasound allows us to study the 
resistance index, systolic-diastolic ratio and pulsation 
index in the umbilical artery, which makes it possible to 
assess the state of fetoplacental blood flow. An 
increase in resistance indices predicts unfavorable 
perinatal outcomes [6, 9, 18]. The absence or reverse 
diastolic blood flow is an indication for emergency 
delivery. 

3D / 4D ultrasound with reconstruction in the STIC 
(Spatio-Temporal Image Correlation) mode allows us to 
obtain a detailed image of the umbilical cord in volume, 
improving the diagnosis of nodes, attachment features 
and spatial relationships with the fetus [5, 19]. 

Cardiotocography (CTG) makes it possible to monitor 
the condition of the fetus in the third trimester and 
during labor. Allows to identify signs of hypoxia 
(decelerations, decreased variability), especially if 
there is a suspicion of entanglement or knot [1, 8], this 
makes it possible to avoid serious complications and 
improve birth outcomes. 

Prenatal karyotyping/chromosomal microarray 
analysis (CMAA) is recommended when a single 
umbilical artery is detected in combination with other 
ultrasound markers of fetal abnormalities or 
intrauterine growth retardation to exclude 
chromosomal pathology [2, 10]. 

Magnetic resonance imaging (MRI) of the fetus is rarely 
used, in complex diagnostic cases, for example, to 
clarify the nature of large cysts or vascular relationships 
if vasa praevia is suspected with a velmen attachment 
[20]. 

The principles of managing patients with umbilical cord 
pathology include, first of all, clarifying the diagnosis. A 
thorough ultrasound with color Doppler/ED and 
Doppler to confirm the type of pathology and assess 
fetoplacental blood flow [5, 6]. Extended echographic 
and genetic screening is used when a single umbilical 
artery or umbilical cord cysts are detected with a 
mandatory detailed examination of the fetal anatomy 
(echocardiography, neurosonography, etc.). In the 
presence of combined markers, a consultation with a 
geneticist and invasive diagnostics are prescribed [2, 9, 



American Journal of Applied Science and Technology 11 https://theusajournals.com/index.php/ajast 

American Journal of Applied Science and Technology (ISSN: 2771-2745) 
 

 

10, 16]. Regular ultrasound monitoring (fetal growth, 
amniotic fluid volume, Doppler) and CTG allow 
monitoring the condition of both the fetus and the 
mother. The frequency is determined by the type of 
pathology and the presence of complications (IUGR, 
impaired blood flow). In the case of an uncomplicated 
single umbilical artery or false nodes - standard 
monitoring. In case of velmen attachment, true nodes, 
short umbilical cord, blood flow disorders - enhanced 
monitoring (weekly or more often in the third 
trimester) [1, 6, 12]. Treatment of placental 
insufficiency in case of IUGR and blood flow disorders 
is carried out in hospital, vascular therapy and 
hemostasis control are indicated [18]. 

In most umbilical cord pathologies (entanglement 
without blood flow disorders, single umbilical artery 
without intrauterine growth restriction/anomalies), 
vaginal delivery is possible under careful continuous 
CTG monitoring [1, 8]. 

Indications for planned cesarean section (CS): 
Confirmed velum insertion with risk of vasa praevia 
(especially with low placenta/presentation) [12, 13]; 
severe intrauterine growth restriction against the 
background of umbilical cord pathology with blood 
flow disorders; some cases of true knots (debatable, 
individual decision) [14]; short umbilical cord less than 
40 cm. 

If signs of acute fetal hypoxia appear according to CTG 
during labor, rupture of vessels (vasa praevia), or 
prolapse of the umbilical cord, an emergency CS is 
performed [1, 13]. 

In case of entanglement or suspicion of a knot, careful 
management of the second period is necessary 
(exclusion of pushing "for contractions", episiotomy), 
and readiness for an emergency CS. In case of a velem 
attachment, extremely careful opening of the fetal 
bladder (amniotomy) is contraindicated if vasa praevia 
is suspected [12, 13]. Discussion. Pathologies of the 
umbilical cord structure are a frequent finding in 
obstetric practice. Despite the often benign course of 
many anomalies (false knots, isolated single umbilical 
artery without IUGR, loose entanglement), their 
diagnosis requires increased attention due to the 
potential risk of serious ante- and intranatal 
complications. Modern ultrasound methods, especially 
those using Doppler technologies and 3D/4D 
reconstruction, are the cornerstone of prenatal 
diagnostics of umbilical cord pathologies, allowing to 
identify most significant anomalies in the second 
trimester [5, 6, 19]. The key aspect of management is a 
differentiated approach: from standard observation at 
low risk to intensive monitoring and planned operative 
delivery at high risk (Velmen insertion, vasa praevia, 

true nodes with impaired blood flow, severe IUGR 
against the background of a single umbilical artery) [1, 
12, 14]. The importance of early diagnosis of vasa 
praevia cannot be overestimated, since timely planned 
CS prevents catastrophic bleeding in the fetus [13]. 
Further research should be aimed at clarifying the 
prognostic significance of various Doppler parameters 
in different pathologies, developing risk stratification 
algorithms and optimizing the timing of delivery. 

CONCLUSION 

Pathologies of the umbilical cord structure are a 
significant perinatal risk factor. Knowledge of their 
prevalence, pathogenesis of possible complications 
and mastery of modern diagnostic methods 
(ultrasound with Doppler, 3D/4D) are mandatory for a 
practicing obstetrician-gynecologist. Early detection, 
careful assessment of the fetus (exclusion of combined 
anomalies, monitoring of growth and blood flow) and 
an individualized approach to planning the timing and 
method of delivery can significantly improve perinatal 
outcomes. Particular attention should be paid to 
diagnostics and management tactics in case of vasa 
praevia insertion (risk of vasa praevia) and conditions 
associated with acute intranatal hypoxia. 

REFERENCES 

Airas U, Heinonen S. Clinical significance of true 
umbilical knots: a population-based analysis. Am J 
Perinatol. 2002;19(3):127-32. doi:10.1055/s-2002-
25304. 

Chow JS, Benson CB, Doubilet PM. Frequency and 
nature of structural anomalies in fetuses with single 
umbilical arteries. J Ultrasound Med. 1998;17(12):765-
8. doi:10.7863/jum.1998.17.12.765. 

Ebbing C, Kessler J, Moster D, Rasmussen S. Single 
umbilical artery and risk of congenital malformation: 
population-based study in Norway. Ultrasound Obstet 
Gynecol. 2017;49(4):450-455. doi:10.1002/uog.15920. 

Derbala Y, Grochal F, Jeanty P. Vasa previa. J Prenat 
Med. 2007;1(1):2-13. 

Ghi T, Youssef A, Pilu G, et al. Sonographic diagnosis of 
umbilical cord abnormalities: a national survey. 
Ultrasound Obstet Gynecol. 2019;53(6):806-811. 
doi:10.1002/uog.20192. 

Heifetz SA. Single umbilical artery. A statistical analysis 
of 237 autopsy cases and review of the literature. 
Perspect Pediatr Pathol. 1984;8:345-78. 

Hasegawa J, Matsuoka R, Ichizuka K, et al. Velamentous 
cord insertion: significance of prenatal diagnosis. J 
Ultrasound Med. 2009;28(7):899-903. 
doi:10.7863/jum.2009.28.7.899. 

Lee VR, Darwin C, Goffinet F, et al. Umbilical cord 



American Journal of Applied Science and Technology 12 https://theusajournals.com/index.php/ajast 

American Journal of Applied Science and Technology (ISSN: 2771-2745) 
 

 

complications: a review. Am J Obstet Gynecol MFM. 
2021;3(6):100431. doi:10.1016/j.ajogmf.2021.100431. 

Martínez-Payo C, Caballero P, Ruiz F, et al. [Single 
umbilical artery: prenatal diagnosis and perinatal 
implications]. Prog Obstet Ginecol. 2004;47(8):355-
362. 

Predanic M, Perni SC, Friedman A, et al. Fetal growth 
assessment and perinatal outcome in pregnancies with 
an isolated single umbilical artery. Obstet Gynecol. 
2005;106(5 Pt 1):1093-7. 
doi:10.1097/01.AOG.0000182579.41577.0c. 

Rembouskos G, Cicero S, Longo D, et al. Single umbilical 
artery at 11-14 weeks' gestation: relation to 
chromosomal defects. Ultrasound Obstet Gynecol. 
2020;56(6):843-847. doi:10.1002/uog.21968. 

Sepulveda W, Rojas I, Robert JA, et al. Prenatal 
detection of velamentous insertion of the umbilical 
cord: a prospective color Doppler ultrasound study. 
Ultrasound Obstet Gynecol. 2003;21(6):564-9. 
doi:10.1002/uog.132. 

Sullivan EA, Javid N, Duncombe G, et al. Vasa previa: 
diagnosis, management, and the role of ultrasound. 
Aust N Z J Obstet Gynaecol. 2021;61(3):331-338. 
doi:10.1111/ajo.13332. 

Vora S, Walls M. True knot of the umbilical cord: a 
difficult prenatal diagnosis. Ultrasound. 2018;26(1):55-
61. doi:10.1177/1742271X17724153. 

Weissman A, Jakobi P, Bronshtein M, Goldstein I. 
Sonographic measurements of the umbilical cord in 
pregnancies complicated by gestational diabetes. J 
Ultrasound Med. 1995;14(12):907-11. 
doi:10.7863/jum.1995.14.12.907. 

Zangen R, Boldes R, Yaffe H, et al. Umbilical cord cysts 
in the second and third trimesters: significance and 
prenatal approach. Ultrasound Obstet Gynecol. 
2010;36(3):296-301. doi:10.1002/uog.7606. 

Prefumo F, Fichera A, Pagani G, et al. The natural 
history of umbilical cord cysts: a role for three-
dimensional ultrasound? Prenat Diagn. 
2016;36(13):1196-1200. doi:10.1002/pd.4961.  

Baschat AA, Gembruch U, Harman CR. The sequence of 
changes in Doppler and biophysical parameters as 
severe fetal growth restriction worsens. Ultrasound 
Obstet Gynecol. 2001;18(6):571-7. doi:10.1046/j.0960-
7692.2001.00591.x.  

Ghi T, Youssef A, Piva M, et al. The use of STIC in the 
diagnosis of umbilical cord knots. J Matern Fetal 
Neonatal Med. 2012;25(11):2249-51. 
doi:10.3109/14767058.2012.684169.   

Lau WC, Leung WC, Chin R. Prenatal diagnosis of vasa 
previa by magnetic resonance imaging. Hong Kong Med 

J. 2003;9(1):69-71. 

Iskandarovna T. N. REVIEW OF THE LITERATURE ON 
RECENT RESEARCH IN THE FIELD OF OBSTETRICS AND 
GYNECOLOGY //International Journal of Medical 
Sciences And Clinical Research. – 2024. – Т. 4. – №. 12. 
– С. 28-33. 

Iskandarovna T. N. CURRENT TRENDS IN GYNECOLOGY 
//International Journal of Medical Sciences And Clinical 
Research. – 2024. – Т. 4. – №. 05. – С. 91-96. 

Zafarovna B. Z. SEXUAL DYSFUNCTION IN PREGNANCY: 
PROBLEMS AND SOLUTIONS //International Journal of 
Medical Sciences And Clinical Research. – 2024. – Т. 4. 
– №. 10. – С. 30-34.  


