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Type‐3 vasa previa: normal umbilical cord insertion cannot exclude vasa previa in cases with abnormal placental location

2019; Wiley; Volume: 55; Issue: 4 Linguagem: Inglês

10.1002/uog.20347

1469-0705

T. Suekane, Daisuke Tachibana, Ritsuko Pooh, Takuya Misugi, Masayasu Koyama,

Grief, Bereavement, and Mental Health

Vasa previa is a severe condition which, if not recognized before rupture of the membranes or labor onset, may lead to fetal exsanguination due to laceration of vulnerable fetal blood vessels which lack the protection of Wharton's jelly1. Catanzarite et al. classified vasa previa into two varieties: Type 1, in which there is a single placental lobe with velamentous cord insertion; and Type 2, in which the vessels traversing the cervix are connected between the lobes of a multilobed placenta2. We report here two cases of vasa previa which could not be classified into either of these types. In the first case, a 32-year-old nulliparous woman who had conceived spontaneously was referred to our hospital at 22 weeks' gestation due to suspicion of placenta previa. Although the umbilical cord was shown to have normal insertion into the placenta (Figure 1a), after resolution of placenta previa over a period of 6 weeks (Figure 1b), fetal vessels were found at the internal os of the cervix. The patient was admitted at 31 weeks' gestation for management as vasa previa. Scheduled Cesarean section was performed at 35 weeks, and a healthy female neonate weighing 2206 g was born with Apgar scores of 5 and 7 at 1 min and 5 min, respectively. Umbilical artery blood pH was 7.305 and hemoglobin was 12.3 g/dL. After delivery, fetal vessels running within the membrane were seen, although umbilical cord insertion was normal (Figure 1c,d). In the second case, a 33-year-old nulliparous woman who had conceived spontaneously was referred to our hospital at 16 weeks' gestation with an ovarian cyst which resolved spontaneously. She was admitted for management of placenta previa at 33 weeks. Transvaginal ultrasound examination revealed a fetal vessel near the internal os of the cervix, connecting to the low-lying placenta, although normal cord insertion was shown by transabdominal ultrasound examination (Figure 1e,f). Scheduled Cesarean section was performed at 35 weeks' gestation and a healthy female neonate weighing 2285 g was born with Apgar scores of 7 and 8 at 1 min and 5 min, respectively. Umbilical artery blood pH was 7.281 and hemoglobin was 14.8 g/dL. After delivery, fetal vessels running within the membrane were seen, although umbilical cord insertion was normal (Figure 1g,h). These two cases of vasa previa had an abnormal orbit of fetal vessels, which were once inserted normally into the placenta as umbilical cords. Some of the vessels branched out from the placental surface and returned subsequently to the placental cotyledons, following a path with a shape similar to the orbit of a boomerang. Vasa previa is known to occur after resolution of placenta previa3. These cases highlight a new type of vasa previa (Type 3), in which fetal vessels follow a boomerang orbit, without velamentous cord insertion or bilobed/accessory placenta. Meticulous observation of fetal vessels running near the internal os using color Doppler imaging should be performed in cases of placenta previa and those of low-lying placenta, regardless of whether umbilical cord insertion is normal.