Velamentous insertion of umbilical cord with vasa praevia: case series and literature review

A velamentous umbilical cord is characterized by membranous umbilical vessels at the placental insertion site that are prone to compression and rupture, especially when they are located in the membranes covering the cervical os (vasa praevia). The velamentous insertion of the umbilical cord, with a reported incidence of 1% in singleton pregnancies and 15% in monochorionic twin gestations, has been associated with obstetric complications: fetal growth restriction, prematurity, congenital anomalies, low Apgar scores, fetal bleeding with acute fetal distress and placental retention. The pathogenesis is unknown, but the trophotropism theory is the most common and supported by the association of velamentous cord insertion and placenta praevia. The prevalence of vasa praevia is of approximately 1/ 2500 deliveries; the risk factors include the use of assisted reproductive technologies, low-lying placenta or placenta praevia, bilobed or succenturiate lobe placenta and multiple gestation. The diagnosis is rarely established before delivery and consequently the fetal mortality is extremely high. We report two cases of velamentous marginal umbilical cord insertion associated with vasa praevia (type 1 vasa praevia) and placenta praevia diagnosed during a routine mid-trimester fetal 2D ultrasound scan, color and power Doppler transvaginal ultrasound cervical assessment. The ultrasound examination revealed one umbilical vessel crossing the internal os of the cervix entering the placental margin and connecting to the subchorionic vasculature, remaining immobile when the uterus was shaken, the color Doppler imaging enhancing the identification of the vessel. The patients were admitted to the hospital in the third trimester and deliveries were planed and successfully performed at 38 weeks gestation, being confirmed by a macroscopic examination ultrasound diagnostic.