Umbilical Cord Encirclement in Twins
Authors: Adinma J.I. Brian‐D , Agbai Andy O. 
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because although it is a retrospective study we have not published information previously on umbilical cord entanglement in twins and we would encourage readers to submit prospective information on this potentially very important problem. As the authors indicate Doppler ultrasound is used in some centres now to detect cord entanglement prior to labour. Indeed in 1994 when the editor visited hospitals in the province of Jiangsu in China he was told that cord entanglement detected by Doppler ultrasound was an indication they used for Caesarean section. The Caesarean section rate in the hospitals concerned was approximately 30%. There is also the question of whether umbilical cord entanglement or abnormally short or long cords can have significance in terms of intrauterine growth and fetal well‐being. The umbilical cord is around the neck of the fetus in 15–30% of singleton births (A) and it is generally accepted that a cord around the neck causes fetal distress and fetal death only in labour when the cord becomes tightened by descent of the fetus in contradistinction to the cord that is entangled around the baby's body which is more characteristically seen in cases of fetal death in utero before labour. The editor has served as a member of the Stillbirth Subcommittee in the State of Victoria since 1969 and in his experience it is very difficult for the committee members to decide in many cases of stillbirth whether the umbilical cord entanglement which has been noted was an acceptable cause of the fetal death in the absence of petechial haemorrhages in the head and neck, evidence that tightness of the cord has caused a groove in the fetal neck or evidence of umbilical vessel thrombosis. There is a great variation in umbilical cord accidents being accepted as a cause of stillbirths in various series. The presence of a perinatal pathologist is essential on a Stillbirth Subcommittee to help adjudicate on these problems. We need more information concerning the incidence and variety of cord entanglement in multiple pregnancy. We agree with the authors that Doppler study may provide further useful information.

Summary: The incidence of umbilical cord encirclement in twins in this study was 10.1%. Twins with tight cord entanglement (TCE) had a 1‐minute Apgar score predominantly at the range of 0–6, (3 of 4), unlike those with loose cord entanglement (LCE) whose Apgar scores at 1 minute occurred evenly in the 0–6 (15 of 29) and 7–10 (14 of 29) score range. The perinatal mortality rate was significantly higher for tight cord‐entangled twins (750 per 1,000) compared to noncord‐entangled (NCE) (58 per 1,000) and all twins (61 per 1,000). All the perinatal deaths occurred in the tight cord‐entangled (TCE) twins, 2 of the 3 being in second twins with gestational age less than 30 weeks. The umbilical cord was significantly longer in cord‐entangled twins compared to all twins (p <0.0005) by 11.7 cm for twin 1 and 10.4 cm for twin 2. No difference occurred in birth‐weight between cord‐entangled twins 1 and 2 and between them and noncord‐entangled twins. There was no difference in the overall mode of delivery for the cord entangled, nonentangled and all twins, although cord entanglement was more prevalent in spontaneous vertex vaginal deliveries compared to other modes of delivery for the first twin only.