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Impact of velamentous cord insertion on perinatal outcomes: A systematic review and meta-analysis

Published:November 11, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100812

      Abstract

      Introduction

      : Velamentous cord insertion (VCI) may be identified prenatally, but the clinical implications of this diagnosis remain controversial. The aim of this meta-analysis was to quantitively summarize current data on the association of VCI and adverse perinatal outcomes.

      Data sources

      : A systematic search was performed in Medline, Scopus, and the Cochrane Library as of 22nd May 2022 to identify eligible studies.

      Study eligibility criteria

      : Observational studies including singleton pregnancies with VCI, either prenatally or postnatally identified, and comparing them to those with central/eccentric cord insertion (CCI) were considered eligible.

      Study appraisal and synthesis methods

      : The quality of the studies was assessed with the Newcastle-Ottawa scale and the risk of bias with the QUIPS tool. The main outcome was small for gestational age neonates. Heterogeneity of the studies was evaluated using a Q test and an I2 index. Analyses were performed using a random-effects model with outcome data reported as relative risk or mean difference with 95% confidence interval.

      Results

      : In total, nine cohort and two case-control studies, of which four with prenatal and seven with postnatal VCI diagnosis, were included. The overall prevalence of VCI was estimated to be 1.4% among singleton pregnancies. Compared to the CCI control group, pregnancies with VCI were at higher risk of several adverse perinatal outcomes, namely small for gestational age (SGA) neonates (RR: 1.93; CI: 1.54-2.41), preeclampsia (RR: 1.85; CI: 1.01-3.39), pregnancy induced hypertension (RR: 1.58; CI: 1.46-1.70), stillbirth (RR: 4.12; CI: 1.92-8.87), placental abruption (RR: 2.94; CI: 1.72-5.03), preterm delivery (RR: 2.14; CI: 1.73-2.65), emergency cesarean delivery (RR: 2.03; CI: 1.22-3.38), 1-min Apgar score <7 (RR: 1.53; CI: 1.14-2.05), 5-min Apgar score <7 (RR: 1.97; CI: 1.43-2.71) and neonatal intensive care unit admission (RR: 1.63; CI: 1.32-2.02). In a sub-group analysis, prenatally diagnosed VCI was associated with SGA (RR: 1.66; CI: 1.19-2.32), stillbirth (RR: 4.78; CI: 1.42-16.08) and preterm delivery (RR: 2.69; CI: 2.01-3.60). In a sensitivity analysis of studies excluding cases with vasa previa, VCI was associated with an increased risk of SGA (RR: 2.69; CI: 1.73-4.17), pregnancy induced hypertension (RR: 1.94; CI: 1.24-3.01) and stillbirth (RR: 9.42; CI: 3.19-27.76), but not preterm delivery (RR: 1.92; CI: 0.82-4.54).

      Conclusions

      : VCI is associated with several adverse perinatal outcomes, including stillbirth and these associations persist when only prenatally diagnosed cases are considered and when vasa previa cases are excluded. According to these findings, the exact pathophysiology should be further investigated and an effective prenatal monitoring plan should be developed.

      Keywords

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