Case notes
A 26-year-old woman, gravida 3, para 2, gave birth to spontaneous monochorionic triamniotic female triplets at 36 weeks and 1 day. They were delivered by a scheduled—and uncomplicated—cesarean section. One week earlier, ultrasonography indicated concordant growth with estimated fetal weights ranging from the 32-35th percentiles despite eccentric cord insertion for triplet A and velamentous cord insertion for triplet B. The latter was diagnosed at 19 2/7 weeks’ gestation.
In fact, the weights of neonates A, B, and C were 5 lb 1 oz (2295 g), 4 lb 11 oz (2120 g), and 5 lb 12 oz (2610 g), placing them in the 7th, 3rd, and 28th weight percentiles, respectively. The largest neonate weighed 18.8% more than the smallest.
Conclusions
Weights correlated with cord insertion site. The smallest neonate had a velamentous insertion, the largest had a central insertion, and the infant with the intermediate weight had an eccentric attachment of the cord ( Figure ). Eccentric attachment represents an insertion that is not central, velamentous, or marginal; often these are “almost marginal,” as was the case with this neonate. All 3 had APGAR scores of 9 and 9 at 1 and 5 minutes of birth, respectively. Mother and infants did well postoperatively and were discharged on day of life 4.
Though few studies exist of higher-order multiples, twins, especially those with monochorionicity, have been shown to have a significantly higher risk of velamentous cord insertion, and this abnormality is associated with birthweight disparity and intrauterine growth restriction. Further, discordant pairs have higher rates of perinatal and neonatal mortality and low 5-minute Apgar scores, even after controlling for gestational age. Our patient’s triplets, each with an insertion at a different site in the placenta, provided a unique illustration of umbilical cord attachment and its possible contribution to neonatal weight disparities among multiples.
The authors report no conflict of interest.
Reprints not available from the authors.
Cite this article as: Baxi LV, George EM. Three-way tie: the umbilical cord insertion site was different for each member of a set of triplets. Am J Obstet Gynecol 2013;209:590.e1.
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