Causes of Death in Newborn with Double Nuchal Cord and Multi-Organ Necrosis
The immediate cause of death was multi-organ failure from coagulative necrosis of vital organs (adrenals, liver, kidneys); the antecedent cause was severe perinatal asphyxia/hypoxic-ischemic injury; and the underlying cause was double nuchal cord coil leading to umbilical cord compression and compromised placental circulation.
Pathophysiologic Sequence
Underlying Cause: Double Nuchal Cord Coil
- Double (or multiple) nuchal cord entanglements occur in approximately 3.8% of term deliveries and represent a mechanical cause of compromised fetal circulation 1
- Multiple nuchal cord entanglements are significantly associated with abnormal fetal heart rate patterns during labor, meconium passage, and umbilical artery acidosis (pH ≤7.10) with an odds ratio of 2.2 1
- Tight nuchal cord specifically causes fetal distress in 51% of cases and is associated with birth asphyxia in 61% of affected infants 2
- The cord entanglement creates mechanical compression of umbilical vessels, leading to intermittent or sustained reduction in placental blood flow 3
Antecedent Cause: Severe Perinatal Asphyxia/Hypoxic-Ischemic Injury
- The double nuchal cord caused prolonged or severe umbilical cord compression, resulting in profound hypoxia and metabolic acidosis during the perinatal period 1
- Severe hypoxic episodes in newborns characteristically produce metabolic acidosis, cardiovascular instability, acute renal failure, and acute neurological dysfunction 4
- This hypoxic-ischemic insult triggers a cascade of cellular injury affecting multiple organ systems, particularly those with high metabolic demands and watershed perfusion zones 4
Immediate Cause: Multi-Organ Failure from Coagulative Necrosis
Adrenal Necrosis:
- Bilateral adrenal coagulative necrosis represents a classic manifestation of severe perinatal asphyxia due to the adrenal glands' high metabolic rate and vulnerability to hypoxic-ischemic injury
- Adrenal hemorrhage and necrosis occur in the context of cardiovascular instability and shock states following severe hypoxic events 4
Acute Tubular Necrosis (Kidneys):
- Acute renal failure with tubular necrosis is a well-documented consequence of severe hypoxic episodes in newborns 4
- The kidneys are particularly vulnerable to ischemic injury during periods of cardiovascular compromise and reduced perfusion
Hepatic and Gallbladder Necrosis:
- Extensive coagulative necrosis of the liver and gallbladder indicates profound ischemic injury to the hepatobiliary system
- Hepatic necrosis occurs in the context of severe hypoxic-ischemic encephalopathy and represents end-organ damage from prolonged hypoperfusion 5
Clinical Context and Mechanism
- The pattern of multi-organ coagulative necrosis (adrenals, liver, kidneys) without significant abnormalities in other organs is pathognomonic for severe, sustained hypoxic-ischemic injury rather than infectious or metabolic causes 4
- This distribution reflects the "diving reflex" response where blood flow is preferentially shunted to the brain and heart during severe hypoxia, leaving other organs vulnerable to ischemic necrosis
- The presence of double nuchal cord as the only identifiable antecedent event, combined with this specific pattern of organ injury, establishes the causal chain from mechanical cord compression to asphyxia to multi-organ failure 2, 1
Important Caveats
- Not all cases of nuchal cord result in adverse outcomes—loose nuchal cords have significantly better outcomes than tight cords 2
- The severity of organ damage in this case suggests either prolonged compression during labor or acute severe compression that was not immediately recognized or could not be relieved 1
- Immediate cord clamping before delivery of the shoulders (when nuchal cord is tight) has been associated with hypovolemia, anemia, shock, and hypoxic-ischemic encephalopathy, which may have contributed if this intervention was performed 3