Clinical Significance of Furcate Umbilical Cord Insertion
Furcate cord insertion is an extremely rare and potentially life-threatening umbilical cord abnormality that requires heightened surveillance and careful delivery planning due to the risk of vessel rupture, fetal hemorrhage, and sudden intrauterine fetal death.
What is Furcate Cord Insertion?
Furcate insertion occurs when the umbilical vessels separate and branch from the cord substance before reaching the placenta, leaving them unprotected by Wharton's jelly at the insertion site 1, 2. This creates vulnerable, exposed vessels that lack the protective cushioning normally present in standard cord insertions 1.
Key Clinical Risks
Immediate Life-Threatening Complications
- Vessel rupture and fetal hemorrhage can occur spontaneously or during delivery, potentially causing sudden intrauterine fetal death 1, 3
- Cord avulsion during delivery has been documented, requiring immediate neonatal resuscitation and blood transfusion 3
- Manual placental removal attempts can result in vessel avulsion at the furcate insertion site 4
Associated Pathological Changes
- The placental tissue beneath the furcate insertion often shows fibrin deposition, focal infarction, and deficient parenchymal tissue replaced by white, elastic hard tissue 1
- These pathological changes may contribute to compromised placental function 1
Prenatal Detection and Surveillance
Diagnostic Approach
Detailed color Doppler ultrasound during the second-trimester anatomy scan (18-22 weeks) is essential for identifying this abnormality 5, 1. The characteristic finding is umbilical vessels separating from the cord substance before placental insertion, visible on color Doppler imaging 1, 2.
Surveillance Protocol Once Diagnosed
- Serial ultrasound monitoring should focus on fetal growth assessment, amniotic fluid volume, and umbilical artery Doppler velocimetry throughout the remainder of pregnancy 5
- Umbilical artery Doppler assessment should be performed if growth restriction is suspected or documented 5
- Consider more frequent monitoring given the potential for sudden complications 1, 2
Delivery Management
Labor induction at term (37 weeks) with immediate availability of neonatal resuscitation is recommended 2, 3. Key delivery considerations include:
- Avoid cord traction during placental delivery due to high risk of vessel avulsion at the furcate insertion site 4
- Have blood products immediately available for potential neonatal transfusion 3
- Ensure neonatal resuscitation team is present at delivery given the risk of acute hemorrhage 3
- While vaginal delivery has been successful in reported cases, cesarean delivery should be strongly considered, particularly if additional risk factors are present 2, 4
Special Populations at Higher Risk
Pregnancies conceived through assisted reproductive technologies, particularly in women with Müllerian anomalies (such as unicornuate uterus), warrant heightened suspicion for furcate insertion 6. These patients may also have concurrent placenta accreta, further complicating management 6.
Critical Pitfalls to Avoid
- Most cases remain undiagnosed prenatally due to lack of awareness and inadequate color Doppler evaluation of the cord insertion site 1, 3
- Assuming favorable outcomes based on rarity is dangerous—while many cases have good outcomes, catastrophic hemorrhage can occur without warning 3
- Routine cord traction during third stage of labor can be catastrophic with furcate insertion and should be avoided 4