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JOURNAL OF
THE ANATOMICAL SOCIETY OF INDIA

Vol. 49, No. 2, December, 2000


In this issue :

Editorial
Dr. Patnaik V.V.Gopichand

Gross Anatomy of the Caudate Lobe of the Liver
Sahni, D., Jit, I., Sodhi L. Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Branching Pattern of Axillary Artery - A Morphological Study
*Patnaik V.V.G., Kalsey, G; Singla Rajan, K. Department of Anatomy, Government Medical College, Amritsar, *Patiala. INDIA

The Course, Relations and The Branching Pattern Of The Middle Meningeal Artery In South Indians
Manjunath, K.Y. & Thomas, I.M. Department of Anatomy, St. John�fs Medical College, Bangalore-560 034 INDIA

Morphometry of the Human Inferior Olivary Nucleus
Dhall, U; Chhabra, S. & Rathi, S.K. Department of Anatomy, Pt. B.D. Sharma P.G.I.M.S., Rohtak. INDIA

Management of Turner Syndrome in India Using Anthropometric Assessment of Response to Hormone Replacement Therapy.
Sehgal R. and Singh A. Department of Anatomy, Maulana Azad Medical College and Associated Lok Nayak, G.B. Pant & G.N.E.C. Hospitals, New Delhi ? 110 002 INDIA.

Insertion Of Umbilical Cord On The Placenta In Hypertensive Mother
Rath* G, Garg** K, and Sood*** M. *Department of Anatomy, ***Department of Obstetrics & Gynaecology, Lady Hardinge Medical College, New Delhi-110001 **Department of Anatomy, Santosh Medical College, Gaziabad. INDIA

Utility Of Finger Prints in Myocardial Infarction Patients
Dhall, U; Rathee, S.K; *Dhall, A; Department of Anatomy & *Medicine, Pt. B.D. Sharma, PGIMS, Rohtak. INDIA

The Prenatal Parotid Gland
Fouzia Nayeem, Sagaff S., *Krishna G., **Rao S. Department of Anatomy, K.A.A.U. Jeddah. Department of *Pediatrics & **Surgery, Osmania Medical College, Hyderabad. INDIA

Possibility of Cell Death Induced Skeletal Malformations Of The Upper Limb
Sinha, D.N. Department of Anatomy, B.R.D. Medical College, Gorakhpur?273013 INDIA,

Efficacy of Manual Bladder Expression in Relieving Urine Retention After Traumatic Paraplegia In Experimental Animals.
Preeths, T.S., Sankar, V. Muthusamy, R. Department of Anatomy, Dr. A. Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai 600 113, India.

Stress And Serum Cholesterol Levels-An Experimental Study
Jain, S.K. *Pandey, S.N. *Srivastava, R.K. Ghosh, S.K. Department of Anatomy, D.R.P.G. Medical College, Kangra at Tanda. * Department of Anatomy, G.S.V. Medical College, Kanpur.

Effect of Ibuprofen On White Cell Series of Bone Marrow Of Albino Rats
* Bhargava, R., Chandra, N., Naresh, M., *Sakhuja S. * Department of Anatomy, M.L.N. Medical College, Allahabad * Lady Hardinge Medical College, N. Delhi, India.

JB4 An Embedding Medium For Flourescent Tracer Technique
*Gupta, M; **Mishra, S., ***Sengupta P. Department of Anatomy, *PGI, Chandigarh; **AIIMS, N. Delhi; ***UCMS, New Delhi. INDIA

Comparative Anatomy of Cardiac Veins in Mammals
Kumar Keshaw Department of Anatomy, Institute of Medical Sciences B.H.U., Varanasi?5. INDIA

Aplasia Cutis Type 9 With Trisomy-13 Syndrome ? A Rare Association
Adhisivam, B, Narayanan, P, Vishnu Bhat, B, *Ramachandra Rao. R*, *Rao. S*, Kusre, G.* Department Pediatrics & *Anatomy, JIPMER, Pondicherry - 605 006

Absence of Musculocutaneous Nerve And The Innervation of Coracobrachialis, Biceps Brachii And Brachialis From The Median Nerve
Sud, M.; Sharma A. Department of Anatomy, Christian Medical College, Ludhiana. Punjab INDIA.

A Rare Pseudo Ansa Cervicalis: A Case Report
Indrasingh I. and Vettivel S. Department of Anatomy, Christian Medical College, Vellore, India

A Rare Variation In The Relation Of Omohyoid Muscle: A Case Report
Vettivel, S. Korula, A. and Koshy S. Department of Anatomy, Christian Medical College, Vellore, India

Surgical Incisions ? Their Anatomical Basis Part II - Upper Limb
1Patnaik V.V.G., 2Singla Rajan. K., 3 Gupta P.N. Department of Anatomy, Government Medical College, Patiala1, Amritsar2, 3Department of Orthopedics, Government Medical College, Chandigarh. INDIA

Anatomy Of Temporomandibular Joint?A Review
1Patnaik V.V.G., 3Bala Sanju; 2Singla Rajan K. Department of Anatomy, Govt. Medical College, 1Patiala, 2Amritsar, 3Department of Oral & Maxillofacial Surgery, Pb. Govt. Dental College, Amritsar


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J Anat. Soc. India 49(2) 149-152 (2000)
Insertion Of Umbilical Cord On The Placenta In Hypertensive Mother

Rath* G, Garg** K, and Sood*** M. *Department of Anatomy, ***Department of Obstetrics & Gynaecology, Lady Hardinge Medical College, New Delhi-110001 **Department of Anatomy, Santosh Medical College, Gaziabad. INDIA

Abstract : The site of insertion of umbilical cord of placenta in pregnancy with hypertensive disorder was studied and the insertion percentage was calculated with the help of d/r x 100 ('d' stands for the minimum distance between the site of insertion and margin of placenta, and 'r' for radius of the surface area of placenta). The association between the insertion percentage in placentae of different size categories and that with birthweight of infants were calculated in relation to normal, mild, moderate and severe hypertensive mothers. It was noticed that only in severe hypertensive cases, the marginal attachment of umbilical cord with 0-25 insertion percentage, scored the highest in the series with 42%. It may be attributed to hamper the growth of fetus to a maximum level resulting in low birth weight babies. If diagnosed in the first and second trimester, added precautions could be instituted during labour to reduce further risk to the mother and fetus.

Keywords : Umbilical cord, placenta, maternal hypertension.

Introduction :

Hypertensive disorders are common complications of pregnancy. Pregnancy may induce hypertension in previously normotensive women or aggravate this condition in those who are already hypertensive. It was observed by Damania et al (1989) that hypertension causes low birth weight, low placental weight and other placental abnormalities. Aherne and Dunhill (1966) described relation between birth weight, placental area and placental volume in normal infants. Thomson et al (1969) and Younoszai and Haworth (1969) reported that the placental weight and size are directly proportional to the birth weight. Perceival (1980) observed that the eccentric attachment of the umbilical cord was most common in normal placenta. Shanklin (1970) noticed velamentous or marginal type of cord insertion in infants weighing less than 2500 gms. The reports on the attachment of umbilical cord on placenta, specifically in hypertensive disorders of the pregnancy are scanty. Therefore, it was decided to study the exact site of umbilical cord attachment in pregnancy associated with mild, moderate and severe hypertension and to correlate it with the birth weight of the new born.

Material and Methods :

Two hundred and eighteen placentae were obtained from the labour room of the department of Obstetrics and Gynaecology, Smt. Sucheta Kripalani Hospital, New Delhi. Normal placentae were obtained from uneventful pregnancies ending at term. In all the cases, there was normal vaginal delivery without any complication with the exception of three cases, where the delivery was aided with the forceps. Placentae associated with hypertensive mothers were mostly from 36-38 weeks of gestation with vaginal delivery and twenty placentae were delivered by caesarean section due to fetal distress. The placentae were grouped depending on the degree of hypertension (as described by Derek 1982) in the mothers (Table 1).

Table-1. Number of cases in relation to hypertension

Type of case Blood Pressure (mm of Hg) No of cases
Normal
Pregnancy
100
80
74
Mild H.T. 120  130
90    99
54
Moderate H.T. 140    170
100    110
38
Severe H.T. > 170
   120
52

In all the cases, the amnion and chorion were trimmed from the placentae. The umbilical cord was cut 4 cms from the site of insertion. Each placenta was washed and surfaces dried between blotting papers and their weight was noted. The minimum distance between the site of insertion and the margin of the placenta was measured and denoted as 'd'. The surface area of the placenta was recorded by cutting out its shape on a piece of plastic sheet which was mapped on a graph sheet to calculate the area. Assuming the placenta to be a perfect circle, the mean radius 'r' was estimated from the surface area. The insertion percentage i.e. d/r X 100 was then worked out.

A low insertion percentage implied a marginal insertion, while a high insertion percentage indicated a centrally attached umbilical cord. Each placenta was placed in one of the four categories depending upon the insertion percentage i.e. central, medial, lateral and marginal. The mean birth weight of infants falling into each placental group and cord insertion category was then noted. Ultrasound report of insertion of umbilical cord was also recorded in 74.8% (163/218) of the normotensive and hypertensive mothers.

Results :

The site of insertion of umbilical cord was found to be central (76-100 insertion percentage), medial (51-75 insertion percentage), lateral (26-50 insertion percentage) and marginal (0-25 insertion percentage). Insertion of the umbilical cord in relation to the normal and hypertensive cases with their respective percentages was calculated (Table-2).

The birth weight of infants belonging to normotensive and hypertensive mothers was noted. The placental weight and surface area were recorded. The feto-placental ratio was calculated. The weight of the placenta and infants in hypertensive group were found to be lower than the normal group. The mean feto-placental ratio of the hypertensive groups were less than those of the normal group. The mean surface area of the placentae of the hypertensive group was shorter than that of the normotensive mothers (Table 3).

The association between the insertion percentage, size of the placenta and the birth weight of infants were calculated in relation to normal, mild, moderate and severe hypertensive mothers. It was found to be significant (Table - 4). Ultrasound report also revealed that marginal insertion of umbilical cord was more common in the hypertensive subgroup.

Table-2. Number of hypertensive cases with percentages in relation to insertion of the umbilical cord

Category Site of Insertion (Insertion Percentage)
Central
(76-100)
Medical
(51-75)
Lateral
(26-50)
Marginal
(0-25)
Normotensive group
(n=74)
18(24) 16(22) 20(27) 20(27)
Hypertensive group
Mild
(n=54)
12(22) 12(22) 16(30) 14(26)
Moderate
(n=38)
8(21) 10(26) 10(26) 10(26)
Severe
(n=52)
10(23) 8(15) 12(20) 22(42)

Table-3. Mean birth weight, placental weight, placental area, and feto-placental ratio belonging to normotensive and hypertensive mothers.

Cases Mean Birth Weight (in gms) + S.D. Mean Placental Weight (In gms) + S.D. Mean Placental area (in Sq.cm.) Feto Placental Ratio Square of Co-efficient of correlation R2 `t' Signi ficance, F Remarks
Normal
(n=74)
2718.297
+532.578
382.148
+52.321
254.63 7.11 0.94964 2.326 .0000 Highly Significant
Hypertensive
Mothers
Mild
(n=54)
2404.037
+360.311
351.308
+64.047
251.73 6.84 0.94758 2.779 .0000 Highly Significant
Moderate
(n=38)
2205.263
+424.692
338.024
+57.807
245.39 6.52 0.95098 1.960 .0000 Highly Significant
Severe
(n=52)
2011.923
+459.688
332.410
+60.037
209.36 6.05 0.95693 2.576 .0000 Highly Significant

Table-4. Association between insertion percentage, surface area and birth weight of placentae of normotensive and hypertensive mothers

Site of Insertion of umbilical cord (Insertion %) Distribution of hypertensive cases Surface area of placenta (sq.cm) Square of Co-efficient of co-relation (R2) Significance (F) Remarks
151-200 201-250 251-300 301-350
Central
(76-100)
Normal
Mild
Moderate
Severe
2300(2)
2100(2)
2160(2)
1500(2)
2555(4)
2350(2)
2270(2)
2100(2)
3440(6)
2363(6)
2550(2)
2600(4)
3552(6)
2850(2)
3000(2)
3170(2)
0.93335
0.85630
0.93853
0.89438
0.0000
0.0000
0.0001
0.0000
Significant
Significant
Significant
Significant
Medial
(51-75)
Normal
Mild
Moderate
Severe
2400(2)
2280(2)
2000(2)
1700(2)
2356(6)
2400(2)
1950(2)
2100(2)
2540(2)
2650(6)
2550(4)
2400(2)
2953(6)
3200(2)
2800(2)
2520(2)
0.93697
0.90597
0.98749
0.88601
0.0000
0.0006
0.0000
0.0008
Significant
Significant
Significant
Significant
Lateral
(26-50)
Normal
Mild
Moderate
Severe
2680(2)
2360(2)
1900(2)
1790(4)
2280(4)
2480(2)
2165(4)
2000(2)
2980(4)
2594(10)
2400(2)
2345(4)
3221(10)
2730(2)
2550(2)
2450(2)
0.95329
0.96203
0.98485
0.98776
0.0000
0.0000
0.0000
0.0000
Significant
Significant
Significant
Significant
Marginal
(0-25)
Normal
Mild
Moderate
Severe
1713(6)
1475(4)
1700(2)
1350(6)
2240(6)
2055(4)
1405(4)
1630(6)
2375(4)
2350(4)
2000(2)
1820(6)
2705(4)
2400(2)
2380(2)
2250(4)
0.86120
0.89302
0.93458
0.98760
0.0000
0.0000
0.0000
0.0000
Significant
Significant
Significant
Significant

Discussion :

Damania et al (1989) had studied sixty placentae of hypertensive disorders of pregnancy and had reported that birth weight, placental weight and feto-placental ratio were less in hypertensive cases than in the normotensive controls. It corresponds to the findings of Thomson et al (1969). In our analysis too, it was observed that birth weight, placental weight, surface area of the placenta and feto-placental ratio of the mild, moderate and severe hypertensive mothers are less than those of the normotensive mothers, being least in the severe hypertensive sub-group. In our study, the birth weight shows an increase with the ascending surface area of the placenta. The feto-placental ratio is found to be almost constant in normal and hypertensive disorders. This is in confirmity with the findings of Younoszai and Haworth (1969) who have reported that the placental weight and size are directly proportional to the birth weight. Perceival (1980) has reported that in 73 percent of cases, the site of insertion of umbilical cord is eccentric in position (somewhere between the centre and edge of the placenta). In our study, the marginal attachment of umbilical cord with 0-25 insertion percentage was seen in 27%, which is higher by 7% as noted by Perceival (1980). The distribution of four categories of insertion of umbilical cord is almost equal in normotensive group. Even amongst the mild and moderate hypertensive subgroups, the distribution of four categories is almost similar. Only in the severe hypertensive cases the marginal attachment of umbilical cord with 0-25 insertion percentage score was the highest with 42%. This high percentage in severe hypertension may be responsible for the low birth weight babies.

Woods and Malan (1978) have studied 940 placentae and found no correlation between the birth weight and the site of cord insertion in normal term infants. However, in the present study, even in normotensive mothers the marginal attachment of umbilical cord was correlated with low birth weight babies. Besides the normotensive mothers, even in cases of mild, moderate and severe hypertensive cases, the marginal attachment of umbilical cord was related to low birth weight, most commonly noticed in the severe hypertensive sub-group. These findings are similar to those reported by Shanklin (1970), who after studying 5000 placentae, observed a high degree of correlation between anomalous cord insertion and low birth weight.

The association between marginal attachment of the cord and low birth weight is statistically significant. The low birth weight may be explained by an altered distribution of fetal blood in the placenta as a result of different modes of arrangement of intracotyledonary vessels of placentae of complicated pregnancy (Rath et al 1994). This vascular arrangement may be hampering equal distribution of blood flow in the placenta, increasing the risk to the mother and fetus. Sonographic study could also show clearly the site of insertion of the umbilical cord of the placenta and in hypertensive mothers, it was mostly marginal. It confirms the observations of Pretorius et al (1996) and Di Salvo et al (1998). In case the ultrasound report reveals marginal attachment, it is advisable to get it confirmed by colour doppler imaging, if possible. In conclusion, the present study reveals the method of precise location of umbilical cord by calculation of insertion percentage. It is noticed that the marginal insertion is associated with hypertension and that it can be diagnosed during antenatal check up by available technique to further strengthen the proposed precautions to be taken during and after labour.

References :

1. Aherne, W, Dunhill, M.S. (1966) : Quantitative anatomy of the placenta. Journal of Pathology and Endocrinology 91: 123-139.
2. Damania, K.R, Salvi, VS, Ratnaparkhi, S.K. Daftary, S.N. (1989): The placenta in Hypertensive disorders of pregnancy. Journal of Obstetrics and Gynaecology of India 39: 28-31.
3. Derek, L.J: Fundamentals of Obstetrics and Gynaecology, In: Hypertensive disease in Pregnancy (Toxaemias of Pregnancy) 4th Edn Vol.1, Faber and Faber, London. pp 217-227. (1982).
4. DiSalvo, D.N; Benson, C.B; Laing, F.C; Brown, D.L; Frates, M.C; Doubilet, P.M. (1998): Sonographic evaluation of the placental cord insertion site. American Journal of Roentgenology 170: 1295-1298.
5. Perceival, R. "Holland and Brews, Manual of Obstetrics" In: Chorion and placenta with placental Ischaemia. 14th Edition. The English Language Book Society and Churchill Living Stone, 30-50. (1980)
6. Pretorius, D.H; Chau, C; Poeltler D.M; Mendoza, A; Catanzarite, V.A; Hollenbach, K.A. (1996): Placental cord insertion visualization with prenatal ultrasonography. Journal of Ultrasound Medicine 15: 585-593.
7. Rath, G; Garg. K; Anand, C; Kawle, M. (1994): Vascular pattern of human placenta in complicated pregnancy; A corrosive cast study. Annals of the National Academy of Medical Sciences (India) 30: 17-22.
8. Shanklin, D.R; (1970): The influence of Placental lesions on the Newborn Infant: Pediatric Clinics of North America 17, 25-42.
9. Thomson, A.M; Billewicz, W.Z; Hytten, F.E; (1969): The weight of the placenta in relation to birth weight. Journal of Obstetrics and Gynaecology of British Common wealth 76, 865-872.
10. Woods, D.L; Malan, A.F; (1978): The site of Umbilical cord insertion and Birthweight. British Journal of Obstetrics and Gynaecology 85, 332-333.
11. Younoszai M.K; Haworth, J.C. (1969): Placental dimensions and relations in pre-term, term and growth retarded infant. American Journal of Obstetrics and Gynaecology 103: 265-271.



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