Furcate Cord Insertion

Furcate cord insertion is a rare abnormality in which the umbilical vessels separate from the cord just before the placental surface and run for a distance without the protective Wharton's jelly. It matters because the exposed vessels can be compressed or torn, causing fetal bleeding, distress or death, and because the cord can break at delivery.

• Risk factors: multiple pregnancy, assisted conception, velamentous insertion in one pregnancy, smoking.
• Often found only on examination of the placenta.
• Antenatal detection is difficult.

Women have no symptoms. Some have reduced fetal movements, growth restriction or abnormal heart rate tracings in labour.

• Normal examination in most.
• Sudden bradycardia at rupture of membranes is rare.
• Differential diagnosis: velamentous cord insertion, battledore placenta, vasa previa, marginal insertion, cord entanglement.
• Complications: cord vessel compression, rupture of vessels with fetal bleeding, fetal distress, growth restriction, stillbirth, cord avulsion at delivery, retained placenta.

The approach is detailed ultrasound with colour Doppler of the cord insertion, supported by the placental examination.

• Ultrasound: the cord vessels visibly splay out before reaching the placental surface, with a gap in the surrounding jelly; colour Doppler to show the vessels in the membranes.
• Exclude vasa previa by colour Doppler across the membranes and over the os.
• Growth scans at 28 and 32 weeks; umbilical artery Doppler; cardiotocography from 32 weeks.
• Confirmation at birth by examining the placental surface.

The principle is growth and heart rate surveillance with a plan for gentle cord handling and neonatal readiness.

• Supportive: reassure; stop smoking; daily fetal movement counts; birth in a facility with caesarean section and neonatal care.
• Pharmacological: aspirin 150 mg oral at night from 12 weeks to 36 weeks if uterine artery Doppler is abnormal; betamethasone 12 mg IM twice, 24 hours apart, between 24 and 34 weeks and 6 days if preterm delivery is likely; oxytocin 10 IU IM at birth; newborn O negative packed cells 10 to 20 mL/kg IV for anaemia after cord injury.
• Procedures: growth scans every 4 weeks from 28 weeks; delivery at 38 to 39 weeks; continuous cardiotocography in labour; caesarean section for pathological tracing; controlled cord traction with the uterus guarded, avoiding forceful traction.
• Red flags: bleeding at rupture of membranes with fetal heart changes, reduced fetal movements, falling growth centile, abnormal cardiotocography.
• Follow-up: antenatal review every 2 to 4 weeks; newborn haemoglobin if cord vessels tore; placental histology.