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Umbilical Cord
Paula Krakowiak, MS, Erin N. Smith, BS, Guy de Bruyn, MBBCH, and
Mona T. Lydon-Rochelle, PhD, MPH
OBJECTIVE: To identify risk factors and outcomes associated with a short umbilical cord.
METHODS: We conducted a population-based case-control study using linked Washington State birth certificate
hospital discharge data for singleton live births from 1987 to
1998 to assess the association between maternal, pregnancy,
delivery, and infant characteristics and short umbilical
cord. Cases (n 3,565) were infants diagnosed with a short
umbilical cord. Controls (n 14,260) were randomly selected
from among births without a diagnosis of short umbilical
cord.
0029-7844/04/$30.00
doi:10.1097/01.AOG.0000102706.84063.C7
119
120
Krakowiak et al
Table 1. Selected Characteristics of Mothers Delivering Infants With Short Umbilical Cords Compared With Mothers
Delivering Infants Without Short Umbilical Cords, Washington State, 19871998
Short cord (N 3,565)*
394 (11.1)
901 (25.3)
1120 (31.4)
823 (23.1)
325 (9.1)
1579 (11.1)
3572 (25.1)
4220 (29.6)
3284 (23.0)
1597 (11.2)
318 (15.4)
631 (30.5)
1120 (54.1)
1630 (19.7)
2722 (32.9)
3935 (47.5)
2654 (74.8)
896 (25.2)
10530 (74.0)
3703 (26.0)
2768 (80.6)
216 (6.3)
91 (2.7)
303 (8.8)
55 (1.6)
0 (0.0)
10797 (77.7)
845 (6.1)
471 (3.4)
1449 (10.4)
325 (2.3)
5 (0.0)
964 (27.0)
562 (15.8)
1003 (28.1)
209 (5.9)
827 (23.2)
4661 (32.7)
2201 (15.4)
3572 (25.1)
774 (5.4)
3050 (21.4)
19 (0.6)
2752 (83.6)
433 (13.2)
87 (2.6)
107 (0.8)
10796 (81.0)
1985 (14.9)
442 (3.3)
Krakowiak et al
121
Table 2. Selected Risk Factors and Characteristics Associated With the Presence of Short Umbilical Cords, Washington
State, 19871998
Short cord (N 3,565)* No short cord (N 14,260)* cOR 95% CI aOR 95% CI
Maternal characteristics and
behaviors
Body mass index
18.5
18.524.9 (ref)
25.0
Smoking
Alcohol
Maternal medical conditions
Anemia
Cardiac disease
Diabetes mellitus
Hypertension
Epilepsy
Genital herpes
Reproductive history
Parity
1
2 (ref)
3
Among women with prior
pregnancies
Prior fetal loss
Previous preterm infant
Prenatal procedures
Amniocentesis
Not done (ref)
First or second trimester
Third trimester
Ultrasound
Pregnancy complications
First-trimester bleeding
Oligohydramnios
Polyhydramnios
Incompetent cervix
Placenta previa
Gestational diabetes
Preeclampsia
Eclampsia
Fetal factors
Female
Any malformation
91 (6.3)
975 (66.8)
393 (26.9)
602 (18.0)
78 (2.9)
282 (5.1)
3360 (61.1)
1860 (33.8)
2464 (18.3)
310 (2.8)
1.1
1.0
0.7
1.0
1.0
0.9, 1.4
178 (5.0)
3 (0.1)
0 (0.0)
20 (0.6)
1 (0.0)
88 (2.5)
814 (5.7)
35 (0.3)
43 (0.3)
122 (0.9)
14 (0.1)
385 (2.7)
0.9
0.3
0.7, 1.0
0.1, 1.1
0.7
0.3
0.9
0.4, 1.1
0.0, 2.2
0.7, 1.2
1911 (54.8)
1014 (29.1)
565 (16.2)
5961 (42.6)
4543 (32.4)
3498 (25.0)
1.4
1.0
0.7
1.3, 1.6
627 (31.0)
31 (1.9)
3082 (32.2)
195 (2.5)
1.0
0.8
0.9, 1.1
0.5, 1.1
3289 (96.5)
82 (2.4)
36 (1.1)
1560 (52.1)
13063 (95.5)
457 (3.3)
155 (1.1)
6956 (57.9)
1.0
0.7
0.9
0.8
0.6, 0.9
0.6, 1.3
0.7, 0.9
27 (0.9)
46 (1.3)
21 (0.6)
3 (0.1)
13 (0.4)
29 (2.0)
162 (4.5)
3 (0.1)
120 (1.0)
130 (0.9)
60 (0.4)
25 (0.2)
95 (0.7)
154 (2.9)
794 (5.6)
57 (0.4)
0.9
1.4
1.4
0.5
0.5
0.7
0.8
0.3
0.6, 1.4
1.0, 2.0
0.9, 2.3
0.1, 1.6
0.3, 1.0
0.5, 1.0
0.7, 1.0
0.1, 1.4
1979 (55.5)
340 (9.5)
6956 (48.8)
902 (6.3)
1.3
1.6
1.2, 1.4
1.4, 1.8
0.6, 0.8
0.9, 1.1
0.8, 1.3
0.6, 0.8
1.0
0.8
1.0
0.6, 1.0
0.7, 1.4
0.8
0.5, 1.1
0.4
0.1, 1.5
cOR crude odds ratio; CI confidence intervals; aOR adjusted odds ratio; ref referent category.
Values are presented as n (%).
* Column figures may not add up to the total because of missing values.
See text for explanation of variables for which adjustment was to be carried out.
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Krakowiak et al
Table 3. Selected Congenital Malformations and Anomalies of Infants Diagnosed With a Short Umbilical Cord Compared
With Infants Without a Short Umbilical Cord, Washington State, 19871998
Chromosomal
Gastrointestinal
Circulatory/respiratory
Integument
Musculoskeletal
Genitourinary
Central nervous system
Other malformations
OR
95% CI
30 (0.8)
21 (0.6)
70 (2.0)
110 (3.1)
76 (2.1)
52 (1.5)
6 (0.2)
28 (0.8)
23 (0.2)
30 (0.2)
122 (0.9)
280 (2.0)
202 (1.4)
146 (1.0)
26 (0.2)
69 (0.5)
5.3
2.8
2.3
1.6
1.5
1.4
0.9
1.6
3.2, 8.6
1.6, 4.8
1.7, 3.1
1.3, 2.0
1.2, 2.0
1.0, 2.0
0.4, 2.2
1.1, 2.5
Krakowiak et al
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Table 4. Delivery and Fetal and Infant Characteristics Associated With the Presence of a Short Umbilical Cord Among
Infants Without Any Congenital Malformations, Washington State, 19871998
Outcomes
Delivery
Malposition
Breech
Transverse
Other
No malposition (ref)
Induced labor
Stimulated labor
Abruptio placenta
Prolonged labor (EM)
Primiparas
Secundiparas
Multiparas
Prolonged 2nd stage (EM)
Primiparas
Secundiparas
Multiparas
Third/fourth degree lacerations
Retained placenta
Postpartum hemorrhage (g, EM)
1500
15002499
25003999
4000
Delivery method
Spontaneous vaginal (ref)
Operative vaginal
Cesarean delivery
Fetal and infant
Gestational age (wk)
1832
3336
3742 (ref)
4345
Size for gestational age
Small
Average (ref)
Large
Birth weight (g)
1500
15002499
25003999 (ref)
4000
5-minute Apgar
Asphyxia
Hypoxic-ischemic encephalopathy (EM)
1500
15002499
25003999
4000
Birth injury
Fetal distress (EM)
Male
Female
Meconium aspiration
Meconium moderate/heavy
Assisted ventilation
Infant death (wk, EM)
2432
3336
3742
4345
Short cord
(N 3,225)*
No short cord
(N 13,358)*
72 (2.2)
7 (0.2)
87 (2.7)
3059 (94.9)
396 (12.7)
490 (15.9)
59 (1.8)
198 (6.3)
150 (8.7)
38 (4.1)
10 (2.0)
118 (3.7)
93 (5.4)
23 (2.5)
2 (0.4)
293 (9.3)
43 (1.3)
100 (3.1)
0 (0.0)
3 (1.6)
81 (2.9)
16 (9.0)
cRR
95% CI
490 (3.7)
75 (0.6)
328 (2.5)
12465 (93.3)
2076 (16.0)
1860 (14.5)
177 (1.3)
682 (5.2)
522 (9.4)
95 (2.2)
65 (2.0)
354 (2.7)
289 (5.2)
48 (1.1)
17 (0.5)
878 (6.7)
109 (0.8)
419 (3.1)
0 (0.0)
13 (3.0)
336 (3.1)
70 (3.8)
0.6
0.4
1.1
1.0
0.8
1.1
1.4
1.2
0.9
1.9
1.0
1.4
1.0
2.2
0.8
1.4
1.6
1.0
0.5, 0.8
0.2, 0.8
0.9, 1.4
0.7, 0.9
1.0, 1.2
1.0, 1.8
1.0, 1.4
0.8, 1.1
1.3, 2.7
0.5, 1.9
1.1, 1.7
0.8, 1.3
1.4, 3.6
0.2, 3.3
1.2, 1.6
1.2, 2.3
0.8, 1.2
0.5
0.9
2.4
0.1, 1.8
0.7, 1.2
1.4, 4.0
2107 (66.8)
799 (25.4)
247 (7.8)
8722 (66.5)
1871 (14.3)
2524 (19.2)
1.0
1.6
0.5
1.4, 1.7
0.4, 0.5
17 (0.6)
132 (4.2)
2913 (93.9)
41 (1.3)
86 (0.7)
403 (3.1)
12324 (94.8)
185 (1.4)
0.8
1.4
1.0
0.9
0.5, 1.4
1.1, 1.7
279 (9.6)
2484 (85.1)
157 (5.4)
673 (5.4)
10297 (82.3)
1533 (12.3)
1.6
1.0
0.5
1.4, 1.9
8 (0.3)
191 (6.2)
2732 (88.0)
172 (5.5)
54 (1.7)
76 (2.4)
109 (3.4)
5 (50.0)
18 (9.3)
83 (2.9)
3 (1.7)
229 (7.3)
330 (10.2)
195 (13.7)
135 (7.5)
21 (0.7)
137 (5.2)
60 (2.3)
15 (0.5)
0 (0.0)
1 (0.8)
14 (0.5)
0 (0.0)
71 (0.5)
419 (3.2)
10694 (82.3)
1814 (14.0)
180 (1.4)
262 (2.0)
318 (2.4)
30 (38.5)
61 (14.2)
186 (1.7)
39 (2.1)
640 (4.9)
753 (5.6)
427 (6.3)
326 (5.0)
69 (0.5)
659 (6.0)
247 (2.3)
46 (0.4)
21 (24.4)
2 (0.5)
22 (0.2)
1 (0.5)
0.4
1.7
1.0
0.4
1.2
1.2
1.4
1.3
0.7
1.7
0.8
1.5
1.8
2.2
1.5
1.3
0.9
1.0
1.4
0.2, 0.9
1.5, 2.0
1.5
2.7
0.7, 1.3
aRR
95% CI
1.0
0.9, 1.2
1.2
0.9, 1.4
1.0
0.9, 1.1
1.0
1.4
0.4
1.3, 1.5
0.4, 0.5
1.0
1.0
1.0
0.9
0.6, 1.5
0.8, 1.2
0.9
1.5
1.0
0.4
0.6, 1.5
1.3, 1.8
1.2
1.0, 1.3
1.7
1.0, 2.9
0.7, 1.3
0.4, 0.5
0.4, 0.5
0.9, 1.7
0.9, 1.5
1.2, 1.8
0.7, 2.6
0.4, 1.1
1.3, 2.2
0.3, 2.6
1.3, 1.7
1.6, 2.1
1.9, 2.6
1.2, 1.8
0.8, 2.1
0.7, 1.0
0.8, 1.3
0.8, 2.4
0.1, 16.7
1.4, 5.3
1.3
2.4
0.4, 0.5
0.1, 13.6
1.2, 4.6
cRR crude risk ratio; CI confidence intervals; aRR adjusted risk ratio; ref referent category; EM effect modification.
Values are presented as n (%).
* Column figures may not add up to the total because of missing values.
See text for explanation of variables for which adjustment was to be carried out.
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Krakowiak et al
in common with a previous study,1 we found no association of short umbilical cords with maternal smoking or
alcohol intake.
Several studies2,3,12 have implicated a relationship between the presence of oligohydramnios during pregnancy and the subsequent development of a short umbilical cord. Miller et al2,3 hypothesized that the umbilical
cord grows in response to tensile forces exerted on the
cord by fetal movements. Moessinger et al12 showed that
in the presence of oligohydramnios, the umbilical cords
of rat fetuses were 65% of control length. We did not
detect an association between oligohydramnios or hydramnios and a greater or lesser likelihood of being a
case, respectively. Likewise, more recent studies4,5 using
animal models have argued against the stretch hypothesis, stating that the umbilical cord continues to grow
throughout pregnancy in an almost linear fashion. Instead, these studies have proposed a multifactorial explanation for the occurrence of short cords.
Indeed, in this study, no single factor accounted for
the occurrence of all short cords, suggesting a multifactorial etiology. Surprisingly, fewer than 10% of case
infants were reported as having congenital anomalies.
Our data suggest an association of short cords with
particular malformation sequences, particularly those
caused by chromosomal anomalies. Other important
sequences may be those affecting gastrointestinal and
circulatory-respiratory systems. Previous studies of the
association of short cords with malformation sequences
and fetal problems have defined several groups of such
sequences and problems among infants including stillborns and those who died shortly after birth due to
multiple severe anomalies. These include ADAM sequence, cyllosomus/pleurosomus, acephalus-acardia,
presumed primary defect of the umbilical cord and abdominal wall formation, schisis association, and reduced
fetal movement.3,19 Such anomalies are usually multisystem disorders, although they principally involve the
central nervous system, limbs, and cardiovascular system or are associated with defects in the formation of the
anterior abdominal wall. Of interest, in our study, malformations of the central nervous system were not associated with the occurrence of short cords, and the association of musculoskeletal malformations was modest.
Such associations, if present, would have supported the
stretch hypothesis for the lengthening of the cord and
indeed formed the basis of some previous arguments2,3
in favor of the stretch hypothesis. Miller et al3 stated
that extremes of decreased fetal movement occur in cases
of amelia, acardia, arthrogryposis, and atrophy of spinal
muscles. Moessinger et al12 suppressed fetal movement
by curarization, which led to the development of shorter
cords among rat fetuses. By extension, severe central
Krakowiak et al
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Krakowiak et al
Received May 23, 2003. Received in revised form September 17, 2003.
Accepted September 26, 2003.
Krakowiak et al
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