Sextuple rings of nuchal cord by breech presentation: a warning sign.

A 30-year primigravida presented at 35 weeks and 5 days gestation with persistent breech for external cephalic version (ECV). Systematic ultrasound examination showed a normally grown fetus with extreme looping of nuchal cord (NC) around the fetal neck with head hyperextension (Fig. a and b). On 3D ultrasound there was an impression of "tribal neck rings" (Fig. c). No free umbilical cord was seen in the amniotic fluid. ECV was not performed. At 37 weeks gestation the patient had reduced fetal movements. Fetal doppler showed normal resistance index (RI) of the umbilical (RI 0.56) and middle cerebral (RI 0.73) arteries. Cardiotocogram and amniotic fluid index (14.2) were normal. The fetal head was not mobile on palpation. On ultrasound, the fetal neck with six NC loops appeared anchored to the placenta on the upper posterior uterine wall. The breech was not engaged in the pelvis. The mother declined conservative management and a caesarean initially planned for 39 weeks gestation was performed at 37 weeks and one day. A healthy 2685-gram baby was born with sextuple tight loops of NC (Fig. d). Umbilical artery pH was 7.29 and base excess -5.2. Apgar scores were 4, 6 and 8 at 1, 5 and 10 minutes respectively. Neonatal admission was not indicated. This article is protected by copyright. All rights reserved.