Single umbilical artery aneurysm: a rare case report and review of perinatal management – Journal of Cardiothoracic Surgery

Report on Single Umbilical Artery Aneurysm and its Implications for Sustainable Development Goal 3

This report outlines the clinical significance, diagnosis, and management of Single Umbilical Artery Aneurysm (SUAA), a rare and potentially fatal vascular anomaly. The findings are framed within the context of the United Nations Sustainable Development Goals (SDGs), particularly SDG 3: Good Health and Well-being, which aims to reduce maternal mortality and end preventable deaths of newborns.

Clinical Profile and Impact on SDG 3 Targets

Pathophysiology and Associated Risks

Single Umbilical Artery (SUA) is a common structural abnormality, while the associated Umbilical Artery Aneurysm (UAA) is exceptionally rare. The condition poses a significant threat to achieving SDG Target 3.2 (end preventable newborn deaths) due to its association with severe adverse outcomes.

• High-Risk Association: SUAA is linked to fetal malformations, intrauterine growth restriction (IUGR), aneuploidy, and fetal death.
• Adverse Outcomes: Over 60% of reported cases result in adverse pregnancy outcomes, directly impacting neonatal survival rates.
• Anatomical Vulnerability: Aneurysms are most commonly located at the placental insertion of the umbilical cord, where there is less protective Wharton’s jelly. This positioning can lead to compression of adjacent vessels, compromising fetal health.

Mechanisms of Fetal Compromise

The development of SUAA can lead to critical complications that undermine fetal well-being, a core component of SDG 3.

1. Vascular Compression: The aneurysm can compress the umbilical vein, impairing the transport of oxygen and nutrients to the fetus.
2. Hypoxia Risk: Compression of the umbilical artery can result in intrauterine hypoxia.
3. Thrombosis: Altered blood flow within the aneurysm may lead to vascular thrombosis, further increasing the risk of intrauterine fetal death (IUFD).

Diagnostic and Management Protocols to Advance Health Outcomes

The Role of Prenatal Diagnostics in Achieving Universal Health Coverage (SDG 3.8)

Early and accurate diagnosis is essential for managing SUAA and improving fetal outcomes. Access to quality diagnostic services like prenatal ultrasonography is a key element of universal health coverage (SDG 3.8).

• Primary Diagnostic Tool: Prenatal ultrasonography is critical for detection, which most often occurs in the middle to late stages of gestation (22-34 weeks).
• Key Sonographic Findings: Diagnosis is confirmed by identifying an aneurysmal-like dilation of the single umbilical artery, often with a thin wall and turbulent blood flow visible on Color Doppler imaging.
• Differential Diagnosis: Accurate diagnosis requires distinguishing SUAA from other conditions such as umbilical vein aneurysms, umbilical cord cysts, and placental vascular tumors, underscoring the need for skilled healthcare professionals.

Management and Delivery Strategies

Strategic management and delivery planning are vital to mitigate risks and support the goals of reducing maternal and neonatal mortality (SDG 3.1 and 3.2).

1. Prenatal Monitoring:
   • Low-Risk Cases: Require assessment every 2–3 weeks.
   • High-Risk Cases: (e.g., complicated by FGR or thrombosis) require weekly monitoring of aneurysm size, umbilical artery blood flow, and fetal well-being via Non-Stress Tests (NST) and Biophysical Profile (BPP) scoring.
2. Delivery Method Determination:
   • Vaginal Delivery: May be considered for aneurysms under 2 cm located away from the fetal insertion, with no associated complications.
   • Cesarean Delivery: Recommended for aneurysms ≥ 2 cm, those located near the fetal end, or cases with thrombosis, FGR, or abnormal blood flow to prevent acute fetal distress during labor.

A Multidisciplinary Approach: A Model for SDG 17 (Partnerships for the Goals)

Collaborative Care for Improved Outcomes

The effective management of high-risk pregnancies like SUAA exemplifies the importance of partnerships, as highlighted in SDG 17. A multidisciplinary approach is recommended to enhance diagnostic accuracy and improve fetal outcomes.

• Expert Collaboration: Management should involve a team of maternal-fetal medicine specialists, experienced ultrasound technicians, and pathologists.
• Dynamic Monitoring: Continuous prenatal monitoring by specialists is required to assess hemodynamic changes and potential thrombus formation.
• Post-Delivery Analysis: Immediate pathological examination of the placenta and umbilical cord is crucial to confirm the diagnosis, understand the lesion’s characteristics, and guide subsequent clinical management.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being

   The entire article is centered on a specific medical condition, Umbilical Artery Aneurysm (UAA), that affects fetal and neonatal health. It discusses diagnosis, risks, and management strategies aimed at preventing mortality and improving health outcomes for both the fetus and the mother. The text explicitly mentions concerns such as “fetal death, and neonatal complications,” “adverse pregnancy outcomes,” and the goal of “improving both maternal and fetal safety,” which are core tenets of SDG 3.

2. What specific targets under those SDGs can be identified based on the article’s content?

• Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

  Although the article does not focus on maternal death, it emphasizes the importance of management plans to ensure “maternal and fetal safety.” The recommendation for a “multidisciplinary approach” and timely interventions like an “emergency cesarean delivery” are crucial for managing high-risk pregnancies, which directly contributes to preventing maternal complications and mortality.

• Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.

  This is the most directly relevant target. The article repeatedly highlights that UAA is a “potentially fatal vascular anomaly” associated with “fetal death, and neonatal complications.” It states that “over 60% of reported cases are associated with adverse pregnancy outcomes” and warns against “intrauterine fetal death (IUFD).” The entire diagnostic and management protocol described, from ultrasound monitoring to deciding on the delivery method, is aimed at preventing these deaths and ensuring the survival and well-being of the newborn.

• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

  The article implicitly addresses this target by detailing the necessity of advanced and specialized healthcare services. The management of UAA requires “prenatal ultrasonography,” “Color Doppler imaging,” “non-stress tests (NST),” and access to surgical procedures like “emergency cesarean section.” Furthermore, the recommendation for a “multidisciplinary approach” involving “maternal-fetal medicine specialists, ultrasound technicians, and pathologists” underscores the need for a robust and accessible healthcare system with specialized personnel to provide quality care for high-risk pregnancies.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

• Indicator for Target 3.1 & 3.2: Incidence of adverse pregnancy outcomes, fetal death, and neonatal complications.

  The article provides a direct, though not globally standardized, indicator by stating that “over 60% of reported cases are associated with adverse pregnancy outcomes.” Reducing this percentage through better diagnosis and management would be a clear measure of progress. The article’s focus on preventing “fetal death” and “intrauterine fetal death (IUFD)” implies that the rates of these events in pregnancies complicated by UAA are critical indicators of healthcare effectiveness.

• Indicator for Target 3.8: Availability and use of diagnostic and emergency services.

  The article implies the importance of tracking the availability and utilization of specific health services. Progress could be measured by indicators such as:

  • The proportion of high-risk pregnancies monitored with advanced technologies like “high-frequency ultrasound” and “Doppler flow studies.”
  • The rate of timely “emergency cesarean delivery” in cases showing signs of “intrauterine distress.”
  • The availability of “multidisciplinary” teams, including “maternal-fetal medicine specialists, ultrasound technicians, and pathologists,” for managing complex cases.

  These serve as proxy indicators for access to quality essential healthcare services as outlined in Target 3.8.

4. Summary Table of Findings

Source: cardiothoracicsurgery.biomedcentral.com