A 36-year-old woman (gravida 2, para 1) with a monochorionic, monoamniotic twin pregnancy was admitted to the hospital at 32 weeks of gestation for a planned cesarean section. The antenatal course had been unremarkable. Routine cardiotocography before the procedure showed severe variable decelerations of the fetal heart rate in one of the twins; the tracing in the other twin was normal. A cesarean section was subsequently performed, and twin girls were delivered. The Apgar scores for both twins were 7 at 1 minute and 8 at 5 minutes. Complex knots in the umbilical cords were seen after delivery. Results of blood gas analysis of cord blood were normal. True knots in the umbilical cord are associated with intrapartum complications and fetal distress. Complex knotting to the extent seen in this case in the umbilical cords of monochorionic twins is uncommon. The twins were admitted to the neonatal intensive care unit, and both were discharged from the hospital after 40 days.
Francesca Arezzo, M.D.
Giuseppe Muzzupapa, M.D.
University of Bari, Bari, Italy