Importance of umbilical cord examination in neonates
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A vaginally delivered, term infant presented on the fourth day of life with lethargy, abdominal distension and bilious vomiting. He accepted breastfeeds and passed meconium on the first day. However, on the second day, he developed rapidly increasing abdominal distension, non-bilious vomiting and refusal to feeds for which he was admitted at a nursing home and received antibiotics, intravenous fluid and other supportive care. Abdominal radiograph showed dilated bowel loops. However, within 12
hours, he developed respiratory distress and shock requiring intubation and inotropes. The infant was referred to us with a possibility of severe sepsis with intestinal obstruction.

At admission, he had generalised abdominal distension and absent bowel sounds. On examination, we noticed thickened, gangrenous and foul-smelling umbilical cord. There was no evidence of omphalitis/abdominal wall cellulitis. Also, there was a swelling, covered with the skin arising from the base of the cord. Therefore, the possibility of accidental clamping and laceration of bowel were considered. Abdominal radiograph showed air–fluid level with a gaseous shadow in the umbilical cord suggesting entrapped intestinal loop ). These findings confirmed the diagnosis of umbilical cord hernia (UCH) with an intestinal laceration. The baby underwent urgent exploratory laparotomy. Resection of the gangrenous bowel margins followed by an end-to-end anastomosis was done, and the abdomen was closed in layers. There were no other associated malformations. Unfortunately, the baby developed severe sepsis and died on the second postoperative day.

UCH is an under-reported entity it is often misdiagnosed as ‘omphalocele minor’ due to similarities in appearance but can be distinguished by the careful examination of the morphologic characteristics of the umbilical cord insertion. An omphalocele result from primary failure of the body folds to form the umbilical ring, thus creating an abdominal wall defect, whereas, in UCH, the abdominal wall and umbilical ring are intact. In omphalocele, the rectus muscles have a broad insertion laterally on the costal margins instead of meeting in the midline at the xiphoid, as seen in UCH. Moreover, in omphalocele, the umbilical cord has a characteristic abnormal insertion at the top of the herniated sac, whereas, in UCH, the bowel herniates into the base of a normally inserted umbilical cord