A Rare Case of Double True Umbilical Cord Knots With a Nuchal Cord: A Case Report.

A double true umbilical cord knot (TUCK) is a rare complication of pregnancy that is often missed on ultrasonography. The stricture caused by TUCK can lead to occlusion of fetal circulation, fetal asphyxia, and subsequent death. Despite these risks, there is a lack of evidence and no specific consensus on both antepartum and intrapartum management of TUCK. We report a rare case of a healthy male neonate with a double TUCK and nuchal cord delivered vaginally with a vacuum assist. A 26-year-old female, G2P1001, at 39 weeks of gestation, presented to the labor and delivery unit for induction of labor for suspected fetal macrosomia. The labor course was complicated by recurrent variable decelerations during the second stage of labor, which prompted an assisted vaginal delivery. Upon delivery, a single tight nuchal cord was noted, which was successfully reduced. Further examination revealed two TUCKs. Subsequently, the umbilical cord was doubly clamped and cut, and the neonate was transferred to the NICU team for further evaluation. Neonatal and maternal outcomes were reassuring, with no immediate complications observed.  The umbilical cord plays an essential role in transporting nutrients and oxygen to the fetus and discarding waste products. Polyhydramnios, small fetus size, gestational DM, and male fetuses have been reported to be associated with an increased risk of TUCK. Despite advancements in prenatal imaging, true knots remain difficult to detect until delivery. If TUCK remains undiagnosed until delivery, it increases the likelihood of fetal compromise and death. Therefore, close surveillance is warranted in these unusual cases. This case highlights the critical need for monitoring throughout pregnancy, allowing for timely intervention and optimization of maternal and neonatal outcomes.  The coexistence of double TUCK and nuchal cord is a rare complication that is difficult to detect prenatally due to nonspecific imaging findings. In light of the lack of evidence-based treatment options available, we highlight the importance of further research for an accurate prenatal diagnosis of TUCK and to reduce complications and fetal demise.