UMBILICAL CORD ACCIDENTS

DR PADMASRI RPROF & HOD, DEPT OF OBSTETRICS &

GYNAECOLOGYSAPTHAGIRI INSTITUTE OF MEDICAL SCIENCES

1

• “Cord accident,” defined by obstruction of fetal blood flow through the umbilical cord, is a common ante- or perinatal occurrence.

• Obstruction can be either acute, as in cases of cord prolapse during delivery, or sub acute to-chronic, as in cases of grossly abnormal umbilical cords

2

Placental findings in cord accidents. Mana M ParastFrom Stillbirth Summit 2011, Minneapolis, USA

TYPES

Acute events

• Umbilical Cord Prolapse

• Vasa Praevia

Sub Acute on Chronic• Loops• Knots• Entanglements• Coiling• Torsion• Rupture• Haematomas, thrombosis• Cysts, tumours• Nuchal Cord• Insertion - velamentous cordCORD COMPRESSION – SUDDEN

IUD’s

3

CORD COMPRESSION

2 Principles of asphyxia are:

a. Cord compression -preventing venous return to the fetus

b. Umbilical vasospasm -preventing venous and arterial blood flow to and from the fetus due to exposure to external environment.

4

Recovery time from compression

• 1min, 1 time 100% compression – 5 mins to recover- oxygen levels decrease by 50%

• 5 mins comp – 30 mins to recover

• Continued 5 min compressions every 30 mins causes fetal decompensation

RISK FACTORS FOR CORD PROLAPSE

GENERAL PROCEDURE RELATED

MultiparityArtificial rupture of membranes with high presenting part

Low birthweight (< 2.5 kg) Vaginal manipulation of the fetus with ruptured membranes

Preterm labour (< 37+0 weeks)

External cephalic version (during procedure)

Fetal congenital anomalies Internal podalic version

Breech presentation Stabilising induction of labour

Transverse, oblique and unstable lie*

Insertion of intrauterine pressure transducer

Second twin Large balloon catheter induction of labour

Polyhydramnios

Unengaged presenting part

Low-lying placenta

6RCOG Green-top Guideline No. 50, 2014

MANAGEMENT• Call for help• Counsel the woman and

her birth partner• Move the woman into the

knee-chest or exaggerated Sims’ position

• Stop oxytocin augmentation if in progress

• Elevate the presenting part digitally or by bladder filling

• To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina

• Continue to assess fetal heart rate

• Expedite the birth of the baby. At full dilatation, vaginal birth may be an option depending on parity and engagement of head

• Transport the woman to the operating theatre, if required

• Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically or when the delivery is likely to be delayed.Tocolysis may allow time for regional anaesthesia to be administered.

7

VASA PRAEVIA

• Vasa praevia is a rare but potentially serious condition in which blood vessels carrying blood between the placenta and the baby cross over the cervix.

• These vessels may bleed if the woman goes into labour, if the waters break, or if the cervix opens

8

TYPES

Type 1 vasa praevia occurs with velamentous insertion of the

umbilical cord into the placenta

9

Type II vasa praevia occurs with avelementous fetal vessel connecting the placenta to a succinuriateplacental lobe.

PRESENTATION – CLASSICAL TRIAD

• The mortality rate in this situation is around 60%.• If detected antenatally improved survival rates of up to 97%

have been reported.

10

MEMBRANE RUPTURE

PAINLESS VAGINAL BLEEDING

(BENCKISER’S HEMORRHAGE)

FETAL BRADYCARDIA/DEATH

Vasa previa management

11

Caeserean section

Antenatally confirmedVasa previa

Preterm contractions/Short cervix/

Low lying placenta

No risk factors

Prophylactic hospitalization(from 30-32 weeks)

May consider conservative management on OP basis

Antenatal corticosteroids

Elective LSCS between 35-37 weeks

Unconfirmed, Detected during labour

Don’t wait for confirmation

Fetal exsanguination

Emergency Caeserean section

Neonatal resuscitationO Rh –ve Blood

CONCLUSION

• Vasa previa is an uncommon but potentially life threatening condition for the fetus /neonate.

• Perinatal outcomes improve significantly when antenatal diagnosis enables planned management that includes elective Caesarean section by 35 weeks gestation before the onset of labour.

12

NUCHAL CORD – NOOSE OR NECKLACE?

• NUCHAL CORD - Cord round the neck, 360 deg

• Two types of cord around foetal neck.

• TYPE A- umbilical cord encircles the fetal neck in a sliding manner (less dangerous)

• TYPE B- Nuchal cord encircles the neck in a locking manner (very dangerous)

13

ULTRASOUND DIAGNOSIS OF NC

2 Views• They should be identified by presence of the cord in the

transverse and sagittal planes of the neck and lying around at least three of the four sides of the neck

• On sagittal view –NC seen as dimples at the posterior neck of the fetus

• Although there appears to be a linear increase over gestation in the presence of both single and multiple loops, NC keeps appearing and disappearing over time.

• The difficulty encountered in visualizing the NC at term and prior to induction of labor is due to fetal crowding, low position of the fetal head or reduced amniotic fluid volume .

• Generally, the sensitivity of diagnosis is higher with color Doppler imaging, and it may have a particular advantage in the presence of ruptured membranes

14

UMBILICAL CORD COILING

• Whether an umbilical cord is normal, hypercoiled or hypocoiled is dependent on the number of coils present in the cord – this is known as the umbilical coiling index (UCI).

• Sonographic umbilical coiling index is defined as number of vascular coil in a given cord.

• Usually 1 coil / 5 cm of umbilical cord length and may coil as many as 40 times.

• < 10th percentile

– hypocoiled.

• 10th – 90th percentile

– normocoiled .

• >90th percentile

– hypercoiled.

Summary

• UCA can be acute event or acute on chronic

• Training and CP guidebook / box should be in place for quick action

• Diagnose VP antenatally in 2nd trimester to reduce perinatal mortality to nil

• Be wary of Type B Nuchal Cord which can be dangerous to the fetus

• Look for UCI to rule out hypo/hypercoiling of cord