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Female Reproductive System ORGAN SYSTEMS

Umbilical cord prolapse (UCP)

Umbilical cord exits the cervical opening before the fetal presenting part.

Introduction

Umbilical cord exits the cervical opening before the fetal presenting part.

Cord presentation (fore-lying cord):

Presence of the umbilical cord (UC) between the fetal presenting part and the cervix, regardless of the membrane status (intact/ruptured)
  • OBSTETRIC EMERGENCY

Classification

  • Overt UCP: Cord past the presenting part)
  • Occult UCP: Cord alongside the presenting part)

Aetiology

Obstetric risk factors:

UCP is commonly seen in multiparas with malpresentation
  • Maternal age ≥ 35years
  • Multiparity
  • Malpresentations: Transverse lie > Footling (breech) > Knee (breech)
  • Preterm labor (< 37 weeks)
  • Low birth weight
  • Polyhydramnios
  • Multiple pregnancies
  • Non-engaged presenting part PPROM
  • Male sex of the newborn

Iatrogenic UCP:

Up to 50% of cases
  • Artificial rupture of fetal membranes (ARM): Especially in multipara with high non-engaged head
  • External cephalic version (ECV)
  • Placement of cervical ripening balloon/intrauterine pressure catheter/fetal scalp electrode
  • Other factors: Attempted rotation of the fetal head, poor prenatal care

Pathophysiology

Compression of the UC can lead to either profound or total acute asphyxia or subacute hypoxia with different neonatal outcomes

Pathophysiology of cord prolapse is almost an “all or none event”, either causing overwhelming neurological injury and death or causing little or no cerebral injury, and this is supported by the very low incidence of stillbirth/neonatal death, neonatal encephalopathy, and cerebral palsy.

Resultant compression of the cord by the descending fetus during delivery leads to fetal hypoxia and bradycardia which can result in serious complications.

Complications

Perinatal mortality and morbidity largely depend on the location where the prolapse occurred (inside or outside the hospital facility) and the gestational age/birthweight of the fetus
  • Perinatal morbidity: Low 5-minute Apgar scores, assisted ventilation requirement, low cord pH
  • Meconium aspiration
  • Hyaline membrane disease
  • Neonatal seizures
  • Neonatal encephalopathy (2%): neonatal seizures or two of the following lasting longer than 24 h: abnormal consciousness, difficulty maintaining respiration or feeding (both of central origin), or abnormal tone/reflexes
  • Cerebral palsy (0.43%)
Pie chart showing perinatal mortality caused by umbilical cord prolapse | Fahmy, M. (2018). Umbilical Cord Prolapse BT – Umbilicus and Umbilical Cord. In M. Fahmy (Ed.) (pp. 75–77). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-319-62383-2_16

Diagnosis

Seeing/palpating the prolapsed cord in addition to the presence of abnormal fetal heart (FH) tracings

Continuous fetal monitoring:

  • Abnormal fetal heart rate (FHR) tracings: Recurrent, variable, sudden severe, and/or prolonged (≥ 1 minute) decelerations (first sign) (67% cases)

USG:

Fahmy, M. (2018). Umbilical Cord Prolapse BT – Umbilicus and Umbilical Cord. In M. Fahmy (Ed.) (pp. 75–77). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-319-62383-2_16

Differential diagnosis:

  • Soft mass in the vagina:
    • Presence of fetal limb
    • Caput succedaneum
    • Face presentation
  • Sudden FHR decelerations (fetal bradycardia):
    • Maternal hypotension
    • Placental abruption
    • Uterine rupture

Management

Initial steps:

Prompt recognition and rapid action are the mainstays of managing this emergency.
  • Call for help
  • Continuous fetal monitoring
  • O2 by face mask (for fetal distress)

Immediate delivery

Royal College of Obstetricians and Gynecologists (RCOG) recommendation: Diagnosis-to-delivery interval (DDI) must be < 30 minutes in order to optimize the perinatal outcome, particularly in the presence of evidence of fetal compromise
  • Cesarean section (delivery mode of choice)
  • Vaginal/instrumental delivery: Tried if deemed quicker, particularly in 2nd stage of labor (usually if station > +2)
  • Contraindications for immediate delivery:
    • Fetal demise (except when in transverse lie)
    • Lethal fetal anomalies
    • Pre-viable gestation

Measures to relieve cord compression

Diagnosis-to-delivery interval should ideally be less than 30 minutes; however, if it is expected to be lengthy, measures to relieve cord compression should be attempted.
  • Manual elevation of the presenting part
  • Vago’s method (bladder filling): Filling bladder with ≥ 500cc NS or when bladder is visible above the pubic area would relieve cord compression by elevating the presenting part and may help in decreasing uterine contractions
  • Funic reduction (rarely done): Manual cord replacement to above the presenting part into the uterus

Tocolytics:

Decreases uterine contractions, relieving pressure on prolapsed cord in addition to improving the placental perfusion and hence the blood supply to the baby

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