UMBILICAL CORD ABNORMALITIES & ITS OBSTETRIC OUTCOME BY DR SHASHWAT JANI

Umbilical Cord Abnormalities

( Imp. For Obst. Outcome )

Dr. Shashwat Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.Mobile : 99099 44160.

E-mail : [email protected]

May 1, 2023 Dr Shashwat Jani. 9909944160.

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Structure and function

Umbilical cord is covered by amnion and contains a single umbilical vein, and two umbilical arteries supported in Wharton jelly.

Amnion covers the umbilical cord except near the fetal insertion, where an epithelial covering is substituted.


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The arteries wind around the umbilical vein in a spiral fashion and, because the vessels are longer the cord itself, there are a number of foldings or tortuorties producing protusions or false knots on the cord surface.

The Wharton jelly protects the vessels from undue torsion and compression.


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Abnormalities… Length Cord Coiling Single Umbilical Artery Four-vessel cord Abnormalities of cord insertion Cord Abnormalities capable of impeding

blood flow Torsion and Strictures Hematoma Cysts


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Abnormal Cord Length

• Normal cord length is 50-60cm, averagely 55cm

• Short cord: < 35cm is defined as short cord, may lead to fetal distress, placental abruptio, prolonged labour.

• Long cord: > 80cm is defined as long cord, higher occurrence of cord around neck, cord around body, cord knot, cord prolapse and cord compression.


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Umb. Cord Diameter• Lean cords are associated with IUGR• Large diameter cords are associated

with macrosomia• Clinical utility of parameter – unclear


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Umb. Cord Coiling Cord vessels spiral through the cordUCI ( Umbilical Coiling Index ) - is the no.

of complete coils divided by the cord length in cm

They grouped the UCI as follows: < 10th percentile — hypocoiled; 10th – 90th percentile — normocoiled; > 90th percentile — hypercoiled.


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Umb. Cord Coiling


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• Antenatal UCI has the lower sensitivity than the measurement postpartum.

• Hyper coiling is linked with fetal demise, IUGR & intrapartum hypoxia.

• Abnormal UCI has been related to trisomies & single umbilical artery


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Abnormalities of U. Cord Insertion• Usually the cord is inserted at or near the

center of the fetal surface of placenta.• Various cord insertion variations are:

Marginal Insertion ( Battledore Placenta )Furcate insertionVelamentous insertionVasa praevia

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Abnomalities Definition Incidence Significance

Furcate insertion Umbilical vessels separate from the cord substance before their insertion into the placenta

Rare

Margnial Inserion Battledore placenta : cord insertion at the pla-cental margin

7% at term

Cord being pulled off during delivery of the placenta

Velamentous In-sertion

Umbilical vessels separate in the membranes at a dis-tance from the placental margin Reach surrounded only by a fold of amnion

1.1% more frequently with twins 28% of triplets


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Battledore Placenta

Velamentous Placenta


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Vasa Previa Associated with velamentous insertion when

some of the fetal vessels in the membranes cross the region of the cervical os below the presenting fetal part.

Incidence : 1 / 5200 pregnancies - ½ : associated with velamentous inserion - ½ : marginal cord insertions and bilobedor, suc-

centuriate – lobed placentas.


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Risk factors : - bilobed , succenturiate or low-lying placenta - Multifetal pregnancy - Pregnancy resulting from in vitro fertilization Diagnosis :• Color Doppler examination (low sensitivity with

ultrasound) - Perinatal diagnosis : associated with increased

survival (97:44) - Antenatal diagnosis : associated with decreased

fetal mortality compared with discovery at delivery


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Hemorrhage antepartum or intrapartum : vasa previa and a ruptured fetal vessel

exists Detecting fetal blood - Apt test - Wright stain : to smear the blood on glass

slides stain the smears with Wright stain and examine for nucleated RBC

- Normally : are present in cord blood but not maternal blood

Risk of low lying placenta : 80%


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Doppler scan to detect Vasa Previa


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Management of Vasa Previa

• If diagnosed prenatally–Planned cesarean section (early enough to

avoid emergency, but late enough to avoid prematurity)–Baby requires aggressive resuscitation +

blood transfusion


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• If intra partum vaginal bleeding :

SpeculumApt test - fetal hemoglobin is alkali

resistant.If fetal bleeding confirmed, immediate

cesarean section


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Abnormalities Of Vessels Number :

• Single umbilical artery : Results due to atrophy of the previously

existing umbilical artery.

• 4 vessel cord : - Quiet uncomman - May be a venous remnant - Association with CMF is not clear


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Single Umbilical Artery• Absence of one umbilical artery

INCIDENCE :

- 0.63 % in live births - 1.92 % in perinatal deaths - 3 % in twinsIncidence is increased in women with :

Diabetes EpilepsyPETAPHOligohydramniosHydramniosChromosomal abnormalities


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Single Umb. Art. & CMFAbout 30% of all infants with only one umbilical artery

have congenital anomalies .

– Associated CMF : Aneuploidies

Tracheo-oesophagial fistula

Renal agenesis Imperforate anus Vertebral defects

– 34% are growth restricted– 17% deliver preterm


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Fused umbilical arteryRarely umbilical artery may fail to splitShared ,fused lumenMay involve the entire length or may

be partial (towards the placental insertion site)


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Hyrtl Anastomosis :

Anastomosis b/w the two umb. Arteries with in 3 cm of placental insertion site

Acts as a pressure equalising system b/w the two umbilical Aa.

Improves placental perfusion during uterine contractions /during compression of one of the umbilical arteries.


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Knots False knots :• Result from kinking of the vessels to

accommodate length of cord and are due to redundancies of Umbilical vessels / Wharton’s jelly.


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True Knots • Incidence 1 – 2 %• More common in monoamniotic twins• Active fetal movements create true knots• Risk of still births is increased 5 to 10 folds in

those with true knots.• FHR abnormalities are common during labor

but cord blood PH values are normal .


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Umb. Cord Loops The cord is frequently coiled around the fetus More likely with longer cords Loops around fetal neck are termed a nuchal cord

(uncommon cause of adverse PN outcome) Contractions may compress the nuchal cord and cause FHR

decelerations and low umbilical artery

Incidence : 1 loop of Nuchal cord 20-34% 2 loops of nuchal cord 2.5-5% 3 loops of nuchal cord 0.2-0.5%


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Single is safer than multiple umbilical cord loops around the fetal neck.

Two types of cord loops around the fetal neck :

Type A umbilical nuchal cord encircles the fetal neck in a sliding manner (less dangerous)

Type B nuchal cord encircles the neck in a locking manner (very dangerous).


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ManagementAt the time of birth: -• Look for cord around the neckIf it is loose enough for the cord to be

slipped over the babies head.If the cord is wrapped multiple times it may

take a while.


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• At this time, if the cord is too tight and has to be cut before the baby is born.

• This necessitates babies birth rapidly, since it is no longer getting nutrients from the mother via placenta.


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Torsion & StrictureTorsion : Incidence : rare Result from fetal movements during which the cord normally

becomes twisted fetal circulation is compromised. Stricture : More serious Most infants with this finding are stillborn Associated with an extreme focal deficiency in Wharton jelly. In mono amnionic twins, a significant fraction of the high

perinatal mortality rate is attributed to entwining of the umbilical cords before labor.


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Hematoma

Accumulations of blood are associated with short cords, trauma and entanglement

Result from the rupture of a varix, usually of the umbilical vein with effusion of blood into the cord

Caused by umbilical vessel venipuncture


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Umb. Cord Cysts May be found along the course of the cord True cysts:

› Epithelium lined› Remnants of the allantois› Coexist with patent urachus

False Cysts: Due to degeneration of wharton’s jelly. Single cyst may resolve completely Multiple cysts may be associated with miscarriage /aneuploidy.


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Umb. Cord Position ( Prolapse )Types of umbilical cord prolapse : Occult cord prolapse Overt cord prolapse Funic presentation = cord presentation = procubitus.


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Definition

• Ruptured membranes – occult cord prolapse (descent of the umbilical

cord alongside)

– overt cord prolapse (umbilical cord past the

presenting part).


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NO ruptured membranes Funic presentation = cord presentation =

procubitus → one or more loops of umbilical cord

between the fetal presenting part and the cervix,. • If the cervix is opened the cord can be

easily palpated through the membranes.


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Etiology Any obstetric condition that

predisposes to poor application of the fetal presenting part to the cervix may result in prolapse of the umbilical cord.


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Predisposing Factors

PrematurityAbnormal presentations (breech, brow, face,

transverse)Multiple gestationPlacenta praeviaPolyhydramniosPremature rupture of the membranesExcessive length of the cord


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Maternal factors • Multiparity • Pelvic tumors • Abnormal birth canal

Iatrogenic factor• Artificial rupture of membranes

with an unengaged presentation


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Clinical diagnosis• Overt cord prolapse visualizing the cord

protruding from the introitus (second or third degree of prolapse), by speculum ex. or by palpating loops of cord in the vaginal canal (first degree prolapse).

• Funic presentation speculum and bimanual ex.• Occult prolapse Suspected if fetal heart rate

changes (variable decelerations) due to intermittent compression of the cord are detected during monitoring.


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If compression is complete and prolonged it induces asphyxia, metabolic acidosis and death.

Asphyxia → hypoxic-ischaemic encephalopathy and cerebral palsy.

• The causes of asphyxia:Cord compression preventing venous return to the fetus

Umbilical arterial vasospasm secondary to exposure to vaginal fluids and/or air.


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PreventionHigh-risk patients : Malpresentations + poorly applied cephalic

presentations → US at the onset of labor during labor patients at risk for → continuosly

monitored for abnormalities of FHR avoid amniotomy until the presenting part is

well applied to the cervix. at time of spontaneous membrane rupture a

prompt, careful pelvic examination.


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MANAGEMENT Venous access Consent Immediate CS. The manual replacement is NOT recommended. To prevent vasospasm - minimal handling of

loops of cord lying outside the vagina and cover them in surgical packs soaked in warm saline.

Thank you

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UMBILICAL CORD ABNORMALITIES & ITS OBSTETRIC OUTCOME BY DR SHASHWAT JANI

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