UMBILICAL CORD....................................

UMBILICAL CORD

1. UMBILICAL CORD Dr. ARCHANA ASOK

2. CONTENTS DEFINITION DEVELOPMENT STRUCTURES FUNCTIONS CORD PATHOLOGIES NABI NADI

3. DEFINITION The Umbilical cord or Funis forms the connecting link between the fetus and the placenta through which the fetal blood flows to and from the placenta.

4. DEVELOPMENT At week 2 the blastocyst has two parts the inner embryoblast and outer trophoblast. This trophoblast later divides into cytotrophoblast and syncytiotrophoblast Later the embryoblast also forms two distinct layers called epiblast and hypoblast. The epiblast forms the amniotic cavity and the hypoblast the yolk sac.

5. Then the cells from epiblast differentiate to form the extraembryonic mesoderm cells which lines the inside of the two trophoblast and forms the chorion This space eventually becomes chorionic cavity. Embroblast is connected to chorion by an extra embryonic mesoderm called the body/connecting stalk(This is the primary structure of umbilical cord)

6. At week 3 embryo folds in 2 directions forming cranial and caudal folds. This folding shapes the part of yolk sac into gut tube. Later gut tube divides into foregut, midgut and hind gut. Mid gut opens into the yolksac and this connection is called vitelline duct (this is the second structure of umbilical cord)

7. At the same time the hindgut grows a little longer called the allantois which drains the bladder and this is the third structure of umbilical cord.

8. At week 4 the amniotic cavity folds in around the embryo and the body stalk, vitelline duct and allantois gets pushed together and forms the umbilical cord. The cells that line the amniotic cavity which are derived from the epiblast cells starts to generate a lot of amniotic fluid and this causes amnion to swell up and take over most of the space in the chorionic cavity.

9. CROSS SECTION After the formation of umbilical cord the vitelline duct and yolk sac will shrink and disappear and in rare cases vitelline duct won’t regress leaving behind a tiny bit of mid gut that later becomes meckel’s diverticulum.

10. CROSS SECTION Where as allantois continue developing into bladder and leaves behind a remnant called ‘Urachus’ in fetus later renamed as median umbilical ligament So all that remain in umbilical cord is allantois, 1 umbilical vein, 2 umbilical arteries and wharton’s jelly.

11. STRUCTURES Covering epithelium- Lined by a single layer of amniotic epithelium but shows stratification like that of fetal epidermis at term Wharton’s jelly- I t consists of elongated cells in a gelatinous fluid formed by mucoid degeneration of the extraembryonic mesodermal cells. It is rich in mucopolysaccharides and has got protective function of the umbilical cord Blood vessels- Initially it will have 4 vessels 2 umbilical arteries and 2 umbilical veins. The arteries are derived from the internal iliac arteries of the fetus and carry venous blood from fetus to placenta. Of the 2 veins one disppears by 4th month of gestation and carry oxygenated blood from placenta to fetus.

12. Remnant of the umbilical vesicle (yolk sac) and its vitelline duct- Remnant of the yolk sac may be found as a small yellow body near the attachment of the cord to the placenta or in rare cases proximal part of duct persists as Mackel’s diverticulum. Allantois- A blind tubular structure may be occasionally present near fetal end which is continuous inside the fetus with its Urachus and the bladder

13. FUNCTIONS

14. CORD ABNORMALITIES

15. 1) ABNORMALITIES OF CORD INSERTION Usually the cord is inserted near or at the centre of the fetal surface of placenta

16. MARGINAL INSERTION / BATTLEDORE PLACENTA A condition in which the umbilical cord is inserted at or near the placental margin rather than in the center Complications associated with battledore placenta are fetal anoxia during labor due to cord compression and intrauterine growth restriction due to impaired blood flow thereby leading to preterm labor.

17. FURCATE INSERTION Furcate umbilical cord insertions are rare obstetrical findings. This variant is defined by an umbilical cord which branches prior to contacting the placental surface. Complications include: IUGR, IUFD, foetal distress, APH, rupture, thrombosis etc

18. VELAMENTOUS INSERTION Velamentous cord insertion is a pregnancy complication that happens when the umbilical cord from the fetus doesn’t insert into the placenta correctly. The cord attaches just to the membrane leaving the blood vessels unprotected and vulnerable .

19. VASA PREVIA V asa previa with velamentous cord insertion.Vasa previa sometimes happens with velamentous cord insertion, where the umbilical cord doesn’t insert into the placenta normally. Instead, the umbilical cord blood vessels travel outside the placenta, where they’re unprotected and at risk of breaking. If the placenta is low lying the umbilical cord vessels are near to the cervix and the exposed blood vessels are especially vulnerable to bursting once labor begins and the fetus starts moving toward the cervix. Management: As it is entirely foetal blood immediate vaginal or cs should be done. In case of severe blood loss Hb of foetus should be assessed and if necessary blood tranfusion should be done. vessels

20. 2) ABNORMAL CORD LENGTH Normal cord length is 30-100cm (on an average of 40cm)

21. ABNORMAL CORD LENGTH

22. CLINICAL SIGNIFICANCE OF EITHER VARIETY Failure of external cephalic version ( ECV is a procedure where manual attempts are done to turn breech positioned baby into cephalic position through the mother's abdomen ) With short cord attempted ECV can cause: fetal distress due to reduced blood flow from pulling which can cause Non-reassuring fetal heart rate ,placental abruption and cord rupture With long cord : true knot, entanglement and cord prolapse can happen Prevent descend of presenting part especially during labor

23. Seperation of normally situated placenta Favor malpresentation Fetal distress in labor

24. 3) SINGLE UMBILICAL ARTERY The umbilical cord typically contains two arteries and one vein. Single umbilical artery (SUA) refers to a variation of umbilical cord anatomy in which there is only one umbilical artery. Seen more common in twin pregnancy, mother with DM,epilepsy, oligohydramnios, hydramnios, pre eclampsia and APH. It is frequently associated with congenital malformation of foetus, renal and genital anomalies, chances of abortion, aneuploidy like trisomy 18, IUGR, prematurity and increased perinatal mortality.

25. 4) FOUR VESSEL CORD Four vessel umbilical cord anomaly commonly seen are 2 umbilical arteries and 2 umbilical veins .

26. 5) HEMATOMA Umbilical cord hematoma is defined as the extravasation of blood, mainly venous, in the Wharton's jelly that covers the umbilical vessels

27. 6) TORSION AND STRICTURES Stricture of the umbilical cord i s defined as a decrease in diameter in relation to the remaining umbilical cord Torsion is the excessive twisting of the umbilical cord which leads to blockage of the blood supply and the subsequent death of the fetus

28. NABHI NADI According to susrutha- “ मातस्तु खलु रसवाह्यं नद्यां गर्भनाभिनाडीप्रतिबद्धं सस्य मातुरह रसवीर्यमभिभवति ” (su.sa 3/39) T he Rasa of the mother which flows through her Rasav ahi N adi becomes connected to the fetus via the Garbha N abhi nadi . Through this connection, the M a tura Rasa V i rya (maternal nutritive potency) reaches the embryo, nourishing it and supporting its Vardhana .

29. According to dalhana : “ Thatha cha bhoja garbhe runadhi srothamsi rasaraktha vahani vai :/ Rakthajarayu bhavathy nadi cha eva rasathmika :// Garbha obstructs both rasa & raktha vaha srothas and from the rasa forms nabhi-nadi .

30. Nabhigatha vyadhis Nabhipaka - T he disease is explained in arogya kalpadruma as a complication of improper cutting of umbilical cord. Nabhi thundi - V itiated vata along with vitiated pitta swells up the umbilicus presented with pain is known as nabhi tundi roga Nabhi vrana - A fter the cord fall off at times in and around the stump area there will be production of an ulcer, which will not heal easily.

31. Asamyak nabhi nadi chedana vyadhis IMMEDIATE COMPLICATIONS 1. AAYAAM A Elongation of umbilicus by improper cutting of umbilical cord. 2. VYAYAAM A Vyayaam a simply indicates a large umbilicus. But signs of herniation are not yet seen in vyayaam a ,however it is described as an abnormal condition. Vyayaam a may be considered as one of the stages of umbilical hernia. 3. UTTUNDITA It shows features of both aayaam a and vyayaam a i.e elongation and enlargement.

32. LATE COMPLICATIONS 4. PINDALIKA In this condition, herniation is circular(parimandal a yukta) i.e rounded swelling - Umbilical granuloma, polyp. 5. VINAMIKA Here the umbilicus is inflamed and centrally depressed, elevated near the edges and concave in the middle – umbilical cyst/swelling. 6. VIJRAMBHIKA A fluctuating/pulsatile swelling present at umbilical region. Raised and depressed frequently – umbilical hernia.

33. Kanta veshtana (cord round neck) प्रततोत्तान शायिन्याः पुनर्गर्भस्य नाभ्याश्रया नाडी कण्ठमनुवेष्टयति। ( च . सं . शा . 8) This is a grave situation according to ayurveda. The cause of which is mentioned as lying in supine position.

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