UMBILICAL CORD ABNORMALITIES & ITS OBSTETRIC OUTCOME BY DR SHASHWAT JANI

UMBILICAL CORD ABNORMALITIES & ITS OBSTETRIC OUTCOME BY DR SHASHWAT JANI

1. 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 : [phone]. E-mail : [email protected]

2. 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. 29-Jun-16 2 Dr Shashwat Jani. 9909944160.

3. 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. 29-Jun-16 Dr Shashwat Jani. 9909944160. 3

4. 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 29-Jun-16 4 Dr Shashwat Jani. 9909944160.

5. 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 . 29-Jun-16 5 Dr Shashwat Jani. 9909944160.

6. Umb. Cord Diameter Lean cords are associated with IUGR Large diameter cords are associated with macrosomia Clinical utility of parameter – unclear 29-Jun-16 6 Dr Shashwat Jani. 9909944160.

7. Umb. Cord Coiling Cord vessels spiral through the cord UCI ( 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 ; 10 th – 90 th percentile — normocoiled ; > 90 th percentile — hypercoiled . 29-Jun-16 7 Dr Shashwat Jani. 9909944160.

8. Umb. Cord Coiling 29-Jun-16 Dr Shashwat Jani. 9909944160. 8

9. 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 29-Jun-16 9 Dr Shashwat Jani. 9909944160.

10. 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 insertion Velamentous insertion Vasa praevia 29-Jun-16 10 Dr Shashwat Jani. 9909944160.

11. 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 placental margin 7% at term Cord being pulled off during delivery of the placenta Velamentous Insertion Umbilical vessels separate in the membranes at a distance from the placental margin Reach surrounded only by a fold of amnion 1.1% more frequently with twins 28% of triplets

12. Battledore Placenta 29-Jun-16 12 Dr Shashwat Jani. 9909944160. Velamentous Placenta

13. 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 , succenturiate – lobed placentas. 29-Jun-16 13 Dr Shashwat Jani. 9909944160.

14. 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 29-Jun-16 Dr Shashwat Jani. 9909944160. 14

15. 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% 29-Jun-16 15 Dr Shashwat Jani. 9909944160.

16. Doppler scan to detect Vasa Previa 29-Jun-16 Dr Shashwat Jani. 9909944160. 16

17. 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 29-Jun-16 17 Dr Shashwat Jani. 9909944160.

18. If intra partum vaginal bleeding : Speculum Apt test - fetal hemoglobin is alkali resistant. If fetal bleeding confirmed, immediate cesarean section 29-Jun-16 18 Dr Shashwat Jani. 9909944160.

19. 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 29-Jun-16 19 Dr Shashwat Jani. 9909944160.

20. Single Umbilical Artery Absence of one umbilical artery INCIDENCE : - 0.63 % in live births - 1.92 % in perinatal deaths - 3 % in twins Incidence is increased in women with : Diabetes Epilepsy PET APH Oligohydramnios Hydramnios Chromosomal abnormalities 29-Jun-16 20 Dr Shashwat Jani. 9909944160.

21. 29-Jun-16 21 Dr Shashwat Jani. 9909944160.

22. Single Umb. Art. & CMF About 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 29-Jun-16 22 Dr Shashwat Jani. 9909944160.

23. Fused umbilical artery Rarely umbilical artery may fail to split Shared ,fused lumen May involve the entire length or may be partial (towards the placental insertion site) 29-Jun-16 23 Dr Shashwat Jani. 9909944160.

24. 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. 29-Jun-16 24 Dr Shashwat Jani. 9909944160.

25. 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. 29-Jun-16 25 Dr Shashwat Jani. 9909944160.

26. 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 . 29-Jun-16 26 Dr Shashwat Jani. 9909944160.

27. 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% 29-Jun-16 27 Dr Shashwat Jani. 9909944160.

28. 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). 29-Jun-16 28 Dr Shashwat Jani. 9909944160.

29. Management At the time of birth: - Look for cord around the neck If 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. 29-Jun-16 Dr Shashwat Jani. 9909944160. 29

30. 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. 29-Jun-16 Dr Shashwat Jani. 9909944160. 30

31. Torsion & Stricture Torsion : 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 . 29-Jun-16 31 Dr Shashwat Jani. 9909944160.

32. 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 29-Jun-16 32 Dr Shashwat Jani. 9909944160.

33. 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 . 29-Jun-16 33 Dr Shashwat Jani. 9909944160.

34. Umb. Cord Position ( Prolapse ) Types of umbilical cord prolapse : Occult cord prolapse Overt cord prolapse Funic presentation = cord presentation = procubitus. 29-Jun-16 34 Dr Shashwat Jani. 9909944160.

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36. Definition Ruptured membranes occult cord prolapse (descent of the umbilical cord alongside) overt cord prolapse (umbilical cord past the presenting part). 29-Jun-16 36 Dr Shashwat Jani. 9909944160.

37. 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. 29-Jun-16 37 Dr Shashwat Jani. 9909944160.

38. 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. 29-Jun-16 38 Dr Shashwat Jani. 9909944160.

39. Predisposing Factors Prematurity Abnormal presentations (breech, brow, face, transverse) Multiple gestation Placenta praevia Polyhydramnios Premature rupture of the membranes Excessive length of the cord 29-Jun-16 39 Dr Shashwat Jani. 9909944160.

40. Maternal factors Multiparity Pelvic tumors Abnormal birth canal Iatrogenic factor Artificial rupture of membranes with an unengaged presentation 29-Jun-16 40 Dr Shashwat Jani. 9909944160.

41. 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. 29-Jun-16 41 Dr Shashwat Jani. 9909944160.

42. 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. 29-Jun-16 42 Dr Shashwat Jani. 9909944160.

43. Prevention High-risk patients : M alpresentations + 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. 29-Jun-16 43 Dr Shashwat Jani. 9909944160.

44. 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. 29-Jun-16 44 Dr Shashwat Jani. 9909944160.

45. Thank you