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Umbilical Cord Accidents

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Umbilical Cord Accidents UMBILICAL CORD ACCIDENTS DR PADMASRI R PROF & HOD, DEPT OF OBSTETRICS & GYNAECOLOGY SAPTHAGIRI 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 Placental findings in cord accidents. Mana M Parast From Stillbirth Summit 2011, Minneapolis, USA 2 TYPES Acute events Sub Acute on Chronic • Umbilical Cord Prolapse • Loops • Knots • Vasa Praevia • Entanglements • Coiling • Torsion • Rupture • Haematomas, thrombosis • Cysts, tumours • Nuchal Cord • Insertion - velamentous cord CORD 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 Artificial rupture of membranes with high Multiparity presenting part Vaginal manipulation of the fetus with ruptured Low birthweight (< 2.5 kg) membranes Preterm labour (< 37+0 External cephalic version (during procedure) weeks) Fetal congenital anomalies Internal podalic version Breech presentation Stabilising induction of labour Transverse, oblique and Insertion of intrauterine pressure transducer unstable lie* Second twin Large balloon catheter induction of labour Polyhydramnios Unengaged presenting part Low-lying placenta RCOG Green-top Guideline No. 50, 2014 6 MANAGEMENT • Call for help • Expedite the birth of the baby. At full • Counsel the woman and dilatation, vaginal birth may be an her birth partner option depending on parity and • Move the woman into the engagement of head knee-chest or exaggerated • Transport the woman to the operating Sims’ position theatre, if required • Stop oxytocin augmentation • Tocolysis can be considered while if in progress preparing for caesarean section if • there are persistent fetal heart rate Elevate the presenting part abnormalities after attempts to digitally or by bladder filling prevent compression mechanically or • To prevent vasospasm, when the delivery is likely to be there should be minimal delayed. handling of loops of cord Tocolysis may allow time for regional lying outside the vagina anaesthesia to be administered. • Continue to assess fetal heart rate 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 Type II vasa praevia occurs with a velamentous insertion of the velementous fetal vessel connecting umbilical cord into the placenta the placenta to a succinuriate placental lobe. 9 PRESENTATION – CLASSICAL TRIAD MEMBRANE RUPTURE PAINLESS FETAL VAGINAL BLEEDING BRADYCARDIA/DEATH (BENCKISER’S HEMORRHAGE) • The mortality rate in this situation is around 60%. • If detected antenatally improved survival rates of up to 97% have been reported. 10 Vasa previa management Caeserean section Antenatally confirmed Unconfirmed, Vasa previa Detected during labour No risk factors Preterm contractions/ Don’t wait for Short cervix/ confirmation Low lying placenta May consider conservative management on OP basis Fetal exsanguination Prophylactic hospitalization (from 30-32 weeks) Emergency Antenatal corticosteroids Caeserean section Neonatal resuscitation Elective LSCS between 35-37 weeks 11 O 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.
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