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Term Pregnancy with Umbilical Cord Prolapse

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Term Pregnancy with Umbilical Cord Prolapse View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Available online at www.sciencedirect.com Taiwanese Journal of Obstetrics & Gynecology 51 (2012) 375e380 www.tjog-online.com Original Article Term pregnancy with umbilical cord prolapse Jian-Pei Huang a,b,*, Chie-Pein Chen a,c, Chih-Ping Chen a,d, Kuo-Gon Wang a,c, Kung-Liahng Wang a,b,d a Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan b Mackay Medicine, Nursing and Management College, Taipei, Taiwan c Division of High Risk Pregnancy, Mackay Memorial Hospital, Taipei, Taiwan d Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan Accepted 10 March 2011 Abstract Objective: To investigate the incidence, management, and perinatal and long-term outcomes of term pregnancies with umbilical cord prolapse (UCP) at Mackay Memorial Hospital, Taipei, from 1998 to 2007. Materials and Methods: For this retrospective study, we reviewed the charts, searched a computerized birth database, and contacted the families by telephone to acquire additional follow-up information. Results: A total of 40 cases of UCP were identified among 40,827 term deliveries, an incidence of 0.1%. Twenty-six cases (65%) were delivered by emergency cesarean section (CS). Of the neonates, 18 had an Apgar score of <7 at 1 minute, 10 of these scores being sustained at 5 minutes after birth, and three infants finally died. Eleven UCPs occurred at the vaginal delivery of a second twin, and nine with malpresentation. All of the infants who had good perinatal outcomes also had good long-term outcomes. Poor perinatal outcomes occurred in cases where there was a delayed diagnosis, or an inability to carry out an emergency CS or a prompt vaginal delivery. Conclusion: Early detection of UCP and expeditious delivery are crucial to good perinatal outcomes. An emergency CS remains the mainstream management. Multiparous women whose cervixes are nearly fully dilated and who are expecting babies relatively smaller than their elder brothers or sisters born vaginally may still have vaginal deliveries managed by well-experienced birth teams, with good perinatal outcomes. Otherwise, vaginal delivery is not recommended and CS is the wiser choice. Copyright Ó 2012, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved. Keyword: umbilical cord prolapse Introduction chance of UCP when the pregnant woman is multiparous, the fetus is small, the fetus presentation is faulty, the fetus is male, Umbilical cord prolapse (UCP) is a rare obstetric emer- the fetus is a second-born twin, or the baby is delivered gency that threatens the life and wellbeing of the fetus. Its prematurely [4e7, 9]. In fact, most cases of UCP occur in term incidence ranges from 0.1% to 0.6% in the literature [1e9].In pregnancies with fetuses of normal birth body weight and recent decades, however, this incidence has decreased and a vertex presentation [5e7]. perinatal outcomes have improved due to the more liberal use UCP still carries a high perinatal mortality and morbidity of cesarean section (CS) and better neonatal resuscitation with [1,2,4,6e9], due to either a mechanical occlusion resulting successive care [5e9]. To our knowledge, there is a higher from prolonged compression of the umbilical cord under the fetal presenting part, or an umbilical cord vasospasm triggered by the comparatively cooler temperature in the vagina. Both may lead to perinatal hypoxic encephalopathy or death. * Corresponding author. Department of Obstetrics and Gynecology, Mackay Memorial Hospital, 92, Sector 2, Zhong-San North Road, Taipei, Taiwan. Consequently, UCP has the potential to become a medicolegal E-mail address: [email protected] (J.-P. Huang). issue, especially when a low-risk pregnant woman with a term 1028-4559/$ - see front matter Copyright Ó 2012, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.tjog.2012.07.010 376 J.-P. Huang et al. / Taiwanese Journal of Obstetrics & Gynecology 51 (2012) 375e380 pregnancy suddenly experiences an unfavorable labor course unit (NICU) for patients suffering from UCP was also higher with UCP and delivers a severely damaged newborn. than the average (35% vs. 5.2%; p < 0.01). In summary, the Additionally, we are very interested in the long-term cases with UCP tended to be characterized by a multiparous outcome of newborns after UCP. Only two studies [10,11] mother, a multifetal pregnancy, malpresentation, a male fetus, have mentioned this topic. The first reported on cases of CS delivery, or low Apgar scores, along with higher NICU preterm premature rupture of membranes with UCP and the admission and perinatal mortality rates (Table 1). second on only four infants who had suffered UCP after term Twenty-six babies (65%) were delivered by emergency CS, pregnancies. Important data on living neonates who had UCP the other 14 cases having VDs with or without the assistance are still conspicuously lacking based on our literature review. of vacuum aspirators, forceps, and fundal pressure. CS Because a controlled, prospective study of UCP would be not remains the main mode of delivery for patients with UCP only impossible but also unethical, we decided to conduct because it may have the potential benefit of decreasing the a retrospective study. In order to develop a better strategy for number of newborns with low Apgar scores at 1 and 5 managing UCP in the future, we analyzed risk factors and minutes, as well as lowering NICU admission and perinatal clinical management approaches, along with the perinatal and mortality and morbidity rates [5e8]. In our study, however, all long-term outcomes of fetuses who had had UCP but whose of the indicators of perinatal outcome, including low Apgar mothers had previously been low-risk pregnant women. score at 1 minute (38.5% vs. 57.1%) and 5 minutes (15.4% vs. 42.9%), NICU admission rate (30.8% vs. 42.9%), neonatal Materials and methods admission days (6.9 Æ 4.9 vs. 5.0 Æ 1.3), long-term neuro- logical sequelae (3.8% vs. 0%), and perinatal mortality (38.5/ Included in this study were term pregnant women who 1,000 vs. 142.9/1,000) were not statistically different between delivered at Mackay Memorial Hospital, Taipei, Taiwan, from the CS and VD groups. One surviving newborn suffered from January 1998 to December 2007, whose newborns experi- a neonatal seizure, and had hypotension during the first 23 enced UCP after the mothers had been admitted to hospital. days of admission, with long-term sequelae of epilepsy, severe UCP was diagnosed if there was descent of a segment of spasticity in all four limbs, impaired vision and hearing, and umbilical cord through the cervix into the vagina or onto the the development of retardation requiring rehabilitation. vulva during the first or second stage of labor. Cases of occult One neonatal death occurred in the CS group, a case of twin cord prolapse or cord presentation were excluded. pregnancy originally planned as a VD. However, the fetal The clinical characteristics, management, and perinatal position of the second twin changed suddenly after delivery of outcomes were collected by retrospective chart reviews the first twin and was combined with spontaneous amnio- combined with computerized birth database searches, as well chorion membrane rupture and UCP. Manual internal rotation as telephone contacts postneonatal period follow-up. The data was tried for nearly 10 minutes, with intermittent severe collected were analyzed using descriptive statistics, Student t test, Chi-square, or Fisher’s exact test using the statistical software Statistica, release edition 7.0. Differences were Table 1 considered significant at p < 0.05. Clinical characteristics and perinatal outcomes of pregnant women delivering at term with and without umbilical cord prolapse (UCP). Results Cases Cases p with without UCP UCP A total of 40 cases of UCP were identified from 40,827 (n ¼ 40) (n ¼ 40,787) term deliveries over the study period of 10 years, registering Maternal age (y) 30.3 Æ 5.2 29.8 Æ 4.9 0.83 an incidence of 0.1%. The mean maternal age was 30.3 Æ 5.2 Gestational age (weeks) 38.1 Æ 0.8 38.3 Æ 0.9 0.92 (21e40) years old, and the mean gestational age was Parity 1.8 Æ 0.8 1.5 Æ 0.9 0.75 38.1 Æ 0.8 (37e40) weeks. Twenty-six (65%) of the 40 Multiparity (%) 65 43.3 0.056 < women delivering with UCP were multiparous. Eleven Multifetal pregnancy (%) 27.5 4.8 0.001 (27.5%) had twin pregnancies with the UCP happening at Fetal presentation at delivery vaginal delivery (VD) of the second twin. Nine of the UCPs Vertex (%) 65 96.4 <0.001 < occurred with malpresentation. Although malpresentation of Breech (%) 27.5 3.5 0.001 Transverse (%) 7.5 0.1 <0.001 the fetus predisposes to UCP, most cases (65%) of UCP Male newborn (%) 70 52.8 0.029 actually occurred in women with a normal vertex presentation Percentage of cesarean 65 30.3 <0.001 fetus. Twenty-eight (70%) newborns were male, and 26 cases sections (%) (65%) were delivered by emergency CS. Vacuum or forceps-assisted 25 20.8 0.51 Eighteen (45%) neonates had Apgar scores < 7 at 1 minute, vaginal delivery (%) Newborn birth body weight (g) 2927 Æ 393 3112 Æ 446 0.68 10 of these being sustained at 5 minutes after birth, and three Apgar score < 7 at 1 minute (%) 45 4.6 <0.001 finally died, giving a perinatal mortality rate of 75/1,000, Apgar score < 7 at 5 minutes (%) 25 3.4 <0.001 which was much higher than the average of 15.8/1,000 seen in Neonatal intensive care unit 35 5.2 <0.001 the population serving as a control over the same study period admission rate (%) < ( p < 0.01).
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