ABNORMALITIES OF THE UMBILICALABNORMALITIES OF THE UMBILICALCORDCORD

ASSOCIATE PROFESSORIOLNDA ELENA BLIDARU

MD, PhD

General aspectsGeneral aspects morphologytwo arteries and one vein (spiraling or

twisting). the extracellular matrix → Wharton

jelly. covered by amnionplaced in the space created by

generalized flexion of

fetus bodyfunctions

The umbilical cord pathology

A. Abnormalities of development

B. Accidental pathology

A.A. Abnormalities of developmentAbnormalities of development

abnormalities of cord

insertion

-marginal insertion

-velamentous insertion

abnormalities in cord length

tumors of umbilical cord

vascular anomalies (single

umbilical artery)

Abnormalities of cord insertionAbnormalities of cord insertion.

Marginal insertion

2% - 15% . associated with preterm labour (?). US.

Battledore placenta

Abnormalities of cord insertionAbnormalities of cord insertion

Velamentous insertion

> 1% of singleton deliveries → more frequently with twins → almost the rule with triplets.

Abnormalities of cord insertionAbnormalities of cord insertion

Velamentous insertion

Abnormalities of cord insertionAbnormalities of cord insertion

Velamentous insertion - vasa praeviaFetal vessels run in the membranes below the presenting fetal part.Spontaneous / artificial rupture of membranes - rupture the vessels - fetal exsanguination – Benkiser syndrome. Hypoxia if the vessels are compressed between baby and birth canal.Fetal mortality - 33-100%, if not dg. prenatally.

Abnormalities of cord insertionAbnormalities of cord insertion Velamentous insertion - vasa praevia

SymptomsAsymptomaticsudden onset of painless bleeding in 2nd or 3rd trimester or at the rupture of membranes

No sign / symptom of placenta praevia or abruption.

IUGR/ Congenital malformation

Abnormalities of cord insertionAbnormalities of cord insertion Velamentous insertion - vasa praevia

Antenatal Diagnosis

Checking placental cord connection (US).

Can be diagnosed as early as 16 weeks.

Abnormalities of cord insertionAbnormalities of cord insertion Velamentous insertion - vasa praevia Doppler scan to detect Vasa praevia

Abnormalities of cord insertionAbnormalities of cord insertion Velamentous insertion - vasa praevia

ManagementIf diagnosed prenatally

◦Planned cesarean section (early enough to avoid emergency, but late enough to avoid prematurity)

◦Baby requires aggressive resuscitation + blood transfusion

Abnormalities of cord insertionAbnormalities of cord insertion Velamentous insertion - vasa praevia

ManagementIf intrapartum vaginal bleeding

SpeculumApt test - fetal hemoglobin is

alkali resistant.If fetal bleeding confirmed,

immediate cesarean section.

Abnormalities in cord lengthNormal 55 cm

1. Cord absence (achordia)

2. Excessively short umbilical cord (< 35cm) abnormal presentations fetal heart rate injuries abruptio placenta rupture → hemorrhage → fetal death anomalies of parturition inversion of the uterus.

Abnormalities in cord length

3. Excessive length (cord length >

70cm)

vascular occlusion (thrombi)

true knots

cord prolapse

loops of the cord.

B.B. Accidental pathologyAccidental pathology

loops knots prolapse thrombosis ruptures

eventualities which lead to umbilical vessels compression and fetal distress.

Loops of the cord

coiling around portions of the fetus, usually the neck.

favourized by excessive cord length, polyhydramnios.

as the presentation descends the birth canal, contractions compress the cord vessels, which cause fetal heart rate deceleration.

fetal distress induced by tight umbilical cord loop is an indication for cesarean section.

Umbilical cord knots

True knots - distinguished from

false knots (varicosities or

accumulations of Wharton's jelly) ►

no clinical significance

True knots result from active fetal

movements (1.1 % of births).

UMBILICAL CORD PROLAPSEUMBILICAL CORD PROLAPSE

Definition

Ruptured membranes ◦occult cord prolapse (descent of

the umbilical cord alongside)

◦overt cord prolapse (umbilical

cord past the presenting part).

UMBILICAL CORD PROLAPSEUMBILICAL CORD PROLAPSENO 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.

UMBILICAL CORD PROLAPSEUMBILICAL CORD PROLAPSE

Umbilical cord prolapse

Types of umbilical cord prolapse1.occult cord prolapse 2.overt cord prolapse3.funic presentation = cord

presentation = procubitus.

Overt cord prolapse is always associated with rupture of the membranes and displacement of the cord into the vagina, often throughout the introitus.

Umbilical cord prolapseEtiology

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

Umbilical cord prolapseOvular factors

prematurityabnormal presentations (breech, brow,

face, transverse)multiple gestationplacenta praeviapolyhydramniospremature rupture of the membranesexcessive length of the cord

Umbilical cord prolapseMaternal factors

multiparity pelvic tumors abnormal birth canal

Iatrogenic factorartificial rupture of membranes

with an unengaged presentation

Umbilical cord prolapseClinical 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.

Umbilical cord prolapseIf 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.

Umbilical cord prolapsePrevention

high-risk patients malpresentations + poorly applied cephalic

presentations → US at the onset of laborduring labor patients at risk for →

continously 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.

Umbilical cord prolapseMANAGEMENT

1.Venous access2.Consent3.Immediate CS.4.The manual replacement is NOT recommended.

5.To prevent vasospasm - minimal handling of loops of cord lying outside the vagina and cover them in surgical packs soaked in warm saline.

Umbilical cord prolapseNeonatal prognosis

Fetal morbidity and mortality rates are high

the prognosis depends upon the degree and

duration of umbilical cord compression

If the diagnosis is made early and the duration

of complete cord occlusion is less than 5

minutes, the prognosis is good.

Neonatologist is mandatory.