UMBILICAL CORD ABNORMALITIES & ITS OBSTETRIC OUTCOME BY DR SHASHWAT JANI

1. 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 : 99099 44160.
E-mail : drshashwatjani@gmail.com

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.
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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.
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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
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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.
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Dr Shashwat Jani.
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6. Umb. Cord Diameter
• Lean cords are associated with IUGR
• Large diameter cords are associated
with macrosomia
• Clinical utility of parameter – unclear
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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;
 10th – 90th percentile — normocoiled;
 > 90th percentile — hypercoiled.
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8. Umb. Cord Coiling
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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
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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
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11. www.realpt.co.kr
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
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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.
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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
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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%
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16. Doppler scan to detect Vasa Previa
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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
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18. • If intra partum vaginal bleeding :
Speculum
Apt test - fetal hemoglobin is alkali
resistant.
If fetal bleeding confirmed, immediate
cesarean section
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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
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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
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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
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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)
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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.
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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.
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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 .
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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%
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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).
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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.
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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.
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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.
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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
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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.
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34. Umb. Cord Position ( Prolapse )
Types of umbilical cord prolapse :
 Occult cord prolapse
 Overt cord prolapse
 Funic presentation = cord presentation = procubitus.
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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).
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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.
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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.
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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
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40. Maternal factors
• Multiparity
• Pelvic tumors
• Abnormal birth canal
Iatrogenic factor
• Artificial rupture of membranes
with an unengaged presentation
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Dr Shashwat Jani.
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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.
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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.
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43. Prevention
High-risk patients :
 Malpresentations + 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.
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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.
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Dr Shashwat Jani.
9909944160.