Umbilical Cord Disorder

•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.
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.
Abnormalities...5Length
• ■ Cord Coiling Single Umbilical Artery■ Four-vessel cord■
Abnormalities of cord insertion▪ Cord Abnormalities capable of
impeding blood flow■ Torsion and Strictures■ Hematoma■ Cysts
• Abnormal Cord LengthNormal cord length is 50-60cm, averagely
55cmShort 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.
• Umb. Cord CoilingCord vessels spiral through the cordUCI (Umbilical
Coiling Index) - is the no. of complete coils divided by the cord
length in стThey grouped the UCI as follows:➤ < 10th percentile -
hypocoiled;➤ 10th – 90th percentile - normocoiled;> > 90th
percentile - hypercoiled.
• Abnormalities of U. Cord InsertionUsually 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 insertionVelamentous insertion❖Vasa praevia
• Vasa PreviaAssociated 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.
• ■ Risk factors:- bilobed, succenturiate or low-lying placenta- Multifetal
pregnancy- Pregnancy resulting from in vitro
fertilizationDiagnosis :Color Doppler examination (low sensitivity
with ultrasound)- Perinatal diagnosisassociated with
increasedsurvival (97:44)- Antenatal diagnosis: associated with
decreased fetal mortality compared with discovery at delivery
• Abnormalities Of Vessels Number:Single umbilical artery:Results due
to atrophy of the previously existing umbilical artery.4 vessel
cord :Quiet uncommanMay be a venous remnantAssociation with
CMF is not clear
• Single Umbilical Artery• Absence of one umbilical
arteryINCIDENCE :0.63% in live births- 1.92% in perinatal deaths3%
in twinsIncidence is increased in women
with :DiabetesEpilepsyPETAPHOligohydramniosHydramniosChromos
omal abnormalities
• Fused umbilical arteryRarely umbilical artery may fail to
splitShared,fused lumenMay involve the entire length or may be
partial (towards the placental insertion site)
• KnotsFalse knots:Result from kinking of the vessels to accommodate
length of cord and are due to redundancies of Umbilical vessels /
Wharton's jelly.
• True KnotsIncidence 1-2%• More common in monoamniotic twins•
Active fetal movements create true knotsRisk 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.CC[C
• ManagementAt the time of birth: -Look for cord around the neckIf 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.
• • 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.
• Torsion & StrictureTorsion :Incidence : rareResult from fetal
movements during which the cord normally becomes twistedfetal
circulation is compromised.Stricture:More serious▪ Most infants
with this finding are stillbornAssociated 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.
• 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
• Umb. Cord CystsMay be found along the course of the cordTrue
cysts:> Epithelium lined> Remnants of the allantois› Coexist with
patent urachusO False Cysts:Due to degeneration of wharton's
jelly.• Single cyst may resolve completely• Multiple cysts may be
associated with miscarriage /aneuploidy.
• Maternal factorsMultiparity• Pelvic tumorsAbnormal birth
canallatrogenic factor• Artificial rupture of membranes with an
unengaged presentation
• Clinical diagnosisOvert 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 bimanualex.Occult
prolapse → Suspected if fetal heart ratechanges (variable
decelerations) due to intermittent compression of the cord are
detected during monitoring.
• 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.