ABNORMALITIES OF THE UMBILICAL

CORD
 General aspects
 morphology
 two arteries and one vein (spiraling or
twisting).
 the extracellular matrix → Wharton
jelly.
 covered by amnion
 placed in the space created by
generalized flexion of fetus body
 functions
 The umbilical cord pathology

A. Abnormalities of development

B. Accidental pathology
A. Abnormalities 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 insertion
.

Marginal
insertion
2% - 15% .
 associated with preterm
labour (?).
Battledore
placenta
Abnormalities of cord insertion
Velamentous
insertion
> 1% of singleton
deliveries → more
frequently with twins
→ almost the rule
with triplets.
Abnormalities of cord insertion
Velamentous insertion
Abnormalities of cord insertion
Velamentous insertion - vasa praevia
Fetal 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.
Abnormalities of cord insertion
Velamentous insertion - vasa praevia
Symptoms
 Asymptomatic
 sudden 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 insertion
Velamentous insertion - vasa praevia
 Antenatal Diagnosis

 Checking placental cord connection

 Can be diagnosed as early as 16 weeks.

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

Management
If 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 insertion
Velamentous insertion - vasa praevia
 Management
If intrapartum vaginal bleeding

 Speculum
 Apt test - fetal hemoglobin is
alkali resistant.
 If fetal bleeding confirmed,
immediate cesarean section.
 Abnormalities in cord length
Normal  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. Accidental 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 PROLAPSE
Definition

 Ruptured membranes
◦ occult cord prolapse (descent of the
umbilical cord alongside)
◦ overt cord prolapse (umbilical cord past
the presenting part).
UMBILICAL CORD PROLAPSE
 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.
UMBILICAL CORD PROLAPSE
 Umbilical cord prolapse
Types of umbilical cord prolapse
1. occult cord prolapse
2. overt cord prolapse
3. 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 prolapse
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.
Umbilical cord prolapse
Ovular factors

 prematurity
 abnormal presentations (breech, brow,
face, transverse)
 multiple gestation
 placenta praevia
 polyhydramnios
 premature rupture of the membranes
 excessive length of the cord
Umbilical cord prolapse
Maternal factors
 multiparity
 pelvic
tumors
 abnormal birth canal
Iatrogenic factor
 artificial
rupture of membranes
with an unengaged presentation
 Umbilical cord prolapse
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.
 Umbilical cord prolapse
 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.
 Umbilical cord prolapse
Prevention
High-risk patients
 malpresentations + poorly applied cephalic
presentations → US at the onset of labor
 during 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 prolapse
MANAGEMENT
1. Venous access
2. Consent
3. 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 prolapse
Neonatal 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.