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...
• ■ 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 Length
• Normal 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.
Umblical Cord Coiling
Cord 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 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 insertionVelamentous insertion❖Vasa
praevia
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.
■ 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
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
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
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)
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
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.CC[C
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.
• 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 & 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.
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 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.
Maternal Factors
• Multiparity
• Pelvic tumors
• Abnormal birth canal
• latrogenic factor
• Artificial rupture of membranes with an unengaged presentation
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 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.