UMBILICAL CORD ACCIDENTS - BSOG
Transcript of UMBILICAL CORD ACCIDENTS - BSOG
UMBILICAL CORD ACCIDENTS
DR PADMASRI RPROF & HOD, DEPT OF OBSTETRICS &
GYNAECOLOGYSAPTHAGIRI INSTITUTE OF MEDICAL SCIENCES
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• “Cord accident,” defined by obstruction of fetal blood flow through the umbilical cord, is a common ante- or perinatal occurrence.
• Obstruction can be either acute, as in cases of cord prolapse during delivery, or sub acute to-chronic, as in cases of grossly abnormal umbilical cords
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Placental findings in cord accidents. Mana M ParastFrom Stillbirth Summit 2011, Minneapolis, USA
TYPES
Acute events
• Umbilical Cord Prolapse
• Vasa Praevia
Sub Acute on Chronic• Loops• Knots• Entanglements• Coiling• Torsion• Rupture• Haematomas, thrombosis• Cysts, tumours• Nuchal Cord• Insertion - velamentous cordCORD COMPRESSION – SUDDEN
IUD’s
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CORD COMPRESSION
2 Principles of asphyxia are:
a. Cord compression -preventing venous return to the fetus
b. Umbilical vasospasm -preventing venous and arterial blood flow to and from the fetus due to exposure to external environment.
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Recovery time from compression
• 1min, 1 time 100% compression – 5 mins to recover- oxygen levels decrease by 50%
• 5 mins comp – 30 mins to recover
• Continued 5 min compressions every 30 mins causes fetal decompensation
RISK FACTORS FOR CORD PROLAPSE
GENERAL PROCEDURE RELATED
MultiparityArtificial rupture of membranes with high presenting part
Low birthweight (< 2.5 kg) Vaginal manipulation of the fetus with ruptured membranes
Preterm labour (< 37+0 weeks)
External cephalic version (during procedure)
Fetal congenital anomalies Internal podalic version
Breech presentation Stabilising induction of labour
Transverse, oblique and unstable lie*
Insertion of intrauterine pressure transducer
Second twin Large balloon catheter induction of labour
Polyhydramnios
Unengaged presenting part
Low-lying placenta
6RCOG Green-top Guideline No. 50, 2014
MANAGEMENT• Call for help• Counsel the woman and
her birth partner• Move the woman into the
knee-chest or exaggerated Sims’ position
• Stop oxytocin augmentation if in progress
• Elevate the presenting part digitally or by bladder filling
• To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina
• Continue to assess fetal heart rate
• Expedite the birth of the baby. At full dilatation, vaginal birth may be an option depending on parity and engagement of head
• Transport the woman to the operating theatre, if required
• Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically or when the delivery is likely to be delayed.Tocolysis may allow time for regional anaesthesia to be administered.
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VASA PRAEVIA
• Vasa praevia is a rare but potentially serious condition in which blood vessels carrying blood between the placenta and the baby cross over the cervix.
• These vessels may bleed if the woman goes into labour, if the waters break, or if the cervix opens
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TYPES
Type 1 vasa praevia occurs with velamentous insertion of the
umbilical cord into the placenta
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Type II vasa praevia occurs with avelementous fetal vessel connecting the placenta to a succinuriateplacental lobe.
PRESENTATION – CLASSICAL TRIAD
• The mortality rate in this situation is around 60%.• If detected antenatally improved survival rates of up to 97%
have been reported.
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MEMBRANE RUPTURE
PAINLESS VAGINAL BLEEDING
(BENCKISER’S HEMORRHAGE)
FETAL BRADYCARDIA/DEATH
Vasa previa management
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Caeserean section
Antenatally confirmedVasa previa
Preterm contractions/Short cervix/
Low lying placenta
No risk factors
Prophylactic hospitalization(from 30-32 weeks)
May consider conservative management on OP basis
Antenatal corticosteroids
Elective LSCS between 35-37 weeks
Unconfirmed, Detected during labour
Don’t wait for confirmation
Fetal exsanguination
Emergency Caeserean section
Neonatal resuscitationO Rh –ve Blood
CONCLUSION
• Vasa previa is an uncommon but potentially life threatening condition for the fetus /neonate.
• Perinatal outcomes improve significantly when antenatal diagnosis enables planned management that includes elective Caesarean section by 35 weeks gestation before the onset of labour.
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NUCHAL CORD – NOOSE OR NECKLACE?
• NUCHAL CORD - Cord round the neck, 360 deg
• Two types of cord around foetal neck.
• TYPE A- umbilical 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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ULTRASOUND DIAGNOSIS OF NC
2 Views• They should be identified by presence of the cord in the
transverse and sagittal planes of the neck and lying around at least three of the four sides of the neck
• On sagittal view –NC seen as dimples at the posterior neck of the fetus
• Although there appears to be a linear increase over gestation in the presence of both single and multiple loops, NC keeps appearing and disappearing over time.
• The difficulty encountered in visualizing the NC at term and prior to induction of labor is due to fetal crowding, low position of the fetal head or reduced amniotic fluid volume .
• Generally, the sensitivity of diagnosis is higher with color Doppler imaging, and it may have a particular advantage in the presence of ruptured membranes
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UMBILICAL CORD COILING
• Whether an umbilical cord is normal, hypercoiled or hypocoiled is dependent on the number of coils present in the cord – this is known as the umbilical coiling index (UCI).
• Sonographic umbilical coiling index is defined as number of vascular coil in a given cord.
• Usually 1 coil / 5 cm of umbilical cord length and may coil as many as 40 times.
• < 10th percentile
– hypocoiled.
• 10th – 90th percentile
– normocoiled .
• >90th percentile
– hypercoiled.
Summary
• UCA can be acute event or acute on chronic
• Training and CP guidebook / box should be in place for quick action
• Diagnose VP antenatally in 2nd trimester to reduce perinatal mortality to nil
• Be wary of Type B Nuchal Cord which can be dangerous to the fetus
• Look for UCI to rule out hypo/hypercoiling of cord