1. ABNORMALITIES OF THE UMBILICAL CORD ASSOCIATE PROFESSOR IOLNDA ELENA BLIDARU MD, PhD

2. 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

3. The umbilical cord pathology A. Abnormalities of development B. Accidental pathology

4. 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)

5. Abnormalities of cord insertion. Marginal insertion 2% - 15%. associated with preterm labour (?). US. Battledore placenta

6. Abnormalities of cord insertion Velamentous insertion > 1% of singleton deliveries → more frequently with twins → almost the rule with triplets.

7. Abnormalities of cord insertion Abnormalities of cord insertion Velamentous insertion

8. 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. Fetal mortality - 33-100%, if not dg. prenatally.

9. Abnormalities of cord insertion 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

10. Abnormalities of cord insertion Abnormalities of cord insertion Velamentous insertion - vasa praevia Antenatal Diagnosis Checking placental cord connection (US). Can be diagnosed as early as 16 weeks.

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

12. Abnormalities of cord insertion 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

13. Abnormalities of cord insertion 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.

14. 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.

15. Abnormalities in cord length 3. Excessive length (cord length > 70cm) vascular occlusion (thrombi) true knots cord prolapse loops of the cord.

16. B.Accidental pathology loops knots prolapse thrombosis ruptures eventualities which lead to umbilical vessels compression and fetal distress.

17. 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.

18. 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).

19. UMBILICAL CORD PROLAPSE Definition Ruptured membranes ◦ occult cord prolapse (descent of the umbilical cord alongside) ◦ overt cord prolapse (umbilical cord past the presenting part).

20. 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.

21. UMBILICAL CORD PROLAPSE

22. 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.

23. 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.

24. 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

25. Umbilical cord prolapse Maternal factors multiparity pelvic tumors abnormal birth canal Iatrogenic factor artificial rupture of membranes with an unengaged presentation

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.