Umbilical cord prolapse
- Melissa Bush, MD
Melissa Bush, MD
- Assistant Clinical Professor of Obstetrics and Gynecology, University of California, Irvine
- Keith Eddleman, MD
Keith Eddleman, MD
- Professor of Obstetrics and Gynecology
- Director of the Obstetrics
- Mount Sinai Medical Center
- Victoria Belogolovkin, MD
Victoria Belogolovkin, MD
- Obstetrix Medical Group
In overt umbilical cord prolapse, the cord slips ahead of the presenting part of the fetus and protrudes into the cervical canal or vagina, or beyond. It is an obstetrical emergency because the prolapsed cord is vulnerable to compression, umbilical vein occlusion, and umbilical artery vasospasm, which can compromise fetal oxygenation. In occult umbilical cord prolapse, the cord slips alongside, but not ahead of, the presenting part. The occult prolapsed cord is also vulnerable to compression and its sequelae. Membranes are usually ruptured in both settings.
Umbilical cord prolapse occurred in 0.17 and 0.18 percent of live born deliveries in two large series [1,2].
The pathogenesis of umbilical cord prolapse is not always clear. One probable mechanism is high outward flow of amniotic fluid at rupture of membranes that carries the umbilical cord past an unengaged fetal presenting part. Another probable mechanism is disengagement of the presenting part during obstetric procedures, allowing the cord to prolapse.
Umbilical cord prolapse primarily occurs in two settings: (1) when the presenting part does not adequately fill the pelvis because of maternal or fetal characteristics, and (2) when obstetric interventions are performed that dislodge the presenting part. Although observational studies suggest that obstetric interventions increase the risk of cord prolapse, it is often difficult to determine whether cord prolapse would have occurred spontaneously if the intervention had not been performed .
Fetal and maternal factors that have been associated with cord prolapse include:
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- Roberts WE, Martin RW, Roach HH, et al. Are obstetric interventions such as cervical ripening, induction of labor, amnioinfusion, or amniotomy associated with umbilical cord prolapse? Am J Obstet Gynecol 1997; 176:1181.
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- Lange IR, Manning FA, Morrison I, et al. Cord prolapse: is antenatal diagnosis possible? Am J Obstet Gynecol 1985; 151:1083.
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- Raga F, Osborne N, Ballester MJ, Bonilla-Musoles F. Color flow Doppler: a useful instrument in the diagnosis of funic presentation. J Natl Med Assoc 1996; 88:94.
- Kinugasa M, Sato T, Tamura M, et al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J Obstet Gynaecol Res 2007; 33:612.
- RISK FACTORS
- CLINICAL FINDINGS
- Differential diagnosis
- MANAGEMENT OF INTRAPARTUM CORD PROLAPSE
- Our approach
- Intrauterine resuscitation
- - Manually elevate the presenting part
- - Place patient in Trendelenburg or knee chest position
- - Retrofill the bladder
- - Administer a tocolytic
- - Consider manually replacing the prolapsed cord
- Special situations
- Prolapse on an antepartum unit
- - Pre-hospital cord prolapse
- - Previable gestational age
- ANTICIPATION AND PREVENTION OF CORD PROLAPSE
- Anticipating and managing risk
- - Pregnancies with funic presentation
- Minimizing risk from obstetric maneuvers
- SUMMARY AND RECOMMENDATIONS