Cord complications: associated risk factors and perinatal outcome

doi:10.4236/ojog.2011.14033

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Open Journal of Obstetrics and Gynecology, 2011, 1, 174-177

doi:10.4236/ojog.2011.14033 Published Online December 2011 (http://www.SciRP.org/journal/ojog/

OJOG

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG

Cord complications: associated risk factors and

perinatal outcome

Vijayata Sangwan, Smiti Nanda, Mukesh Sangwan, Roopa Malik, Manisha Yadav

Department of Obstetric & Gynecology, Pt. B. D. Sharma PGIMS, Rohtak, India.

Email: [email protected]

Received 30 July 2011; revised 4 September 2011; accepted 15 September 2011.

ABSTRACT

Objective: To assess the perinatal outcome in patients

with cord presentation and cord prolapse over a pe-

riod of 2 years and to assess the obstetric risk factors

associated with these cord complications. Design: Re-

trospective case study. Setting: A tertiary health care

centre of India. Sample: All cases of cord presenta-

tion and cord prolapse diagnosed in the department

over a period of 2 years (2009-2010). Methods: The

information regarding maternal presentation at the

time of admission, mode of delivery, and neonatal out-

come was retrieved from case sheets of patients avai-

lable in Medical Record Department. Maternal fac-

tors in terms of age, parity, gestational age, mode of

presentation, mode of delivery were analysed. Foetal

outcome was assessed by Diagnosis to Delivery In-

terval, APGAR score at 0 minutes and 5 minutes, foe-

tal weight and need for NICU admission. Results: The-

re were 53 cases of cord complications, out of which 7

(13.20%) had cord presentation and 46 (86.80%) had

cord prolapse. Among these 46 patients, 11 patients

developed cord prolapse in labour room (3 after arti-

ficial rupture of membranes and 8 after spontaneous

rupture of membranes), rest 34 patients presented in

emergency with cord prolapse. There were 79.24%

multiparous patients, 16 patients had malpresenta-

tions and breech was commonest malpresentation.

Forty one patients had positive cord pulsations at the

time of admission, all these patients underwent emer-

gency caesarean section and all had live babies. Twe-

lve patients reported to us with absent cord pulsation,

3 among these underwent section for obstructed la-

bour with hand and cord prolapse, rest 9 delivered

vaginally. The average DDI was 26.00 minutes, DDI

in patients developed cord prolapse in hospital was

18.90 minutes ± 5.48 minutes, whereas in patients

admitted with cord prolapse as emergency, the DDI

was 29.34 minutes ± 6.37 minutes (p < 0.05). Conclu-

sion: Analysis of the study concluded that the delive-

ry interval between cord prolapse and delivery of the

foetus is very important. Shortening of this interval

can decrease neonatal complication at birth and re-

duce NICU admission.

Keywords: Cord Complications; Perinatal; Caessrean

Section

1. INTRODUCTION

Umbilical cord prolapse is a rare obstetric complication

usually necessitating emergent delivery. It is life threa-

tening emergency for the foetus as the blood flow th-

rough the umbilical vein is compromised by cord com-

pression. The incidence of cord prolapse reported in lite-

rature ranges from 0.1% - 0.6% and has remained con-

stant over the last centuary [1]. A number of unavoidable

risk factors have been associated with increased inci-

dence of cord prolapse which include malpresentation,

prematurity, multiple gestations, premature rupture of mem-

branes & polyhydramnios. Remarkably high correlation

of cord prolapse and obstetric interventions such as foe-

tal scalp electrode application, insertion of intrauterine

catheter, induction of labour with artificial rupture of

membranes (ARM) is reported. Post natal mortality and

morbidity has fallen significantly as a result of advances

in management of cord prolapse and NICU care. Diag-

nosis to Delivery Interval (DDI) of 20 minutes - 30 mi-

nutes has been recommended by various international

obstetric societies [2,3]. The primary objective of this

study was to assess the perinatal outcome in patients of

cord prolapse and cord presentation over a period of 2

years. A secondary objective was to assess the obstetric

risk factors associated with these cord complications.

2. METHODS

This was a retrospective study conducted at Pt. B D

Sharma PGIMS Rohtak, a tertiary health care unit with

an average of 11,000 - 12,000 deliveries per year. The

information was retrieved from case sheets of patients

V. Sangwan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 174-177 175

available in Medical Record Department. Maternal con-

dition at the time of admission in terms of age, parity,

gestational age, foetal presentation, status of membranes

and mode of delivery were statistically analysed (Inde-

pendent sample T test). Different cord complications

were defined as follows to made diagnosis. Overt cord

prolapse was defined as the descent of the cord through

the cervix in to the vagina or onto the vulva. Cord pres-

entation meant the presence of one or more loops of um-

bilical cord between the fetal presenting part and the

fetal membranes overlying the cervical os. At admission,

the fetal condition was assessed and those with maturity

of >32 weeks and positive cord pulsations were immedi-

ately shifted for caesarean section. In these patients, in

order to alleviate pressure on cord, the cord was imme-

diately placed high up in vagina, presenting part was

elevated simultaneously and bladder filled with 500 ml

normal saline (Vago method) [4-10] until the patient was

on operating table. Foetal outcome was assessed in terms

of neonatal weight, APGAR score at 0 minutes and 5 mi-

nutes and NICU admission. Neonatal asphyxia was iden-

tified by the pediatrician on clinical grounds. In the pa-

tients getting admitted in emergency with complaint of

leaking per vaginum for varying duration, it was difficult

to comment on exact time of cord prolapse. Thus, Diag-

nosis to Delivery Interval was calculated as the time be-

tween reporting of patient and delivery of the foetus.

3. RESULTS

Amongst 22,681 deliveries over a period of 2 years, 53

cases of umbilical cord complications were identified,

giving the incidence of cord complication as 0.23 %. Out

of these 53 patients, 18 (33.96%) patients reported to us

with intact membranes and 35 (66.07%) patients re-

ported to us with complaints of leaking per vaginum for

varying duration and cord prolapse. In 18 patients with

intact membranes, 7 had cord presentation, 3 patients de-

veloped cord prolapse after artificial rupture of mem-

branes in the labour room and 8 admitted patients de-

veloped spontaneous leaking per vaginum leading to co-

rd prolapse. The details regarding patient profile are de-

scribed in Table 1.

Table 2 explains the risk factors of cord prolapse in

our study. Malpresentation was the commonest cause and

breech was the commonest malpresentation. The cervical

dilatation at the time of presentation was <5 cm in 34

(64.11%) and >5 cm in 19 (35.89%) patients.

Table 3 shows about perinatal characteristics in the

study. At admission, cord pulsations were present in 41

patients, rest of the fetuses (12) were already dead. All

patients with positive cord pulsations were immediately

shifted to operation theatre for urgent LSCS and all had

live babies. The fetal maturity in these was 32 weeks (1),

33 weeks - 36 weeks (8), rest 32 were >36 weeks. Among

these, birth weight of 18 babies was 1.5 kg to 2.5 kg, 23

babies were of 2.6 kg to 3.5 kg, and 2 babies weigh more

than 3.6 kg. Apgar score was <5 at first minute in 8

neonates, in 5 neonates it remained <5 at 10 min and

they were admitted in NICU. These 5 fetuses were born

to mothers who had been admitted as emergencies with

cord prolapse.

Of the 12 patients admitted with absent cord pulsa-

tions, 3 mothers had presented with obstructed labour

and had to be taken up for section for the sake of mother.

Rest 9 were delivered vaginally.

Table 1. Characteristic of patients with cord complications.

Characteristics No. of patients % of patient

Age group (years)

<20 03 5.6

21 - 25 37 69.81

>25 13 24.52

Parity

Nulliparous 11 20.75

multiparous 42 79.24

Gestational age (weeks)

<37 09 16.98

>37 44 83.01

Presentation

Vertex 37 69.81

Nonvertex 16 30.18

Cord complications

Cord presentation 07 13.20

Cord prolapse in hospital 11 20.75

Cord prolapse at admisson 35 67.92

Cervical dilatation (cm)

<5 34 64.15

>5 19 35.84

Table 2. Risk factors for cord prolapse.

Sr. no.Risk factor No. of patients % of patient

1 Multiparity 42 79.24

Malpresentation 16 30.18

Breech 08 15.09

Transverse lie 04 7.54

Compound presentation 04 7.54

3 Unengaged head 09 16.98

4 Twins 02 3.77

5 Prematurity 09 16.98

6 Artificial rupture of membranes 03 7.54

V. Sangwan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 174-177

176

Table 3. Perinatal characteristics.

Characteristic No. of patients % of patient

Cord pulsations at diagnosis

Present

Absent

77.35

22.64

Fetal Maturity

<28 wks

28 wks - 32 wks

33 wks - 36wks

≥37 wks

3.77

9.43

83.01

Apgar at 1 min.

18.86

58.49

Fetal weight at birth(kg)

<2.5

>2.5

30.18

69.81

Baby status

Live

dead

77.35

22.64

Sex

Male

female

35 (2 twins)

66.03

37.73

Mode of delivery

Emer. LSCS

NVD

83.01

16.98

Baby admission

NICU

With mother

9.43

67.92

The perinatal mortality in our study was 0.52 per 1000

births. The average DDI in our study was 26.00 minutes.

In the patients who had developed leaking in the hospital,

the DDI was 18.90 minutes ± 5.48 minutes with no

NICU admission and good Apgar score post delivery;

whereas in patients admitted with cord prolapse as emer-

gency, the DDI was 29.34 minutes ± 6.37 minutes (p <

0.05).

4. DISCUSSION

Cord prolapse and cord presentation are the obstetric

emergencies that change the management of a simple

pregnancy and necessiate urgent delivery. They are asso-

ciated with high perinatal mortality and morbidity. Suc-

cessful outcome depends on several maternal and foetal

factors. Incidence of cord prolapse in our study was 2.3

per 1000 deliveries .Other studies have reported the in-

cidence of 1.5, 1.4 per 1000 deliveries, 2.7 and 2.8 per

1000 deliveries [2,4-6].

Associated risk factors are those that predispose a

woman to have incompletely filled pelvis in the presence

of ruptured membranes. In the present study, the risk fa-

ctors for cord presentation and cord prolapse were found

in 39 (71.07%) patients. Multiparity is associated with

increased risk of cord prolapse. It is accounted by the

fact that in multipara, the engagement of presenting part

occurs late, and as a result with rupture of membranes,

cord slips down in vagina. In our study, 79.24% patients

were multiparous and 8 (15.09%) were >P4. Malpresenta-

tions were present in 16 (30.18%) and breech was com-

monest malpresentation. Prematurity was a cause in 9

(16.98%) patients. Other studies on risk factors associ-

ated with cord prolapse have also reported the same fac-

tors [7,8]

The perinatal mortility in our study was 0.52 per 1000

births. All these deaths were unavoidable as all had ab-

sent cord pulsations at the time of presentation. A few

studies reported high perinatal mortality [2,9]. Literature

suggests that cord prolapse occurring outside the hospi-

tal is consistently associated with a high perinatal mor-

tality rate (38% - 42%). In contrast, cord prolapse in a

labour room where patient is under monitoring, the peri-

natal mortality is very low (0% - 3%).

The cause of fetal distress in cord prolapse is cord

compression and urgent caesarean section releives that

compression. Studies revealed that DDI >30 minutes

associated with lower Apgar score [1]. In our study DDI

was found 26.00 minutes which is well within the rec-

ommended range and comparable with other studies re-

ported on cord prolapse. According to international bod-

ies, the time required to perform an emergency cesarean

section should not exceed 30 minutes [4]. The ACOG

also recommends incision time of 20 minutes - 30 minu-

tes to appropriate emergency caessrean section in patient

of cord prolapse. Literature suggests that DDI alone is

not the only contributing factor [9-12]. The other factors

like degree of cord compression, length of cord prola-

psed, prior hypoxia, CTG abnormalties may influence

foetal outcome. Inspite of widespread prevalence of risk

factors of cord prolapse, this problem is very rare. It may

be attributed to tone of the cord, its collagenous contents,

and its relation to lower segment. Studies also suggest

that intrapartum USG in patients prone for developing

cord prolapse before ARM may decrease the incidence

of cord prolapse [2,4].

The perinatal mortality and morbidity due to cord pro-

lapse has significantly improved over past century as a

result of advances in labour management, improved sur-

gical techniques and neonatal intensive care. However,

studies have revealed that perinatal outcome can further

be improved by a multiprofessional obstetric emergency

training sessions [3]. In our study, patients who had de-

veloped cord prolapsed in the labor room had average

DDI of 18.90 min, and no NICU admission. While pa-

V. Sangwan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 174-177

177

tients, who presented with cord prolapse, had an average

DDI of 29.34 min. This may be because of the extra time,

required in preparing patient for operation theatre. The

literature suggests that the main reason, why units fail to

comply with the 30 minutes target, delay in shifting pa-

tient to theatre [3]. Thus in order to achieve the advocated

DDI of <30 minutes, planned protocols for the manage-

ment of cord prolapse and the necessary drill of the rou-

tine staff to shift the patient on to OT table at the earliest,

needs to be strongly followed in the labour rooms.

OJOG

5. CONCLUSIONS

In our study, we concluded that the delivery interval be-

tween cord prolapse and delivery of the foetus is very

important. Shortening of this interval can decrease neo-

natal complication at birth and reduce NICU admission.

The preparatory time of patient for operation theatre and

her shifting to operation theatre where sister and para-

medical staff plays important role, is very crucial for the

patient. So, there should be written protocol for the staff,

alarming system in labour room to alert the whole team

should be there, to decrease DDI and improve neonatal

outcome.

REFERENCES

[1] Monique, G.L. (2006) Umbillical cord prolapse CME

review article. Obstetrical and Gynecological Survey, 61,

269-277.

[2] Khan, R.S., Naru, T. and Nizami, F. (2007) Umblical

cord prolapse-A review of diagnosis to delivery interval

on perinatal and maternal outcome. Journal of Pakistan

Medical Association, 57, 487-491.

[3] Siassakos, D., Harafa, Z., Sibanda, T., Fox, R., Donald, F.,

Winter, C. and Draycott, T. (2009) Retrospective cohort

study of diagnosis delivery interval with umbilical cord

prolapse: The effect of team training. British Journal of

Obstetrics and Gynaecology, 116, 1089-1096.

d oi: 10. 1111/j .14 71-0528.2009.02179.x

[4] Al Marzowki, A.M. and El Shobokshi, A.S. (2009) Audit

of cord prolapse. Management at King Abdulaziz Uni-

versity Hospital. Journal of King Abdulaziz University,

Medical Sciences, 16, 35-42.

[5] Bako, B., Chama, C. and Audu, B.M. (Sep2009) Emer-

gency obstetric care in a Nigerian tertiary hospital: A 20

year review of umbilical cord prolapse. Nigerian Journal

of Clinical Practice, 12, 232-236.

[6] Traore, Y., et al. (2006) Frequency of cord prolapse: Etio-

logical factors and foetal prognosis in 47 cases in a hea-

lth centre. Medicine For Mali, 21, 25-29.

[7] Dilbaz, B., Ozturkoglu, E., Dilbaz, S., Oztuck, N., Siva-

slioglu, A.A. and Haberal, A. (2006) Risk factors and

perinatal outcome associated with umbilical cord prola-

pse. Archives of Gynecology and Obstetrics, 274, 104-

107. doi:10.1007/s00404-006-0142-2

[8] Kahana, B., Sheinar, E., Levy, A. and Mazor, M. (2004)

Umbilical cord prolapse and perinatal outcomes. Interna-

tional Journal of Gynecology and Obstetrics, 84, 127-

132. doi:10.1016/S0020-7292(03)00333-3

[9] Faiz, S.A., Habib, F.A., Sporrong, B.G. and Khalil, N.A.

(2003) Results of delivery in umbilical cord prolapse.

Saudi Medical Journal, 24, 754-757.

[10] Bord, I., Gemu, O., Anleby, E.Y. and Shenhav, S. (2010)

The value of bladder filling in addition to manual eleva-

tion of presenting foetal part in cases of cord prolapse.

Archives of Gynecology and Obstetrics, 15.

[11] Tan, W.C., Tan, L.K., Tan, H.K. and Tan, A.S. (2003)

Audit of crash emergency caesarean section due to cord

prolapse in terms of response time and perinatal outcome.

Annals, Academy of Medicine, 32, 638-641.

[12] Prabulos, A.M. and Philipson, E.H. (1998) Umbilical

cord prolapse. Is the time from diagnosis to delivery cri-

tical? Journal of Reproduction Medicine, 43, 129-132.