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Updated: Nov 29 2019

Umbilical Cord Prolapse

  • Snapshot
    • A 30-year-old G1P0 woman of 38 week gestation presents to the hospital with contractions. In the labor and delivery room, she undergoes rupture of membranes. Shortly after, the fetal heart monitor reveals variable decelerations. A vaginal exam is conducted and the umbilical cord is palpated between the presenting part of the fetus and the cervical os. An ultrasound is done to confirm this diagnosis. As intrauterine manipulation is attempted, the fetal heart monitor shows bradycardia. The patient is prepped for a cesarean section.
  • Introduction
    • Overview
      • umbilical cord prolapse results from umbilical cord that presents anterior to the presenting part of the fetus, causing it to protrude first from the cervical os
      • this is an obstetrical emergency as compression or occlusion of the umbilical cord will lead to fetal oxygen deprivation
        • treatment is usually emergent delivery
  • Epidemiology
    • Incidence
      • rare, 0.16-0.18% of live births
    • Risk factors
      • obstetrical intervention (50%)
        • manual rotation of fetal head
        • iatrogenic rupture of membranes
        • forcep or vacuum delivery
      • malpresentation
      • low lying placenta
      • prematurity
      • polyhydramnios
      • prolonged labor
    • Pathogenesis
      • mechanism
        • unclear, may be related to increased outward flow of amniotic fluid during rupture of membranes
  • Presentation
    • Symptoms
      • common symptoms
        • abrupt onset of fetal rhythm abnormalities
          • bradycardia
          • variable decelerations
        • occurs after rupture of membranes or obstetrical intervention
        • usually painless
    • Physical exam
      • inspection
        • visualization of umbilical cord ahead of presenting fetus
  • Imaging
    • Ultrasound
      • indications
        • suspected diagnosis of umbilical cord prolapse
      • findings
        • umbilical cord visualized between presenting fetus and cervical os
  • Differential
    • Abruptio placentae
      • key distinguishing factors
        • may also present with fetal heart rate changes
        • characterized by vaginal bleeding and abdominal pain
  • Treatment
    • Medical
      • intrauterine manipulation to free the fetus
        • indication
          • initial treatment
        • modalities
          • elevating presenting part
          • changing maternal position (i.e., in Trendelenberg)
    • Surgical
      • immediate delivery via cesarean section
        • indications
          • intrauterine manipulation is not successful
          • fetal or maternal distress
  • Complications
    • Fetal mortality
      • 0-3% mortality rate
  • Prognosis
    • Worse prognosis if prolapse occurs outside the hospital
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