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    Umbilical cord prolapse

    A plan for an ob emergency

     

    Umbilical cord prolapse (UCP) is a well-known obstetric emergency in which the umbilical cord passes through the cervix at the same time as or in advance of the fetal presenting part. The cord is then prone to compression between the fetal presenting part and the surrounding soft tissues or bony pelvis, which can lead to fetal hypoxia. Although not a common obstetric emergency, UCP is one in which the initial response can make a difference in the quality of maternal and infant outcomes.

    Incidence of UCP is estimated to be between 1.4 and 6.2 per 1000 pregnancies.1 Although this has not changed in the last century, perinatal outcomes for UCP have improved significantly. Historically, UCP has been associated with poor neonatal outcomes, with perinatal mortality ranging from 32% to 47% in the early to mid 20th century.2 Current rates of perinatal mortality in cases of UCP are estimated to be 10% or less.1-4 The most likely explanations for these vastly improved outcomes are the increased availability of cesarean delivery and advances in neonatal resuscitation.

    Diagnosis

    UCP can be occult or overt. Occult prolapse occurs when the cord passes through the cervix alongside the fetal presenting part; it is neither visible nor palpable. In overt prolapse, the cord presents in advance of the fetus and is visible or palpable within the vaginal vault or even past the labia.

    Prolapse of the cord often leads to cord compression which, in turn, leads to abnormal findings on fetal heart rate (FHR) tracings in 41% to 67% of cases.3,5 These changes may present as a severe, sudden deceleration, often with prolonged bradycardia, or recurrent moderate-to-severe variable decelerations. The diagnosis of overt UCP is made on vaginal examination, which will reveal a palpable umbilical cord (usually a soft, pulsating mass) within or visibly extruding from the vagina. A confirmed diagnosis of occult UCP is rare, because it cannot be definitively diagnosed even when Doppler ultrasound imaging is employed. Attempts to identify occult prolapse with imaging could delay necessary treatment for this emergent condition. Occult UCP likely is the cause of some cases of urgent cesarean delivery for unexplained fetal bradycardia.

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    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
    Bradley D. Holbrook, MD
    Dr. Holbrook is a senior resident in the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine, ...

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