MCN Notes on Umbilical Cord Prolapse

Umbilical Cord Prolapse

What is the umbilical cord?

The umbilical cord is a flexible, tube-like structure that, during pregnancy, connects the fetus to the mother. The umbilical cord is the baby’s lifeline to the mother. It transports nutrients to the baby and also carries away the baby’s waste products. It is made up of three blood vessels – two arteries and one vein.


What is umbilical cord prolapse?

Umbilical cord prolapse is a complication that occurs prior to or during delivery of the baby. In a prolapse, the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. The cord can then become trapped against the baby’s body during delivery. Umbilical cord prolapse occurs in approximately one in every 300 births.

What causes an umbilical cord prolapse?

The most common cause of an umbilical cord prolapse is a premature rupture of the membranes that contain the amniotic fluid. Other causes include:
• Premature delivery of the baby
• Delivering more than one baby per pregnancy (twins, triplets, etc.)
• Excessive amniotic fluid
• Breech delivery (the baby comes through the birth canal feet first)
• An umbilical cord that is longer than usual

What are the consequences of umbilical cord prolapse?

An umbilical cord prolapse presents a great danger to the fetus. During the delivery, the fetus can put stress on the cord. This can result in a loss of oxygen to the fetus, and may even result in a stillbirth.

How is an umbilical cord prolapse detected?

The doctor can diagnose a prolapsed umbilical cord in several ways. During delivery, the doctor will use a fetal heart monitor to measure the baby’s heart rate. If the umbilical cord has prolapsed, the baby may have bradycardia (a heart rate of less than 120 beats per minute). The doctor can also conduct a pelvic examination and may see the prolapsed cord, or palpate (feel) the cord with his or her fingers.

How is an umbilical cord prolapse managed?

Because of the risk of lack of oxygen to the fetus, an umbilical cord prolapse must be dealt with immediately. If the doctor finds a prolapsed cord, he or she can move the fetus away from the cord in order to reduce the risk of oxygen loss.
In some cases, the baby will have to be delivered immediately by cesarean section. If the problem with the prolapsed cord can be solved immediately, there may be no permanent injury. However, the longer the delay, the greater the chance of problems (such as brain damage or death) for the baby.

Hydatidiform mole

Definition

A hydatidiform mole is a rare mass or growth that may form inside the uterus at the beginning of a pregnancy. See also choriocarcinoma.

Alternative Names

Hydatid mole; Molar pregnancy

Causes

A hydatidiform mole results from over-production of the tissue that is supposed to develop into the placenta. The placenta normally nourishes a fetus during pregnancy. Instead, these tissues develop into a mass. The mass is usually made up of placental material that grows uncontrolled. Often, there is no fetus at all.
The cause is not completely understood. Potential causes may include defects in the egg, abnormalities within the uterus, or nutritional deficiencies. Women under 20 or over 40 years of age have a higher risk. Other risk factors include diets low in protein, folic acid, and carotene.

Symptoms

• Vaginal bleeding in pregnancy during the first trimester
• Nausea and vomiting, severe enough to require hospitalization in 10% of cases
• An abnormal growth in the size of the uterus, for the stage of the pregnancy
o Excessive growth in approximately 1/2 of cases
o Smaller-than-expected growth in approximately 1/3 of cases
• Symptoms of hyperthyroidism:
o Rapid heart rate
o Restlessness, nervousness
o Heat intolerance
o Unexplained weight loss
o Loose stools
o Trembling hands
o Skin warmer and more moist than usual
• Symptoms similiar to preeclampsia that occur in the 1st trimester or early in the 2nd trimester. (This almost always indicates hydatidiform mole, because preeclampsia is extremely rare this early in normal pregnancies.)
o High blood pressure
o Swelling in feet, ankles, legs
o Proteinuria

Note: All symptoms occur in conjunction with a potential, suspected, or confirmed pregnancy.

Exams and Tests

A pelvic examination may show signs similar to a normal pregnancy, but the uterine size may be abnormal and fetal heart tones are absent. Additionally, some bleeding may be noted.

Tests typically include:
• Measurement of serum HCG to confirm pregnancy. Repeated HCG measurements can be used to monitor the rate and consistency of decline if a hydatidiform mole is suspected.
• An ultrasound of the pelvis.
• A chest X-ray and abdominal CT or MRI will be recommended for some patients.

This disease may also alter the results of the following tests:
• Transvaginal ultrasound
• HCG (quantitative)

Treatment

If a miscarriage does not occur and the diagnosis is confirmed, a therapeutic abortion is performed by suction curettage (D and C).
Following either case, serum HCG levels are monitored to assure they return to a normal, non-pregnant level. A hysterectomy may be an option for older women who do not desire future pregnancies.

Outlook (Prognosis)

More than 80% of hydatidiform moles are benign (non-cancerous). The outcome after treatment is usually excellent. Close follow-up is essential. Highly effective means of contraception are recommended to avoid pregnancy for at least 6-12 months.
In 10-15% of cases, hydatidiform moles may develop into invasive moles. These may intrude so far into the uterine wall that hemorrhage or other complications develop.
In 2-3% of cases, hydatidiform moles may develop into choriocarcinoma, which is a malignant, rapidly growing, and metastatic (spreading) form of cancer. Despite these factors, which normally indicate a poor prognosis, the rate of cure after treatment with chemotherapy is high.
Over 90% of women with malignant, non-spreading cancer are able to survive and retain their ability to have children. In those with metastatic (spreading) cancer, remission remains at 75-85%, although the ability to have children is usually lost.

Possible Complications

Lung insufficiency may develop after evacuation of the uterus in cases where the uterus enlarges to greater than 16 weeks gestational size.

When to Contact a Medical Professional

Call your obstetrician if you suspect a hydatidiform mole.
If you have symptoms suggestive of preeclampsia -- such as severe swelling in the legs and feet, abdominal pain and high blood pressure -- see your health care provider immediately, call 911, or get to the emergency room. This can rapidly become a life-threatening emergency.

Prevention

Adequate nutrition may reduce the risk