1 Umbilical cord abnormalities Abnormal cord insertion Hyper- or - - PDF document

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1 Umbilical cord abnormalities Abnormal cord insertion Hyper- or - - PDF document

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Stillbirth Summit 2017 Novel Approaches to Managing Umbilical Cord and Placental Issues Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan Junichi Hasegawa Causes of fetal death after 20

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Novel Approaches to Managing Umbilical Cord and Placental Issues Department of Obstetrics and Gynecology,

  • St. Marianna University School of Medicine, Kanagawa, Japan

Junichi Hasegawa Stillbirth Summit 2017

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Causes of fetal death after 20 weeks’ gestation

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

God-given safeties in umbilical cord

Amniotic fluid Wharton’ jelly Coiling Two arteries

When these favorable mechanisms are broken down, fetus might take a risk !

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Umbilical cord abnormalities Abnormal cord insertion Hyper- or Hypo-coiled cord Cord entanglement Single umbilical artery Umbilical cord prolapse

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Abnormal Cord Insertion

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Normal placenta and umbilical cord

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Abnormal Cord Insertions

Marginal Velamentous Vasa previa 5% 2% 1/2000

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Strong compression

Wharton’s jelly

Normal cord

Pathophysiology of velamentous insertion

membrane

A A V

Lack of Wharton’s jelly Vessels are easily compressed !

Velamentous

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Vasa Previa

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

FHR at 34 weeks

Emergency CS was determined !

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Frequencies of VD・NRFS・eC/S

Hasegawa Ultrasound Obstet. Gynecol. 2006.a

Marginal (%) * * Velamentous

eC/S NRFS

* : p<0.05 (3037) (29) (10) (30) (5) upper middle lower

VD

* * * *

Ultrasound diagnosis of velamentous insertion

Marginal Velamentous

(1) Umbilical vessels enter the placenta margin parallel to the uterine wall and connect to superficial placental vessels. (2) The umbilical vessels diverge as they traverse the membrane. (3) The cord insertion is immobile, even when the uterus is shaken.

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Transvaginal ultrasound pictures of vasa previa

Case 5 Case 1 Case 2 Case 3 Case 6 Case 4 Case 7 Cord insertion on the lower uterine segment is strongly associated with vasa previa. Hasegawa Fetal diagnosis and Ther. 2007 Case 8

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Diagnosis of vasa previa should be made during early second trimester !

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Vasa previa is not infrequent

1/500

by ultrasound diagnosis 1/2000 (retrospective estimation)

Hasegawa , “Vasa previa is not infrequent” J Mater. Fetal Neonat. Med. 2012

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Hasegawa , “Vasa previa is not infrequent” J Mater. Fetal Neonat. Med. 2012

Vasa previa in the first trimester

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Probe beyond the surface

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Screening of vasa previa

Variables Adjusted OR (95% CI) p-value Aberrant vessels on membrane 65.1 (5.8-733) 0.001 Cord insertion on the lower uterus 344.7 (31-3838) <0.001 Hasegawa et al. Prenatal Diagnosis, 2010

Confirmation of normal placental location with normal insertion is recommended for safe delivery !

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Summary (abnormal insertion)

Velamentous vessels on the lower uterus is high risk. In vasa previa, fetal death is avoidable only antepartum ultrasound diagnosis and elective CS. Case with vasa previa should be performed CS before rupture of membrane until 36 weeks’ gestation.

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Hyper-coiled Cord

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Hyper-coiled cord

Coiling Index = 1

  • ne cycle of coil (cm)

Degani et al. Obstet Gynecol, 1995

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Antenatal and postnatal Coiling Index

10% tile 50% tile 90% tile Measurement at (n)

Hypo- Normo- Hyper-

18-22wks (258) 0.23 0.37 *0.58 28-32wks (196) 0.21 0.34 *0.49 At delivery (1969) 0.10 0.17 *0.27

* : p<0.05 ANOVA, post-hoc test Kurita and Hasegawa Fetal Diag. Ther. 2010

Abnormal antenatal Coiling Index > 0.5 (2.0 cm/cycle)

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Pathophysiology of hyper-coiled cord Complicated narrow cord (umbilical ring)

Easy to obstruct

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Hyper-coiled cord and fetal death

Pregnant parturient visited to our hospital due to lack of fetal movement at 22 weeks +5. Diagnosis of fetal death caused by umbilical ring constriction was made.

Hasegawa Ultrasound Obstet. Gynecol. 2010

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Summary (Hyper-coiled cord)

Strict FHR monitoring during labor is required in cases with hyper-coiled cord. Precise observations are required in FGR or abnormal Doppler findings associated with hyper-coiled cord. However, fetal death often occurs during early-mid

  • gestation. It is not avoidable and predictable.
  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Hypo-coiled cord

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Cord entanglement

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Cord entanglement 30% of all deliveries Nuchal cord is most frequently observed

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Incidence of acute delivery stratified by number of nuchal cord

30.8%＊ 20.9%＊ 13.3% 13.3% 25.0%＊ 7.0% 6.6% 5.7% Multiparous n=1770 Nulliparous n=2382 *:p<0.05 Ose and Hasegawa J Jpn Society of Perinatal and Neonatal Medicine, 2013

Summary (nuchal cord)

Twice 3 times 4 times

Although there appears to increase over gestation in the presence of cord entanglement, nuchal cord keeps appearing and disappearing over time. Thus, number of the nuchal cord is determined near the term.

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Fore-lying cord and Umbilical cord prolapse

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Fore-lying cord Umbilical cord prolapse

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

内子宮口 Transvaginal ultrasound picture of fore-lying cord Uterine Os Fetal head Umbilical cord

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

FHR at 33 weeks

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Umbilical cord prolapse

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Clinical risk factors for poor neonatal outcomes in umbilical cord prolapse from nation wide survey in Japan Purpose: To clarify the clinical risk factors associated with poor neonatal

  • utcomes due to umbilical cord prolapse.

Methods: A postal questionnaire survey was attempted in Japan. The clinical risk factors and managements associated with poor neonatal outcomes were analyzed in cases of umbilical cord prolapse treated in Japan.

2007-2011 Delivery institution 942 Deliveries 2,037,460 Umbilical cord prolapse 369 (174 institutions) Incidence 0.018%, 1:5521

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Outcomes

Fore-lying Prolapse (85) (284) Intact survival 88.2 % (75) 78.9 % (224) Survival with disability 7.6 % (6) 6.7 % (19) Neonatal death 1.2 % (1) 5.3 % (15) Fetal death 0 % (0) 3.2 % (9) Unknown 3.5 % (3) 6.0 % (17)

Hasegawa, J Mater. Fetal Neonat. Med. 2016

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Occurrence of cord prolapse

Hasegawa, Arch Gynecol Obstet 2015

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Outcomes (after 36 weeks)

Fore-lying Prolapse (40) (168) Intact survival 97.5 % (39) 87.5 % (147) Survival with disability 2.5 % (1) 7.1 % (12) Neonatal death 0 % (0) 1.8 % (3) Fetal death 0 % (0) 2.4 % (4) Unknown 0 % (0) 0.6 % (1)

Hasegawa, J Mater. Fetal Neonat. Med. 2016

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Risk factors Adjusted odds ratio (95% confidence interval) Prolapsed amniotic sac 4.49 (1.31, 15.42) Preterm labor 2.99 (1.25, 7.17) Replacement of cord into the uterus 2.87 (1.03, 7.95) Intrapartum diagnosis 0.28 (0.11, 0.75) Emergency cesarean section 0.11 (0.04, 0.28) The results of the multivariate regression analysis for poor outcomes

Hasegawa, J Mater. Fetal Neonat. Med. 2016

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

The cumulative survival curves regarding the interval between the diagnosis and the delivery for the intact survival and poor outcome infants Intact survival (n=138) Not intact survival, neonatal or intrapartum death (n=27)

p=0.047

Hasegawa, J Mater. Fetal Neonat. Med. 2016

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

After prolapse before CS

Relieve pressure on the cord or Knee-chest position

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Umbilical cord prolapse after onset of labor

Hasegawa, Arch Gynecol Obstet 2015

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Station at prolapse

n=96

Hasegawa, Arch Gynecol Obstet 2015

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Dilatation of os at prolapse

n=186

Hasegawa, Arch Gynecol Obstet 2015

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Timing of prolapse

Singleton, head presentation n=181

Hasegawa, Arch Gynecol Obstet 2015

Unruptured (fore-lying) 13% Spontaneous ruptured 35% During amniotomy 24% Independent of rupture 28%

Summary (umbilical cord prolapse)

Cord prolapse is associated with abnormal fetal position polyhydramnios use of dilatation balloon prolapsed amniotic bag in the early gestation placental cord insertion on the lower uterus Do not touch the umbilical cord, even when prolapse occur. Emergency CS is required. Fetal presenting part should be pushed back into the uterus until delivery.

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Managements of delivery in cases with umbilical cord abnormalities

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Aspects of FHR in abnormal umbilical cord

Ultrasound diagnosis is not GOAL !

Continuous FHR monitoring !

Method of continuous investigation inside

  • f the uterus is only FHR tracing !!!

Purpose of screening is to obtain healthy babies !!

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Frequency of decelerations in cord abnormalities

10 20 30 40 50 Control MCI VCI HCC NC 10 20 30 40 50 60 70 80 90 Control MCI VCI HCC NC

1st stage of labor 2nd stage of labor

ED VD LD PD

(487) Means±SD (%) (56) (41) (13) (240) (471) (53) (36) (12) (232)

* * *

*: p<0.0001 using analysis of variance; between control and each cord abnormalities, p<0.0001 using the Bon-ferroni post-hoc test.

Hasegawa JOGR 2009 Means±SD (%)

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Variable decelerations even without or weak uterine contraction. FHR monitoring is most important before onset and during first stage of labor. Atypical variable decelerations might be showing compression of weak point of the umbilical cord.

Aspects of FHR in abnormal umbilical cord

Hasegawa J Perinatal Medicine 2009 Hasegawa J Obstetrics and Gynaecology Res. 2009 Krebs AJOG 1983 Atypical Variable Decelerations

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Screening（first trimester）

Location of cord insertion Cases whose umbilical cord insertion located into lower uterine segment have frequently cord and placental abnormalities later in pregnancy. Two umbilical arteries Agenesis type of single umbilical artery is associated with fetal congenital anomalies.

Hasegawa , “Vasa previa is not infrequent” J Mater. Fetal Neonat. Med. 2012

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Screening（second trimester）

Placenta previa Velamentous insertion or vasa previa Umbilical cord coiling

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Screening（third trimester）

Fore-lying cord Nuchal cord Obstructive type of single umbilical artery Re-confirm of umbilical cord abnormalities, risk assessment, and determination of management at delivery.

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Risks Ultrasonographic findings High risk When high possibility of NRFS is suspected, but not indication of elective CS (estimated emergency CS > 10%) Velamentous cord insertion Marginal insertion on the low uterus Hyper-coiled cord Three or more nuchal cords Obstructed single umbilical artery Low-lying placenta FGR (≦-2.0SD) Middle risk When slight high possibility of NRFS is suspected, compared with low risk. (estimated emergency CS <10%) Twice nuchal cords Agenesis type of single umbilical artery FGR (-2.0 < FW ≦-1.5SD) Low risk Without any abnormalities Elective CS Cases have maternal or fetal indication Vasa previa, Velamentous insertion on the low uterus or with long vessels Fore-lying cord, Polyhdramnios

Risk classifications

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Extreme high risk Intensive FHR monitoring during pregnancy Elective CS High risk Induction of labor Middle risk Continuous FHR monitoring during labor Low risk

Management of delivery

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Frequencies of NRFS and emergency CS stratified by risk classifications

6.2% 11.1% 17.6% 1.0% 4.4% 8.8%

* * * *

Frequency (%)

*: p<0.05 compared with Low risk

n=600 n=34 n=45

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  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Junichi Hasegawa hasejun@oak.dti.ne.jp Detection of placenta and umbilical cord abnormalities are also required in antenatal ultrasound screening. According to ultrasound diagnosis, risk classification before onset of labor is strongly recommended for safe deliveries. Continuous FHR tracing shows fetal condition, but only during tracing ! The use of FHR monitoring under familiarization of the umbilical cord abnormalities is the best way to avoid fetal complications.

Conclusions

  • St. Marianna University School of Medicine Dept. of Obstetrics and Gynecology Hasejun

Thank you for your attention !

  • Mt. Fuji from Yokohama