List of contents
● Cord prolapse and
Amniotic fluid embolism
cord presentation
● Definition ● Risk factors
● Classification ● Onset
● Etiology ● Pathophysiology
● Diagnosis ● Symptoms
● Prevention ● Investigations
● Management ● Management
● vasa previa
● Definition
● Risk factors
● Complications
● Management
UMBILICAL CORD PROLAPSE
Definition
Abnormal descent of the umbilical cord by the side of
the presenting part is called umbilical cord prolapse
CLASSIFICATION
● Cord presentation : The umbilical cord lies
alongside or below presenting part with membranes
still intact
● Cord prolapse : The cord is lying inside the vagina
or outside the vulva following rupture of membrane
● Occult prolapse : the umbilical cord lies
alongside the presenting part and is not palpable
on vaginal examination
ETIOLOGY
● Malpresentations(breech with footling,compound
presentation
● Prematurity
● Multiple pregnancy
● Contracted pelvis
● Twins
● Hydramnios,
● Low lying placenta
● Battledore placenta
● AROM with a mobile presenting part
● Version or manual rotation
DIAGNOSIS
CORD PRESENTATION
● Vaginal examination : The pulsations of the umbilical
cord are felt through the intact membranes
CORD PROLAPSE
● Vaginal examination:The cord is palpated directly by
the fingers and pulsation can be felt
● Cardiotocography
● USG
OCCULT PROLAPSE—is difficult to diagnose. The
possibility should be suspected if there is persistence of
variable deceleration of fetal heart rate pattern detected on
continuous electronic fetal monitoring
PREVENTION
● Patient should be hospitalised at 37 weeks in
unstable and transverse lies
● Vaginal examination
● Amniotomy should be done only when the
presenting part fixes in the pelvis
● If there is unexplained fetal distress, always check
for cord prolapse
MANAGEMENT
● Urgent cesarean delivery
● If cervix is fully dilated and vertex is engaged
immediate safe vaginal delivery is possible
● If fetus is dead, no active intervention is required
and spontaneous vaginal delivery is allowed
● Immediate safe vaginal delivery is not possible:
First aid management:
Aim :is to minimize pressure on the cord till such
time when the patient is prepared for assisted
delivery or is transferred to an equipped hospital.
TEMPORARY MEASURES
● The presenting part is pushed up and away from
the cord by a hand in the vagina
● Bladder filling-400-750ml of normal saline with a
Foley’s catheter, the balloon is inflated and the
catheter is clamped
● Posture-Knee chest position
or head down tilt position
● Administer oxygen
● If there are strong contractions, a tocolytic can be
given
VASA PREVIA
Definition
It is the term used when fetal blood vessel lies over
the os in front of the presenting part
RISK FACTORS
● Placenta previa
● Velamentous insertion of umbilical cord
● Multi lobed placenta
● Multiple pregnancy
DIAGNOSIS :
- By USG with a color doppler
COMPLICATIONS
● Blood vessels at cervix may rupture or get
compressed
● Rapid blood loss
● Fetal distress
● Fetal death
Management
● Hospitalise the mother in third trimester
● Perform cesarean section around 37 weeks of
pregnancy or earlier if bleeding
● Start blood transfusion
AMNIOTIC FLUID
EMBOLISM
DEFINITION
Amniotic fluid and fetal cells enters the
bloodstream of the mother to trigger a serious
reaction. This reaction then results in
cardiorespiratory (heart and lung) collapse and
massive bleeding (coagulopathy).
Risk factors
● Advanced maternal age.
● Placenta problems. Abnormalities in the placenta
—
● Preeclampsia. Having high blood pressure and
excess protein in urine after 20 weeks of
pregnancy (preeclampsia) can increase your risk.
● Medically induced labor.
● Operative delivery. Having a C-section, a forceps
delivery or a vacuum extraction might increase
your risk of amniotic fluid embolism.
● Polyhydramnios.
ONSET
● After amniotomy and at cesarean section
● In labor, with strong uterine contractions
● Immediate postpartum period
Pathophysiology
Phase -1
Amniotic fluid and fetal cells enters the maternal
circulation
Release of biomedical mediator
Pulmonary artery vasospasm
Pulmonary hypertension
Elevated right ventricular pressure
Hypoxia
Myocardial and pulmonary capillary damage
Left heart failure
Acute respiratory distress syndrome
Phase-2
Biomedical mediators DIC Hemorrhage and
uterine atony
Symptoms
● Embolism causing acute respiratory distress or
even death
● Haemorrhage
● DIC
● Cyanosis
● Cardiorespiratory arrest
Investigations
● Coagulation profile
● ECG-Tachycardia, ST segment and T wave
changes
● Arterial blood gases
● Chest X-ray
Management
● Maintenance of perfusion
● ET intubation and mechanical ventilation with
100% oxygen
● Consider pulmonary artery catheterization in
patients who are hemodynamically unstable.
● Aminophylline IV for respiratory distress
● Correction of specific coagulation defects with fresh
blood, FFP, Platelets
● Placenta increta and percreta are best managed by
hysterectomy after resuscitation and blood
transfusion
Reference
● Dutta D.C, Textbook of Obstetrics.Jaypee Brothers
medical publisher Limited. 8th edition.New
Delhi,2015.p:462-463
● Reader.Martin.Koniak-Griffin maternity
Nursing.Family, newborn, and women’s health
care.Wolters Kluwer publisher.19th edition.New
Delhi. 2014. p:469--470.
