dilemmas in the management of nuchal cord
TRANSCRIPT
Dilemmas in the management of nuchal cord
Amita SunejaProfessor
UCMS & GTBH
Most controversial Least exlored area
Is not an intrinsic reason for obstetrical
intervention
Very common condition• 20-25%• 1 in 5 fetuses at
TOD
DilemmasAntenatal Counselling
Antenatal monitoring
Mode of delivery
Intrapartum monitoring
Whether or not nuchal cords are associated with
significantly increased adverse
fetal outcome?
Nuchal cord & Asphyxia
Diagnosis of nuchal cord
• Nuchal cord- 360 degree around the neck• Ultrasonic diagnosis in Antenatal period• 2D USG / Doppler / 3D USG• Diagnostic criteria• Diagnostic accuracy : 35% - 80%• Can diagnose multiple loops: 2%(two loops) &
0.2% (> 2loops)• CAN NOT differentiate between tight & loose
cord
Behaviour of nuchal cord during ANP
Gestation in weeks Am J Obstet Gynecol 2003 %
J PNM 2008 % persistence %
20-24 6 ↓
24-26 12
30-32 7.5 8.8
36-38 37 26.5 26.6
No fetal compromise in ANP 85 (labour)
Nuchal Cords appear & disappear Rare before 20 weeksIncidence increases as gestation increases
Whether or not nuchal cords are associated with significantly increased adverse fetal outcome ?
Monoamniotic twins
Retrospective studies
1,82,000 births, power to determine even minor associations, proves conclusively
that nuchal cord (single or multiple
loops) is NOT assoaciated with►Adverse perinatal
outcome►Less birth weight►More caesarean
sections
2008Tight nuchal cord vs
loose cordAbn FHR : 23.5% vs
8.7%→ SApgar < 7 at 1’→ S
Ogueh et al “Umbilical cord nuchal loops are
associated with induction of labor, slow progress of labor, and
shoulder dystocia”
Prospective cross sectional studiesKUMJ 2006 512 deliveries 18% single loop, 3% multiple loops Abn FHR, MSL, instrumental delivery ↑ in
nuchal group but not significant LSCS were more in non nuchal gp Apgar <7 at 1’ was more in nuchal gp but at 5’
was not differentNOT associated with adverse Perinatal outcome
Prospective double blind studies
Eur J Obstet Gynecol Repr Biol 2005
• 352, Vx, SLF, 37-39 weeks• USG 38 weeks• Sens & spec: 85 & 89%• NOT associated with
abnormal intra partum CTG / clinically significant Apgar score
• Nullipara with nuchal cord had higher incidence of LSCS (18%)
Obstet Gynecol 2005• 289 women• USG just before induction• Sens: 37%• No significant ↑ risk of LSCS
(35 Vs 28%, RR- 1.22; 95% CI0.08-1.8), ID for AFD, Abn FHR, Apgar < 7 at 1’, UBA pH < 7.1 or NICU admissions
Nuchal cord & feal acidosis
J perinatology and Turkish j paed 2005 UBA BG shows acidosis, hypoxia, hypercarbia, Apgar<7 at 1’
Obstet Gynecol surv 2000 : Tight nuchal cord at time of delivery may predict a subclinical deficit in neurodevelopmental performance at one year of age
Multiple loops
Records of 326 infants with multiple loops Vs 2191with
single loopHigh FHR abn in second stage
↑ IDRest was not different
36 Weeks with ↓ fetal movements
USG: 8 loops around neckInduction with oxytocin
AFD after 6 hrsLSCS
Primi at 36 weeks with PIH Single umbilical A
karyotype normal nuchal cord spontaneous labor No abn
FHR NVD two loops around neck
Can nuchal cord be cause of still birth?
• Int J Obstet Gynecol 2000: 98 SB (84 AP + 14 IP)
• Nuchal cord (single or multiple) is insufficient evidence to explain • Do complete work up of SB• Autopsy• HPE of UC & placenta
OR CI
Abnormal fetus 19.0 9.4 – 35.4
Placental abruption 7.5 1.2 – 25.9
Substance abuse 2.4 1.0 – 4.8
MSL 2.0 1.3 – 3.1
Nuchal cord (any) 1.0 0.6 – 1.6
Summary
USG accuracy is not 100%
In majority: Not associated with
adverse perinatal outcome
Few studies show FHR abnormal
patterns, acidosis and low Apgar at
1’with recovery at 5’
In absence of decreased foetal movements or
other indicator of fetal tests &
especially single cord loop→ do
nothing and reassure.
NST can be undertaken with
the full knowledge that we lack
prospective studies to support that Ultrasonically
diagnosed nuchal cord is a valid
indication for fetal testing
Given the minor ↓ in pH, fetal
monitoring in labour would appear to be
prudent but no data is available to
address this issue.
Food for thought
Tight cord to cut or not
Nuchal cord at TOD
THANK YOU