JSAFOG

10.5005/jp-journals-10006-1522
Risk Factors, Maternal and Neonatal Outcome in Umbilical Cord Prolapse
ORIGINAL ARTICLE

Risk Factors, Maternal and Neonatal Outcome in Umbilical

Cord Prolapse in South Indian Population
1
Madhusmita Hembram, 2Haritha Sagili

ABSTRACT Source of support: Nil

Objective: To assess associated risk factors, maternal and Conflict of interest: None
neonatal outcome of pregnancies complicated by umbilical cord
Date of received: 4 October 2017
prolapse in South Indian population.
Date of acceptance: 4 December 2017
Study design: It was a descriptive study. Risk factors, maternal
and neonatal outcome were noted down retrospectively from Date of publication: January 2018
case records of mothers affected by umbilical cord prolapse
from April 2014 to March 2016.
INTRODUCTION
Results: There were 39 cases of umbilical cord prolapse in
2 years. The incidence of umbilical cord prolapse in our hospital Umbilical cord prolapse is an obstetric emergency which
was 0.1%. Most of the women were ≤ 25 years of age (72%).
Primis were 56%. Most common presentation in umbilical cord can convert an uneventful ongoing normal pregnancy to a
prolapse was cephalic presentation (64%). Among the affected sudden emergency. Normal fetus in utero is at higher risk
individuals, 82% had term gestation, 79% had higher presenting of sudden intrauterine death by cord compression due to
part, and 87% had spontaneous rupture of membranes. Babies
umbilical cord prolapse. The incidence of cord prolapse
were delivered by lower segment cesarean section (LSCS) in
95% and birth weight was ≥2.5 kg in 67% of cases with umbili- has been reported to be 0.1 to 0.6% worldwide.1,2 Studies
cal cord prolapse. Decision to delivery interval (DDI) was ≤30 regarding cord prolapse are scarce in comparison to other
minutes in 84% of cases. APGAR score was ≥7 at 1 minute obstetrical emergencies. Most of the previous studies
in 65% and ≥7 at 5 minutes in 83% of cases. There were 15
have shown that those mothers having risk factors like
neonatal intensive care unit (NICU) admissions and 2 stillbirths.
Most common gender was male (75%). polyhydramnios, noncephalic presentation, abnormal lie,
multiparity, prematurity, etc., are at higher risk of cord
Conclusion: In our study, maternal risk factors were different
from traditional risk factors in relation to age, parity, period of prolapse.3-7 But, in modern obstetric practice, singleton
gestation, presentation, and birth weight. But, station of present- term pregnancies with cephalic presentation and sponta-
ing part, early dilatation of cervix at diagnosis, and male gender neous rupture of membrane are risk factors for umbilical
predominance were similar to traditional risk factors. Neonatal
outcome was good in our study with no birth injuries. All cases cord prolapse.8 Improvement in emergency LSCS facil-
should be monitored properly to reduce the occurrence of umbili- ity and NICU care might help in improving neonatal
cal cord prolapse even in low-risk population. Early detection and outcome. Hence, the present study was conducted with
intervention is required for good neonatal outcome. Umbilical
an objective to observe associated maternal risk factors,
cord prolapse should be managed by an expert obstetrician.
maternal outcome, and neonatal outcome of pregnancy
Keywords: Maternal, Neonatal, Umbilical cord prolapse.
complicated by umbilical cord prolapse in South Indian
How to cite this article: Hembram M, Sagili H. Risk Factors, population.
Maternal and Neonatal Outcome in Umbilical Cord Prolapse
in South Indian Population. J South Asian Feder Obst Gynae
2017;9(4):323-326. MATERIALS AND METHODS
This descriptive study was conducted in the Department
of Obstetrics and Gynecology, Jawaharlal Institute of
1
Assistant Professor, 2Additional Professor
Postgraduate Medical Education & Research, Puducherry,
1
Department of Obstetrics and Gynecology, Mahatma Gandhi a tertiary care referral center in South India. Medical
Medical College & Research Institute, Pillaiyarkuppam, Puducherry
records of all cases of umbilical cord prolapse from April
India
2014 to March 2016 were collected from the medical record
2
Department of Obstetrics and Gynecology, Jawaharlal Institute
section of the hospital. Those cases where umbilical cord
of Postgraduate Medical Education & Research, Puducherry
India was felt vaginally or seen prolapsed out of the introitus
were considered as umbilical cord prolapse and included
Corresponding Author: Madhusmita Hembram, Assistant
Professor, Department of Obstetrics and Gynecology, Mahatma as the subjects. In case of multiple pregnancies, details of
Gandhi Medical College & Research Institute, Pillaiyarkuppam the baby in which cord prolapse occurred were consid-
Puducherry, India, Phone: +914132616700, e-mail: titimadhusmita@ ered. Maternal details like age, obstetric index, number
gmail.com
of fetuses, period of gestation, presentation, station of
Journal of South Asian Federation of Obstetrics and Gynaecology, October-December 2017;9(4):323-326 323
Madhusmita Hembram, Haritha Sagili

presenting part, dilatation of cervix at diagnosis, spon- Table 2: Intrapartum details

taneous or artificial rupture of membrane, DDI, mode of Parameters Number Percentage
delivery and neonatal outcome including APGAR scores, Mode of delivery
NICU admissions, stillbirths, birth weight, and sex of LSCS 37 95.0
the baby were recorded. The results were calculated by Instrumental delivery 1 2.5
Spontaneous delivery 1 2.5
Statistical Package for the Social Sciences software version
DDI
19 and expressed in percentages.
≤30 minutes 33 84.61
>30 minutes 6 15.39
RESULTS
There were a total of 39 cases of umbilical cord prolapse
Table 3: Neonatal outcome
from April 2014 to March 2016. Total number of deliver-
Parameters Number Percentage
ies over the same period was 31,281 and the incidence of
Birth weight
umbilical cord prolapse was 0.1%. Antepartum maternal
<2.5 kg 21 43.75
risk factors are summarized in Table 1. The mean age ≥2.5 kg 27 56.25
of the subjects was 24.5 years. Only one woman was APGAR score
35 years old. There were eight multiple pregnancies 1 minute
among which only one was triplets and rest were twins. <7 16 35.42
Intrapartum details are described in Table 2. In the present ≥7 32 64.58
study, one had normal vaginal delivery, one had forceps 5 minutes
delivery, and the remaining had emergency cesarean <7 9 18.75
≥7 39 81.25
section. In most of the cases delivery was not imminent,
Place of postdelivery care
so to prevent poor neonatal outcome, decision was taken
NICU 15 31.25
for category one cesarean section. Neonatal outcome is Mother side 33 68.75
tabulated in Table 3. Among total 48 babies, only 2 were Viability of the baby
stillborn (4.16%) though cesarean section was done for Stillborn 2 4.16
Alive 46 95.84
Sex
Table 1: Maternal risk factors Male 36 75
Parameters Number Percentage Female 12 25
Age
≤25 years 28 71.79
both of them. Both of them were referred from other
>25 years 11 28.21
Parity hospitals. So, delayed intervention was responsible for
Primigravida 22 56.41 negative outcome. Among the two stillbirths the first
Multigravida 17 43.58 was twin pregnancy with first breech with cord prolapse.
Number of fetuses Emergency cesarean section saved the second twin with
Singleton 31 79.48 APGAR of 5 and 7 at 1 and 5 minutes respectively. The
Twins 7 17.94 second stillbirth was at period of gestation of 28 weeks
Triplet 1 2.58 and 5 days and birth weight of 800 gm. There were no
Presentation
birth injuries or congenital anomalies in any of the babies
Cephalic 25 64.10
delivered. Though there were NICU admissions, all the
Breech 8 20.51
Transverse 6 15.39 babies were discharged along with the mother.
Period of gestation
<37 weeks 7 17.49 DISCUSSION
≥37 weeks 32 82.51
The incidence of umbilical cord prolapse in our hos-
Station
pital was 0.1%, which is consistent with incidence of
<(−3) 26 78.78
≥(−3) 7 21.22
umbilical cord prolapse worldwide. Two studies have
Rupture of membranes shown similar incidence of umbilical cord prolapse as
Spontaneous 34 87.17 ours.9,10
Artificial 5 12.83 Umbilical cord prolapse is more frequent in advanced
Dilatation of cervix age 11,12 but, in our study umbilical cord prolapse
<5 cm 31 79.48 occurred in a younger age group, which is in agreement
≥5 cm 8 20.52 with another study.13 The younger affected cases in the

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 JSAFOG

Risk Factors, Maternal and Neonatal Outcome in Umbilical Cord Prolapse

present study may be attributed to early marriage in our on neonatal outcome unless there is severe fetal distress
population. not relieved by intrauterine resuscitation.9 In our study,
Studies have shown that multigravidas are most com- mean decision to delivery time was 21.47 minutes with
monly affected with umbilical cord prolapse.9,13 But, in good neonatal outcome.
the present study, most of the umbilical cord prolapse Cesarean section has been shown to be associated with
occurred in primigravida. more birth injuries than vaginal birth.12 But, we contra-
Multiple pregnancies are associated with umbilical dict the statement in our study as 37 among total 39 had
cord prolapse.5,14,15 But, in present study singleton preg- cesarean section without any birth injuries. Our study
nancy was associated with more cases of umbilical cord advocates for cesarean section when immediate delivery
prolapse. Number of cases of umbilical cord prolapse due is not anticipated. We believe that iatrogenic birth injury
to multiple pregnancies was higher in our study when is surgeon expertise dependent. In our tertiary center,
compared with another study from India.16 abruption, fetal distress, etc., contribute to major bulk of
Though studies have shown umbilical cord prolapse category 1 cesarean section without any significant birth
to be more common in noncephalic presentation,13,14,17 injuries. Instrumental vaginal delivery can also have more
in the present study, most of the cases were cephalic. complicated birth injuries than cesarean section if not
Similar to our study, some other studies have also shown done by well-trained obstetricians. So, we prefer expert
higher incidence of umbilical cord prolapses with cephalic obstetrician in the scenario of umbilical cord prolapse.
presentation.8,9,12,16 Risk of perinatal mortality due to umbilical cord prolapse
Most studies have shown umbilical cord prolapse to is decreased by cesarean section.7
be frequent in preterm pregnancies,5,17-19 but on the con- Umbilical cord prolapse leads to early complications
trary, in our study umbilical cord prolapse was frequent like low APGAR score, asphyxia, stillbirth, and neonatal
in term pregnancies. Our study is supported by three death. According to one study, umbilical cord prolapse
other studies which also found that term gestations are is an independent risk factor for perinatal mortality.24
the ones mostly affected by umbilical cord prolapse.8,9,12 According to Murphy and MacKenzie, fetal outcome is
The risk factor in our study similar to the traditional not dependent on cardiotocography, low APGAR score,
risk factor is higher station of the presenting part. In most and acidemia; rather, mortality is associated with con-
cases of our study, station was −3 or above. Unengaged genital anomalies and prematurity.1 In the present study,
head is one of the known risk factors for umbilical cord APGAR score was good. Stillbirth in the present study
prolapse as proven by other studies.8,14,15 was much less when compared with one study where it
In the present study, spontaneous rupture of mem- was 68.2%.13 We consider this outcome to be due to early
branes was associated with higher incidence of umbili- detection and delivery of the babies. Cesarean delivery
cal cord prolapse than artificial rupture of membranes. decreased the risk of neonatal mortality in umbilical cord
prolapse. The Royal College of Obstetricians and Gynae-
Similar to our study, some studies have shown more cases
cologists also recommends emergency cesarean section
of umbilical cord prolapse with spontaneous rupture
when vaginal delivery is not imminent.25 In the present
of membranes,5,8,12 but one study10 has shown more
study, 56.25% of the babies born after cord prolapse
number of umbilical cord prolapse with artificial rupture
had birth weight more than 2.5 kg, which is supported
of membranes.
by several studies where birth weight was more than
Traditionally, it has been observed that early dilatation
2.5 kg.9,13,16 Out of all newborns, 31.25% required NICU
is associated with umbilical cord prolapse. Present study
care and all of them were discharged along with mother
also showed higher incidence of umbilical cord prolapse
after proper management. Good NICU facility is required
in dilatation less than 5 cm.
for survival of the affected newborn.
Adverse neonatal outcome increases with increase
Umbilical cord prolapse is more associated with male
in DDI.1,20 The American Congress of Obstetricians and
babies than female babies,9,12 similarly, in our study also,
Gynecologists recommends the decision to delivery
umbilical cord prolapse was more with male fetuses.
time to be between 20 and 30 minutes. Boyles and Katz21
concluded that decision to delivery time of more than
CONCLUSION
10 minutes is an independent risk factor for poor neonatal
outcome in umbilical cord prolapse and Khan et al8 were In our study, maternal risk factors were different from
of the opinion in their study that 39.28% of newborns traditional risk factors with respect to age, parity, period
with poor APGAR score at 5 minutes had DDI within of gestation, number of fetuses, presentation, and birth
20 minutes, but studies have shown that DDI in the range weight. But, station of presenting part, early dilatation
of 10 to 30 minutes has good fetal outcome.22,23 One study of cervix at diagnosis, and male gender predominance
was of the opinion that DDI does not have adverse effect were similar to traditional risk factors. All cases should be
Journal of South Asian Federation of Obstetrics and Gynaecology, October-December 2017;9(4):323-326 325
Madhusmita Hembram, Haritha Sagili

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cord prolapse even in low-risk population. Early detection prolapse, associated factors and fetal outcome: a report of
47 Cases from the Yaounde Central Hospital, Cameroon. Clin
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Mother Child Health 2010 Jul;7(1):1179-1182.
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14. Bako B, Chama C, Audu BM. Emergency obstetrics care in a
obstetrician. Nigerian tertiary hospital: a 20 years review of umbilical cord
prolapse. Niger J Clin Pract 2009 Sep;12(3):232-236.
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