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Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 32 year old multigravid woman was transferred from a regional hospital at 23+1 weeks of gestation with a history of spontaneous rupture of membranes. Her past history included a normal vaginal delivery complicated by manual removal of the placenta and postpartum curettage for retained products. She had later undergone further curettages for miscarriage. Subsequently, she developed Asherman's Syndrome requiring hysteroscopic division of adhesions for secondary infertility.

The presenting complaint was of a painless watery vaginal discharge over the preceding 10 days with associated bloody mucous loss. At the regional hospital, hourglassing of the membranes through the cervix was observed. During transfer her membranes spontaneously ruptured. On admission to our tertiary hospital 3½ hours later, sterile speculum examination revealed umbilical cord in the vagina. The fetal heart was present and normal in rate. Nifedipine administered at the regional hospital was ceased. Intravenous antibiotic therapy was commenced and two doses of Celestone were given (11.4 mg, 12 hours apart). Ultrasound examination demonstrated a live, well-grown fetus in a footling breech presentation and severe oligohydramnios consistent with ruptured membranes. The umbilical cord was seen to be prolapsing through a partially dilated cervix. The placenta was normally situated. There was a small area of very thin (3 mm) myometrium suggestive of placenta accreta.

The woman and her husband were advised of the poor prognosis for the pregnancy, fetal survival and risk of long term disability if delivered at this gestation, and potential maternal complications. The risks of classical caesarean section, the significance of placenta accreta and the potential for hysterectomy were fully discussed. Conservative management was recommended as the best option both to reduce maternal morbidity and prolong the pregnancy to a gestation that may improve fetal outcome.

Intravenous antibiotics were changed to oral erythromycin (250 mg QID). The woman was monitored for signs of chorioamnionitis and ordered bed rest. One week later, repeat ultrasound demonstrated normal fetal growth and biophysical parameters. Fetal presentation was unchanged and no amniotic fluid was seen. The umbilical cord filled the cervix and the vagina, with no cord seen in the uterus. The cervix remained 2–3 cm dilated. Cord flow Dopplers were normal with a S/D ratio of 2.5. Myometrium remained thin but normal vascularity was demonstrated confounding definitive diagnosis of placenta accreta.

During admission, the cord prolapsed outside of the vagina on a number of occasions, mainly when the patient passed a bowel motion. It was digitally replaced into the vagina each time. Thereafter, the woman was instructed to place a tampon into the vagina prior to each bowel motion and remove it immediately afterwards. The woman remained clinically well with no signs of chorioamnionitis. Clear vaginal loss continued. Regular full blood examination confirmed normal white cell count, however, C-reactive protein was raised up to 48 mg/L. Each day the fetal heart was auscultated using a sonacaid. Cardiotocography was not performed because the decision had been made to deliver only on maternal indications (i.e. bleeding complications, sepsis or if labour ensued) prior to 26 weeks of gestation.

Classical caesarean section was performed at 26+1 weeks of gestation with patient consent for hysterectomy if needed. The placenta was anterofundal, removed manually and good haemostasis was achieved. Estimated fetal blood loss was 500 mL. A live male baby was born weighing 658 g with Apgar scores of six at 5 minutes and seven at 10 minutes.

The infant was intubated, ventilated and exogenous surfactant administered in the operating theatre. He was transferred to the Neonatal Intensive Care Unit and commenced on empiric antibiotic therapy after blood culture was obtained. Initial haematological markers of sepsis were benign and blood culture did not isolate any organisms. Airway pressure support was finally ceased at 35+6 weeks postmenstrual age. Continuous low flow nasal oxygen was required for chronic neonatal lung disease. He was exclusively fed on his mother's own breastmilk. Routine cranial ultrasounds on days 5, 14 and 42 were all normal.

Histopathological examination of the cord and placenta was consistent with premature rupture of membranes. Placental culture revealed a light growth of candida (Torulopsis) glabrata and mixed anaerobic organisms.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

Umbilical cord prolapse is an uncommon but potentially lethal obstetric emergency. The reported incidence varies from 0.14% to 0.62%, with perinatal mortality rates ranging from 55 to 430 in 1000.1 Predisposing factors include low birthweight, fetal malpresentation, multiparity, premature rupture of membranes, multiple gestation and obstetric manipulation. All can result in inadequate filling of the maternal pelvis with the fetal presenting part.1–3 Prompt delivery is usually required for fetal survival, often by emergency caesarean section unless, vaginal birth is imminent.

In this case, the woman was only 23 weeks of gestation at the time of diagnosis of the umbilical cord prolapse. The unique feature of this case was the additional complication of previous uterine surgery for Asherman's Syndrome and attendant risk of placenta accreta.

On literature review only one case of fetal survival after cord prolapse for more than three days is reported.4 In that case, caesarean section was performed at 23+5 weeks following premature uterine contractions and detection of severe variable decelerations on cardiotocography. The baby survived and no long term complications were noted after an eight month follow up period. Another case report described an interval of seven days between diagnosis of cord prolapse and delivery but with subsequent neonatal death at 10 hours of age due to intraventricular haemorrhage.5 To our knowledge, our case reports the longest length of time (three weeks) of conservative management for cord prolapse, resulting in fetal survival.

In a retrospective study of 132 cases examining the mortality and morbidity associated with cord prolapse, neonatal condition, as assessed by Apgar scores and cord blood gas analysis, was not obviously influenced by the time interval between diagnosis of cord prolapse and delivery.6 Fetal mortality was attributed to prematurity and congenital anomalies, rather than birth asphyxia. In another review of 65 cases of cord prolapse, the asphyxiated neonate was found to have a shorter than average time from diagnosis to delivery, suggesting that the time from diagnosis to delivery may not be the only determinant of fetal outcome.7

A number of manoeuvres are described to reduce the risk of cord compression including manual elevation of the presenting part off the cord, tocolysis, bladder filling, placing the patient in the knee–chest position and funic reduction.4,5 These manoeuvres were not attempted in our case. The extreme prematurity and low birthweight may have resulted in less cord compression, minimising asphyxia and improving fetal outcome, as has been suggested in previous reports.8 Despite the potential risk of cord spasm, in our patient, digital replacement of the cord following prolapse outside of the vagina appeared to have no immediate adverse effects on the cord or the fetus. In our situation, avoidance of cardiotocography was deliberate as variable fetal heart rate decelerations or bradycardia at this early gestation might prompt unwarranted early delivery.

At 26 weeks of gestation, the fetal survival rate is considerably increased and disability rate decreased when compared with infants delivered at 23 weeks of gestation. In this case, despite a prolonged period of cord prolapse, fetal survival was achieved. In addition, there was no evidence of placenta accreta at delivery and the uterus was preserved. Conservative management allowed delivery at a gestation that was more likely associated with favourable fetal outcome. However, ongoing paediatric review will be required to assess the long term effects on the infant of this unusual course of events.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References

Accepted 12 March 2004