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