Definition/General
Introduction:
Umbilical cord prolapse is an obstetric emergency where the cord descends ahead of the presenting fetal part
It occurs in 0.1-0.6% of deliveries
The condition represents mechanical compression of the cord between fetal parts and maternal pelvis
It can cause severe fetal hypoxia and death.
Origin:
Results from inadequate engagement of fetal presenting part
Rupture of membranes with high presenting part
Polyhydramnios increases risk
Malpresentation (breech, transverse)
Preterm delivery with small fetus.
Classification:
Classified as overt prolapse (cord visible/palpable) or occult prolapse (cord alongside presenting part)
Complete prolapse: cord protrudes from vagina
Incomplete prolapse: cord in vagina but not visible
Cord presentation: cord ahead of presenting part.
Epidemiology:
Incidence: 0.1-0.6% of all deliveries
Higher incidence with malpresentation
More common in preterm deliveries
Associated with high perinatal mortality
Emergency cesarean section required.
Clinical Features
Presentation:
Visible cord at vaginal opening
Palpable cord on vaginal examination
Severe fetal distress
Fetal bradycardia
Variable decelerations
Obstetric emergency.
Symptoms:
Sudden fetal bradycardia
Severe variable decelerations
Cord pulsations felt on examination
Cord visible at introitus
Fetal distress patterns
Emergency delivery indication.
Risk Factors:
Malpresentation (breech, transverse)
Preterm delivery
Polyhydramnios
Multiple pregnancy
Placenta previa
Long umbilical cord
Previous cord prolapse.
Screening:
Continuous fetal monitoring
Immediate vaginal examination with fetal distress
Recognition of cord pulsations
Emergency ultrasound
Preparation for emergency delivery.
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Gross Description
Appearance:
Cord appears compressed and flattened
May show areas of blanching
Congestion if intermittent compression
Color changes from hypoxia
May appear edematous or indurated.
Characteristics:
Mechanical compression marks visible
Vessel flattening at compression sites
Thrombosis may be present
Hemorrhage from vessel damage
Surrounding tissue edema.
Size Location:
Compression typically at pelvic inlet level
Multiple compression sites possible
Cord length usually normal or increased
Entire cord may show ischemic changes.
Multifocality:
Usually involves multiple cord segments
Compression patterns at different levels
May affect all three vessels
Associated with cord edema.
Microscopic Description
Histological Features:
Severe vessel compression with luminal collapse
Endothelial damage and denudation
Thrombosis in compressed vessels
Hemorrhage in vessel walls
Ischemic changes in surrounding tissue.
Cellular Characteristics:
Endothelial cell damage and loss
Smooth muscle necrosis in vessel walls
Inflammatory infiltrate
Red blood cell extravasation
Fibroblast degeneration in Wharton's jelly.
Architectural Patterns:
Complete vessel luminal collapse
Loss of normal vessel architecture
Perivascular hemorrhage
Wharton's jelly edema
Focal tissue necrosis.
Grading Criteria:
Assessment of compression severity
Vessel occlusion degree
Thrombosis extent
Inflammatory response
Tissue necrosis presence.
Immunohistochemistry
Positive Markers:
CD31 highlights damaged endothelium
CD34 in vessel walls
Smooth muscle actin in vessel walls
Fibrin stains show thrombosis
Factor VIII in endothelium.
Negative Markers:
Cytokeratin negative in vessels
No specific negative markers required
Normal vascular markers may be lost
Endothelial markers reduced.
Diagnostic Utility:
Documents vessel damage extent
Confirms thrombosis presence
Assesses tissue viability
Research applications
Medico-legal documentation.
Molecular Subtypes:
No specific classification
Hypoxia markers elevated
Inflammatory mediators present
Cell death markers positive.
Molecular/Genetic
Genetic Mutations:
No specific genetic associations
Cord abnormalities may predispose
Connective tissue variants possible
No familial clustering
Mechanical rather than genetic.
Molecular Markers:
Hypoxia-inducible factors highly upregulated
Inflammatory cytokines elevated
Cell death pathways activated
Stress response proteins
Vascular injury markers.
Prognostic Significance:
Time-dependent outcomes
Duration of compression critical
Severe neurological sequelae possible
High perinatal mortality if delayed delivery
Emergency delivery improves outcomes.
Therapeutic Targets:
Immediate delivery required
Cord compression relief measures
Maternal positioning
Cesarean section preparation
Neonatal resuscitation readiness.
Differential Diagnosis
Similar Entities:
Cord compression from other causes
Nuchal cord
Cord entanglement
Uterine compression
Oligohydramnios effects.
Distinguishing Features:
Prolapse: cord ahead of presenting part
Prolapse: visible/palpable cord
Nuchal: cord around neck
Entanglement: cord around body
Oligohydramnios: reduced fluid.
Diagnostic Challenges:
Clinical recognition critical
Distinguishing from other compression causes
Documentation requirements
Time-sensitive diagnosis
Emergency management.
Rare Variants:
Occult cord prolapse
Funic presentation
Prolapse with cord rupture
Multiple cord loops
Prolapse in multiple pregnancy.
Sample Pathology Report
Template Format
Sample Pathology Report
Complete Report: This is an example of how the final pathology report should be structured for this condition.
Clinical Presentation
Clinical presentation: [overt/occult] cord prolapse with [fetal distress pattern]
Cord Examination
Cord shows [compression marks/blanching/congestion] consistent with mechanical compression
Vessel Assessment
Vessels: [compressed/collapsed/thrombosed], [present/absent] pulsations
Compression Severity
Compression: [mild/moderate/severe] with [partial/complete] vessel occlusion
Time Factors
Duration from diagnosis to delivery: [X] minutes, [immediate/delayed] intervention
Microscopic Findings
Microscopy shows [degree] of vessel damage with [present/absent] thrombosis
Clinical Outcome
Outcome: [live birth/stillbirth], [normal/compromised] neonatal condition
Final Diagnosis
Umbilical cord prolapse with [degree] of compression injury