Nuchal cord

Nuchal cord
Classification and external resources
ICD-10	O69.1, P02.5
ICD-9	762.5
MeSH	D053589

A nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck^[1] 360 degrees. Nuchal cords are very common, with prevalence rates of 6% to 37%. Up to half of nuchal cords resolve before delivery.^[2]

Classification

• A "Type A" nuchal cord is wrapped around the neck 360 degrees.
• A "Type B" pattern is described as a hitch which cannot be undone and ends up as a true knot.^[3]

Diagnosis

In 1962, J. Selwyn Crawford MD from the British Research Council defined nuchal cord as 360 degrees around the fetal neck. Dr Crawford commented "It is all the more remarkable, therefore, that little work has been done ... to analyze its effects during labor and delivery". To date there is no prospective case control double-blind study looking at the issue of nuchal cord. Observational studies vary in opinion as to the degree of poor outcomes with the error of not including both Type A and B nuchal cord forms. Also not included in these studies is which umbilical cord form (of the 8 different possible structures) was in a nuchal cord form. These oversights invalidate any study to date. The impact of Nuchal Cord on the fetus is unknown. Ultrasound diagnosis of a cord around the neck was first described in 1982.^[4] “Coils occur in about 25% of cases and ordinarily do no harm, but occasionally they may be so tight that constriction of the umbilical vessels and consequent hypoxia result.” Williams Obstetrics 16th Edition, has only one single sentence in the entire textbook regarding cords around the neck:

(P.421) By contrast , the First Edition of the Encyclopaedia Britannica from 1770 had 20 pages of information about Umbilical Cord Pathology with drawings of Umbilical Cord Entanglement. The Royal College of OBGYN has these images on its brochure. There are currently three recent texts on Ultrasonography which demonstrate the ability of ultrasound to identify umbilical cord issues with reliability as of 2009.

A study published in 2004 was done to establish just how sensitive ultrasound is in diagnosing a nuchal cord.^[5] Each of 289 women, who were induced the same day, underwent a transabdominal ultrasound scan with an Aloka 1700 ultrasound machine with a 3.5 MHz abdominal probe, using gray-scale and color Doppler imaging immediately prior to induction of labor. Presence of the cord was sought in the transverse and sagittal plane of the neck. A nuchal cord was diagnosed if the cord was visualized lying around at least 3 of the 4 sides of the neck. A cord was actually present at delivery in 52 of the 289 women. Only 18 of the 52 cords or 35% of the nuchal cords were detected on ultrasound done immediately before delivery, and 65% of nuchal cords were not detected. Of the 237 cases where there was no cord at delivery, ultrasound had false positive results, i.e. diagnosed a cord in 44 of the 237 cases (19%) in which there was no cord present at all. In this study, ultrasound was only 35% accurate at finding a single loop, and only 60% accurate at detecting a nuchal cord wrapped multiple times around the neck.

In no study was it possible by ultrasound to distinguish between a loose or a tight cord on ultrasound, although at least 3 attempted to do so. Peregrine^[5] concludes that ultrasound diagnosis of nuchal cords will only be useful if we are able to do so reliably and predict which of those fetuses are likely to have a problem., However, perinatologists routinely look for umbilical cord issues in monoamniotic twins. Studies have shown an improvement in outcomes where cord entanglement was prenatally identified in these cases. Ultrasound measurement of the velocity of flow in the cord may be useful in the management of twins and chronically growth-retarded fetuses.Of course this depends on the training of the sonographer. To date there are no ultrasound courses which teach the identification of nuchal cord to physicians or technicians. A recent review by Wilson of the American Academy of Ultrasonography Technicians recommends the documentation of umbilical cord issues.^[6]

Clapp^[7] attempted to find out at what rate nuchal cords come and go during pregnancy. He recruited 84 healthy, non-smoking, non-substance abusing women carrying a single fetus, with certain dates before the 20th week of gestation. They all agreed to 4 extensive ultrasounds at 24-26, 30-32, 36–38 weeks gestation and during labor and delivery. They evaluated fetal biometry, fetal tone, fetal motion including breathing movements, amniotic fluid volume, fetal flow redistribution, velocity flow profiles from the umbilical artery at the body wall and placental insertion and at the origin of fetal middle cerebral artery. Finally, color flow Doppler imaging was used to determine whether a nuchal cord was present. Clapp reports that in 60%, or 50 of the 84 fetuses studied, a nuchal cord was seen on ultrasound at one of the 4 evaluations. He found that the presence of a nuchal cord linearly increases as the pregnancy continues. See table below. The presence of nuchal cord rose with advancing gestation. Larson ^[8] found this to be true. He found of the 13,895 singleton deliveries, a nuchal cord linearly increased every week of gestation, appeared in 6% at 20 weeks to 29.0% at 42 weeks' gestation.

Prognosis and treatment

Retrospective data of over 182,000 births, with the statistical power to determine even mild associations, suggest that a single or multiple nuchal cords at the time of delivery is not associated with adverse perinatal outcomes, is associated with higher birthweights and fewer caesarean sections in births.^[9][10][11] Although some studies have found that a tight nuchal cord is associated with short term morbidity, it is unclear whether such outcomes are actually a result of the presence of the nuchal cord itself, or as a result of clamping and cutting the cord ^[12]

Management of a presenting nuchal cord should be tailored to protect umbilical circulation whenever possible. Techniques to preserve an intact nuchal cord depend on how tightly the cord is wrapped around the infant’s neck. If the cord is loose, it can easily be slipped over the infant’s head. The infant can be delivered normally and placed on maternal abdomen as desired. If the cord is too tight to go over the infant’s head, the provider may be able to slip it over the infant’s shoulders and deliver the body through the cord. The cord can then be unwrapped from around the baby after birth. Finally, if the cord is too tight to slip back over the shoulders, one may use the somersault maneuver to allow the body to be delivered.^[13][14] The birth attendant may also choose to clamp and cut the umbilical cord to allow for vaginal delivery if other methods of nuchal cord management are not feasible.

References

1. ^ "Fetus or Newborn Problems: Labor and Delivery Complications: Merck Manual Home Edition". http://www.merck.com/mmhe/sec22/ch261/ch261c.html#sec22-ch261-ch261c-1292a. Retrieved 2010-03-27. 
2. ^ "Ultrasound Detection of Nuchal Cord Prior to Labor Induction and the Risk of Cesarean Section". http://journals.lww.com/obgynsurvey/Abstract/2005/08000/Ultrasound_Detection_of_Nuchal_Cord_Prior_to_Labor.10.aspx. Retrieved 2010-07-09. 
3. ^ Collins JH (2002). "Umbilical cord accidents: human studies". Semin. Perinatol. 26 (1): 79–82. doi:10.1053/sper.2002.29860. PMID 11876571. 
4. ^ Jouppila P, Kirkinen P. Ultrasonic diagnosis of nuchal encirclement by the umbilical cord: a case report. J Clin Ultrasound 1982; 10:59-62.
5. ^ ^{a b} Peregrine E. O’Brien P. Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005; 25:160-4.
6. ^ Wilson B. Sonography of the Placenta and Umbilical Cord. Radiologic Technology. 2008;79 (March/April):333S.
7. ^ Clapp JF 3rd, Stepanchak W, Hashimoto K, Ehrenberg H, Lopez B. The natural history of antenatal nuchal cords. Am J Obstet Gynecol. 2003;189(2):488-93.
8. ^ Larson JD, Rayburn WF, Harlan VL. Nuchal cord entanglements and gestational age. Am J Perinatol. 1997;14(9):555-7.
9. ^ Mastrobattista JM et al. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol. 2005;22(2):83-5.
10. ^ Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries—do we need to know? Obstet Gynecol. 2005;106(1):23-8.
11. ^ Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet. 2006 May;274(2):81-3. Epub 2005 Dec 23.
12. ^ Reed, R, Barnes, M & Allan, J 2009, ‘Nuchal cords: Sharing the evidence with parents’, British Journal of Midwifery, vol. 17, no. 2, pp. 106-109.
13. ^ http://cordclamping.info/publications/NC%20Article%20JMWH%202005.pdf
14. ^ Reynolds, L (1999). "Practice tips. "Somersault" maneuver for a tight umbilical cord". Canadian family physician Medecin de famille canadien 45: 613. PMC 2328444. PMID 10099799. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2328444. 

• ^ Reed R, Barnes M, Allan J. Nuchal cords: sharing the evidence with parents. The British Journal of Midwifery. 2009; 17 (2) 106-109
• Miser, WF (1992). "Outcome of infants born with nuchal cords". The Journal of family practice 34 (4): 441–5. PMID 1556538. 

External links

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