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DOI 10.1007/s00404-013-3072-9
MATERNAL-FETAL MEDICINE
Abstract
Purpose Birth asphyxia leading to acidosis comprises
2060 % of perinatal mortality. Nuchal cord (NC) is one of
the possible causes of birth asphyxia. Majority of fetuses
who are antenatally detected to have nuchal cord are able
to achieve successful vaginal birth. The purpose of this
study was to analyze the effect of nuchal cord on fetal acid
base status and perinatal outcome in vaginal deliveries.
Study design 150 parturients were equally divided into
three groups after vaginal delivery based on no NC, single
and multiple loops. Umbilical cord arterial blood was
analyzed for biochemical markers i.e. pH, PO2, SPO2,
PCO2, HCO3-, standard base excess and lactate for acidosis. Labor complications like abnormal FHR, meconiumstained liquor, prolonged second stage, instrumental vaginal delivery, third stage complications were compared. In
neonates, birth weight, Apgar score B7 at 5 min, NICU
admission and other morbidity and mortality during hospital stay were compared among groups using suitable
statistical tests. Above parameters were also compared
between tight and loose loops.
Result Nuchal cord groups had significantly higher frequency of labor complications than no NC group, especially tight loops. Neonates with NC had significantly
higher frequency of meconium-stained liquor, Apgar
Y. Narang N. B. Vaid S. Jain (&) A. Suneja K. Guleria
B. Gupta
Department of Obstetrics and Gynaecology, University College
of Medical Sciences and GTB Hospital, Dilshad Garden,
New Delhi, India
e-mail: sumeet_singla@rediffmail.com;
drsandy2010@rediffmail.com
M. M. A. Faridi
Department of Pediatrics, University College of Medical
Sciences and GTB Hospital, Dilshad Garden, New Delhi, India
Introduction
Umbilical cord provides nutrients and performs gaseous
exchange besides support and adherence to the fetus. A
long umbilical cord can facilitate movements and descent
during delivery but has the potential to entangle around the
neck, limb or torso [1].
Nuchal cord is defined as the umbilical cord being
wrapped 360 around the fetal neck [2]. It has been referred
to as one of the dangers of eight month by Hippocrates
in a book entitled De Octimestripartu [3]. It is estimated
that NC affects 2333 % of all pregnancies [2]. Single loop
is seen in 2334 %, two loops in 2.55 % and 3 loops are
found in 0.20.5 % of all pregnancies. More than three
loops are very rare and have been reported as isolated case
reports [2]. A maximum of nine loops have been reported
till date [4]. The loops may be loose which can be easily
slipped over fetal head or tight requiring clamping before
untwining during delivery.
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were recorded. FHR was denoted clinically as non-reassuring, if there was any tachycardia, bradycardia or irregularity. Second stage was considered as prolonged if [1 h
in multigravida and if [2 h in primigravida. Apgar score,
birth weight and need for NICU admission were compared
among groups. Also duration of hospital stay and any other
morbidity and mortality were noted.
This study focussed on the labor and delivery outcome
in apparently low risk obstetric patients delivering vaginally, where NC was an incidental finding. Antenatal
detection of NC with ultrasound was not done. Assuming
that majority of deliveries with nuchal cord occur vaginally, we wanted to purely evaluate its role in labor and
perinatal outcome in vaginal births. Cesarean section was
not included to avoid bias, as the most common indication
for emergency cesarean section being fetal distress (FD)
which could be due to meconium staining, non-progress of
labor, uterine inertia, second stage arrest, cephalopelvic
disproportion, if associated with presence of NC, then NC
would be labeled as cause of FD and as indication of
cesarean section. Cases with severe fetal distress or other
complication would anyway have gone for a cesarean
section.
Result
Analysis was done between nuchal and no nuchal cord
groups, single and multiple loops and loose and tight
loops
All demographic parameters were well matched in all groups.
Nuchal cord was significantly more frequent in multi parous
(p = 0.002) women compared to primigravida. Length of
cord was found to be significantly longer in nuchal compared
to no nuchal group (No NC * 48.20 4.31 cm, single
NC * 53.32 6.53 cm, and multiple NC * 52.80
8.20 cm, respectively (p value = 0.01).
Significant difference with respect to non-reassuring
FHR (p = 0.006), meconium-stained liquor (p = 0.004),
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p value
7.27 0.065
\0.001
Pair wise
p value
A vs B \ 0.001
B vs C = 0.703
C vs A \ 0.001
PO2 (mmHg)
30.66 4.99
28.44 6.73
26.14 8.47
0.005
A vs B = 0.326
B vs C = 0.290
C vs A = 0.004
SPO2 (%)
56.50 10.6
53.3 15.3
51.3 13.0
0.149
PCO2 (mmHg)
43.0 3.98
42.0 6.711
43.8 6.17
0.311
HCO3- (mEq/l)
22.0 1.29
21.5 1.84
21.1 1.98
0.023
A vs B = 0.364
B vs C = 0.682
C vs A = 0.019
SBE (mEq/l)
-2.42 1.23
-3.41 1.51
-3.57 3.10
0.014
A vs B = 0.061
B vs C [ 0.99
C vs A = 0.021
Lactate (mmol/l)
2.68 1.15
3.94 1.03
4.10 1.05
\0.001
A vs B \ 0.001
B vs C = 0.845
C vs A \ 0.001
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On comparing biochemical markers, significant difference in mean pH (p B 0.001), PO2 (p = 0.005), bicarbonate (p = 0.005), SBE (p = 0.014) and lactate (p B
0.001) levels were found in NC group as compared to no
NC group (Table 1; Fig. 3). pH and lactate were found to
correlate significantly only in multiple loops (r = -0.555,
p \ 0.001). The mean pH in no NC, single NC and
multiple NC was 7.35, 7.28 and 7.27, respectively. On
comparing loose vs tight loops, mean pH was 7.29 and
7.25, respectively. They were all in the pre-acidotic range,
even for the NC groups and did not reflect a severe
acidosis.
p value
7.29 0.05
7.25 0.07
0.004
PO2 (mmHg)
SPO2 (%)
28.11 7.71
56.64 13.4
25.96 7.50
48.87 14.0
0.056
0.006
PCO2 (mmHg)
41.53 5.69
44.10 6.88
0.049
HCO3- (mEq/l)
21.89 1.96
20.87 1.76
0.008
SBE (mEq/l)
-2.89 1.96
-3.98 2.66
0.024
3.67 0.79
4.38 1.12
\0.001
Lactate (mmol/l)
On comparing outcomes in loose vs tight cord nonreassuring FHR, meconium staining, prolonged second
stage, operative vaginal delivery and PPH were many times
more in tight compared to loose cord group; the difference
was significant for meconium and highly significant for rest
of the parameters.
Apgar score B7 and need for NICU admission were
significantly more in tight nuchal group compared to loose.
However, the presence of NC was not found to affect birth
weight in any of the groups.
PH, SPO2, HCO3-, SBE were all significantly lower in
tight nuchal group, whereas lactate was found to be significantly higher in tight NC group (Table 2).
Discussion
Cord entanglement especially single loose loops are common findings in delivery and many studies in past have
suggested its presence as benign occurrence. However,
very few studies in past have actually compared outcomes
in single NC vs multiple NC and loose vs tight NC,
moreover Umbilical artery (UA) blood gas along with
lactate have been included in limited studies. In this study,
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in NC groups in both term and post term deliveries. Peregrine et al. [5] found that women with NC had no significantly higher risk of emergency cesarean section as
compared to no NC group.
Risk of abruption, cord tear, shoulder dystocia uterine
inversion and PPH due to NC has been mentioned in the
literature [12]. In our study, no such labor complications
were encountered except PPH which was comparable
among all groups. This probably could be due to that linear
segment of the cord was not too short in any of our cases.
Shortest length of the cord in present study was 38 cm in
single loop group with tight cord.
Birth weight was not significantly different in NC (single and C2) compared to no NC group in this study. This
was consistent with previous clinical trials, where authors
could not find difference in mean birth weight in NC vs no
NC group. While Clapp et al. [17] stated that birth weight
could be affected if the NC persists for C4 weeks during
antenatal period. However, the presence of NC is mostly
transient, which could be one possible explanation for
comparable birth weight in our study. Also, umbilical cord
encirclements are associated with a relative lengthening of
the umbilical cord [18]. In our study, cord length was found
significantly longer in NC group (p = 0.01). Because there
is positive correlation between cord length and fetal
weight, this association tends to offset the effects of the
encirclements, giving the newborns a more normal birth
weight [19]. Maximum cord length in this study was 72 cm
in a neonate with four nuchal loops.
Apgar score B7 at 5 min and NICU transfer was significantly higher in NC group; however, all neonates were
discharged healthy within a week, except for one neonatal
death, due to birth asphyxia and sepsis.
The comparative study between two subgroups with
loose and tight NC showed significant higher frequency of
non-reassuring FHR, meconium-stained liquor, prolonged
second stage, operative vaginal delivery, PPH, Apgar
score B7 at 5 min and NICU transfer. Singh et al. [20]
found significant higher frequency of fetal distress and
primary cesarean section in tight NC group compared to
loose, whereas Ngowa et al. [15] did not find any significant increase in the above parameters in tight NC group.
pH in NC groups was found to be comparatively lower than
no NC group, especially in tight and multiple NC group.
However, non NC group had pathological range biochemical derangement. This finding probably suggests that
presence of NC interrupts umbilical blood flow to some
extent causing some biochemical derangement, more so in
multiple and tight NC. However, most with adequately
functioning placenta is able to compensate quickly; therefore, blood analysis from our study suggests that NC
groups were able to sustain and compensate reduced blood
flow, and thus were able to undergone vaginal delivery
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Conclusion
Nuchal cord has been found to be a common occurrence in
pregnancy and mostly benign in nature. Patients are likely
to have uneventful labor as cord compression is transient
and most foetuses are able to compensate for reducing
umbilical blood flow and deliver uneventfully. Routine
None.
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