Espresso: Cord Prolapse

What is cord prolapse? 

• Definition 

• When the cord moves out of the cervix in front of the fetal presenting part; can usually only happen when rupture of membranes has occurred 

• Otherwise, it is called funic presentation (cord presenting with intact membranes)

• Uncommon: 1.4-6.2/1000 

• Majority of them happen in singleton gestation, but there is an increased risk in twin pregnancies of the second twin 

• Risk Factors

• PPROM - especially if the fetus is not in the cephalic position 

• Multifetal gestation 

• Polyhydramnios 

• Fetal growth restriction 

• Preterm labor 

• AROM when fetal head is not well engaged 

• Nearly half of cases are attributed to iatrogenic causes 

• 57% occur within 5 minutes of membrane rupture, and 67% occur within 1 hour of rupture 

• Why do we care? 

• Compression of the cord → vasoconstriction and → fetal hypoxia 

• Can lead to fetal death or brain damage if not rapidly diagnosed and managed 

How can I recognize cord prolapse? 

• Exam 

• Palpation of a pulsatile mass in the vaginal vault or at the cervix 

• No need for radiographic or laboratory confirmation 

• Fetal heart tracing 

• Usually can see recurrent variable decelerations or fetal bradycardia 

• Differential diagnosis 

• Another mass in the vagina could be fetal malpresentation 

• Other causes of fetal bradycardia/decelerations should also be considered 

How do I manage cord prolapse if it is found? 

• Reduction of the cord – if possible 

• This is usually not possible if there is large amount of cord in the vagina, and not recommended 

• However, if there is small amount of cord at the internal cervical os, at times, it is possible to reduce it back beyond the present part 

• However, if there is recurrent prolapse … 

• Expedient delivery

• Usually via cesarean delivery 

• Prior to getting to the operating room, the goal should be decompression of the umbilical cord 

• Elevate the fetal presenting part as interval to umbilical cord decompression can be associated with worse outcomes than interval to delivery 

• Decompression can be done manually: place finger or hand in the vagina and gently elevate the head or presenting part off of the umbilical cord 

• Do not put additional pressure on the cord → can lead to vasospasm 

• Another way of decompression 

• Place pregnant patient into steep Trendelenburg or knee-chest position 

• Usually if there is not a provider who is able to do manual decompression or if there is prolonged interval to delivery (ie. transfer to hospital) 

• If there is visible cord protruding from the introitus, try to place a warm, moist sponge or towel over the cord to prevent vasospasm

• Or can replace into vagina 

What are the outcomes, and how do I prevent prolapse? 

• Prognosis 

• Fetal mortality is <10% now that we are able to complete cesarean sections in a timely manner 

• In earlier studies, the range was 32-47% 

• Gestational age and location of prolapse (in or out of hospital) can significantly determine outcomes 

• Cord prolapse outside of hospital carries 18x increased risk of fetal mortality 

• Prevention 

• For patients who are at increased risk of cord prolapse (ie. PPROM, malpresentation), they should be encouraged to deliver at a hospital 

• Early recognition training by both patient and providers

• SIM! 

• ACOG recommend against routine amniotomy in normally progressing labor unless needed for fetal monitoring 

• AROM - if needed, make sure that there is engagement of the fetal head 

• If AROM is needed, but there is polyhydramnios or high fetal station, can use a fetal scalp electrode to rupture the amniotic sac to slowly release fluid 

Pessaries for the GYN Patient, feat. Dr. Edward Kim

What are pessaries?

• Pelvic organ prolapse (or POP) and stress urinary incontinence (or SUI) are common problems that impact millions of women in the world.

• A pessary is a support device placed vaginally that can be used to treat symptoms of POP, SUI, or both.

  • Pessaries are generally cost effective, well-tolerated, safe and can help avoid surgery.

    • For POP, up to 90% of patients report relief of symptoms like pressure and bulge.

    • For SUI, about half of patients report improvement in urinary symptoms.

History of the pessary

• Historically, the first use of pessary for reduction of pelvic organ prolapse was described by Hippocrates.

  • He put a halved pomegranate soaked in wine into the vagina.

• In 1860, Dr. Hugh Lenox Hodge, an ob/gyn faculty at the University of Pennsylvania, used newly developed vulcanized rubber to create a pessary shaped more anatomically.

  • Today, most pessaries are made of soft, flexible silicone thus considered non-allergenic.

The Modern Pessary

• The most commonly used pessaries are ring, Gellhorn and donut. 

  • Ring pessary is a go-to in practice.

    • Subtypes: Ring without support

    • Ring with support (kinda looks like a mini frisbee),
      Ring without support with a knob

    • Ring with support with a knob.

      • The knob sits under the pubic bone and helps with stress urinary incontinence. So a ring with support and a knob will address POP and SUI. Rings can be removed by patients fairly easily.

  • A Gellhorn has a stem and a concave disc (kinda looks like a baby pacifier).

    • The concave disc part sits below the vaginal apex and creates somewhat of a suction.

    • The stem sits posteriorly and prevents the pessary from flipping around.

      • Gellhorns are little more difficult to place. Patients seldom can remove them on their own.

      • For removal, a provider usually needs to grasp the stem with their fingers or a ring forceps, gently wiggle it out to break the suction allowing for removal.

      • Gellhorns are generally used for more severe prolapse.

  • A donut (as the name implies) looks like a mini donut and it achieves its function by occupying the vagina.

    • A donut works better for more severe prolapse, as well, and difficult for patients to remove on their own.

Indication and counseling:

• Patients with symptomatic POP or SUI who desire to avoid surgery, poor candidate for surgery, desire further childbearing, current pregnancy or within 12 months postpartum.

• Contraindications include:

  • active pelvic infection,

  • latex allergy (as some inflatable pessary are composed of latex),

  • non adherence to care and follow up

• Studies report a very wide range of patient acceptance of pessary: from 42 to 100%.

  • Patients who decline tend to be younger, sexually active,  nulliparous, or have severe POP or SUI and desire surgical correction.

  • But it also depends on the counseling. In our practice, we discuss pessary in the range of management options for POP and SUI. We sometimes use it as a bridge between now and surgery for patients who prefer symptom relief now.

Placement:

• Placement comes with practice and it often involves trial and error.

• There have been no identified reliable predictors of which size pessary should be tried first.

• Start with a ring with support pessary (ring with support and a knob if also trying to address SUI).

• Identifying the starting size (say, 3, 4, 5) comes with practice and pelvic exam. Wet it with warm water first.

  • You could use lubricant but if you use too much it may be too slippery for you to handle and also easier for it to be expelled.

• Fold it in half like a taco, insert, and allow it to resume its disc shape in situ. Remember, it should NOT be painful. If the patient says it’s painful once it’s placed, then it is often too big.

  • Liken it to a corrective device like glasses or contact lens. When you first start using it, you notice that it’s there. But it should not be painful and with time you often forget it’s there.

• Then have pt Valsalva.

  • It’s okay that you can see the pessary descend as long as it does not completely get expelled.

• Then have them ambulate and go to the toilet and Valsalva with a toilet hat to catch the pessary if it does get expelled.

  • If it’s still in situ after that and patient has no discomfort, we send them home with it.

• Placement of Gellhorn, donuts, and other types of pessaries are little different and may be best reserved for providers who have more experience with them. But I think ring pessaries can be something everyone can have in their toolbox.

Maintenance:

• Patients who wish to and have the dexterity to maintain the pessaries on their own are instructed to take it out and clean with warm soapy water as often as they want but usually at least once a week.

  • If they are unable to, then typically they come to the clinic every 3-4 months for maintenance.

• Patients with Gellhorn, donut, or other types of pessaries that patients cannot remove easily on their own also follow up every 3-4 months. At these visits, the pessary is removed, gently cleaned, and a speculum exam is done to assess for any excoriation or abrasion.

• For postmenopausal patients without contraindication for topical vaginal estrogen, we typically have them use it to prevent significant vaginal excoriation or abrasion since atrophy can worsen these.

Complications:

• Most common complaints are increase or change in vaginal discharge or odor. Reassurance and ruling out for vaginitis and bacterial vaginosis are reasonable next steps. Reports of vaginal bleeding long after placement warrants exam in the office.

• Spontaneous expulsion or difficulty with voiding or defecation or pain often means a different size or shape should be tried.

• Pessaries that have been left in situ and neglected for prolonged period of time should be taken seriously. Embedded pessaries may need removal under general anesthesia.

• But overall, it is generally very safe.

Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

• Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

• Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

• Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.