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«Jason H. Collins, M.D. Charles L. Collins, M.D. Candace C. Collins, M.D. This Book is Dedicated to the parents who have experienced the loss of a ...»

-- [ Page 1 ] --

SILENT RISK

Issues about the Human Umbilical Cord

Jason H. Collins, M.D.

Charles L. Collins, M.D.

Candace C. Collins, M.D.

-- This Book is --

Dedicated to the parents

who have experienced the loss

of a newborn secondary

to an umbilical cord accident.

- Contents -

Acknowledgements

Preface

Introduction

Chapter 1 Origin of the Umbilical Cord

Chapter 2 The Umbilical Cord: Problem of Supply and Demand Chapter 3 Fetal Behavior and Physiology Chapter 4 What We Have Learned from Animal Study Chapter 5 Management of the Umbilical Cord During Pregnancy Chapter 6 The Future of Umbilical Cord Research Recommended reading

- ACKNOWLEDGEMENTS -

We would like to thank the patients who provide us with the need to find a solution to the problem of umbilical cord accidents. Many parents courageously came forward and shared with us their experiences of umbilical cord related stillbirth. To discuss these events is difficult for them because to lose a normal fetus is so unique an experience.

Many scientists, researchers, physicians, midwives and nurses over the years have grappled with this issue. One who stands out in modern times is Jason C. Birnholz, M.D. who summarized

the issue of the “supply line” (umbilical cord). In the context of an overall vision he states:

“The practical goal of clinical obstetrics is to deliver an infant who will not only survive but de- velop without handicap from a prenatal or perinatal insult.”* Oakbrook, Illinois 1990 This goal requires the application of tools called ultrasonography and fetal heart rate moni- toring. Because of the efforts of Dr. Douglas Howry and Dr. John J. Wild, we can view the fetus in the uterus. Thanks to Dr. Edward H. Hon, fetal heart rate monitoring became established in obstet- rical care. Many individuals have added to these great works and continue to do so today.

Now, many differing opinions exist about how effective these tools have been to reproduc- tive care and “outcomes.” Let there be no mistake: to view the fetus and assess its physiology offers a chance to save a dying fetus where otherwise there would be no chance.

Many thanks go to Tulane University Medical Library whose holdings of journals, texts and special collections offer a repository of knowledge covering 200 years of obstetrical medicine.

Margaret Verzwyvelt, Patsy Copeland and Cathleen Furlong provided much valuable time retriev- ing articles and hunting down rare interlibrary loans. Thank you to Mr. W. Postel for allowing the many unusual requests to hold his books at home for weeks.

Lastly, thank you to Jeanette Beauman, the Executive Secretary of the Pregnancy Institute, who typed everything, mailed everything and did everything to bring this book to reality. Thank you to Patricia Taylor who donated her editorial expertise and believed in the book.

Ecologic Physiology of the Fetus, Ultrasonography of Supply Line Deprivation Syndromes, Radiology Clinics of North America, Vol 28, No 1, Jan 1990.

Preface “Congenital abnormalities of the human umbilical cord and placenta may result in significant complications during labour. The ill-effects are predominantly upon the newborn - less common maternal morbidity and mortality may result.” Albert A. Earn, M.D., M.Sc.

Winnipeg, Canada 1951 The issue of umbilical cord related fetal harm and fetal stillbirth is unaddressed in modern reproductive care. Although observations of umbilical cord related deaths have not necessarily proven causation, it is difficult not to ask “what is the relationship?” It is time to answer this question and to discern the full ramifications of umbilical cord related injury and death. The information discussed here is based on 8 years of research and a review of medical journals and texts.

The authors have searched over 300 articles to provide a current panorama of this reproductive quirk which is not limited to humans. In addition, the Pregnancy Institute is dedicated to solving the problem of umbilical cord accidents. The Pregnancy Institute is a 501(c)-3 nonprofit medical research corporation co-founded by Jason H. Collins, M.D., an obstetrician interested in improving birth outcomes, Charles L. Collins, B.S.E., M.D., a pathologist interested in placental changes, and Candace C. Collins, M.D., a pediatric ophthalmologist interested in learning disabilities. By assembling this story it is our goal to persuade other researchers to turn their attention to the problem of solving umbilical cord accidents and anomalies. Hopefully the future will see a permanent solution. The mother, also, can play a role in solving the tragedy of umbilical cord accidents.

While it is unknown how much time is needed for a fetus to die, it is believed that some fetuses die slowly. Fetal behavior is consistent and can have a repetitive (circadian) rhythm. As discussed later, awareness of fetal movements, sleep-wake cycles and tendencies may provide an initial warning of a compromised fetus. Verbalizing these changes to the obstetrician may alert everyone of the need for a closer look at the fetus with ultrasound and fetal monitoring. We hope that after reading this book you, the reader, will have a greater understanding of this tragedy. The expectant mother will hopefully understand her role in solving this tradgedy.





“A survey of a number of British and American textbooks has yielded scant information on this subject [of umbilical cord complications].” Kan Pun Shui, B.S., M.B.

Nickolson J. Eastman, M.D.

Hong Kong, 1956 (Figure 1) “Birthing Stones”, Oahu

Introduction

–  –  –

One has to wonder what thoughts prehistoric humans had when confronted with the stillbirth of a baby entangled in its umbilical cord. Some insights from more recent times suggest the umbilical cord represented an omen, a sacred talisman, predictor of future fertility. In Europe, Australia, Africa, and Hawaii, the umbilical cord was dried and soaked in water for consumption to ensure future fertility. It was eaten, hung from tree branches, and stuffed in volcanic rock crevices at sites such as the “Birthing Stones” in Kukahiioko, Oahu (Figure 1). Chinese literature suggests the cord had medicinal properties.

European insights beginning with Galen (129 - 200 A.D.) suggested the umbilical cord served to nurture the fetus through arteries and veins. Leonardo da Vinci (1452 - 1519) observed that the cord was as long as the fetus at a given gestational age. Spiglius (1631) determined blood flow direction, and Harvey (1657) suggested that interruption of this blood flow could be the cause of fetal death if the cord was compressed.

Early descriptions of fetal loss from cord entanglement date as far back as 200 years ago. In 1750 the British obstetrician William Smellie (Figure 2) describes case #172 in Treatise on The Theory and Practice of Midwifery as a stillborn with four cords around the neck. (Figures 3 & 4).

By the 1800s, many observations were recorded of distressed fetuses born with cord entanglement and cord abnormalities. A review of these early descriptions suggest clinical symptoms such as “pulling” sensations felt at the top of the uterus and excessive fetal movement followed by decreased fetal activity prior to fetal death.

Today, the field of obstetrics is confronted with the issue of umbilical cord complications a timeless, almost prehistoric example of how imperfect reproductive evolution sometimes can be.

Issues of birth-related blood loss, infection, and surgical intervention (C-section) have matured.

Premature birth, congenital anomalies and toxemia still challenge the obstetrical community. Because umbilical cord accidents may represent a small number of fetal deaths, the motivation to

i (Figure 2) William Smellie

investigate this reproductive tragedy may not be seen as urgent. However, out of 4 million births per year in the U.S., an estimated 4,000 umbilical cord related deaths occur. This is known as mortality.

What harm occurs to the live born fetus due to an umbilical cord complication is unknown. Obstetrical scientists call this harm morbidity. This morbidity is studied in terms of delivery “outcome,” meaning what harm is noticeable and how much. This harm often goes unnoticed for years. What harm does occur is rarely recorded.

Prenatal umbilical cord compression is currently suspected to provide such morbidity as neurologic damage. This damage may be as subtle as mild learning disabilities or as obvious as

ii(Figure 3)

iii cerebral palsy. This is currently considered speculative by most, but not all, reproductive scientists.

The Perinatal Umbilical Cord Project (PUCP), an ongoing project at The Pregnancy Institute, seeks to understand the issue of umbilical cord complications, an event particularly tragic to the mother. If mothers are to be comforted, an explanation of how these events happen is important. The PUCP has established a scientific method (protocol) of observation and has prospectively inspected over 1,000 pregnancy cases. (Figure 5), Method: All patients receive standard prenatal care starting with an exam at 8 to 10 weeks.

This includes a vaginal ultrasound, a second ultrasound at 20 weeks, and a third ultrasound study at 28 weeks screens for umbilical cord problems. Also, at every visit the fetal heart rate is studied for 10 to 15 minutes and recorded. Patients identified with umbilical cord abnormalities (UCA) are watched bi-weekly. Repeat studies with ultrasound and fetal heart rate monitoring occur as needed.

As evidence and data accumulate, the authors hope that a solution can be created which will allow successful management of the normal pregnancy threatened by an umbilical cord complication.

–  –  –

It has been estimated that 30% of births have some type of umbilical cord finding. This statistic implies a potential for fetal harm that may not be appreciated by scientific and public health authorities. Not knowing how many fetuses are harmed by their umbilical cords prevents research into the issue. If neurological harm can occur as the result of umbilical cord problems, then this mechanism of harm to the fetus needs to be investigated.

Every fetus should have the opportunity to begin life with all its God-given talents and abilities. Realistically, this may not be possible, but some physically normal newborns could benefit from a reduction in the risks of a cord mishap. It is estimated that learning disabilities may represent 15% of children today. What if one-third of these learning disabilities are due to some type of cord complication? The issue of cerebral palsy is important, but currently no solution and few insights exist as to its origin. Preventing the stillbirth of a normal infant would be an important step in identifying cord-related harm. What is the size of the problem, and what best describes each part of the problem of umbilical cord mishaps?

Disruption of the umbilical cord’s supply line is a major source of harm to the developing fetus. It is estimated that every third to fourth delivery has an identifiable umbilical cord abnormality or anomaly. What is unknown is how these findings affect the fetus in degrees. The obvious effect is that stillbirth can result from the closing of the supply line.

The expectant mother can play a role in solving the tragedy of umbilical cord accidents.

1 SILENT RISK

While it is unknown how much time is needed for a fetus to die, it is believed that some fetuses die slowly. Fetal behavior is consistent and can have a repetitive (circadian) rhythm. As discussed later, awareness of fetal movements, sleep-wake cycles and tendencies may provide an initial warning of a compromised fetus. Verbalizing these changes to the obstetrician may alert everyone of the need for a closer look at the fetus with ultrasound and fetal monitoring.

To understand umbilical cord related complications, an understanding of fetal developmental physiology is imperative. The umbilical cord begins to form between four and six weeks, as the embryonic disc takes a cylindrical shape. Located at the lower third of the embryo, the proximal portion of the umbilical cord begins to form and develops a sac (herniation). The proximal portion houses the guts (intestines) until the tenth week of gestation. At this time the umbilical cord is short, usually shorter than the head-to-tail (crown-rump) length of the embryo and of proportionately large diameter. It is not able to tolerate rotation about itself or the formed embryo. In fact, as the umbilical cord elongates, the proximal cord encompassing the intestinal pouch cannot be disturbed. This initial stalk develops in the center of the implantation site, which is the reason the cord presents at the center of the afterbirth (placenta).

By ten weeks, the intestines leave the proximal cord and return to the stomach, the elongation of the cord begins, and the location of the umbilicus (bellie button) positions in the middle third of the embryo. The elongation of the umbilical vein and arteries coincides with the development of Wharton’s jelly, an umbilical cord connective tissue.

(Figure 6) The responsibilities of the cord are numerous.

(Figure 6 - 10 week embryo) For example, the cord manages its own growth, elongation, and expansion, accommodates increasing blood flow, and possibly assists the fetal heart. It also must regulate blood flow and its fluidity (thickness/thinness). In addition, the umbilical arteries and vein contain muscular coats that allow constriction of the vessels at birth or dilation of the vessels during growth. The umbilical cord also must produce its own chemistry to prepare for its role in birth and separation from the newborn umbilicus (a process which takes 7 to 10 days).

Located within the cord are the umbilical vein and arteries. The relationship of the umbili

<

2SILENT RISK

cal vein to the umbilical arteries changes with development. These changes can result in cord abnormalities which will be discussed in the next chapter. Initially, two arteries send blood with waste products from the embryo to the afterbirth (placenta), and the one umbilical vein sends oxygen and nutrient-enriched blood to the embryo from the placenta. This circulation pattern must respond over time to the constantly changing fetal requirements and demands.



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