What is the management and treatment of umbilical hematoma?

Umbilical Hematoma: Comprehensive Overview

Definition and Clinical Significance

Umbilical cord hematoma is a rare but potentially catastrophic obstetric complication occurring in approximately 1 in 5,500 pregnancies, with poor outcomes in approximately 50% of cases 1, 2. These hematomas result from rupture or lesion of umbilical vessel walls—most commonly the umbilical vein—and can cause fetal mortality through compression of cord vessels, acute blood loss, and resultant severe hypoxia 3, 1.

Pathophysiology and Risk Factors

Mechanism of Injury

• Vascular wall rupture is the primary mechanism, typically involving the umbilical vein rather than arteries 3, 2
• Compression of cord vessels by expanding hematoma causes acute interruption of fetal blood flow 3
• Fetal blood loss into the hematoma cavity contributes to acute anemia and circulatory collapse 3

Predisposing Factors

• Vascular wall abnormalities: Defects in elastin and smooth muscle components predispose to rupture 3
• Inflammatory conditions: Chorioamnionitis and funisitis weaken vessel integrity 3, 1
• Mechanical factors: Cord traction, twisting, prolapse, or shortness of the cord 2
• Prolonged rupture of membranes increases infection risk and subsequent vascular compromise 3
• Post-maturity has been associated with increased risk 2
• In many cases, the etiology remains idiopathic despite thorough investigation 1

Clinical Presentation

Fetal Manifestations

• Acute fetal distress with sudden onset of severe decelerations and loss of baseline variability 2
• Unexpected stillbirth, often occurring in the late stages of labor 4
• In rare cases, neonates may be asymptomatic at birth despite massive hematoma 5

Timing

• Most commonly occurs at the end of pregnancy (third trimester) or during labor 1, 4
• Can present as sudden, unexpected fetal demise in previously uncomplicated pregnancies 4

Diagnosis

Prenatal Detection

• Umbilical cord hematomas are rarely diagnosed prenatally due to their acute nature and rapid progression 1, 4
• Ultrasound may identify cord abnormalities if performed during the acute event, though this is uncommon

Postnatal/Post-Mortem Diagnosis

• Macroscopic examination reveals visible hematoma(s) along the umbilical cord 2
• Histopathologic examination is essential to identify vascular wall alterations, inflammatory vasculopathy, or structural defects 1
• Careful examination of the umbilical cord is fundamental for determining cause of death, providing closure for families, and addressing potential medicolegal concerns 4

Management

Intrapartum Recognition

• Immediate cesarean section is indicated for acute fetal distress with severe decelerations and loss of baseline variability 2
• Anticipate neonatal anemia and prepare for immediate resuscitation 2

Neonatal Resuscitation

• Expect low Apgar scores requiring aggressive resuscitation 2
• Immediate assessment of hemoglobin/hematocrit for severe anemia (hemoglobin may be as low as 11.6 g/dL) 2
• Monitor for hypoxic-ischemic encephalopathy given the acute hypoxic insult 2

Postnatal Evaluation

• Complete pathologic examination of placenta and umbilical cord with both macroscopic and microscopic assessment 1
• Document number, size, and location of hematomas 2
• Histologic evaluation of vessel walls for structural abnormalities or inflammatory changes 3, 1

Prognosis and Outcomes

The prognosis for umbilical cord hematoma is grave, with mortality or significant morbidity occurring in approximately 50% of cases 1, 2. Outcomes include:

• Intrauterine fetal demise from acute anoxia secondary to cord compression 1
• Neonatal death from hypoxic-ischemic encephalopathy despite successful delivery 2
• Rare survival without complications in cases of massive hematoma without hypoxic event 5

Prevention and Risk Mitigation

Antenatal Surveillance

• Maintain high index of suspicion in pregnancies with prolonged rupture of membranes or signs of chorioamnionitis 3
• Consider more frequent fetal monitoring in post-term pregnancies 2

Intrapartum Vigilance

• Continuous electronic fetal monitoring during labor to detect acute changes 2
• Immediate intervention for sudden onset of severe fetal distress with loss of variability 2

Key Clinical Pitfalls

• Failure to examine the umbilical cord thoroughly post-mortem may result in missed diagnosis and inability to provide families with explanation for fetal death 4
• Assuming other causes of fetal distress without considering rare cord pathology can delay appropriate investigation 4
• Underestimating the severity of acute fetal distress patterns associated with cord hematoma may result in delayed delivery 2