Cord Prolapse

Descent of the umbilical cord through the cervix, alongside or ahead of the presenting part, following rupture of membranes, an obstetric emergency given the risk of cord compression between the presenting part and the maternal pelvis, causing acute fetal hypoxia.

Risk factors include malpresentation (particularly footling breech and transverse lie), polyhydramnios, prematurity, multiple pregnancy, and a high or ill-fitting presenting part at the time of membrane rupture (spontaneous or artificial).

This is an obstetric emergency requiring immediate action to relieve cord compression while preparing for expedited delivery:

Call for immediate senior help: obstetric, anesthetic, and neonatal teams
Relieve pressure on the cord: the examiner's fingers remain in the vagina, elevating the presenting part off the cord, maintained continuously until delivery; the mother is positioned in knee-chest position or left lateral with a pillow under the hip (exaggerated Sims position) to use gravity to reduce pressure on the cord
Bladder filling: instilling 500 to 750 mL of saline into the maternal bladder via a catheter can further elevate the presenting part off the cord, particularly useful during transfer to theatre
Tocolysis (terbutaline 250 mcg SC, or an equivalent agent) may be used to reduce contractions and further relieve pressure while preparing for delivery
Immediate delivery: category 1 emergency cesarean section is the standard approach if vaginal delivery is not imminent; if the cervix is fully dilated and delivery by instrumental vaginal birth is immediately achievable and safe, this may be preferred given the speed advantage
Avoid handling the cord unnecessarily, since manipulation can precipitate vasospasm and worsen fetal compromise
Continuous attempt to keep the cord warm and moist if it is exteriorized, though the priority remains relief of compression and expedited delivery rather than cord management itself

Referral: maximum obstetric emergency requiring immediate activation of the full emergency delivery team.

Eclampsia

Also known as: Eclamptic seizure

Occurrence of generalized tonic-clonic seizures in a woman with pre-eclampsia (new-onset hypertension + proteinuria and/or other organ dysfunction after 20 weeks gestation), not attributable to other causes.

Represents the severe end of the pre-eclampsia/HELLP spectrum, a hypertensive emergency of pregnancy with significant maternal and fetal mortality risk. Can occur antepartum, intrapartum, or postpartum (up to 6 weeks, though most occur within 48 hours).

Pre-eclampsia severity features indicating progression risk: severe hypertension (≥160/110), severe headache, visual disturbance (scotomata, blurred vision), epigastric/RUQ pain, hyperreflexia/clonus, rapidly worsening renal function, pulmonary edema, HELLP features (Hemolysis, Elevated Liver enzymes, Low Platelets).

Generalized tonic-clonic seizure, typically preceded by (though sometimes without) warning signs: severe headache, visual disturbance, epigastric pain, hyperreflexia/clonus, sudden severe hypertension
Post-ictal confusion/drowsiness as with any generalized seizure
May occur with BP not extremely elevated — eclampsia can occur even with only mild-moderately elevated BP, so absence of severe hypertension does not exclude the diagnosis
Signs of associated HELLP/severe pre-eclampsia: RUQ/epigastric tenderness, jaundice, easy bruising/petechiae, oliguria
Fetal status: assess for distress (abnormal CTG); placental abruption can coexist (vaginal bleeding, abdominal pain, uterine tenderness)
Complications: HELLP syndrome, DIC, placental abruption, acute kidney injury, pulmonary edema, cerebral hemorrhage (leading cause of eclampsia-related death), hepatic rupture, aspiration pneumonia

Primarily clinical — a new seizure in a pregnant or recently postpartum woman with hypertension/proteinuria is eclampsia until proven otherwise; treatment should not be delayed for extensive workup.

BP measurement, urinalysis (proteinuria — though not required for diagnosis if other severe features present)
FBC (platelets — thrombocytopenia in HELLP), LFTs (elevated transaminases), U&E/creatinine, coagulation profile if HELLP/abruption suspected
Uric acid: often elevated, supportive but not diagnostic
LDH, peripheral blood film (schistocytes — microangiopathic hemolysis)
CTG: assess fetal wellbeing once mother stabilized
CT/MRI head: NOT routinely required if typical eclamptic seizure with prompt recovery — reserved for atypical presentation (focal deficit, onset >48h postpartum, refractory to magnesium, diagnostic uncertainty) to exclude hemorrhage, PRES, venous sinus thrombosis

Differentials: epilepsy, other causes of seizure in pregnancy (hypoglycemia, electrolyte disturbance, cerebral venous sinus thrombosis, PRES, intracranial hemorrhage, TTP) — consider particularly if atypical features (focal deficit, seizure before 20 weeks, very late postpartum onset, poor response to magnesium).

Immediate priorities — ABC, protect airway, prevent injury:

Position in left lateral position (reduces aortocaval compression, protects airway)
Oxygen, suction as needed, protect from injury (do not restrain forcefully)
Most eclamptic seizures are self-limiting within 1-2 minutes

Magnesium sulfate — the definitive treatment, for both acute seizure control AND prevention of further seizures (superior to benzodiazepines/phenytoin for this indication):

Loading dose: 4g IV over 5-10 minutes (or 4-6g per local protocol)
Maintenance infusion: 1g/hour IV, continued for 24 hours after the last seizure or after delivery, whichever is later
If further seizure despite magnesium: additional bolus 2g IV
Monitor for magnesium toxicity — narrow therapeutic window: deep tendon reflexes hourly (loss of reflexes is the earliest sign), respiratory rate (maintain >12/min), urine output (≥25mL/hour — magnesium is renally excreted and accumulates in oliguria)
Antidote for toxicity: calcium gluconate 10mL of 10% solution IV over 10 minutes

BP control (severe hypertension, ≥160/110):

IV labetalol (10-20mg bolus, repeat/double every 10 min to max 80mg per dose or start infusion), or
IV hydralazine (5-10mg bolus, repeat every 20-30 min), or
Oral nifedipine (10mg immediate-release) if IV access delayed
Target: gradual reduction, avoid precipitous drops (uteroplacental perfusion) — SBP 140-150, DBP 90-100

Definitive management — delivery:

Eclampsia is an indication for delivery once the mother is stabilized — delivery is the only definitive cure
Mode per obstetric factors; vaginal delivery not contraindicated by eclampsia alone if maternal/fetal condition allows
Do NOT delay delivery to achieve an arbitrary gestational age once mother stabilized — maternal condition takes priority
Continue magnesium through delivery and postpartum

Fluid management: cautious, restricted to avoid pulmonary edema — typically total fluids limited to 80mL/hour or 1mL/kg/hr unless significant hemorrhage.

Postpartum monitoring: close BP/neurological/renal monitoring for at least 24-48 hours postpartum, watch for HELLP progression.

Referral: obstetric emergency — senior obstetrician, anesthetist, and neonatal team from presentation; ICU/HDU for severe cases; neurology if atypical features.

Cord Prolapse

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management