Umbilical Cord Haematoma

Umbilical cord haematoma is a collection of blood in Wharton's jelly, caused by rupture of an umbilical vessel. It is rare and follows fetal procedures (cordocentesis, amniocentesis), cord traction, a short or abnormal cord, or occurs without cause. It matters because it can compress the cord vessels and cause fetal death.

• Risk factors: cordocentesis, amniocentesis, intrauterine transfusion, cord traction, short cord, umbilical vein varix, vasculitis.
• Mostly found in the late third trimester or at birth.
• It can cause fetal anaemia from bleeding.

Women are usually well, with reduced fetal movements, abnormal heart rate tracing or a fetal death as the first sign. After a fetal procedure there may be sudden bradycardia.

• Reduced fetal movements.
• Fetal bradycardia or sinusoidal tracing.
• Differential diagnosis: cord cyst, umbilical vein varix, haemangioma of the cord, true knot, cord oedema, omphalocele, thrombosis.
• Complications: cord compression, fetal anaemia, hypoxia, preterm birth, stillbirth, neonatal death, neurological injury.

The approach is ultrasound with colour Doppler of the cord.

• Ultrasound: a heterogeneous or echogenic mass within the cord, with focal swelling and reduced flow in the vessels beyond it.
• Colour Doppler to show compressed vessels; umbilical artery Doppler and cardiotocography for fetal state.
• Middle cerebral artery peak systolic velocity above 1.5 multiples of the median suggests fetal anaemia.
• Maternal blood group and antibody screen; Kleihauer test if fetal bleeding is suspected.

The principle is to monitor closely and deliver if the fetus is viable and the tracing or flow becomes abnormal.

• Supportive: admit; left lateral position; cardiotocography once or twice daily; daily fetal movement counts; blood in the bank; birth in a unit with neonatal intensive care.
• Pharmacological: betamethasone 12 mg IM twice, 24 hours apart, between 24 and 34 weeks and 6 days when delivery is likely; magnesium sulphate 4 g IV over 20 minutes then 1 g per hour until delivery for 24 hours at most before 32 weeks; cefazolin 2 g IV before caesarean section; oxytocin 10 IU IM at birth; newborn O negative packed red cells 10 to 20 mL/kg IV over 30 minutes for anaemia.
• Procedures: delivery by caesarean section for abnormal tracing, absent end diastolic flow or fetal anaemia; delivery at 34 to 37 weeks for a stable fetus with a large collection; intrauterine transfusion for severe fetal anaemia in a fetal medicine unit.
• Special groups: RhD negative women give anti-D immunoglobulin 500 IU IM within 72 hours of fetal bleeding, increased by 125 IU for each 1 mL of fetal red cells above 4 mL.
• Red flags: bradycardia, reduced fetal movements, sinusoidal tracing, absent end diastolic flow, falling fetal movement count.
• Follow-up: scan and cardiotocography twice weekly; newborn haemoglobin and examination of the cord; paediatric review.