Curettage and Marginal Umbilical Cord Insertion What Every Obstetrician Should Know

Introduction

Marginal cord insertion (MCI) the placement of the umbilical cord within 2 cm of the placental edge has long been underrecognized in prenatal assessments. A recent clinical investigation highlights dilatation and curettage (D&C) as a significant risk factor for MCI, bringing new urgency to the practice of post-procedure conception timing. The findings of this study offer crucial guidance for obstetric care providers, especially in developing nations.
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Understanding the Study Key Insights

Published in the Clinical Journal of Obstetrics and Gynecology, the case-control study evaluated 60 cases of MCI among 1470 singleton pregnancies over a five-month period. The researchers aimed to uncover factors contributing to this abnormal cord placement and identified several significant correlations.

Key findings include:

• A 4.1% prevalence of MCI among all deliveries.
• Women with a history of D&C were almost six times more likely to develop MCI.
• Conception within five months of a D&C raised the MCI risk by more than tenfold.
• Additional risk factors: female fetus, parity ≥ 4, and past history of manual vacuum aspiration (MVA).

A detailed analysis can be found in our main journal article URL.

Risk Factors Identified

Curettage-Related Endometrial Damage

Women who underwent D&C procedures had a significantly higher likelihood of MCI. The trauma inflicted on the endometrium can lead to poor regeneration, reducing the placental development area.

• aOR for D&C: 5.97 (95% CI 1.95–18.25)
• Risk is even higher if conception follows within five months post-procedure.

Female Fetal Sex

The study found a strong correlation between MCI and female fetuses (aOR 3.82). Though the reason remains unexplained, this finding aligns with previous international studies.

High Parity

Mothers with four or more prior deliveries showed an elevated risk. This may result from cumulative endometrial trauma due to repeated placental separation.

History of MVA

Though considered less invasive than D&C, MVA was still a contributing factor. Women with previous MVA had a 2.06-fold increased risk of MCI.

Clinical and Public Health Implications

According to the American College of Obstetricians and Gynecologists (ACOG), optimal uterine health is paramount for pregnancy outcomes. This study reinforces that principle, emphasizing the need for careful reproductive planning following intrauterine interventions.

Obstetricians should counsel patients to:

• Delay conception for at least five months after D&C.
• Prioritize MVA over D&C for diagnostic and therapeutic purposes when possible.
• Monitor high-parity pregnancies more closely using second-trimester ultrasounds to detect cord anomalies early.

Recommendations for Future Practice

• Ultrasound Detection: Emphasis on cord insertion location during the second trimester can help predict adverse outcomes.
• Procedure Alternatives: Favoring MVA over D&C can mitigate trauma-related risks.
• Family Planning Guidance: Counseling on appropriate conception intervals post-D&C must become routine.

Read the full study at: https://doi.org/10.29328/journal.cjog.1001054

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