251
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McAdams RM. Increased Odds of Survival or Prevention of Severe Neurological Injury in Extremely Low-Gestational-Age Neonates: Including Placental Transfusion as the First Step to Improve Outcomes in Preterm Newborns. JAMA Netw Open 2019; 2:e191293. [PMID: 30924887 DOI: 10.1001/jamanetworkopen.2019.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ryan M McAdams
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
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252
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Josephsen JB, Buchanan CQ, Strand ML. Delayed Umbilical Cord Clamping in Preterm Infants. Neoreviews 2019; 20:e174-e176. [PMID: 31261058 DOI: 10.1542/neo.20-3-e174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Christopher Q Buchanan
- Department of Obstetrics, Gynecology, and Women's Health, St Louis University School of Medicine, St Louis, MO
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253
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Lodha A, Shah PS, Soraisham AS, Rabi Y, Abou Mehrem A, Singhal N. Association of Deferred vs Immediate Cord Clamping With Severe Neurological Injury and Survival in Extremely Low-Gestational-Age Neonates. JAMA Netw Open 2019; 2:e191286. [PMID: 30924898 PMCID: PMC6450317 DOI: 10.1001/jamanetworkopen.2019.1286] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Deferred cord clamping (DCC) is recommended for term and preterm neonates to reduce neonatal complications. Information on the association of DCC with outcomes for extremely low-gestational-age neonates is limited. OBJECTIVE To compare neonatal outcomes after DCC and immediate cord clamping (ICC) in extremely low-gestational-age neonates. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, eligible neonates born between January 1, 2011, and December 31, 2015, were divided into 2 groups: DCC and ICC. Neonates were recruited from tertiary neonatal intensive care units participating in the Canadian Neonatal Network, and analysis began in January 2018. Neonates were eligible if they were born at 22 to 28 weeks' gestational age and admitted to a participating Canadian Neonatal Network neonatal intensive care unit during the study period. Neonates who were born outside a tertiary-level neonatal intensive care unit, were moribund at birth, needed palliative care before delivery, had major congenital anomalies, or lacked cord clamping information were excluded. MAIN OUTCOMES AND MEASURES Composite of severe neurological injury (intraventricular hemorrhage grade ≥3 with or without persistent periventricular echogenicity) or mortality before discharge. RESULTS Of 8221 admitted neonates, 4680 were included in the study, of whom 1852 (39.6%) received DCC and 2828 (60.4%) received ICC. There were 974 (52.7%) male neonates in the DCC group and 1540 (54.5%) male neonates in the ICC group. Median (interquartile range) gestational age was 27 (25-28) weeks for the DCC group and 26 (25-27) weeks for the ICC group. Median (interquartile range) birth weight was 930 (760-1120) g and 870 (700-1060) g for DCC and ICC groups, respectively. Neonates who received DCC had significantly reduced odds of the composite outcome of severe neurological injury or mortality (adjusted odds ratio [AOR], 0.80; 95% CI, 0.67-0.96), mortality (AOR, 0.74; 95% CI, 0.59-0.93), and severe neurological injury (AOR, 0.80; 95% CI, 0.64-0.99). The odds of bronchopulmonary dysplasia (AOR, 1.00; 95% CI, 0.84-1.19), retinopathy of prematurity stage 3 or higher (AOR, 0.94; 95% CI, 0.71-1.25), necrotizing enterocolitis stage 2 or higher (AOR, 0.86; 95% CI, 0.66-1.12), late-onset sepsis (AOR, 1.02; 95% CI, 0.85-1.22), and receipt of 2 or more blood transfusions (AOR, 0.93; 95% CI, 0.79-1.10) did not differ between the groups. Propensity score-matched analyses revealed lower odds of mortality (AOR, 0.79; 95% CI, 0.65-0.95), late-onset sepsis (AOR, 0.81; 95% CI, 0.69-0.95), and treatment for hypotension (AOR, 0.75; 95% CI, 0.60-0.95) in the DCC group. CONCLUSIONS AND RELEVANCE In this study of extremely low-gestational-age neonates who received DCC or ICC, DCC was associated with reduced risk for the composite outcome of severe neurological injury or mortality.
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MESH Headings
- Delivery, Obstetric/adverse effects
- Delivery, Obstetric/mortality
- Female
- Humans
- Infant, Extremely Premature
- Infant, Newborn
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/mortality
- Nervous System Diseases/epidemiology
- Nervous System Diseases/etiology
- Nervous System Diseases/mortality
- Pregnancy
- Retrospective Studies
- Umbilical Cord/physiology
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Affiliation(s)
- Abhay Lodha
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Prakesh S. Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Amuchou Singh Soraisham
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ayman Abou Mehrem
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nalini Singhal
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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254
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Saroha V, Josephson CD, Patel RM. Epidemiology of Necrotizing Enterocolitis: New Considerations Regarding the Influence of Red Blood Cell Transfusions and Anemia. Clin Perinatol 2019; 46:101-117. [PMID: 30771812 PMCID: PMC6383803 DOI: 10.1016/j.clp.2018.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article summarizes available evidence on the relationship between red blood cell transfusion and anemia, and necrotizing enterocolitis (NEC). We review recent studies that highlight the uncertainty of the effect of red blood cell transfusion on NEC and the potential role of anemia. We also discuss potential pathophysiologic effects of both red blood cell transfusion and anemia and highlight strategies to prevent anemia and red blood cell transfusion. We also discuss ongoing randomized trials that are likely to provide important new evidence to guide red blood cell transfusion practices.
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Affiliation(s)
- Vivek Saroha
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, 2015 Uppergate Dr. NE, 3 floor, Atlanta, GA 30322. Tel 404-727-3236.
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapies, Departments of Pathology and Laboratory Medicine and Pediatrics, Emory University School of Medicine, 101 Woodruff Cir, Atlanta, GA 30322. Tel 404-785-4553.
| | - Ravi Mangal Patel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, 2015 Uppergate Dr. NE, 3 floor, Atlanta, GA 30322. Tel 404-727-3236.
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255
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Gill AW. Postnatal cardiovascular adaptation. Arch Dis Child Fetal Neonatal Ed 2019; 104:F220-F224. [PMID: 30049726 DOI: 10.1136/archdischild-2017-314453] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
The heart undergoes rapid transformations in function during the transition to extrauterine life. Our understanding of the adaptive physiology underlying this process is able to inform the clinical management of infants who are struggling to complete this complex transition. Much of our knowledge of the cardiac transition is derived from the preterm infant in whom the preparative adaptations are incomplete and clinical sequelae all too common. This review will re-examine the cardiac transition highlighting the physiology that drives it and suggest appropriate clinical intervention to support the process.
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Affiliation(s)
- Andrew William Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
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256
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Delayed cord clamping in preterm infants: is it time to become standard practice? J Perinatol 2019; 39:513-515. [PMID: 30538324 DOI: 10.1038/s41372-018-0286-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/14/2018] [Indexed: 11/08/2022]
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257
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Badurdeen S, Roberts C, Blank D, Miller S, Stojanovska V, Davis P, Hooper S, Polglase G. Haemodynamic Instability and Brain Injury in Neonates Exposed to Hypoxia⁻Ischaemia. Brain Sci 2019; 9:E49. [PMID: 30818842 PMCID: PMC6468566 DOI: 10.3390/brainsci9030049] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
Abstract
Brain injury in the asphyxic newborn infant may be exacerbated by delayed restoration of cardiac output and oxygen delivery. With increasing severity of asphyxia, cerebral autoregulatory responses are compromised. Further brain injury may occur in association with high arterial pressures and cerebral blood flows following the restoration of cardiac output. Initial resuscitation aims to rapidly restore cardiac output and oxygenation whilst mitigating the impact of impaired cerebral autoregulation. Recent animal studies have indicated that the current standard practice of immediate umbilical cord clamping prior to resuscitation may exacerbate injury. Resuscitation prior to umbilical cord clamping confers several haemodynamic advantages. In particular, it retains the low-resistance placental circuit that mitigates the rebound hypertension and cerebrovascular injury. Prolonged cerebral hypoxia⁻ischaemia is likely to contribute to further perinatal brain injury, while, at the same time, tissue hyperoxia is associated with oxidative stress. Efforts to monitor and target cerebral flow and oxygen kinetics, for example, using near-infrared spectroscopy, are currently being evaluated and may facilitate development of novel resuscitation approaches.
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Affiliation(s)
- Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Calum Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Douglas Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Suzanne Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Peter Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Graeme Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
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258
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Meyer MP, Nevill E. Optimizing Cord Clamping in Preterm Infants: One Strategy Does Not Fit All. Front Pediatr 2019; 7:46. [PMID: 30873393 PMCID: PMC6400845 DOI: 10.3389/fped.2019.00046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael P. Meyer
- Middlemore Hospital, Auckland, New Zealand
- Department of Paediatrics, The University of Auckland, Auckland, New Zealand
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259
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Bradshaw L, Sawyer A, Armstrong-Buisseret L, Mitchell E, Ayers S, Duley L. Cord pilot trial, comparing alternative policies for timing of cord clamping before 32 weeks gestation: follow-up for women up to one year. BMC Pregnancy Childbirth 2019; 19:78. [PMID: 30791873 PMCID: PMC6383279 DOI: 10.1186/s12884-019-2223-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/15/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The Cord Pilot Trial compared two alternative policies for cord clamping at very preterm birth at eight UK maternity units: clamping after at least 2 min and immediate neonatal care (if needed) with cord intact, or clamping within 20 s and neonatal care after clamping. This paper reports follow-up of the women by two self-completed questionnaires up to one year after the birth. METHODS Women were given or posted the first questionnaire between four and eight weeks after birth, usually before their baby was discharged, and were posted a second similar questionnaire at one year. The questionnaire included the Hospital Anxiety and Depression Scale; the Preterm Birth Experience and Satisfaction Scale (P-BESS) and questions about their baby's feeding. RESULTS Of 261 women randomised (132 clamping ≥2 min, 129 clamping ≤20 s), six were excluded as birth was after 35+ 6 weeks (2, 4 in each group respectively). Six were not sent either questionnaire. The first questionnaire was given/sent to 244 and returned by 186 (76%) (79, 74%). The second, at one year, was sent to 242 and returned by 133 (55%) (66, 43%). On the first questionnaire, 89 (49%) had a score suggestive of an anxiety disorder, and 55 (30%) had a score suggestive of depression. Satisfaction with care at birth was high: median total P-BESS score 77 [interquartile range 68 to 84] (scale 17 to 85). There was no clear difference in anxiety, depression, or satisfaction with care between the two allocated groups. The median number of weeks after birth women breastfed/expressed was 16 (95% confidence interval (CI) 13 to 20, n = 119) for those allocated clamping ≥2 min and 12 (95% CI 11 to 16, n = 103) for those allocated clamping ≤20 s. CONCLUSIONS The response rate was higher for the earlier questionnaire than at one year. A high proportion of women reported symptoms of anxiety or depression, however there were no clear differences between the allocated groups. Most women reported that they had breastfed or expressed milk and those allocated deferred cord clamping reported continuing this for slightly longer. TRIAL REGISTRATION ISRCTN 21456601, registered 28th February 2013, http://www.isrctn.com/ISRCTN21456601.
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Affiliation(s)
- Lucy Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2UH UK
| | - Alexandra Sawyer
- School of Health Sciences, University of Brighton, Falmer, BN1 9PH UK
| | | | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2UH UK
| | - Susan Ayers
- Centre for Maternal and Child Health, School of Health Sciences, City University London, London, EC1V 0HB UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2UH UK
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260
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Milking of the Umbilical Cord in Term and Late Preterm Infants. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9185059. [PMID: 30886867 PMCID: PMC6388319 DOI: 10.1155/2019/9185059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/07/2018] [Accepted: 01/16/2019] [Indexed: 12/24/2022]
Abstract
Introduction Umbilical cord milking is a procedure in which clamped or unclamped umbilical cord is grasped, and blood is pushed (“stripped”) two to four times towards the newborn, in a rapid time frame, usually within 20 seconds. The target of umbilical cord milking is to provide infants with their whole potential blood volume—of which they are deprived when early cord clamping is carried out—completing placental transfusion in a shorter time than delayed cord clamping. The aim of this narrative review is to analyse the literature regarding umbilical cord milking in term and late-preterm infants and to assess all possible benefits and limits of this procedure in clinical practice, especially in comparison to immediate and delayed cord clamping. Methods We analysed literature data concerning maternal, as well as neonatal, outcomes for term and late-preterm (gestational age ≥ 34 weeks) newborns who received umbilical cord milking. Results Most studies show comparable benefits for both umbilical cord milking and delayed cord clamping, especially in terms of haematological parameters when compared to immediate cord clamping. Umbilical cord milking may be a feasible procedure also for newborns requiring resuscitation. Conclusions Literature data concerning positive effects of umbilical cord milking are encouraging and suggest that umbilical cord milking may be a quick and effective method to provide placental transfusions to depressed infants. However, the lack of standardised procedures and the variation in evaluated outcomes as well as the limited number of patients enrolled in trials, along with the retrospective nature of some of them, prevent recommending umbilical cord milking as a routine procedure.
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261
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Zhao Y, Hou R, Zhu X, Ren L, Lu H. Effects of delayed cord clamping on infants after neonatal period: A systematic review and meta-analysis. Int J Nurs Stud 2019; 92:97-108. [PMID: 30780101 DOI: 10.1016/j.ijnurstu.2019.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The majority of current evidences simply showed the short-term benefits of delayed cord clamping, mainly focusing on the first week after birth. Without follow-up data, we can hardly come to the conclusion that delayed cord clamping may do more harm than good. OBJECTIVE To evaluate the long-term effects of delayed cord clamping compared with early cord clamping on infants after neonatal period. DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES PubMed, EMBASE, and the Cochrane Library were systematically searched from inception date to June 22, 2018 for randomized clinical trials comparing early cord clamping with delayed cord clamping in infants beyond 1 month of age. REVIEW METHODS Two reviewers independently assessed trial eligibility and quality and extracted all infants' follow-up data after one month of age, which were divided into two groups for analysis, with follow-up periods of less than 6 months (<6 months) and beyond 6 months (≥6 months) respectively. RESULTS A total of twenty RCTs were identified and included in this study. All data of the twenty studies were pooled for final meta-analysis (3733 infants). Among preterm deliveries, delayed cord clamping slightly increased hematocrit (6-10 weeks) and serum ferritin (6-10 weeks). For term infants, delayed cord clamping reduced the incidence of anemia after six months of age (≥6 months), iron deficiency (< 6 months, ≥6 months) and iron deficiency anemia (4-12 months), while increased mean corpuscular volume before six months of age (< 6 months), hemoglobin after six months of age (≥6 months), serum iron (2-4 months), total body iron (4-6 months), serum ferritin (< 6 months, ≥6 months) and transferrin saturation (2-12 months). There were no significant differences between early versus late cord clamping groups for other variables. CONCLUSION Delayed cord clamping modestly improved hematological and iron status of both preterm and term infants after neonatal period. This affords cogent evidence on the practice of delayed cord clamping for medical staff, especially for countries and regions suffering from relatively higher prevalence rate of iron deficiency during infancy and childhood.
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Affiliation(s)
- Yang Zhao
- Peking University School of Nursing, #38 Xueyuan Road, Hai Dian District, Beijing, 100191, PR China.
| | - Rui Hou
- Peking University School of Nursing, #38 Xueyuan Road, Hai Dian District, Beijing, 100191, PR China
| | - Xiu Zhu
- Peking University School of Nursing, #38 Xueyuan Road, Hai Dian District, Beijing, 100191, PR China
| | - Lihua Ren
- Peking University School of Nursing, #38 Xueyuan Road, Hai Dian District, Beijing, 100191, PR China
| | - Hong Lu
- Peking University School of Nursing, #38 Xueyuan Road, Hai Dian District, Beijing, 100191, PR China.
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262
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Te Pas AB, Hooper SB, Dekker J. The Changing Landscape in Supporting Preterm Infants at Birth. Neonatology 2019; 115:392-397. [PMID: 30974440 PMCID: PMC6604262 DOI: 10.1159/000497421] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/19/2022]
Abstract
Noninvasive ventilation for preterm infants at birth has been recommended and universally adopted. The umbilical cord is often clamped immediately in order to provide the support the infant needs for stabilization. However, recent scientific data from experimental studies that involve animals in transition and human studies using physiological measurements at birth have increased awareness as to how little we know about how these interventions interact and integrate with the infant's changing physiology. It has become clear that in apneic infants the larynx is closed immediately after birth, which can completely negate the effect of noninvasive ventilation of the lung. For this reason, stimulating and supporting spontaneous breathing could enhance the success of noninvasive ventilation. Animal data also demonstrated that the large swings in blood pressure, blood flow, and oxygenation caused by immediate cord clamping can be avoided by postponing cord clamping until lung aeration has been established. In this review we will focus on these "game changers" that have the potential to completely change the approach used in stabilizing preterm infants at birth.
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Affiliation(s)
- Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands,
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Victoria, Australia
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263
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BATMAN D, ÇOBAN A. Gecikmiş Umbilikal Kord Klempleme ve Kord Sıvazlama Uygulamalarinin Prematüre Yenidoğanlarda Etkileri. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2019. [DOI: 10.30934/kusbed.475344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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264
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Stenning FJ, Hooper SB, Kluckow M, Crossley KJ, Gill AW, Wallace EM, Te Pas AB, LaRosa D, Polglase GR. Transfusion or Timing: The Role of Blood Volume in Delayed Cord Clamping During the Cardiovascular Transition at Birth. Front Pediatr 2019; 7:405. [PMID: 31649907 PMCID: PMC6794342 DOI: 10.3389/fped.2019.00405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/19/2019] [Indexed: 01/08/2023] Open
Abstract
Placental transfusion has been thought to be the main benefit of delayed umbilical cord clamping (DCC) in preterm neonates. However, the importance of cardiovascular stability provided by allowing lung aeration prior to cord clamping has recently been highlighted. We aimed to determine the influence of blood volume changes on cardiovascular stability at birth. Preterm lambs (0.85 gestation) were instrumented for measurement of pulmonary, systemic and cerebral blood pressures and flows, systemic oxygen saturation and cerebral oxygenation. Left ventricular output (LVO) was assessed by Doppler Echocardiography. Lambs underwent immediate cord clamping followed by (1) 25 ml/kg infusion of whole blood over (90 s; or 2) withdrawal of 10 ml/kg blood over 90 s. Ventilation was initiated 30 s after volume change (2 min after cord clamping) and was maintained for 30 min. Blood infusion significantly increased pulmonary blood flow (PBF) which maintained systemic cardiac output during the infusion, and increased carotid arterial pressure, flow and heart rate, which remained elevated until after ventilation onset. Upon completion of transfusion PBF rapidly returned to control levels and LVO decreased. Conversely, blood withdrawal decreased PBF and LVO. The cardiovascular changes that accompanied ventilation onset were similar between groups. Providing a blood volume transfusion immediately after umbilical cord clamping maintains PBF and cardiac output during the transfusion, which does not persist beyond the period of the transfusion. Our study implies that an apneic newborn cannot maintain cardiac output through an increase blood volume alone. Importantly, delaying umbilical cord clamping until after breathing/aeration of the lung may be a way to maintain cardiac output throughout delivery at birth.
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Affiliation(s)
- Fiona J Stenning
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and Sydney University, St Leonards, NSW, Australia
| | - Kelly J Crossley
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Andrew W Gill
- Centre for Neonatal Education and Research, The University of Western Australia, Crawley, WA, Australia
| | - Euan M Wallace
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Domenic LaRosa
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
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265
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Ruangkit C, Bumrungphuet S, Panburana P, Khositseth A, Nuntnarumit P. A Randomized Controlled Trial of Immediate versus Delayed Umbilical Cord Clamping in Multiple-Birth Infants Born Preterm. Neonatology 2019; 115:156-163. [PMID: 30481760 DOI: 10.1159/000494132] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Delayed cord clamping (DCC) improves placental transfusion and increases blood volume in preterm infants when compared with immediate cord clamping (ICC). However, evidence to support DCC in multiple-birth preterm infants is still lacking. OBJECTIVE To compare the outcomes of ICC versus DCC in preterm infants of multiple births. STUDY DESIGN Women with a multiple pregnancy, including twins and triplets with a gestational age of 28-36 weeks, were randomized to receive ICC (23 women and 50 infants) or DCC for 30-60 s (24 and 51 infants). The infants' hematocrit on admission, superior vena cava (SVC) flow measured within 24 h, and hematocrit at 8 weeks of age were compared. The use of uterotonic agents during delivery was not controlled in this study. RESULT All infants were delivered by cesarean section (CS) except for 2 sets of twins, 1 in each group. Maternal and infant baseline characteristics in both groups were comparable. There were no significant differences between the groups in admission hematocrit, SVC flow measured within 24 h, hematocrit at 8 weeks of age, or any other neonatal outcomes. The incidence of maternal postpartum hemorrhage (PPH) was higher in the DCC group (4.3% in ICC vs. 25% in DCC, p = 0.04). CONCLUSION DCC for 30-60 s did not improve placental transfusion or increase systemic blood flow in multiple-birth infants born preterm, mostly by CS, when compared with ICC. The finding of a higher PPH rate in the DCC group raises concerns about the maternal safety of this procedure in this patient population.
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Affiliation(s)
- Chayatat Ruangkit
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand,
| | - Sommart Bumrungphuet
- Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panyu Panburana
- Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Anant Khositseth
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pracha Nuntnarumit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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266
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Nudelman MJ, Goel K, Jegatheesan P, Song D, Huang A, Govindaswami B. Haematocrit in <35 weeks preterm infants who received at least 60 seconds of delayed cord clamping: a retrospective observational study. BMJ Paediatr Open 2019; 3:e000531. [PMID: 31646196 PMCID: PMC6782040 DOI: 10.1136/bmjpo-2019-000531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/29/2019] [Accepted: 09/01/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe haematocrit at birth in preterm infants who received ≥60 s of delayed cord clamping (DCC). DESIGN Retrospective observational study. SETTING A California public hospital with an American Academy of Pediatrics level 4 neonatal intensive care unit, with 3500-4000 deliveries annually. PARTICIPANTS 467 preterm infants born at <35 weeks' gestational age (GA) between January 2013 and December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Haematocrit reference ranges for 0-4 hours after birth and paired haematocrit differences between 0-4 and 4-24 hours. METHODS Haematocrits were obtained when clinically indicated and collected from arterial, venous and capillary sources. Haematocrits obtained after packed red blood cell transfusions were excluded. We summarised the first available haematocrit between 0 and 4 hours by GA strata. We used mixed-effects linear regression to describe the associations between haematocrit and predictor variables including GA, male sex and hours after an infant's birth. We also compared paired haematocrits at 0-4 and 4-24 hours after birth. RESULTS The median GA of the 467 included infants was 33.3 weeks, birth weight was 1910 g and DCC duration was 60 s. The mean (95% CI) first haematocrit at 0-4 hours was 46.6 (45.0% to 48.1%), 51.2 (49.6% to 52.8%), 50.6 (49.1% to 52.1%), 54.3 (52.8% to 55.8%) and 55.6 (54.6% to 56.6%) for infants 23-29, 30-31, 32, 33 and 34 weeks' GA strata, respectively. The subanalysis of 174 infants with paired haematocrits at 0-4 and 4-24 hours showed that for each additional hour after birth, the mean (95% CI) haematocrit increased by 0.2 (0.1% to 0.3%), 0.2 (0.1% to 0.4%) and 0.1 (0.0% to 0.2%) for infants in 23-29, 30-31 and 32 weeks' GA strata, respectively. The subanalysis showed no change between the paired haematocrits in the 33 and 34 weeks' GA strata. CONCLUSIONS Our study describes haematocrit in preterm infants who received ≥60 s DCC as standard of care. Haematocrit during the first 0-4 hours in our study is higher than the previously described reference ranges prior to DCC becoming routine clinical practice. The paired second haematocrit at 4-24 hours is higher than haematocrit at 0-4 hours.
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Affiliation(s)
- Matthew Jr Nudelman
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States.,Stanford, School of Medicine, Palo Alto, California, United States.,University of California, San Francisco, San Francisco, California, United States
| | - Keshav Goel
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States
| | - Priya Jegatheesan
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States.,Stanford, School of Medicine, Palo Alto, California, United States
| | - Dongli Song
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States.,Stanford, School of Medicine, Palo Alto, California, United States
| | - Angela Huang
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States
| | - Balaji Govindaswami
- Pediatrics / Newborn Medicine, Santa Clara Valley Medical Center: Hospital and Clinics, San Jose, California, United States.,Stanford, School of Medicine, Palo Alto, California, United States
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267
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Popat H, Galea C, Evans N, Lingwood B, Colditz PB, Halliday R, Osborn D. Effect of Delayed Cord Clamping on Cerebral Oxygenation in Very Preterm Infants. Neonatology 2019; 115:13-20. [PMID: 30199867 DOI: 10.1159/000492712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/07/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE The mechanism of reported benefits of delayed cord clamping (DCC) are unclear. We aimed to determine whether DCC compared to immediate cord clamping (ICC) in very preterm infants improves cerebral oxygenation in the first 24 h. STUDY DESIGN This is a prospective study of a subset of infants at < 30 weeks of gestation who were randomised to DCC (≥60 s) or ICC (< 10 s) and required an indwelling arterial catheter. Regional cerebral oxygenation (rScO2), blood pressure, PI, and peripheral saturation were measured and cerebral fractional tissue oxygen extraction (cFTOE) calculated for the following 3 time intervals: 3-6, 6-12, and 12-28 h of age. Functional ultrasound measures including superior vena cava flow, right ventricular output, ductus arteriosus size and shunt and anterior cerebral artery resistive index were determined. RESULTS The mean (±SD) gestation and birth weight of the 51 study infants were 27 ± 1 weeks and 1,046 ± 241 g respectively. Twenty infants received DCC and 31 received ICC. Baseline demographics were similar between the 2 groups. Comparing DCC and ICC infants, there was no difference in rScO2 or cFTOE at any time point. Three out of 20 infants did not receive DCC due to clinical concerns. A sensitivity analysis revealed that cord clamping ≥30 s was significantly associated with increased rScO2 and decreased cFTOE at all 3 time points after adjusting for gestation. CONCLUSION Although DCC was not associated with changes in cerebral oxygenation overall, sensitivity analysis suggested a possible effect of an increased rScO2 and a decreased cFTOE with ≥30 s of DCC.
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Affiliation(s)
- Himanshu Popat
- The Children's Hospital at Westmead, Westmead, New South Wales, .,University of Sydney, Camperdown, New South Wales,
| | - Claire Galea
- University of Sydney, Camperdown, New South Wales, Australia.,Cerebral Palsy Research Alliance Institute, Sydney, New South Wales, Australia
| | - Nicholas Evans
- University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Barbara Lingwood
- UQ Centre for Clinical Research, The University of Queensland and Royal Brisbane and Women's Hospital, Brisbane City, Queensland, Australia
| | - Paul B Colditz
- UQ Centre for Clinical Research, The University of Queensland and Royal Brisbane and Women's Hospital, Brisbane City, Queensland, Australia
| | - Robert Halliday
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - David Osborn
- University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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268
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Greer R, Safarulla A, Koeppel R, Aslam M, Bany-Mohammed FM. Can Fetal Umbilical Venous Blood Be a Reliable Source for Admission Complete Blood Count and Culture in NICU Patients? Neonatology 2019; 115:49-58. [PMID: 30300890 PMCID: PMC6621551 DOI: 10.1159/000491993] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 07/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Minimizing initial neonatal blood draws and their associated pain is important. The placenta has ample fetal blood that is otherwise discarded; obtaining admission laboratory evaluations from fetal umbilical venous blood (FUVB) may provide a suitable alternative. OBJECTIVE We hypothesized that obtaining an aerobic bacterial blood culture (BCX) and a complete blood count with manual differential (CBC/diff) from FUVB is feasible and yields results comparable to those obtained directly from the neonate. STUDY DESIGN BCX and CBC/diff were attempted on paired samples from FUVB (in the delivery room) and neonatal blood (shortly after NICU admission) of 110 patients. The paired t test, Pearson's correlation coefficient (R), and multivariable linear regression were used for data analysis. RESULTS Positive BCXs were found in 9 of 108 FUVB samples compared to 1 of 91 neonatal samples. Three out of 9 FUVB cultures were true pathogens, including 2 Escherichia coli and 1 viridans group streptococcus, all with negative corresponding paired neonatal cultures. There was 1 positive neonatal BCX, E. coli, with a negative paired FUVB culture. Neonatal hemoglobin (Hb), platelets (PLT), and white blood cells (WBC) all significantly (p < 0.0001) correlated with the paired FUVB samples (R = 0.50, 0.49, and 0.84, respectively). Hb, PLT, and WBC values were clinically comparable but statistically higher in neonatal blood (the differences were 2.3 g/dL, 30,000 cells/μL, and 2,800 cells/μL, respectively; p < 0.007 for all comparisons). CONCLUSIONS FUVB is suitable for obtaining CBC/diff. FUVB is an appropriate second source for BCX as it yields additional true pathogens. Our findings may support the presence of "culture-negative sepsis" in some neonates.
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Affiliation(s)
- Rocky Greer
- Division of Neonatology, Department of Pediatrics, University of California Irvine School of Medicine, Irvine, California, USA
| | - Azif Safarulla
- Division of Neonatology, Department of Pediatrics, University of California Irvine School of Medicine, Irvine, California, USA
| | - Robin Koeppel
- Neonatal Intensive Care Unit, University of California Irvine Medical Center, Orange, California, USA
| | - Muhammad Aslam
- Division of Neonatology, Department of Pediatrics, University of California Irvine School of Medicine, Irvine, California, USA
| | - Fayez M Bany-Mohammed
- Division of Neonatology, Department of Pediatrics, University of California Irvine School of Medicine, Irvine, California,
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269
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Cavallin F, Galeazzo B, Loretelli V, Madella S, Pizzolato M, Visentin S, Trevisanuto D. Delayed Cord Clamping versus Early Cord Clamping in Elective Cesarean Section: A Randomized Controlled Trial. Neonatology 2019; 116:252-259. [PMID: 31266035 DOI: 10.1159/000500325] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/11/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Delaying cord clamping is recommended in order to assure placental transfusion. However, the evidence on cord management in elective cesarean section (CS) is limited. OBJECTIVE To compare delayed cord clamping (DCC) with early cord clamping (ECC) with regard to postnatal adaptation in neonates born through elective CS. METHODS All neonates born ≥39 weeks' gestation born through elective CS were assigned to either the DCC or the ECC arm at a 1:1 ratio according to a computer-generated, randomized sequence. The primary outcome was the hematocrit at day 2 of life. Secondary outcomes included: preductal oxygen saturation and heart rate during the first 10 min of life; transcutaneous bilirubin at day 3; and neonatal blood pressures in the first 3 days of life. Additional outcomes included: time to first spontaneous breath; temperature at admission to normal nursery; weight at discharge; and maternal blood losses. RESULTS Eighty neonates were randomized to the DCC (n = 40) or the ECC (n = 40) arm. The hematocrit at day 2 was significantly higher in the DCC arm than in the ECC arm (mean difference: 6%; 95% CI 3-8; p < 0.0001). The secondary outcome measures were not statistically different between the two arms. No infants needed phototherapy for hyperbilirubinemia during their hospital stay. CONCLUSIONS Delaying cord clamping beyond 60 s increases the hematocrit at day 2 in neonates born through elective CS, without affecting maternal blood losses. Our findings suggest that DCC should be recommended in elective CS, but further studies are warranted to assess long-term outcomes.
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Affiliation(s)
| | - Beatrice Galeazzo
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Vittoria Loretelli
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Stefania Madella
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Martina Pizzolato
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Silvia Visentin
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Daniele Trevisanuto
- Department of Women's and Children's Health, University of Padua, Padua, Italy,
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270
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Knol R, Brouwer E, Klumper FJCM, van den Akker T, DeKoninck P, Hutten GJ, Lopriore E, van Kaam AH, Polglase GR, Reiss IKM, Hooper SB, Te Pas AB. Effectiveness of Stabilization of Preterm Infants With Intact Umbilical Cord Using a Purpose-Built Resuscitation Table-Study Protocol for a Randomized Controlled Trial. Front Pediatr 2019; 7:134. [PMID: 31106181 PMCID: PMC6499150 DOI: 10.3389/fped.2019.00134] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Most preterm infants fail to aerate their immature lungs at birth and need respiratory support for cardiopulmonary stabilization. Cord clamping before lung aeration compromises cardiovascular function. Delaying cord clamping until the lung has aerated may be beneficial for preterm infants by optimizing hemodynamic transition and placental transfusion. A new purpose-built resuscitation table (the Concord) has been designed making it possible to keep the cord intact after preterm birth until the lung is aerated and the infant is respiratory stable and breathing [Physiological-Based Cord Clamping (PBCC)]. The aim of this study is to test the hypothesis whether stabilizing preterm infants by PBCC is at least as effective as the standard approach using time-based Delayed Cord Clamping (DCC). Study design: This is a randomized controlled non-inferiority study including 64 preterm infants born at <32 weeks of gestation. Infants will be randomized to either the PBCC approach or standard DCC. In case of PBCC, infants will be stabilized with an intact umbilical cord and the cord will only be clamped when the infant is considered respiratory stable, defined as the establishment of regular spontaneous breathing, a heart rate ≥100 bpm and oxygen saturation above 90% while using inspired fraction of oxygen (FiO2) < 0.40. The Concord will be used, which allows giving respiratory support with an intact umbilical cord. In the DCC group infants are clamped first before they are transferred to the standard resuscitation table for further treatment and stabilization. Cord clamping is time-based and delayed at 30-60 s. The primary outcome will be the time to respiratory stability of the infant, starting from birth. Secondary outcomes will include details of stabilization, important clinical outcomes of prematurity and maternal safety outcomes. Discussion: We expect that PBCC using the Concord may reduce major morbidities and mortality in preterm infants. The current study protocol will assess the effectivity of stabilization. Once effectivity of stabilization is confirmed, we will start a large multicenter randomized clinical trial to investigate whether PBCC reduces mortality and morbidity in preterm infants compared to the standard approach. Trial registration: Netherlands Trial Registry NTR7194, registered on April 20th, 2018.
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Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Emma Brouwer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Philip DeKoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - G J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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271
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Abstract
Necrotizing enterocolitis (NEC) is the most common serious gastrointestinal morbidity in preterm infants. A number of risk factors for NEC have been reported in the literature. With the exception of decreasing gestational age, decreasing birth weight and formula feeding, there is disagreement on the importance of reported risk factors with uncertain causality. Causal risk factors may be observed at any time before the onset of NEC, including prior to an infant's birth. The purpose of this review is to examine the existing literature and summarize risk factors for NEC. This review may be helpful in understanding the epidemiology of NEC and inform the measurement and assessment of risks factors for NEC in research studies and quality improvement projects.
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Affiliation(s)
- Allison Thomas Rose
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ravi Mangal Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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272
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Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). Am J Obstet Gynecol 2018; 219:533-544. [PMID: 30118692 DOI: 10.1016/j.ajog.2018.08.006] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
Abstract
The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.
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273
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Abstract
This is a review of umbilical cord milking, a controversial technique where the umbilical cord is squeezed several times before it is clamped an cut. While not physiological or natural for newborns, the question lies as to whether it is useful in certain circumstances, namely the depressed newborn. Here we review the literature and discuss why it could be considered as an alternative for the current practice of delayed cord clamping.
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Affiliation(s)
- Anup C. Katheria
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Loma Linda University, Loma Linda, CA, United States
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274
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Bianchi M, Papacci P, Valentini CG, Barbagallo O, Vento G, Teofili L. Umbilical cord blood as a source for red-blood-cell transfusion in neonatology: a systematic review. Vox Sang 2018; 113:713-725. [PMID: 30328121 DOI: 10.1111/vox.12720] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
Abstract
The prevention and treatment of anaemia in newborn patients made tremendous progress in the last decades. However, red-blood-cell (RBC) transfusions remain unavoidable in many neonates candidate to surgery and especially in preterm infants. In particular, anaemia occurring in neonates born at extremely low gestational age is actually severe and frequently requires transfusions. Several approaches have been explored to prevent or even to reduce the threshold and the frequency of RBC transfusions. Among these, umbilical cord blood (UCB) collection and processing to obtain RBC components for autologous or allogeneic transfusion have been extensively investigated. In this systematic review, we revised the literature concerning the use of UCB for either autologous or allogeneic transfusion purposes and we illustrated the rationale for a transfusion therapy tailored to extremely preterm neonates, based on RBC concentrates from allogeneic UCB donations.
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Affiliation(s)
- Maria Bianchi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Patrizia Papacci
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- Terapia Intensiva Neonatale, Rome, Italy
| | - Caterina Giovanna Valentini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Ombretta Barbagallo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Giovanni Vento
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- Terapia Intensiva Neonatale, Rome, Italy
| | - Luciana Teofili
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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275
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Initial hematocrit values after birth and peri/intraventricular hemorrhage in extremely low birth weight infants. J Perinatol 2018; 38:1471-1475. [PMID: 30206347 DOI: 10.1038/s41372-018-0224-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/08/2018] [Accepted: 08/22/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Ischemia followed by reperfusion plays a significant role in the pathogenesis of peri/intraventricular hemorrhage (P/IVH). Delayed cord clamping promotes placental transfusion to newborn and is associated with decreased P/IVH. We hypothesized that extremely low birth weight (ELBW) infants with higher initial hematocrit (Hct) after birth are less likely to develop P/IVH. STUDY DESIGN Pre- and postnatal data on inborn ELBW infants over 7 years were reviewed. We examined the relationship between P/IVH in the first week and initial Hct using logistic regression modeling. RESULTS We studied 225 infants with a median gestational age (GA) 25.7 (22.4-31.7). Forty-one percent had grade I-IV P/IVH. In univariate analysis, cesarean section (CS) and higher GA, birth weight, 5-minute Apgar, and initial Hct were associated with decreased likelihood of P/IVH while higher maximum PCO2 in first 3 days and use of inotropes/vasopressors, postnatal steroid for hypotension, hypernatremia, transfusion, and use of insulin for hyperglycemia during the first week of life were associated with increased likelihood of P/IVH. In multiple regression analysis, only GA, CS, and initial Hct remained significantly associated with P/IVH. Adjusting for GA and CS, the odds of P/IVH was higher with Hct < 40% (OR 2.04, 95% CI [1.11, 3.76]) and Hct < 45% (2.38 [1.19, 4.76]). CONCLUSION Higher initial Hct is associated with decreased P/IVH. Initial Hct < 45% was associated with a 2-fold increase in P/IVH. We speculate that lower initial Hct represents a lower intravascular volume status and promotes cerebral hypoperfusion preceding P/IVH.
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276
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Tran HT, Nippita T, Nguyen PTK, Nguyen PTT, Huynh TTD, Hua OTL, Roberts CL. Knowledge, experience and attitudes towards skin-to-skin contact following Caesarean sections among health professionals in Vietnam. Acta Paediatr 2018; 107:1917-1923. [PMID: 30054942 DOI: 10.1111/apa.14519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/19/2018] [Accepted: 07/25/2018] [Indexed: 11/28/2022]
Abstract
AIM This study explored knowledge, experience and attitudes of health professionals towards early essential newborn care and skin-to-skin contact following Caesarean sections in a tertiary hospital in Central Vietnam. METHOD We conducted a cross-sectional descriptive study using an anonymous questionnaire in March 2016. Health professionals from obstetrics, anaesthesiology and neonatology departments were surveyed. RESULTS All of the 204 surveys were returned, accounting for 82% of total staff involved in the care for women and newborns with Caesarean sections. Correct knowledge of early essential newborn care was lowest among anaesthesiology staff. Health professionals reported that ≥90% of Caesarean section births they attended in the preceding week had skin-to-skin contact. Approximately 16% obstetricians, 71% midwives, 49% anaesthesiology and 76% neonatology staff considered the current frequency of skin-to-skin contact to be about right. The remainder considered the current rate too high. All professional groups identified the main difficulties of conducting skin-to-skin contact as the temperature in the operating theatre and the need for additional staff. Other concerns included increasing the risk of the baby of falling off, prolonging the operation and difficulty to monitor mothers. CONCLUSION The study identifies issues where improvements can be made in the implementation of skin-to-skin contact following Caesarean sections.
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Affiliation(s)
- Hoang Thi Tran
- Da Nang Hospital for Women and Children; Da Nang Vietnam
- Faculty of Medicine and Pharmacy; The University of Da Nang; Da Nang Vietnam
| | - Tanya Nippita
- Sydney Medical School-Northern; the University of Sydney; Sydney NSW Australia
| | - Phuong Thi Kim Nguyen
- Da Nang Hospital for Women and Children; Da Nang Vietnam
- Sydney Medical School-Northern; the University of Sydney; Sydney NSW Australia
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277
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Abstract
A high incidence of postnatal hypothermia has been reported in high-as well low-resource countries and it remains an independent predictor of neonatal morbidity and mortality, especially in very preterm infants in all settings. The temperature of newly born infants should be maintained between 36.5 and 37.5 °C after birth through admission and stabilization. Interventions to achieve this may include environmental temperature 23-25 °C, use of radiant warmers, exothermic mattresses, woollen or plastic caps, plastic wraps, humidified and heated gases. Skin-to-skin contact has been used, especially in low-resource settings. The combinations of these interventions applied to quality improvement initiatives, including staff training, use of checklists, and continuous feedback with the staff involved in the management of the neonate, are key factors to prevent heat loss from delivery room to admission to the neonatal intensive care unit. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.
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Affiliation(s)
- Daniele Trevisanuto
- Department of Women's and Children's Health, Azienda Ospedaliera di Padova, University of Padua, Padua, Italy.
| | - Daniela Testoni
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
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278
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Wang M, Mercer JS, Padbury JF. Delayed Cord Clamping in Infants with Suspected Intrauterine Growth Restriction. J Pediatr 2018; 201:264-268. [PMID: 29954605 DOI: 10.1016/j.jpeds.2018.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/25/2018] [Accepted: 05/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED We evaluated a subset of infants with suspected intrauterine growth restriction or birth weights small for gestational age enrolled in a study of delayed cord clamping for preterm infants. Compared with immediate clamping, delayed cord clamping was associated with no apparent harm and less suspected necrotizing enterocolitis. TRIAL REGISTRATION ClinicalTrials.gov: NCT00818220 and NCT01426698.
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Affiliation(s)
- Meijia Wang
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Judith S Mercer
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI; College of Nursing, University of Rhode Island, Kingston, RI; Department of Pediatrics, Alpert School of Medicine, Brown University, Providence, RI
| | - James F Padbury
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI; Department of Pediatrics, Alpert School of Medicine, Brown University, Providence, RI
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279
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Katheria A, Hosono S, El-Naggar W. A new wrinkle: Umbilical cord management (how, when, who). Semin Fetal Neonatal Med 2018; 23:321-326. [PMID: 30076109 DOI: 10.1016/j.siny.2018.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the past five years, umbilical cord management in both term and preterm infants has come full circle, going from the vast majority of infants receiving immediate cord clamping to virtually all governing organizations promoting placental transfusion, mainly in the form of delayed cord clamping (DCC). Placental transfusion refers to the transfer of more blood components to the infant during the first few minutes after birth. The different strategies for ensuring placental transfusion to the baby include delayed (deferred) cord clamping, milking of the attached cord before clamping, and milking of the cut cord. In this review, we address the current evidence to date for providing placental transfusion in different circumstances and the methods for implementation. We also highlight the gaps in knowledge and areas for future research.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA; Loma Linda Medical University, San Diego, CA, USA.
| | - Shigeharu Hosono
- Division of Neonatology, Nihon University School of Medicine, Tokyo, Japan
| | - Walid El-Naggar
- Division of Perinatal-Neonatal Medicine, Dalhousie University, IWK Health Centre, Halifax, Canada
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280
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Pantoja AF, Ryan A, Feinberg M, DeMarie M, Britton J, Liptsen E, Chen M, Crow J. Implementing delayed cord clamping in premature infants. BMJ Open Qual 2018; 7:e000219. [PMID: 30272030 PMCID: PMC6157520 DOI: 10.1136/bmjoq-2017-000219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 08/02/2018] [Accepted: 08/25/2018] [Indexed: 12/19/2022] Open
Abstract
The practice of delayed cord clamping (DCC) in premature infants has proven benefit to the neonate. In a community-based perinatal centre, the practice of DCC for more than 60 s for premature infants with gestational age of <35 weeks was identified to occur infrequently at 20% in 2013. The perinatology group in conjunction with nursery, labour and delivery, and obstetric staff sought to improve adherence to the best practice of DCC for premature infants. In an effort to achieve this goal, we developed an evidence-based clinical practice guideline, included key stakeholders in its development and provided timely feedback to delivery providers about DCC performance. The frequency of DCC for this population improved from 19.5% in 2013 to 85% in 2017. The success in improving this best practice is attributed to the involvement of the multidisciplinary team who developed the guideline, and the sustained improvement was encouraged with the continued reaffirmation of DCC goals to delivery providers.
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Affiliation(s)
| | - Ann Ryan
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - Michelle Feinberg
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - Mark DeMarie
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - John Britton
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - Ellina Liptsen
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - Maggie Chen
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
| | - Jordan Crow
- Department of Neonatology, Saint Joseph Hospital, Denver, Colorado, USA
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281
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Girish M, Jain V, Dhokane R, Gondhali SB, Vaidya A, Aghai ZH. Umbilical cord milking for neonates who are depressed at birth: a randomized trial of feasibility. J Perinatol 2018; 38:1190-1196. [PMID: 29973664 DOI: 10.1038/s41372-018-0161-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/04/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the feasibility and safety of umbilical cord milking (UCM) in neonates who are depressed at birth. STUDY DESIGN This is a quasi-randomized, non-blinded, controlled trial on infants (≥35 weeks) who were depressed at birth. UCM (cord milked three times) was performed during the even months and the neonates born during the odd months were in the control group. Primary outcome was feasibility and safety. RESULTS A total of 101 infants were enrolled (50 UCM group and 51 control group) between January 2015 and October 2016. UCM was performed in 95% of infants (59/62) who qualified to receive UCM. There were no significant differences in resuscitation delay, resuscitation efforts, and short-term outcomes between the two groups. CONCLUSIONS UCM is feasible for term and late preterm infants who are depressed at birth. A larger clinical trial is needed to evaluate long-term benefits of UCM in neonates with HIE.
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Affiliation(s)
- Meenakshi Girish
- Pediatrics, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India. .,Pediatrics, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India.
| | - Vinita Jain
- Pediatrics, Daga Memorial Women & Child Hospital, Nagpur, Maharashtra, India
| | - Rohinie Dhokane
- Pediatrics, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India
| | | | - Ashish Vaidya
- Pediatrics, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Zubair H Aghai
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
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282
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Knol R, Brouwer E, Vernooij ASN, Klumper FJCM, DeKoninck P, Hooper SB, te Pas AB. Clinical aspects of incorporating cord clamping into stabilisation of preterm infants. Arch Dis Child Fetal Neonatal Ed 2018; 103:F493-F497. [PMID: 29680790 PMCID: PMC6109247 DOI: 10.1136/archdischild-2018-314947] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 12/30/2022]
Abstract
Fetal to neonatal transition is characterised by major pulmonary and haemodynamic changes occurring in a short period of time. In the international neonatal resuscitation guidelines, comprehensive recommendations are available on supporting pulmonary transition and delaying clamping of the cord in preterm infants. Recent experimental studies demonstrated that the pulmonary and haemodynamic transition are intimately linked, could influence each other and that the timing of umbilical cord clamping should be incorporated into the respiratory stabilisation. We reviewed the current knowledge on how to incorporate cord clamping into stabilisation of preterm infants and the physiological-based cord clamping (PBCC) approach, with the infant's transitional status as key determinant of timing of cord clamping. This approach could result in optimal timing of cord clamping and has the potential to reduce major morbidities and mortality in preterm infants.
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Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alex S N Vernooij
- Department of Medical Engineering, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Leids Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | - Philip DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Arjan B te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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283
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Chiruvolu A, Daoud Y, Inzer RW. Effect of delayed cord clamping on very preterm twins. Early Hum Dev 2018; 124:22-25. [PMID: 30099274 DOI: 10.1016/j.earlhumdev.2018.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 07/27/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The very preterm infants of twin births may particularly benefit from delayed cord clamping (DCC) as the likelihood of unfavorable outcome is greater compared to singletons. Unfortunately, there is paucity of available information regarding safety and efficacy of DCC in this group. OBJECTIVE To report the clinical consequences of delayed cord clamping (DCC) in very preterm twins, born between 230/7 and 316/7 weeks gestation. STUDY DESIGN In this pre and post intervention retrospective cohort study, we compared 30 very preterm infants born from 15 twin deliveries during historic study period to 32 very preterm infants born from 16 twin deliveries during DCC study period. During historic study period (August 19, 2013 to January 31, 2015), infants included were eligible to receive DCC, but their cords were immediately clamped. DCC study period (February 1, 2015 to January 31, 2017) included infants who had DCC performed for 60 s after birth. RESULTS The Apgar scores and other resuscitation variables were similar between both groups. After adjusting for gestational age and mode of delivery, significantly fewer infants in the DCC cohort needed red blood cell (RBC) transfusions in first week of life compared to the historic cohort (15.6% vs. 43.3%; P = 0.03). Death and other major neonatal outcomes were similar between both groups. CONCLUSION DCC in very preterm twins was safe, feasible and not associated with any adverse neonatal outcomes compared to early cord clamping. DCC was associated with a significant reduction in early RBC transfusions.
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Affiliation(s)
- Arpitha Chiruvolu
- Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Pediatrix Medical Group, Dallas, TX, USA.
| | - Yahya Daoud
- Department of Quantitative Sciences, Center for Clinical Effectiveness, Office of Chief Quality Officer, Baylor Scott & White Health Care System, Dallas, TX, USA
| | - Robert W Inzer
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
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284
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Benefits of umbilical cord milking versus delayed cord clamping on neonatal outcomes in preterm infants: A systematic review and meta-analysis. PLoS One 2018; 13:e0201528. [PMID: 30161139 PMCID: PMC6116944 DOI: 10.1371/journal.pone.0201528] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 07/17/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Optimum timing of umbilical cord clamping has not been established in preterm infants. OBJECTIVES We compared the short- and long-term effects of umbilical cord milking (UCM) versus delayed cord clamping (DCC) on infants born at less than 37 weeks of gestation. SEARCH METHODS A systematic review and meta-analysis was conducted according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" statement. We searched CINAHL, CENTRAL, EMBASE, MEDLINE, PubMed and ClinicalTrials.gov for relevant randomized controlled trials (RCTs). SELECTION CRITERIA We included individual and clustered RCTs comparing UCM to DCC for infants born before 37 weeks of gestation. DATA COLLECTION AND ANALYSIS Four reviewers independently assessed trial quality and eligibility for inclusion. MAIN RESULTS Two trials (255 preterm infants, 23 0/7 to 32 6/7 weeks of gestation) were included in the analysis. UCM was associated with fewer intraventricular hemorrhages (IVHs) (two trials, 255 infants; relative risk [RR] 0.45, 95% confidence interval [CI] 0.20 to 0.98, low quality of evidence) and UCM was an increased proportion of infants with a Bayley score at 2 years of age (two trials, 174 infants; Cognitive: RR 1.14, 95% CI 1.03 to 1.26, Language: RR 1.24, 95% CI 1.03 to 1.49, low quality of evidence) compared to DCC. CONCLUSIONS UCM wasn't reduced in-hospital mortality and need for transfusion compared to DCC. But our study suggests that UCM may lower the risk of IVH and improve certain neurodevelopmental outcomes compared to DCC in preterm infants.
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285
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Affiliation(s)
- Ola Andersson
- Department of Women's and Childrens Health; Uppsala University; Uppsala Sweden
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286
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Kugelman A, Borenstein-Levin L, Jubran H, Dinur G, Ben-David S, Segal E, Haddad J, Timstut F, Stein I, Makhoul IR, Hochwald O. Less is More: Modern Neonatology. Rambam Maimonides Med J 2018; 9:RMMJ.10344. [PMID: 30089091 PMCID: PMC6115478 DOI: 10.5041/rmmj.10344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Iatrogenesis is more common in neonatal intensive care units (NICUs) because the infants are vulnerable and exposed to prolonged intensive care. Sixty percent of extremely low-birth-weight infants are exposed to iatrogenesis. The risk factors for iatrogenesis in NICUs include prematurity, mechanical or non-invasive ventilation, central lines, and prolonged length of stay. This led to the notion that "less is more." In the delivery room delayed cord clamping is recommended for term and preterm infants, and suction for the airways in newborns with meconium-stained fluid is not performed anymore. As a symbol for a less aggressive attitude we use the term neonatal stabilization rather than resuscitation. Lower levels of oxygen saturations are accepted as normal during the first 10 minutes of life, and if respiratory assistance is needed, we no longer use 100% oxygen but 0.21-0.3 FiO2, depending on gestational age and the level of oxygen saturation. We try to avoid endotracheal ventilation by using non-invasive respiratory support and administering continuous positive airway pressure early on, starting in the delivery room. If surfactant is needed, non-invasive methods of surfactant administration are utilized. Use of central lines is shortened, and early feeding of human milk is the routine. Permissive hypercapnia is allowed, and continuous non-invasive monitoring not only of the O2 but also of CO2 is warranted. "Kangaroo care" and Newborn Individualized Developmental Care and Assessment Program (NIDCAP) together with a calm atmosphere with parental involvement are encouraged. Whether "less is more," or not enough, is to be seen in future studies.
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Affiliation(s)
- Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Huda Jubran
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Shlomit Ben-David
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Elena Segal
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Julie Haddad
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Fanny Timstut
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - Iris Stein
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - Imad R. Makhoul
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
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287
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Schüller SS, Kramer BW, Villamor E, Spittler A, Berger A, Levy O. Immunomodulation to Prevent or Treat Neonatal Sepsis: Past, Present, and Future. Front Pediatr 2018; 6:199. [PMID: 30073156 PMCID: PMC6060673 DOI: 10.3389/fped.2018.00199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/25/2018] [Indexed: 12/12/2022] Open
Abstract
Despite continued advances in neonatal medicine, sepsis remains a leading cause of death worldwide in neonatal intensive care units. The clinical presentation of sepsis in neonates varies markedly from that in older children and adults, and distinct acute inflammatory responses results in age-specific inflammatory and protective immune response to infection. This review first provides an overview of the neonatal immune system, then covers current mainstream, and experimental preventive and adjuvant therapies in neonatal sepsis. We also discuss how the distinct physiology of the perinatal period shapes early life immune responses and review strategies to reduce neonatal sepsis-related morbidity and mortality. A summary of studies that characterize immune ontogeny and neonatal sepsis is presented, followed by discussion of clinical trials assessing interventions such as breast milk, lactoferrin, probiotics, and pentoxifylline. Finally, we critically appraise future treatment options such as stem cell therapy, other antimicrobial protein and peptides, and targeting of pattern recognition receptors in an effort to prevent and/or treat sepsis in this highly vulnerable neonatal population.
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Affiliation(s)
- Simone S. Schüller
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Andreas Spittler
- Department of Surgery, Research Labs & Core Facility Flow Cytometry, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ofer Levy
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Broad Institute of MIT and Harvard, Boston, MA, United States
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288
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Weeks A, Bewley S. Improbable, but plausible, research study: a randomised controlled trial of premature cord clamping vs. neonatal venesection to achieve routine prophylactic neonatal red cell reduction. J R Soc Med 2018; 111:270-275. [PMID: 29985087 DOI: 10.1177/0141076818781406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Andrew Weeks
- 1 Sanyu Research Unit, Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Liverpool L8 7SS, UK
| | - Susan Bewley
- 2 Department of Women and Children's Health, Faculty of Life Sciences and Medicine, Kings College London, St Thomas' Hospital, London SE1 7EH, UK
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289
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Ram Mohan G, Shashidhar A, Chandrakala BS, Nesargi S, Suman Rao PN. Umbilical cord milking in preterm neonates requiring resuscitation: A randomized controlled trial. Resuscitation 2018; 130:88-91. [PMID: 29981817 DOI: 10.1016/j.resuscitation.2018.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/03/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the effect of cord milking on short term morbidity and hematologic parameters at 6 weeks in preterm neonates requiring resuscitation. METHODS This trial randomized preterm infants requiring resuscitation to milking group and no milking group. Multiple pregnancy, Rh negative mothers, hydrops, cord abnormalities were excluded. The primary outcome was hemoglobin and serum ferritin at 6 weeks of life. Secondary outcomes were common preterm morbidities and mortality. RESULTS 60 neonates were included in the study. Infants in the milking group had higher hemoglobin (10.07 g/dl vs 8.9 g/dl; p 0.003) and higher serum ferritin level (244.8 ng/ml vs 148.5 ng/ml; p 0.04) compared to no milking group. CONCLUSIONS In preterm neonates requiring resuscitation, umbilical cord milking results in higher hemoglobin and ferritin at 6 weeks of life. It can be a used as a placental transfusion strategy in preterm neonates requiring resuscitation with no significant adverse effects. CLINICAL TRIAL REGISTRATION Clinical trials registry -India CTRI/2015/01/005436, www.ctri.nic.in.
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Affiliation(s)
- G Ram Mohan
- Department of Neonatology, St. John's Medical College Hospital, Bangalore, India
| | - A Shashidhar
- Department of Neonatology, St. John's Medical College Hospital, Bangalore, India
| | - B S Chandrakala
- Department of Neonatology, St. John's Medical College Hospital, Bangalore, India
| | - S Nesargi
- Department of Neonatology, St. John's Medical College Hospital, Bangalore, India
| | - P N Suman Rao
- Department of Neonatology, St. John's Medical College Hospital, Bangalore, India.
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290
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McAdams RM, Backes CH, Fathi O, Hutchon DJR. Revert to the original: time to re-establish delayed umbilical cord clamping as the standard approach for preterm neonates. Matern Health Neonatol Perinatol 2018; 4:13. [PMID: 29997896 PMCID: PMC6030773 DOI: 10.1186/s40748-018-0081-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/28/2018] [Indexed: 01/18/2023] Open
Abstract
Delayed cord clamping, the common term used to denote placental-to-newborn transfusion at birth, is a practice now endorsed by the major governing bodies affiliated with maternal-newborn care. Despite considerable evidence, delayed cord clamping, not early cord clamping, continues to be viewed as the “experimental” intervention category when discussed in research studies. We provide a brief overview of placental-to-newborn transfusion in relation to birth transitional physiology and discuss areas where we may need to modify our interpretation of “normal” vital signs and laboratory values as delayed cord clamping becomes standardized. We also assert that delayed cord clamping should now be viewed as the standard of care approach, especially given that multiple randomized controlled trials have revealed that early cord clamping, which lacks evidence-based support, is associated with a greater risk for morbidity and mortality than delayed cord clamping.
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Affiliation(s)
- Ryan M McAdams
- 1Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, 1010 Mound St., Rm 414, Madison, WI 53715 USA
| | - Carl H Backes
- 2Department of Pediatrics, The Center for Perinatal Research and The Heart Center, Nationwide Children's Hospital, Columbus, OH USA
| | - Omid Fathi
- 2Department of Pediatrics, The Center for Perinatal Research and The Heart Center, Nationwide Children's Hospital, Columbus, OH USA
| | - David J R Hutchon
- 3Obstetrics and Gynaecology, Darlington Memorial Hospital, Darlington, UK
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291
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Eiby YA, Shrimpton NY, Wright IMR, Lumbers ER, Colditz PB, Duncombe GJ, Lingwood BE. Reduced blood volume decreases cerebral blood flow in preterm piglets. J Physiol 2018; 596:6033-6041. [PMID: 29917228 DOI: 10.1113/jp275583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/11/2018] [Indexed: 12/13/2022] Open
Abstract
KEY POINTS Preterm infants often have poor cardiovascular function that is associated with adverse neurodevelopmental outcomes. Preterm infants may be vulnerable to hypovolaemia due to excessive vasodilatation and leaky capillaries. Following reduction in blood volume, cardiac output and mean arterial pressure were reduced to the same extent in term and preterm piglets. Cerebral blood flow was maintained following blood volume reduction in term but not in preterm piglets. Effective detection and treatment of functional hypovolaemia may reduce the risk of brain injury in preterm infants. ABSTRACT Preterm infants often have impaired cardiovascular function that may contribute to poor neurodevelopmental outcomes. The study aimed to determine the effects of reduced blood volume on cardiovascular function, including cerebral blood flow, in preterm and term piglets. In preterm (97/115 days) and term piglets, up to 10% of the estimated blood volume was removed. Removal of blood was stopped if MAP dropped below 20 mmHg. Heart rate, cardiac contractility and relaxation, cardiac output, mean arterial pressure (MAP), and cerebral blood flow were measured at baseline and again after blood volume reduction. The volume of blood removed was less in preterm piglets than in term piglets (5.1 ± 1.8 vs. 7.7 ± 0.9 mL kg-1 , mean ± SD, P < 0.001). Cardiac output and MAP decreased to the same extent in term and preterm piglets. Cerebral blood flow decreased in preterm but not term piglets and cerebral vascular conductance increased in term piglets only. Compensatory responses to maintain cerebral blood flow after blood volume reduction are active in term piglets but not in preterm piglets. As a result, even a small reduction in blood volume, or an increase in the capacity of the circulatory system leading to functional hypovolaemia, may lead to a significant reduction in cerebral blood flow and contribute to brain injury in preterm neonates.
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Affiliation(s)
- Yvonne A Eiby
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Perinatal Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicole Y Shrimpton
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Perinatal Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ian M R Wright
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Graduate Medicine and The Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Eugenie R Lumbers
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia
| | - Paul B Colditz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Perinatal Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Department of Obstetrics and Gynaecology, Brisbane, Queensland, Australia
| | - Greg J Duncombe
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Department of Obstetrics and Gynaecology, Brisbane, Queensland, Australia
| | - Barbara E Lingwood
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Perinatal Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Department of Obstetrics and Gynaecology, Brisbane, Queensland, Australia
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292
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Kearney L, Kynn M, Reed R, Davenport L, Young J, Schafer K. Identifying the risk: a prospective cohort study examining postpartum haemorrhage in a regional Australian health service. BMC Pregnancy Childbirth 2018; 18:214. [PMID: 29879945 PMCID: PMC5992874 DOI: 10.1186/s12884-018-1852-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/25/2018] [Indexed: 11/11/2022] Open
Abstract
Background In industrialised countries the incidence of postpartum haemorrhage (PPH) is increasing, for which exact etiology is not well understood. Studies have relied upon retrospective data with estimated blood loss as the primary outcome, known to be underestimated by clinicians. This study aimed to explore variables associated with PPH in a cohort of women birthing vaginally in coastal Queensland, Australia, using the gravimetric method to measure blood loss. Methods Women were prospectively recruited to participate using an opt-out consent process. Maternal demographics; pregnancy history; model of care; mode of birth; third stage management practices; antenatal, intrapartum and immediate postpartum complications; gravimetric and estimated blood loss; and haematological laboratory data, were collected via a pre-designed data collection instrument. Descriptive statistics were used for demographic, intrapartum and birthing practices. A General Linear Model was used for multivariate analysis to examine relationship between gravimetric blood loss and demographic, birthing practices and intrapartum variables. The primary outcome was a postpartum haemorrhage (blood loss > 500 ml). Results 522 singleton births were included in the analysis. Maternal mean age was 29 years; 58% were multiparous. Most participants received active (291, 55.7%) or modified active management of third stage (191, 36.6%). Of 451 births with valid gravimetric blood loss recorded, 35% (n = 159) recorded a loss of 500 ml or more and 111 (70%) of these were recorded as PPH. Gravimetric blood loss was strongly correlated with estimated blood loss (r = 0.88; p < 0.001). On average, the estimated blood loss was lower than the gravimetric blood loss, about 78% of the measured value. High neonatal weight, perineal injury, complications during labour, separation of mother and baby, and observation of a gush of blood were associated with PPH. Nulliparity, labour induction and augmentation, syntocinon use were not associated with PPH. Conclusions In contrast to previous study findings, nulliparity, labour induction and augmentation were not associated with PPH. Estimation of blood loss was relatively accurate in comparison to gravimetric assessment; raising questions about routine gravimetric assessment of blood loss following uncomplicated births. Further research is required to investigate type and speed of blood loss associated with PPH.
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Affiliation(s)
- Lauren Kearney
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia. .,University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia.
| | - Mary Kynn
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia
| | - Rachel Reed
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia
| | - Lisa Davenport
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia
| | - Jeanine Young
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia.,Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Keppel Schafer
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia
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293
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Carvalho OMC, Augusto MCC, Medeiros MQ, Lima HMP, Viana Junior AB, Araujo Júnior E, Carvalho FHC. Late umbilical cord clamping does not increase rates of jaundice and the need for phototherapy in pregnancies at normal risk. J Matern Fetal Neonatal Med 2018; 32:3824-3829. [PMID: 29732948 DOI: 10.1080/14767058.2018.1473367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: To verify the relationship between the time of clamping of the umbilical cord and the development of neonatal jaundice, the dosage of bilirubin and the need for phototherapy. Methods: Cross-sectional, retrospective study with 398 parturients at normal risk (single term gestation, no complications during gestation or delivery, birth weight between 2500 and 4499 g). The population was divided into three groups regarding the time of cord clamping: <1 min(117, 29.4%), between 1 and 3 min(228, 57.3%) and >3 min(53, 13.3%). Sociodemographic, clinical and obstetric characteristics, birth and delivery data, and maternal and perinatal outcomes were evaluated. Pearson's chi-square test, Fisher's exact test and the Kruskal-Wallis test were used for comparison between the groups. Statistical significance was considered p < .05. Results: The groups were similar in the development of jaundice (p = .370), bilirubin dosage (p = .342) and need for phototherapy (p = .515). Late clamping was more prevalent in vaginal deliveries when compared to cesarean sections (1-3 min: 64 versus 21.4%, >3 min: 16.6 versus 1%) (p < .001). There was no difference in other maternal or perinatal variables. Conclusion: The clamping time of the umbilical cord showed no association with jaundice, bilirubin dosage, or phototherapy needs in neonates at normal risk. The adoption of late clamping was more prevalent in vaginal deliveries.
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Affiliation(s)
- Ocília Maria Costa Carvalho
- a Assis Chateaubriand Maternity School , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil
| | - Matheus Costa Carvalho Augusto
- b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,c Department of Obstetrics and Gynecology , University of Fortaleza, Council of Europe , Fortaleza , Brazil
| | - Maxsuênia Queiroz Medeiros
- a Assis Chateaubriand Maternity School , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil
| | - Hesly Martins Pereira Lima
- a Assis Chateaubriand Maternity School , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil
| | - Antonio Brazil Viana Junior
- a Assis Chateaubriand Maternity School , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil
| | - Edward Araujo Júnior
- d Department of Obstetrics, Paulista School of Medicine , Federal University of São Paulo (EPM-UNIFESP) , São Paulo , Brazil
| | - Francisco Herlânio Costa Carvalho
- a Assis Chateaubriand Maternity School , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil.,b Department of Maternal and Child , Federal University of Ceará (UFC), Council of Europe , Fortaleza , Brazil
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294
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Ruangkit C, Leon M, Hassen K, Baker K, Poeltler D, Katheria A. Maternal bleeding complications following early versus delayed umbilical cord clamping in multiple pregnancies. BMC Pregnancy Childbirth 2018; 18:131. [PMID: 29728153 PMCID: PMC5935924 DOI: 10.1186/s12884-018-1781-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/26/2018] [Indexed: 11/26/2022] Open
Abstract
Background In 2015, the American Academy of Pediatrics recommended delayed umbilical cord clamping for at least 30–60 s for all infants. However, there is limited data regarding the maternal safety of delayed cord clamping in multiple pregnancies. We aimed to compare the maternal bleeding complications following early cord clamping (ECC) versus of delayed cord clamping (DCC) in multiple pregnancies. Methods A retrospective cohort study of pregnant women with multiples who delivered live-born infants at Sharp Healthcare Hospitals in San Diego, CA, USA during January 1st, 2016 – September 30th, 2017. Bleeding complications of 295 women who underwent ECC (less than 30 s) were compared with 154 women who underwent DCC (more than 30 s). ECC or DCC was performed according to individual obstetrician discretion. Results Four hundred forty-nine women with multiple pregnancies (N = 910 infants) were included in the study. 252 (85.4%) women underwent cesarean section in ECC group vs. 99 (64.3%) in DCC group. 58 (19.7%) women delivered monochorionic twins in ECC group vs. 32 (20.8%) women in DCC group. There was no increase in maternal estimate blood loss when DCC was performed comparing to ECC. There were no differences in operative time, post-delivery decrease in hematocrits, rates of postpartum hemorrhage, bleeding complications, maternal blood transfusions and therapeutic hysterectomy between the two groups. Conclusions No differences in maternal bleeding complications were found with DCC in multiple pregnancies compared to ECC. Delayed cord clamping can be done safely in multiple pregnancies without any increased maternal risk.
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Affiliation(s)
- Chayatat Ruangkit
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Matthew Leon
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, 8555 Aero Dr., Suite 104, San Diego, CA, 92123, USA
| | - Kasim Hassen
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, 8555 Aero Dr., Suite 104, San Diego, CA, 92123, USA
| | - Katherine Baker
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, 8555 Aero Dr., Suite 104, San Diego, CA, 92123, USA
| | - Debra Poeltler
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, 8555 Aero Dr., Suite 104, San Diego, CA, 92123, USA
| | - Anup Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, 8555 Aero Dr., Suite 104, San Diego, CA, 92123, USA.
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295
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Polglase GR, Stark M. Cord clamping in term and pre‐term infants: how should clinicians proceed? Med J Aust 2018. [DOI: 10.5694/mja17.01287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Graeme R Polglase
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC
- Monash University, Melbourne, VIC
| | - Michael Stark
- Women's and Children's Health Network, Adelaide, SA
- Robinson Research Institute, University of Adelaide, Adelaide, SA
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296
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Abstract
Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.
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Affiliation(s)
- Unyime Ituk
- Department of Anesthesia, University of Iowa, Iowa City, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
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297
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Crighton GL, New HV, Liley HG, Stanworth SJ. Patient blood management, what does this actually mean for neonates and infants? Transfus Med 2018; 28:117-131. [PMID: 29667253 DOI: 10.1111/tme.12525] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/08/2018] [Accepted: 03/12/2018] [Indexed: 12/18/2022]
Abstract
Patient blood management (PBM) refers to an evidence-based package of care that aims to improve patient outcomes by optimal use of transfusion therapy, including managing anaemia, preventing blood loss and improving anaemia tolerance in surgical and other patients who may need transfusion. In adults, PBM programmes are well established, yet the definition and implementation of PBM in neonates and children lags behind. Neonates and infants are frequently transfused, yet they are often under-represented in transfusion trials. Adult PBM programmes may not be directly applicable to these populations. We review the literature in neonatal (and applicable paediatric) transfusion medicine and propose specific neonatal PBM definitions and elements.
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Affiliation(s)
- G L Crighton
- Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - H V New
- Clinical Research, NHS Blood and Transplant, London, UK
- Centre for Haematology, Imperial College, London, UK
| | - H G Liley
- Neonatology, Mater Mothers' Hospital, Brisbane, Queensland, Australia
- Mater Medical Research Institute, Brisbane, Queensland, Australia
| | - S J Stanworth
- Clinical Haematology, John Radcliffe Hospital, NHS Blood and Transplant Oxford, Oxford, UK
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
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298
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Koschnitzky JE, Keep RF, Limbrick DD, McAllister JP, Morris JA, Strahle J, Yung YC. Opportunities in posthemorrhagic hydrocephalus research: outcomes of the Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop. Fluids Barriers CNS 2018; 15:11. [PMID: 29587767 PMCID: PMC5870202 DOI: 10.1186/s12987-018-0096-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/09/2018] [Indexed: 12/19/2022] Open
Abstract
The Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop was held on July 25 and 26, 2016 at the National Institutes of Health. The workshop brought together a diverse group of researchers including pediatric neurosurgeons, neurologists, and neuropsychologists with scientists in the fields of brain injury and development, cerebrospinal and interstitial fluid dynamics, and the blood-brain and blood-CSF barriers. The goals of the workshop were to identify areas of opportunity in posthemorrhagic hydrocephalus research and encourage scientific collaboration across a diverse set of fields. This report details the major themes discussed during the workshop and research opportunities identified for posthemorrhagic hydrocephalus. The primary areas include (1) preventing intraventricular hemorrhage, (2) stopping primary and secondary brain damage, (3) preventing hydrocephalus, (4) repairing brain damage, and (5) improving neurodevelopment outcomes in posthemorrhagic hydrocephalus.
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Affiliation(s)
| | - Richard F. Keep
- University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109 USA
| | - David D. Limbrick
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - James P. McAllister
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - Jill A. Morris
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Neuroscience Center, 6001 Executive Blvd, NSC Rm 2112, Bethesda, MD 20892 USA
| | - Jennifer Strahle
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - Yun C. Yung
- Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Rd., Building 7, La Jolla, CA 92037 USA
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299
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Niermeyer S, Perlman JM. Helping Babies Breathe: When Less Is More. Neonatology 2018; 114:124-126. [PMID: 29804105 DOI: 10.1159/000489081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/10/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Susan Niermeyer
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeffrey M Perlman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Weill Cornell Medicine, New York, New York, USA
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300
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Lio A, Aurilia C, Zahra V, Moss TJ, LaRosa DA, Hooper SB, Gill AW, Kluckow M, Nitsos I, Vento G, Polglase GR. Ventilation Prior to Umbilical Cord Clamping Improves Cardiovascular Stability and Oxygenation in Preterm Lambs After Exposure to Intrauterine Inflammation. Front Pediatr 2018; 6:286. [PMID: 30410874 PMCID: PMC6209675 DOI: 10.3389/fped.2018.00286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/17/2018] [Indexed: 11/30/2022] Open
Abstract
Background: Delaying umbilical cord clamping until after aeration of the lung (physiological-based cord clamping; PBCC) maintains cardiac output and oxygenation in preterm lambs at birth, however, its efficacy after intrauterine inflammation is not known. Given the high incidence of chorioamnionitis in preterm infants, we investigated whether PBCC conferred any benefits compared to immediate cord clamping (ICC) in preterm lambs exposed antenatally to 7 days of intrauterine inflammation. Methods: Ultrasound guided intraamniotic injection of 20 mg Lipopolysaccharide (from E. coli:055:B5) was administered to pregnant ewes at 0.8 gestation. Seven days later, ewes were anesthetized, preterm fetuses exteriorised via cesarean section, and instrumented for continuous measurement of pulmonary, systemic and cerebral pressures and flows, and systemic, and cerebral oxygenation. Lambs were then randomized to either PBCC, whereupon ventilation was initiated and maintained for 3 min prior to umbilical cord clamping, or ICC where the umbilical cord was cut and ventilation initiated 30 s later. Ventilation was maintained for 30 min. Results: ICC caused a rapid fall in systemic (by 25%) and cerebral (by 11%) oxygen saturation in ICC lambs, concurrent with a rapid increase in carotid arterial pressure and heart rate. The overshoot in carotid arterial pressure was sustained in ICC lambs for the first 20 min of the study. PBCC maintained cardiac output and prevented the fall in cerebral oxygen delivery at birth. PBCC lambs had lower respiratory compliance and higher respiratory requirements throughout the study. Conclusion: PBCC mitigated the adverse effects of ICC on oxygenation and cardiac output, and therefore could be more beneficial in preterm babies exposed to antenatal inflammation as it maintains cardiac output and oxygen delivery. The increased respiratory requirements require further investigation in this sub-group of preterm infants.
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Affiliation(s)
- Alessandra Lio
- Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Aurilia
- Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerie Zahra
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Timothy J Moss
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Domenic A LaRosa
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Stuart B Hooper
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Andrew W Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Ilias Nitsos
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Giovanni Vento
- Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Division of Neonatology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Graeme R Polglase
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University and Hudson Institute of Medical Research, Melbourne, VIC, Australia
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