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Singh B, Kumar R, Patra S, Bansal N, Singh G, Raghava K, Lodhi SK, Panchal A, Kumar S, Verma R. Comparison of Three Methods of Umbilical Cord Management in Late Preterm and Term Newborns on Hemoglobin and Ferritin Levels at Six Weeks of Age: A Randomized Controlled Trial. Cureus 2024; 16:e59046. [PMID: 38800297 PMCID: PMC11128072 DOI: 10.7759/cureus.59046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Umbilical cord milking (UCM) and delayed cord clamping (DCC) are strategies that improve the hemodynamic condition of the newborn and also increase the storage of iron. This study aimed to compare the effects of DCC with or without milking in late preterm and term neonates at different time intervals after birth (60, 120, and 180 seconds) on hematological and hemodynamic parameters in neonates at six weeks of age. MATERIALS AND METHODS In this double-arm, parallel-group, triple-blind, and active-controlled trial, all 150 eligible neonates were randomized with allocation concealment into three groups: Group A (DCC with UCM at 60 seconds), Group B (DCC with UCM at 120 seconds), and Group C (only DCC for 180 seconds). Hemodynamic parameters were recorded and compared during the first 48 hours, and hematological parameters were compared at six weeks of age. RESULTS At six weeks, a significant difference in hemoglobin levels was noted between Groups A, B, and C (p<0.001). The difference in serum ferritin values at six weeks was also statistically significant in comparisons across all three groups (p=0.003). Regarding secondary outcomes examined, hemodynamic parameters and the incidence of neonatal hyperbilirubinemia were found to be comparable at 48 hours after birth. CONCLUSION DCC followed by UCM at 120 seconds and DCC till 180 seconds proves superior to DCC with UCM at 60 seconds in preserving elevated hemoglobin levels and iron stores in neonates at six weeks of age. DCC for 180 seconds yielded comparable results, followed by UCM at 120 seconds. All three methods are considered safe and effective without compromising the neonate's hemodynamics.
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Affiliation(s)
- Brajendra Singh
- Neonatology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Rakesh Kumar
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Saikat Patra
- Neonatology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Neetika Bansal
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Gaurav Singh
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Kasi Raghava
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Santosh K Lodhi
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Amit Panchal
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Surendra Kumar
- Pediatrics, Maharaja Agrasen Medical College, Agroha, Hisar, IND
| | - Ruchi Verma
- Obstetrics and Gynaecology, Government Institute of Medical Sciences (GIMS), Greater Noida, IND
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Kartal İ, Abbasoglu A, Taysi S. Comparison of Three Different Cord Clamping Techniques Regarding Oxidative-Antioxidative Capacity in Term Newborns. Am J Perinatol 2024; 41:575-579. [PMID: 35026851 DOI: 10.1055/a-1739-3529] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE As newborns are exposed to oxidative stress during delivery, cord clamping techniques play significant role on antioxidant status. In this study, we aimed to show the relationship between early cord clamping (ECC), delayed cord clamping (DCC), and cut-umbilical cord milking (C-UCM) techniques with total oxidant capacity (TOC), total antioxidant capacity (TAC), and peroxynitrite levels. STUDY DESIGN Sixty-nine term infants were selected with Apgar's score of 7 and above in the 1 minute and 5 minutes. The mothers of all infants had uncomplicated pregnancy, had no congenital anomaly, and delivered by cesarean section. Newborns were randomized to one of three groups: ECC (n: 23), DCC (n: 23), or C-UCM (n: 23). After all newborn babies were taken under radiant heater, blood samples were collected from the UC. The plasma samples were then frozen and stored at -80°C until analysis and TOC, TAC, and peroxynitrite levels were studied. RESULTS The ages of the mothers participating in the study were between 17 and 42 years, with an average of 29.14 ± 6.28. Thirty (43.5%) of the babies were girls and 39 (56.5%) were boys. The 5-minute Apgar's score of the babies in ECC group was significantly lower than the babies in DCC and cut cord milking group (p = 0.034; p = 0.034; p < 0.05). The TOC, oxidative stress index (OSI), and peroxynitrite measurements of three groups did not differ statistically. The TAC value of the C-UCM group was significantly higher than the patients with the ECC and DCC groups (p = 0.002; p = 0.019; p < 0.05). CONCLUSION C-UCM and DCC would be feasible methods by increasing antioxidant status and providing protective effect on the future health of the term newborns. KEY POINT · Cord clamping techniques play significant role on antioxidant status of the newborn babies.. · C-UCM and DCC are feasible methods for term newborns.. · Cord clamping methods may play a protective effect on the future health of term newborns..
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Affiliation(s)
- İshak Kartal
- Department of Pediatrics, Viransehir State Hospital, Sanliurfa, Turkey
| | - Aslihan Abbasoglu
- Department of Pediatrics, Neonatology, İzmir Katip Celebi University, Faculty of Medicine, Balatcik Mahallesi, Çiğli İzmir, Turkey
| | - Seyithan Taysi
- Department of Medical Biochemistry, Gaziantep University, Faculty of Medicine, Gaziantep, Gaziantep, Turkey
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de Preud'homme d'Hailly de Nieuport SMI, Krijgh EJC, Pruijssers B, Visser J, van Beek RHT. Delayed cord clamping vs cord milking in elective cesarean delivery at term: a randomized controlled trial. Am J Obstet Gynecol MFM 2024; 6:101279. [PMID: 38232817 DOI: 10.1016/j.ajogmf.2024.101279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Delayed cord clamping has significant beneficial effects on the neonate and its transition to extrauterine life and, therefore, is common practice at vaginal births in the Netherlands. In 2015, 16% of neonates were born via cesarean delivery; moreover, in 81% of these cases, the umbilical cord was clamped and cut immediately. Neonatal benefits of delayed cord clamping are an increased circulating volume of 25 to 30 mL/kg, leading to a higher preload of both the right and left ventricles during the transition from umbilical circulation to pulmonary circulation, thus maintaining a stable left ventricle output, and to higher neonatal hemoglobin and hematocrit levels 24 to 48 hours after birth. Currently, little is known about whether the abovementioned neonatal benefits of delayed cord clamping could apply to neonates delivered by cesarean delivery. In these cases, possible negative effects on neonatal outcomes (ie, neonatal hypothermia, lower Apgar scores, and hyperbilirubinemia) and maternal outcomes (ie, increased maternal blood loss and higher postoperative infection rate) should also be taken into consideration. OBJECTIVE This study aimed to determine whether clamping the umbilical cord after 2 minutes is superior to cord milking during elective cesarean deliveries at term, taking both short- and long-term neonatal and maternal outcomes into consideration, and to determine whether cord milking could be an appropriate alternative to delayed cord clamping. STUDY DESIGN A randomized controlled trial was conducted in a large secondary care center in the Netherlands (Amphia Hospital in Breda) from October 2020 to April 2022. A total of 115 patients who underwent an elective cesarean delivery between 37 0/7 and 41 6/7 weeks of gestation were included. The primary outcomes were neonatal hemoglobin and hematocrit levels at 48 hours after birth. The secondary outcomes were divided into neonatal and maternal outcomes. RESULTS After randomization, 58 participants were treated with cord milking, and 57 participants were treated with delayed cord clamping. There was no significant difference in demographic characteristics between both groups. There was no significant difference in the primary outcomes, with a mean hemoglobin level 48 hours after birth of 12.1 mmol/L in the delayed cord clamping group and 12.2 mmol/L in the cord milking group (P=.80). Regarding our secondary outcomes, there was no significant difference regarding Apgar score, neonatal body temperature, maternal blood loss, and postoperative infection rate between our intervention groups. CONCLUSION Hemoglobin and hematocrit levels at 48 hours after birth showed no significant difference when comparing delayed cord clamping with cord milking. Delayed cord clamping did not lead to increased maternal blood loss or postoperative infections compared with a method with a much shorter timeframe between delivery and clamping of the umbilical cord, namely, cord milking. In addition, delayed cord clamping did not lead to a lower Apgar score or neonatal temperature compared with cord milking. Our research suggests that delayed cord clamping can be safely performed during elective cesarean deliveries at term. If intraoperative circumstances do not allow for delayed cord clamping, cord milking can be an appropriate alternative for the neonate at term.
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Affiliation(s)
| | - Eldin J C Krijgh
- Pediatrics (Drs Krijgh and van Beek), Amphia Hospital, Breda, The Netherlands
| | - Bente Pruijssers
- Departments of Obstetrics and Gynecology (Drs de Preud'homme, Pruijssers, and Visser)
| | - Jantien Visser
- Departments of Obstetrics and Gynecology (Drs de Preud'homme, Pruijssers, and Visser)
| | - Ron H T van Beek
- Pediatrics (Drs Krijgh and van Beek), Amphia Hospital, Breda, The Netherlands
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Bora RL, Bandyopadhyay S, Saha B, Mukherjee S, Hazra A. Cut umbilical cord milking (C-UCM) as a mode of placental transfusion in non-vigorous preterm neonates: a randomized controlled trial. Eur J Pediatr 2023; 182:3883-3891. [PMID: 37336848 DOI: 10.1007/s00431-023-05063-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 06/21/2023]
Abstract
Routine practice of delayed cord clamping (DCC) is the standard of care in vigorous neonates. However there is no consensus on the recommended approach to placental transfusion in non-vigorous neonates. In this trial, we tried to examine the effect of cut umbilical cord milking (C-UCM) as compared to early cord clamping (ECC) on hematological and clinical hemodynamic parameters in non-vigorous preterm neonates of 30-35 weeks gestation. The primary outcome assessed was venous hematocrit (Hct) at 48 (± 4) hours of postnatal age. The important secondary outcomes assessed were serum ferritin at 6 weeks of age, mean blood pressure in the initial transitional phase along with important neonatal morbidities and potential complications. In this single centre randomized controlled trial, 134 non vigorous neonates of 30-35 weeks gestation were allocated in a 1:1 ratio to either C-UCM (n = 67) or ECC (n = 67). For statistical analysis, unpaired Student t and Chi square or Fisher's exact test were used. The mean Hct at 48 h was higher in the C-UCM group as compared to the control group, 50.24(4.200) vs 46.16(2.957), p < .0001. Also significantly higher was the mean Hct at 12 h, 6 weeks and mean serum ferritin at 6 weeks of age in the milked group (p < .0001). Mean blood pressure at 1 h and 6 h was also significantly higher in the milked arm. Need for transfusion and inotropes was less in the milked group but not statistically significant. No significant difference in potential complications was observed between the groups. Conclusion: C-UCM stabilizes initial blood pressure and results in higher hematocrit and improved iron stores. It can be an alternative to DCC in non-vigorous preterm neonates of 30-35 weeks' gestation. Further large multicentric studies are needed to fully establish its efficacy and safety. Trial registration: CTRI/2021/12/038606; registration date December 14, 2021. What is Known: • DCC is the routinely recommended method of placental transfusion for vigorous neonates but no consensus exist for neonates requiring resuscitation at birth. • C-UCM is easier to perform in non-vigorous neonates but there is paucity of studies in the preterm population. What is New: • C-UCM is effective as well as safe in non-vigorous preterm neonates of 30-35 weeks gestational age. • C-UCM holds promise as an alternative to DCC, especially in resource limited settings and in situations where the later is not feasible.
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Affiliation(s)
- Rajib Losan Bora
- Department of Neonatology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Sambhunath Bandyopadhyay
- Department of Obstetrics and Gynaecology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Bijan Saha
- Department of Neonatology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India.
| | - Suchandra Mukherjee
- Department of Neonatology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Abhijit Hazra
- Department of Pharmacology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
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Kilicdag H, Anuk Ince D, Ecevit A. Editorial: Umbilical cord milking-benefits and potential harmful effects. Front Pediatr 2023; 11:1210388. [PMID: 37351313 PMCID: PMC10283007 DOI: 10.3389/fped.2023.1210388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
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Katheria A, Mercer J, Poeltler D, Morales A, Torres N, Lakshminrusimha S, Singh Y. Hemodynamic Changes with Umbilical Cord Milking in Nonvigorous Newborns: A Randomized Cluster Cross-over Trial. J Pediatr 2023; 257:113383. [PMID: 36914049 PMCID: PMC10293099 DOI: 10.1016/j.jpeds.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVE To assess the hemodynamic safety and efficacy of umbilical cord milking (UCM) compared with early cord clamping (ECC) in nonvigorous newborn infants enrolled in a large multicenter randomized cluster-crossover trial. STUDY DESIGN Two hundred twenty-seven nonvigorous term or near-term infants who were enrolled in the parent UCM vs ECC trial consented for this substudy. An echocardiogram was performed at 12 ± 6 hours of age by ultrasound technicians blinded to randomization. The primary outcome was left ventricular output (LVO). Prespecified secondary outcomes included measured superior vena cava (SVC) flow, right ventricular output (RVO), peak systolic strain, and peak systolic velocity by tissue Doppler examination of the RV lateral wall and the interventricular septum. RESULTS Nonvigorous infants receiving UCM had increased hemodynamic echocardiographic parameters as measured by higher LVO (225 ± 64 vs 187 ± 52 mL/kg/min; P < .001), RVO (284 ± 88 vs 222 ± 96 mL/kg/min; P < .001), and SVC flow (100 ± 36 vs 86 ± 40 mL/kg/min; P < .001) compared with the ECC group. Peak systolic strain was lower (-17 ± 3 vs -22 ± 3%; P < .001), but there was no difference in peak tissue Doppler flow (0.06 m/s [IQR, 0.05-0.07 m/s] vs 0.06 m/s [IQR, 0.05-0.08 m/s]). CONCLUSIONS UCM increased cardiac output (as measured by LVO) compared with ECC in nonvigorous newborns. Overall increases in measures of cerebral and pulmonary blood flow (as measured by SVC and RVO flow, respectively) may explain improved outcomes associated with UCM (less cardiorespiratory support at birth and fewer cases of moderate-to-severe hypoxic ischemic encephalopathy) among nonvigorous newborn infants.
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Affiliation(s)
- Anup Katheria
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA.
| | - Judith Mercer
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA; Department of Obstetrics, University of Rhode Island, Kingston, RI
| | - Deb Poeltler
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Ana Morales
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Nohemi Torres
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, CA
| | - Yogen Singh
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA
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Katheria AC, Clark E, Yoder B, Schmölzer GM, Yan Law BH, El-Naggar W, Rittenberg D, Sheth S, Mohamed MA, Martin C, Vora F, Lakshminrusimha S, Underwood M, Mazela J, Kaempf J, Tomlinson M, Gollin Y, Fulford K, Goff Y, Wozniak P, Baker K, Rich W, Morales A, Varner M, Poeltler D, Vaucher Y, Mercer J, Finer N, El Ghormli L, Rice MM. Umbilical cord milking in nonvigorous infants: a cluster-randomized crossover trial. Am J Obstet Gynecol 2023; 228:217.e1-217.e14. [PMID: 35970202 PMCID: PMC9877105 DOI: 10.1016/j.ajog.2022.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/15/2022] [Accepted: 08/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Delayed cord clamping and umbilical cord milking provide placental transfusion to vigorous newborns. Delayed cord clamping in nonvigorous newborns may not be provided owing to a perceived need for immediate resuscitation. Umbilical cord milking is an alternative, as it can be performed more quickly than delayed cord clamping and may confer similar benefits. OBJECTIVE We hypothesized that umbilical cord milking would reduce admission to the neonatal intensive care unit compared with early cord clamping in nonvigorous newborns born between 35 and 42 weeks' gestation. STUDY DESIGN This was a pragmatic cluster-randomized crossover trial of infants born at 35 to 42 weeks' gestation in 10 medical centers in 3 countries between January 2019 and May 2021. The centers were randomized to umbilical cord milking or early cord clamping for approximately 1 year and then crossed over for an additional year or until the required number of consented subjects was reached. Waiver of consent as obtained in all centers to implement the intervention. Infants were eligible if nonvigorous at birth (poor tone, pale color, or lack of breathing in the first 15 seconds after birth) and were assigned to umbilical cord milking or early cord clamping according to their birth hospital randomization assignment. The baseline characteristics and outcomes were collected following deferred informed consent. The primary outcome was admission to the neonatal intensive care unit for predefined criteria. The main safety outcome was hypoxic-ischemic encephalopathy. Data were analyzed by the intention-to-treat concept. RESULTS Among 16,234 screened newborns, 1780 were eligible (905 umbilical cord milking, 875 early cord clamping), and 1730 had primary outcome data for analysis (97% of eligible; 872 umbilical cord milking, 858 early cord clamping) either via informed consent (606 umbilical cord milking, 601 early cord clamping) or waiver of informed consent (266 umbilical cord milking, 257 early cord clamping). The difference in the frequency of neonatal intensive care unit admission using predefined criteria between the umbilical cord milking (23%) and early cord clamping (28%) groups did not reach statistical significance (modeled odds ratio, 0.69; 95% confidence interval, 0.41-1.14). Umbilical cord milking was associated with predefined secondary outcomes, including higher hemoglobin (modeled mean difference between umbilical cord milking and early cord clamping groups 0.68 g/dL, 95% confidence interval, 0.31-1.05), lower odds of abnormal 1-minute Apgar scores (Apgar ≤3, 30% vs 34%, crude odds ratio, 0.72; 95% confidence interval, 0.56-0.92); cardiorespiratory support at delivery (61% vs 71%, modeled odds ratio, 0.57; 95% confidence interval, 0.33-0.99), and therapeutic hypothermia (3% vs 4%, crude odds ratio, 0.57; 95% confidence interval, 0.33-0.99). Moderate-to-severe hypoxic-ischemic encephalopathy was significantly less common with umbilical cord milking (1% vs 3%, crude odds ratio, 0.48; 95% confidence interval, 0.24-0.96). No significant differences were observed for normal saline bolus, phototherapy, abnormal 5-minute Apgar scores (Apgar ≤6, 15.7% vs 18.8%, crude odds ratio, 0.81; 95% confidence interval, 0.62-1.06), or a serious adverse event composite of death before discharge. CONCLUSION Among nonvigorous infants born at 35 to 42 weeks' gestation, umbilical cord milking did not reduce neonatal intensive care unit admission for predefined criteria. However, infants in the umbilical cord milking arm had higher hemoglobin, received less delivery room cardiorespiratory support, had a lower incidence of moderate-to-severe hypoxic-ischemic encephalopathy, and received less therapeutic hypothermia. These data may provide the first randomized controlled trial evidence that umbilical cord milking in nonvigorous infants is feasible, safe and, superior to early cord clamping.
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MESH Headings
- Female
- Humans
- Infant, Newborn
- Pregnancy
- Blood Transfusion
- Constriction
- Cross-Over Studies
- Hemoglobins
- Hypoxia-Ischemia, Brain/etiology
- Infant, Premature
- Placenta
- Umbilical Cord/surgery
- Umbilical Cord Clamping/methods
- Infant, Premature, Diseases/surgery
- Infant, Premature, Diseases/therapy
- Infant, Newborn, Diseases/surgery
- Infant, Newborn, Diseases/therapy
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Affiliation(s)
- Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA.
| | - Erin Clark
- Division of Maternal-Fetal Medicine, The University of Utah School of Medicine, Salt Lake City, UT
| | - Bradley Yoder
- Division of Neonatology, The University of Utah School of Medicine, Salt Lake City, UT
| | - Georg M Schmölzer
- Division of Neonatal-Perinatal Care, University of Alberta, Alberta, Canada
| | - Brenda Hiu Yan Law
- Division of Neonatal-Perinatal Care, University of Alberta, Alberta, Canada
| | - Walid El-Naggar
- Division of Neonatal-Perinatal Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Rittenberg
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sheetal Sheth
- Department of Obstetrics and Gynecology, The GW Medical Faculty Associates, Washington, DC
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH
| | | | - Farha Vora
- Loma Linda Health University, Loma Linda, CA
| | | | - Mark Underwood
- University of California Davis Children's Hospital, Sacramento, CA
| | - Jan Mazela
- Poznan University of Medical Science, Poznan, Poland
| | - Joseph Kaempf
- Providence St. Vincent Medical Center, Providence Health System, Oregon, United States of America
| | - Mark Tomlinson
- Providence St. Vincent Medical Center, Providence Health System, Oregon, United States of America
| | - Yvonne Gollin
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | | | | | - Paul Wozniak
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA; Sharp Grossmont Hospital, La Mesa, CA
| | - Katherine Baker
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Ana Morales
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Michael Varner
- Division of Maternal-Fetal Medicine, The University of Utah School of Medicine, Salt Lake City, UT
| | - Debra Poeltler
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | | | - Judith Mercer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Laure El Ghormli
- The George Washington University Biostatistics Center, Washington, DC
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Angarita AM, Cochrane E, Bianco A, Berghella V. Prevention of postpartum hemorrhage in vaginal deliveries. Eur J Obstet Gynecol Reprod Biol 2023; 280:112-119. [PMID: 36455391 DOI: 10.1016/j.ejogrb.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/07/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Identification of patients at risk for postpartum hemorrhage (PPH) may allow for prompt diagnosis and intervention. Individual risk factors, risk assessment tools and prediction models have been used for determining a patient's risk of PPH. Measures for the prevention of PPH include identification and management of iron deficiency anemia, unit readiness and preparedness through performing regular simulations and having a PPH cart or medication kit readily available, prophylactic uterotonic - carbetocin alone or dual agents such as oxytocin and misoprostol or oxytocin and methylergometrine or antifibrinolytic (oxytocin and tranexamic acid) use in the third stage of labor immediately after fetal head delivery, and controlled cord traction.
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Affiliation(s)
- Ana M Angarita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Elizabeth Cochrane
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Angela Bianco
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
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Murali M, Sethuraman G, Vasudevan J, Umadevi L, Devi U. Delayed cord clamping versus cord milking in vigorous neonates ≥35 weeks gestation born via cesarean: A Randomized clinical trial. J Neonatal Perinatal Med 2023; 16:597-603. [PMID: 38007676 DOI: 10.3233/npm-230069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
BACKGROUND Delayed cord clamping (DCC) is the recommended strategy in neonates not requiring resuscitation, but umbilical cord milking (UCM) can also be used in term babies. DCC has been found to offer advantages more than just placental transfusion. OBJECTIVE To compare the neonatal outcomes of DCC and UCM at birth in vigorous neonates ≥35 weeks born via cesarean section. METHODS We included all vigorous neonates born ≥35 weeks of gestation through the cesarean section in this open-label randomized controlled trial. They were randomized into Group-A (DCC-cord was clamped 60 s after birth) or Group B(UCM). For neonates in Group B, the intact cord was milked at 25 cm from the stump 3 times towards the neonate and then clamped. The primary outcome was hematocrit at 72 h of life. Secondary outcomes were serum ferritin between 6 and 10 weeks of life, serum bilirubin at 72 h of life, need and duration of phototherapy, respiratory distress, hypoglycemia, hypotension, and sepsis. RESULTS Baseline characteristics were similar in both the groups. The mean hematocrit at 72 h was more in the DCC group compared to the UCM group [(55.60±4.50) vs (53.89±4.44), MD (95% CI) = 1.71 (0.26, 3.16); p = 0.021]. There was no significant difference in median serum ferritin between the groups [102.88(84.67-173.24) vs 137.93(85.15-230.40); p = 0.173]. There was no significant difference in clinical outcomes. CONCLUSION In neonates born via cesarean section, DCC resulted in improved hematocrit levels by 72 hours compared to UCM. DCC results in better placental transfusion.
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Affiliation(s)
- Mithuna Murali
- Department of Pediatrics, Chettinad Hospital & Research Institute, Kelambakkam, Kanchipuram, Tamilnadu, India
| | - Giridhar Sethuraman
- Department of Neonatology, Chettinad Hospital & Research Institute, Kelambakkam, Kanchipuram, Tamilnadu, India
| | - Jaishree Vasudevan
- Department of Pediatrics, Chettinad Hospital & Research Institute, Kelambakkam, Kanchipuram, Tamilnadu, India
| | - L Umadevi
- Department of Pediatrics, Chettinad Hospital & Research Institute, Kelambakkam, Kanchipuram, Tamilnadu, India
| | - Usha Devi
- Department of Neonatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Koo J, Kilicdag H, Katheria A. Umbilical cord milking-benefits and risks. Front Pediatr 2023; 11:1146057. [PMID: 37144151 PMCID: PMC10151786 DOI: 10.3389/fped.2023.1146057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.
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Affiliation(s)
- Jenny Koo
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
| | - Hasan Kilicdag
- Divisions of Neonatology, Baskent University Faculty of Medicine, Ankara, Türkiye
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
- Correspondence: Anup Katheria
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11
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Blank DA, Crossley KJ, Thiel A, Rodgers KA, Zahra V, Kluckow M, Gill AW, Polglase GR, Hooper SB. Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs. Front Pediatr 2023; 11:1073904. [PMID: 37025294 PMCID: PMC10071016 DOI: 10.3389/fped.2023.1073904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/17/2023] [Indexed: 04/08/2023] Open
Abstract
Background Umbilical cord milking (UCM) at birth causes surges in arterial blood pressure and blood flow to the brain, which may explain the high risk of intraventricular haemorrhage (IVH) in extremely preterm infants receiving UCM. This high risk of IVH has not been reported in older infants. Objective We hypothesized that lung aeration before UCM, reduces the surge in blood pressure and blood flow induced by UCM. Methods At 126 days' gestation, fetal lambs (N = 8) were exteriorised, intubated and instrumented to measure umbilical, pulmonary, cerebral blood flows, and arterial pressures. Prior to ventilation onset, the umbilical cord was briefly (2-3 s) occluded (8 times), which was followed by 8 consecutive UCMs when all physiological parameters had returned to baseline. Lambs were then ventilated. After diastolic pulmonary blood flow markedly increased in response to ventilation, the lambs received a further 8 consecutive UCMs. Ovine umbilical cord is shorter than the human umbilical cord, with ∼10 cm available for UCMs. Therefore, 8 UCMs/occlusions were done to match the volume reported in the human studies. Umbilical cord clamping occurred after the final milk. Results Both umbilical cord occlusions and UCM caused significant increases in carotid arterial blood flow and pressure. However, the increases in systolic and mean arterial blood pressure (10 ± 3 mmHg vs. 3 ± 2 mmHg, p = 0.01 and 10 ± 4 mmHg vs. 6 ± 2 mmHg, p = 0.048, respectively) and carotid artery blood flow (17 ± 6 ml/min vs. 10 ± 6 ml/min, p = 0.02) were significantly greater when UCM occurred before ventilation onset compared with UCM after ventilation. Conclusions UCM after ventilation onset significantly reduces the increases in carotid blood flow and blood pressure caused by UCM.
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Affiliation(s)
- Douglas A. Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Correspondence: Douglas A. Blank
| | - Kelly J. Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Alison Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Karyn A. Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney NSW, Australia
| | - Andrew W. Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Stuart B. Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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12
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Jain SN, Mehendale AM. A Review on Umbilical Cord Milking and Its Implications in Neonatal Health. Cureus 2022; 14:e30610. [DOI: 10.7759/cureus.30610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
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13
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Atia H, Badawie A, Elsaid O, Kashef M, Alhaddad N, Gomaa M. The hematological impact of umbilical cord milking versus delayed cord clamping in premature neonates: a randomized controlled trial. BMC Pregnancy Childbirth 2022; 22:714. [PMID: 36123638 PMCID: PMC9484179 DOI: 10.1186/s12884-022-05046-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The hematological impact of umbilical cord milking (UCM) was compared to that of delayed cord clamping (DCC) as a faster placental transfusion technique for preterm neonates (between 24 and 34 + 6 weeks gestation). A comparison of important neonatal morbidities was also made. METHODS This was an open-label randomized trial conducted from June 8, 2017, to April 22, 2019. Two hundred patients with preterm deliveries (24 and 34 + 6 weeks gestation) were assigned to the DCC or UCM group at random at a ratio of 1:1. The study power was 80% for a difference in the hematocrit value of 3% and Hb value of one gram, and an alpha error of 0.05. RESULTS The following variables were analyzed in the comparison of UCM vs. DCC: first draw hemoglobin: 17.0 ± 1.9 vs. 16.8 ± 1.8 gm/dl (95% CI -0.75-0.29, P 0.383); first draw hematocrit: 55.6 ± 6.4 vs. 55.2 ± 6.4% (95% CI -2.18-1.38, P 0.659); peak hematocrit: 56.9 ± 6.4 vs. 56.3 ± 6.7% (95% CI -2.41-1.26, P 0.537); the need for respiratory assistance (47% vs. 30%, P 0.020), inotropes (16% vs. 6%, P 0.040), and blood transfusion (26% vs. 12%, P 0.018); and the occurrence of intraventricular hemorrhage (9% vs. 5%, P 0.407), necrotizing enterocolitis (6% vs. 2%, P 0.279), sepsis (25% vs. 15%, P 0.111), and neonatal death (13% vs. 4%, P 0.40). CONCLUSION UCM facilitated a rapid transfer of placental blood equivalent to that of DCC for premature neonates. However, it resulted in increased rates of interventions and morbidities, especially in extremely preterm neonates. TRIAL REGISTRATION The clinical trial was registered on May 10, 2017, with registration number (NCT03147846).
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Affiliation(s)
- Hytham Atia
- Faculty of Medicine, Zagazig University, Zagazig, Sharkia, Egypt. .,Armed Forces Hospitals Southern Region, King Faisal Military City Hospital, Base-villa 68, King Faisal military city, 62417-8183, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Ahmed Badawie
- Armed Forces Hospitals Southern Region, King Faisal Military City Hospital, Base-villa 68, King Faisal military city, 62417-8183, Khamis Mushait, Kingdom of Saudi Arabia.,Faculty of Medicine, October 6 University, Cairo, Egypt
| | - Osama Elsaid
- Armed Forces Hospitals Southern Region, King Faisal Military City Hospital, Base-villa 68, King Faisal military city, 62417-8183, Khamis Mushait, Kingdom of Saudi Arabia
| | - Mahmoud Kashef
- Armed Forces Hospitals Southern Region, King Faisal Military City Hospital, Base-villa 68, King Faisal military city, 62417-8183, Khamis Mushait, Kingdom of Saudi Arabia
| | | | - Mohamed Gomaa
- Armed Forces Hospitals Southern Region, King Faisal Military City Hospital, Base-villa 68, King Faisal military city, 62417-8183, Khamis Mushait, Kingdom of Saudi Arabia
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Kilicdag H, Karagun BS, Antmen AB, Candan E, Erbas H. Umbilical Cord Management in Late Preterm and Term Infants: A Randomized Controlled Trial. Am J Perinatol 2022; 39:1308-1313. [PMID: 33472241 DOI: 10.1055/s-0040-1722327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The study aimed to compare the effects of three different methods of umbilical cord management on hematological parameters in term and late-preterm infants. STUDY DESIGN A randomized controlled trial comparing intact-umbilical cord milking (I-UCM) with cut-umbilical cord milking (C-UCM) and immediate cord clamping (ICC) in neonates born >35 weeks' gestation. RESULTS A total of 587 infants were evaluated. Of these, 197 were assigned to I-UCM, 190 to C-UCM, and 200 to ICC. Mean hemoglobin and hematocrit levels at 48 hours of age were higher in I-UCM group compared with the ICC group (p = 0.002 and p = 0.010, respectively). CONCLUSION These findings suggest that I-UCM is more beneficial choice. Further trials are needed to assess the various long- and short-term effects of different cord milking methods. KEY POINTS · This is the first study comparing these three methods (I-UCM, C-UCM, and ICC) concurrently.. · I-UCM is more beneficial choice.. · Although the terms I-UCM and C-UCM are often used interchangeably, these are different procedures..
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Affiliation(s)
- Hasan Kilicdag
- Department of Pediatrics, Division of Neonatology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | | | - Ali Bulent Antmen
- Department of Pediatrics Hematology, Adana Acibadem Hospital, Adana, Turkey
| | - Erdal Candan
- Department of Obstetrics and Gynecology, Adana Acibadem Hospital, Adana, Turkey
| | - Hale Erbas
- Department of Obstetrics and Gynecology, Adana Acibadem Hospital, Adana, Turkey
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15
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Koo J, Katheria A. Cardiopulmonary Resuscitation with an Intact Umbilical Cord. Neoreviews 2022; 23:e388-e399. [PMID: 35641463 DOI: 10.1542/neo.23-6-e388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The body of literature supporting different umbilical management strategies has increased over the past decade as the role of cord management in neonatal transition is realized. Multiple international governing bodies endorse delayed cord clamping, and this practice is now widely accepted by obstetricians and neonatologists. Although term and preterm neonates benefit in some ways from delayed cord clamping, additional research on variations in this practice, including resuscitation with an intact cord, aim to find the optimal cord management practice that reduces mortality and major morbidities.
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Affiliation(s)
- Jenny Koo
- Sharp Mary Birch, Hospital for Women and Newborn, San Diego, CA.,Sharp Neonatal Research Institute, San Diego, CA
| | - Anup Katheria
- Sharp Mary Birch, Hospital for Women and Newborn, San Diego, CA.,Sharp Neonatal Research Institute, San Diego, CA.,Loma Linda University Medical Center, Loma Linda, CA
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16
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Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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17
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation 2021; 145:e645-e721. [PMID: 34813356 DOI: 10.1161/cir.0000000000001017] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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18
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami M, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2021; 169:229-311. [PMID: 34933747 PMCID: PMC8581280 DOI: 10.1016/j.resuscitation.2021.10.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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19
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Shen SP, Chen CH, Chang HY, Hsu CH, Lin CY, Jim WT, Chang JH. A 20-cm cut umbilical cord milking may not benefit the preterm infants < 30 week's gestation: A randomized clinical trial. J Formos Med Assoc 2021; 121:912-919. [PMID: 34593275 DOI: 10.1016/j.jfma.2021.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND/PURPOSE To evaluate whether a shorter length (20 cm) of C-UCM has potential benefits, compared to immediate cord clamping (ICC), in very preterm babies. METHODS Inborn preterm infants less than 30 weeks of gestational age (GA) were randomly assigned to the 20-cm C-UMC and ICC groups. The primary outcome was the need for packed red blood cell (pRBC) transfusion before the 21st day of life. The secondary outcomes were short- and long-term outcomes related to premature birth. RESULTS Seventy-six neonates were randomized to the two groups. GA were 27.2 ± 1.8 and 27.5 ± 1.7 weeks (p = 0.389) and birth weights were 987 ± 269 and 1023 ± 313 g (p = 0.601) in the 20-cm C-UCM and ICC groups, respectively. There was no significant difference between the groups in terms of the need for pRBC transfusion before the 21st day of life (59.4% versus 71.8%, adjusted odds ratio [aOR] 0.311, 95% confidence interval [CI] 0.090-1.079). An increased prevalence of late-onset sepsis was observed in the 20-cm C-UCM group compared to the ICC group (21.6% versus 5.1%, aOR 5.434, 95% CI 1.033-23.580). The mortality rates were 13.5% and 2.6% in the 20-cm C-UCM and ICC groups, respectively (aOR 5.339, 95% CI 0.563-50.626). The neurodevelopmental outcomes at 2 years of corrected age between the groups were also not statistically significant. CONCLUSION A 20-cm C-UCM showed no effect on reducing the incidence of pRBC transfusion in preterm babies with GA less than 30 weeks compared with ICC in this small-scale randomized controlled trial.
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Affiliation(s)
- Shang-Po Shen
- Department of Pediatrics, Taitung MacKay Memorial Hospital, Taitung County, Taiwan; Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan
| | - Chih-Hao Chen
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan
| | - Hung-Yang Chang
- Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chyong-Hsin Hsu
- Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan
| | - Chia-Ying Lin
- Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan
| | - Wai-Tim Jim
- Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan
| | - Jui-Hsing Chang
- Division of Neonatology, Department of Pediatrics, MacKay Children's Hospital, Taipei City, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; MacKay Junior College of Medicine, Nursing and Management, New Taipei City, Taiwan.
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20
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Fuwa K, Tabata N, Ogawa R, Nagano N, Yamaji N, Ota E, Namba F. Umbilical cord milking versus delayed cord clamping in term infants: a systematic review and meta-analysis. J Perinatol 2021; 41:1549-1557. [PMID: 32973280 DOI: 10.1038/s41372-020-00825-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/08/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Delayed cord clamping (DCC) is recommended for healthy term infants. However, the effectiveness of umbilical cord milking (UCM) in term infants remains unknown. The study aimed to compare the effects of UCM versus DCC on term infants. STUDY DESIGN A systematic review and meta-analysis were conducted which included individual and clustered RCTs comparing UCM with DCC for infants born at ≥37 weeks of gestation. RESULTS Three trials (650 term infants) were included. Compared with DCC, UCM was associated with higher hemoglobin levels at 6 weeks after birth [infants, 621; mean difference, 0.17; 95% confidence interval, 0.05-0.29] and had no statistical differences in hemoglobin levels at birth, serum bilirubin levels at 48 h after birth, or hematocrit levels at 48 h after birth. CONCLUSION This study suggested that UCM might be as beneficial as DCC in term infants, however, further RCTs are required to accurately assess the outcomes.
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Affiliation(s)
- Kazumasa Fuwa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Itabashi, Tokyo, 173-8610, Japan.
| | - Natsuko Tabata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, 594-1101, Japan
| | - Ryo Ogawa
- Division of Neonatology, Nagano Children's Hospital, Azumino, Nagano, 399-8288, Japan
| | - Nobuhiko Nagano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Itabashi, Tokyo, 173-8610, Japan
| | - Noyuri Yamaji
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Chuo, Tokyo, 104-0044, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Chuo, Tokyo, 104-0044, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, 350-8550, Japan
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21
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Surak A, Elsayed Y. Delayed cord clamping: Time for physiologic implementation. J Neonatal Perinatal Med 2021; 15:19-27. [PMID: 34219673 DOI: 10.3233/npm-210745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Delayed cord clamping has been shown to be beneficial in both preterm and term babies. Practice guidelines have not been consistent between centers and the practice of delayed cord clamping has not been standardized. The concept of physiologic-based cord clamping emerged into practice as well. Cord milking has different physiological effect and might be harmful in preterm babies.
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Affiliation(s)
- A Surak
- Division of Neonatology, University of Alberta, Edmonton, AB, Canada
| | - Y Elsayed
- Division of Neonatology, Health Sciences Centre, Winnipeg, MB, Canada
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22
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Effect of Umbilical Cord Milking on Maternal and Neonatal Outcomes in a Tertiary Care Hospital in South India: A Randomized Control Trial. J Obstet Gynaecol India 2021; 72:291-298. [PMID: 35923518 PMCID: PMC9339438 DOI: 10.1007/s13224-021-01515-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022] Open
Abstract
Background and Aim Umbilical cord milking (UCM) has been theorized to increase placental blood transfusion then again, the optimal method of cord clamping at birth is still contested. We aimed to analyse the effects of UCM on the neonatal haematological parameters at 72 h and 6 weeks of age and its association with any adverse effects. Materials and Methods In this randomized control trial, mothers ≥ 34 weeks were randomized into two arms. Under the intervention group, the cord was milked three times before clamping and cutting whereas the controls had the cord clamped and cut without milking. Haemoglobin and haematocrit levels were measured at 72 h. and at 6 weeks. Results A total of 170 mothers were enrolled with 85 subjects in each arm. Baseline characteristics were comparable. In the intervention arm, the mean haemoglobin [18.1 (2.4) g/dL] and haematocrit [54 (7) %] were significantly higher as compared to the control arm [16.4 (2.1) g/dL and 48 (6) %], at 72 h of age. There was also significant increase in the mean haemoglobin [11.6 (1.3) g/dL] and haematocrit [34 (4) %] compared to the controls [10.1 (1.1) g/dL and 30 (3) %], at 6 weeks. No statistical difference was found in the incidence of PPH and duration of third stage. There was no significant rise in hyperbilirubinaemia, phototherapy requirement and polycythaemia among neonates in the intervention group. Conclusion Umbilical cord milking is a sound practical approach to raise the haemoglobin and haematocrit levels up to 6 weeks thereby decreasing the proportion of anaemic infants.
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A randomized controlled clinical trial on peripartum effects of delayed versus immediate umbilical cord clamping on term newborns. Eur J Obstet Gynecol Reprod Biol 2021; 262:99-104. [PMID: 34004481 DOI: 10.1016/j.ejogrb.2021.04.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare the hemoglobin and serum bilirubin concentration of term newborn following delayed and immediate umbilical cord clamping. METHODS A randomized controlled trial of eligible parturients with singleton pregnancy delivered between July 1, 2019 and September 30, 2020 were randomly assigned (1:1 ratio) to either delayed clamping of umbilical cord (60 s after delivery) or immediate clamping (0-15 s) was done. The primary outcome measures included hemoglobin and bilirubin levels of the newborn measured at birth and 48 h of life. Intention-to-treat principle was applied to analysis (www.pactr.org: PACTR201906668876480). RESULTS One hundred and two newborns were randomized into each group and none was lost to follow-up. Participants in both groups had similar socio-demographic and clinical characteristics. At 0 h of birth, cord blood hemoglobin concentration and total bilirubin values were not significantly different between the two groups (p > 0.05). At 48 h of birth, mean hemoglobin concentration was significantly higher in delayed clamping group than immediate clamping group (16.51 ± 1.71 g/dl vs 15.16 ± 2.27 g/dl; p < 0.001) but total mean bilirubin concentration was not significantly different (3.88 ± 1.54 mg/dl vs 3.71 ± 1.20 mg/dl; p = 0.380). There was no significant difference in postpartum hemorrhage (p = 0.653), neonatal jaundice (p = 0.856), and need for phototherapy (p = 0.561) while respiratory symptoms, polycythemia and anemia were not reported. CONCLUSION Delayed cord clamping at childbirth is more advantageous for term infants in terms of more hemoglobin concentration compared to traditional immediate cord clamping. The maternal and perinatal complications were either not significantly different or absent.
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24
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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25
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Yue G, Wu Y, Zhao F, Zhang C, Zhao D, Lu J, Fang Q, Li X, Wei Y, Qian M, Yi L, Zheng S, Ba R, Luo L, Luo J, Zhao S, Lu J, Huang X, Wei G, Xi Y, Gao S, Hu X, Ju R. A 3-armed multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI). Contemp Clin Trials 2021; 103:106337. [PMID: 33662589 DOI: 10.1016/j.cct.2021.106337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
Preterm infants constitute an important proportion of neonatal deaths and various complications, and very preterm infants (VPI) are more likely to develop severe complications, such as intraventricular hemorrhage (IVH), anemia, and sepsis. It has been confirmed that placental transfusion can supplement blood volume in infants and reduce preterm-associated complications, which is further conducive to the development of the nervous system and a better long-term prognosis. Based on these advantages, placental transfusion has been widely used in VPI. There are three main types of placental transfusion: delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), and cut umbilical cord milking (C-UCM). However, the optimal method for PT-VPI remains controversial, and it is urgent to identify the best method of placental transfusion. We plan to fully evaluate the safety and effectiveness of these three placental transfusion methods in VPI in a 3-arm multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI). Trial registration: chictr.org.cn, number ChiCTR2000030953.
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Affiliation(s)
- Guang Yue
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Yan Wu
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, PR China
| | - Fangping Zhao
- Neonatal Department, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, PR China
| | - Chunyi Zhang
- Neonatal Department, Guangdong Women and Children Hospital, Guangzhou, PR China
| | - Dan Zhao
- Neonatal Department, Maternity and Child-Care Hospital of Guangxi Zhuang Autonomous Region, Nanning, PR China
| | - Jingjie Lu
- Neonatal Department, Guiyang Maternal and Child Health Hospital, Guizhou, PR China
| | - Qiaoyan Fang
- Neonatal Department, Hunan Provincial Maternal and Child Healthcare Hospital, Changsha, PR China
| | - Xia Li
- Neonatal Department, Jinan Maternity and Child-Care Hospital, Jinan, PR China
| | - Yijun Wei
- Neonatal Department, Liuzhou Maternity and Child Healthcare Hospital, Liuzhou, PR China
| | - Miao Qian
- Neonatal Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, PR China
| | - Lin Yi
- Neonatal Department, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, PR China
| | - Shan Zheng
- Neonatal Department, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin, PR China
| | - Ruihua Ba
- Neonatal Department, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, PR China
| | - Liqian Luo
- Neonatal Department, Northwest Women's and Children's Hospital, Xi'an, PR China
| | - Jiping Luo
- Neonatal Department, Xichang People's Hospital, Xichang, PR China
| | - Shuai Zhao
- Neonatal Department, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Jiangyi Lu
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xia Huang
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Guoqing Wei
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Yufeng Xi
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Shuqiang Gao
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xuhong Hu
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Rong Ju
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China.
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Gomersall J, Berber S, Middleton P, McDonald SJ, Niermeyer S, El-Naggar W, Davis PG, Schmölzer GM, Ovelman C, Soll RF. Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis. Pediatrics 2021; 147:peds.2020-015404. [PMID: 33632933 DOI: 10.1542/peds.2020-015404] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management at term and late preterm birth. OBJECTIVE To assess effects of umbilical cord management strategies (clamping timing and cord milking) in infants ≥34 weeks' gestational age. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and trial registries searched July 2019. STUDY SELECTION Two authors independently assessed eligibility of randomized controlled trials. DATA EXTRACTION Two authors independently extracted data and assessed evidence certainty (Grading of Recommendations Assessment, Development and Evaluations). RESULTS We identified 46 studies (9159 women and their infants) investigating 7 comparisons. Compared with early cord clamping (ECC) <30 seconds, delayed cord clamping (DCC) ≥30 seconds (33 studies), intact-cord milking (1 study), and cut-cord milking (2 studies) probably improve hematologic measures but may not affect survival without neurodisability, anemia in early infancy, or maternal postpartum hemorrhage. No differences in major neonatal morbidities are seen in studies comparing methods of optimizing placental transfusion (DCC versus cut-cord milking [3 studies], longer delays in clamping [7 studies], or physiologic parameters [3 studies]). Strategies that promote increased placental transfusion may be associated with greater phototherapy use. Evidence for all outcomes was low or very low certainty. LIMITATIONS Incompleteness and low certainty of findings limit applicability. CONCLUSIONS Compared with ECC, DCC or cord milking increases hemoglobin and hematocrit immediately after birth in infants ≥34 weeks' gestational age. The uncertain effects of DCC and cord milking compared with ECC on major morbidities limit usefulness of available evidence for policy and practice.
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Affiliation(s)
- Judith Gomersall
- Women and Children's Hospital, South Australian Health and Medical Research Institute and The University of Adelaide, Adelaide, South Australia, Australia;
| | - Slavica Berber
- Cochrane Breast Cancer Group, Systematic Reviews and Health Technology Assessments National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Philippa Middleton
- Women and Children's Hospital, South Australian Health and Medical Research Institute and The University of Adelaide, Adelaide, South Australia, Australia
| | - Susan J McDonald
- Midwifery Professorial Unit, La Trobe University and Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Susan Niermeyer
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine
| | - Walid El-Naggar
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital and The University of Melbourne, Melbourne, Victoria, Australia
| | - Georg M Schmölzer
- Division of Neonatology, Department of Pediatrics, Medical University Graz, Graz, Austria; and
| | - Colleen Ovelman
- Department of Pediatrics, The Robert Larner College of Medicine, The University of Vermont, Burlington, Vermont
| | - Roger F Soll
- Department of Pediatrics, The Robert Larner College of Medicine, The University of Vermont, Burlington, Vermont
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Zanardo V, Guerrini P, Severino L, Simbi A, Parotto M, Straface G. A Randomized Controlled Trial of Intact Cord Milking versus Immediate Cord Clamping in Term Infants Born by Elective Cesarean Section. Am J Perinatol 2021; 38:392-397. [PMID: 31600796 DOI: 10.1055/s-0039-1697673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We evaluated whether intact umbilical cord milking (UCM) is more effective than immediate cord clamping (ICC) in enhancing placental transfusion after elective cesarean delivery. STUDY DESIGN In a randomized trial, volume of placental transfusion was assessed by Δ hematocrit (Hct) between neonatal cord blood and capillary heel blood at 48 hours of age, corrected for the change in body weight. RESULTS There were no significant differences in cord blood mean Hct values at birth (UCM, 44.5 ± 4.8 vs. ICC, 44.9 ± 4.2%, p = 0.74). Conversely, at 48 hours of age, the UCM group had significantly higher capillary heel Hct values (UCM, 53.7 ± 5.9 vs. ICC, 49.8 ± 4.6%, p < 0.001), supporting a higher placental transfusion volume (Δ Hct, UCM 9.2 ± 5.2 vs. ICC 4.8 ± 4.7, p < 0.001), despite comparable neonatal body weight decrease (UCM, -7.3 vs. ICC, -6.8%, p = 0.77). CONCLUSION Higher Δ Hct between cord blood at birth and capillary heel blood at 48 hours of age, corrected for the change in body weight, suggests that intact UCM is an efficacious and safe procedure to enhance placental transfusion among neonates born via elective cesarean delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT03668782.
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Affiliation(s)
- Vincenzo Zanardo
- Division of Perinatal Medicine, Policlinico AbanoTerme, Abano Terme, Italy
| | - Pietro Guerrini
- Division of Perinatal Medicine, Policlinico AbanoTerme, Abano Terme, Italy
| | - Lorenzo Severino
- Division of Perinatal Medicine, Policlinico AbanoTerme, Abano Terme, Italy
| | - Alphonse Simbi
- Division of Perinatal Medicine, Policlinico AbanoTerme, Abano Terme, Italy
| | - Matteo Parotto
- Department of Anesthesiology, Toronto University, Toronto, Canada
| | - Gianluca Straface
- Division of Perinatal Medicine, Policlinico AbanoTerme, Abano Terme, Italy
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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29
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Prevention of iron deficiency anemia in infants and toddlers. Pediatr Res 2021; 89:63-73. [PMID: 32330927 DOI: 10.1038/s41390-020-0907-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/08/2022]
Abstract
Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem. Identification of anemia is crucial to public health interventions. It is estimated globally that 273 million children under 5 years of age were anemic in 2011, and about ~50% of those cases were attributable to iron deficiency (Lancet Global Health 1:e16-e25, 2013). Iron-deficiency anemia (IDA) in infants adversely impacts short-term hematological indices and long-term neuro-cognitive functions of learning and memory that result in both fatigue and low economic productivity. IDA contributes to death and disability and is an important risk factor for maternal and perinatal mortality, including the risks for stillbirths, prematurity, and low birth weight (Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Ch. 3 (World Health Organization, Geneva, 2004)). Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as delayed cord clamping (DCC). DCC until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. DCC, an effective anemia prevention strategy, requires cooperation among health providers involved in childbirth, and a participatory culture change in public health. Public intervention strategies must consider multiple factors associated with anemia listed in this review before designing intervention studies that aim to reduce anemia prevalence in infants and toddlers. IMPACT: Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem and identification of anemia is crucial to public health interventions. Delayed cord clamping (DCC) until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as DCC.
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Antenatal and perinatal factors influencing neonatal blood pressure: a systematic review. J Perinatol 2021; 41:2317-2329. [PMID: 34365475 PMCID: PMC8440188 DOI: 10.1038/s41372-021-01169-5] [Citation(s) in RCA: 3] [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: 12/10/2020] [Revised: 05/18/2021] [Accepted: 07/14/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A comprehensive understanding of the factors contributing to perinatal blood pressure is vital to ensure optimal postnatal hemodynamic support. The objective of this study was to review existing literature on maternal and perinatal factors influencing blood pressure in neonates up to 3 months corrected age. METHODS A systematic search of published literature in OVID Medline, OVID Embase and the COCHRANE library identified publications relating to maternal factors affecting blood pressure of neonates up to corrected age of 3 months. Summary data were extracted and compared (PROSPERO CRD42018092886). RESULTS Of the 3683 non-duplicate publications identified, 44 were eligible for inclusion in this review. Topics elicited were sociodemographic factors, maternal health status, medications, smoking during pregnancy, and cord management at birth. Limited data were available for each factor. Results regarding the impact of these factors on neonatal blood pressure were inconsistent across studies. CONCLUSIONS There is insufficient evidence to draw definitive conclusions regarding the impact of various maternal and perinatal factors on neonatal blood pressure. Future investigations of neonatal cardiovascular therapies should account for these factors in their study design. Similarly, studies on maternal diseases and perinatal interventions should include neonatal blood pressure as part of their primary or secondary analyses.
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31
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Ortiz-Esquinas I, Rodríguez-Almagro J, Gómez-Salgado J, Arias-Arias Á, Ballesta-Castillejos A, Hernández-Martínez A. Effects of cord milking in late preterm infants and full-term infants: A systematic review and meta-analysis. Birth 2020; 47:259-269. [PMID: 32815178 DOI: 10.1111/birt.12500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/21/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Umbilical cord milking (UCM) consists of performing several milkings of the cord from the placenta to the newborn. The objective was to evaluate the effects of UCM on newborns ≥34 weeks' gestation. METHODS Searches were conducted in MEDLINE, EMBASE, CINAHL, the Cochrane Database of Clinical Trials, and the clinicaltrails.gov database for randomized clinical trials (RCT), with no time or language restrictions, and for articles that compared UCM with other strategies. The main results were initial hemoglobin and hemoglobin after 6 weeks. The data were collected by two reviewers and the quality of the studies was assessed using the Cochrane Manual methodology. RESULTS The sample included 1845 newborns in 10 RCTs. The use of UCM in ≥34 weeks' gestation newborns was not related to initial hemoglobin levels (pooled weighted mean difference: (PWMD = 0.40 g/L [-0.16 to 0.95]) or after 6 weeks (PWMD = 0.07 g/L [-0.29 to 0.27]). A reduction in hemoglobin levels was also observed at 6 weeks when the control group had undergone late clamping (PWDM = 0.16g/L [-0.26 to -0.06]). CONCLUSIONS UCM produced no differences in hematologic variables for newborns with ≥34 weeks of gestation relative to controls. However, a slight decrease in hemoglobin levels is observed at 6 weeks when the control group is made up of newborns with late clamping.
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Affiliation(s)
| | - Julián Rodríguez-Almagro
- Department of Nursing. Ciudad Real School of Nursing, University of Castilla La-Mancha, Ciudad Real, Spain
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, University of Huelva, Huelva, Spain.,Safety and Health Postgraduate Programme, Espíritu Santo University, Guayaquil, Ecuador
| | - Ángel Arias-Arias
- Research Support Unit, "Mancha-Centro" Hospital, Alcazar de San Juan, Ciudad Real, Spain
| | | | - Antonio Hernández-Martínez
- Department of Obstetrics & Gynaecology, Alcázar de San Juan, Ciudad Real, Spain.,Department of Nursing. Ciudad Real School of Nursing, University of Castilla La-Mancha, Ciudad Real, Spain
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32
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Panburana P, Odthon T, Pongmee P, Hansahiranwadee W. The Effect of Umbilical Cord Milking Compared with Delayed Cord Clamping in Term Neonates: A Randomized Controlled Trial. Int J Womens Health 2020; 12:301-306. [PMID: 32368158 PMCID: PMC7173835 DOI: 10.2147/ijwh.s233487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/18/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To study the effect of intact umbilical cord milking (I-UCM) procedure in comparison with the procedure of delayed cord clamping (DCC) in term neonates. Study Design A randomized controlled trial. Setting Department of Obstetrics and Gynecology and Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University. Materials and Methods The study was performed from June 2017 to March 2018. Singleton term pregnant women (37-42 weeks' gestation) were recruited. Neonates were randomized into DCC and I-UCM groups. Umbilical cord was 3 times milked toward the neonate in 25 cm length from umbilical stump which was still attached to the placenta before cutting the cord in I-UCM group. Delay in cord clamping for 60 seconds was performed before the cord cutting in DCC group. Neonatal and maternal outcomes were recorded. Results Of 168 neonates included in this trial, 84 cases were randomized into each group. The baseline characteristics of both groups were comparable. No statistical difference was found in terms of the mean of hemoglobin levels in the DCC and I-UCM groups which were 16.9 (±1.6) g/dl and 17.0 (±1.9) g/dl, respectively (P-value 0.75). There was no difference in terms of adverse neonatal and maternal outcomes in both groups. Conclusion Both I-UCM and DCC revealed a comparable effect on hematologic status without deleterious effects on neonatal and maternal outcomes at the age of 48-72 hours in term neonates.
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Affiliation(s)
- Panyu Panburana
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Theethuch Odthon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pharuhad Pongmee
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wirada Hansahiranwadee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Katheria AC, Rich WD, Bava S, Lakshminrusimha S. Placental Transfusion for Asphyxiated Infants. Front Pediatr 2019; 7:473. [PMID: 31824895 PMCID: PMC6879450 DOI: 10.3389/fped.2019.00473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/29/2019] [Indexed: 12/31/2022] Open
Abstract
The current recommendation for umbilical cord management of non-vigorous infants (limp, pale, and not breathing) who need resuscitation at birth is to immediately clamp the umbilical cord. This recommendation is due in part to insufficient evidence for delayed cord clamping (DCC) or umbilical cord milking (UCM). These methods may provide a neuroprotective mechanism that also facilitates cardiovascular transition for non-vigorous infants at birth.
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Affiliation(s)
- Anup C. Katheria
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Wade D. Rich
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Sunita Bava
- Independent Researcher, San Diego, CA, United States
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34
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Orpak ÜS, Ergin H, Çıralı C, Özdemir ÖMA, Koşar Can Ö, Çelik Ü. Comparison of cut and intact cord milking regarding cerebral oxygenation, hemodynamic and hematological adaptation of term infants. J Matern Fetal Neonatal Med 2019; 34:2259-2266. [PMID: 31475597 DOI: 10.1080/14767058.2019.1662781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Although both delayed umbilical cord clamping and intact umbilical cord milking (I-UCM) provide the effective placental transfusion at birth, these procedures may not be used in neonates needing resuscitation. The aim of this study is to investigate the effect of cut umbilical cord milking (C-UCM), which permits resuscitation during an immediate transition period (ITP). METHODS Sixty-two healthy term infants were randomly divided into C-UCM and I-UCM groups at birth. Approximately 30-cm length of cord was milked towards the baby 2-4 times within 20 seconds after birth in both C-UCM and I-UCM groups while the umbilical cord was cut in the former, and intact in the latter. Heart rate, arterial oxygen saturation (SpO2), cerebral regional oxygen saturation (crSO2) (2nd-15th min), blood pressure (BP) (within 15-30 min), residual placental blood volume (RPBV), and hemoglobin levels (at the sixth hour) were monitored during ITP. RESULTS There were no significant differences in terms of mean gestational age (w) [(39.0 ± 1.2) versus (38.8 ± 1.1)], birth weight (g) [(3351.45 ± 254.30) versus (3256.94 ± 285.52)], Apgar scores at the 5th min (10 ± 0 versus 10 ± 0), first breathing time (sec) (5.4 ± 3.8 versus 5.7 ± 4.1), SpO2, crSO2, BP (mmHg) [(52.9 ± 6.9) versus (51.8 ± 5.7)], hemoglobin levels (g/dl) [(17.7 ± 1.8) versus (18.4 ± 1.4)], and RPBV (ml/kg) [(23.9 ± 4.7) versus (22.9 ± 5.4)] between C-UCM and I-UCM groups (p > .05). CONCLUSION This study showed that C-UCM is as effective as I-UCM on cerebral oxygenation, hemodynamic and hematological adaptation of term infants in ITP. We suggest that C-UCM can provide additional placental transfusion in term neonates exposed to early cord clamping.
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Affiliation(s)
- Ümmühan Seda Orpak
- Division of Neonatology, Department of Pediatrics, Pamukkale University School of Medicine, Denizli, Turkey
| | - Hacer Ergin
- Division of Neonatology, Department of Pediatrics, Pamukkale University School of Medicine, Denizli, Turkey
| | - Ceren Çıralı
- Division of Neonatology, Department of Pediatrics, Pamukkale University School of Medicine, Denizli, Turkey
| | - Özmert M A Özdemir
- Division of Neonatology, Department of Pediatrics, Pamukkale University School of Medicine, Denizli, Turkey
| | - Özlem Koşar Can
- Department of Obstetrics and Gynecology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Ülker Çelik
- Division of Neonatology, Department of Pediatrics, Government Hospital, Denizli, Turkey
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Chaowawanit W, Koovimon P, Soongsatitanon A. The residual blood from segmental umbilical cord milking in preterm delivery. J OBSTET GYNAECOL 2019; 40:205-210. [PMID: 31390905 DOI: 10.1080/01443615.2019.1621812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Umbilical cord milking is an alternative procedure providing blood to infants but there is no study in the proper length of umbilical cord and various gestational age. The aim of this study was to measure the blood volume in the umbilical cord of preterm infants at a certain length and to identify the correlation among blood volume, length, and circumference of umbilical cord, gestational age (GA), birth weight and placenta. Seventy-five pregnant women aged 18 years old and above with 24-36+6 weeks of gestation were included in this cross-sectional study. After delivery, a 15 to 45 cm of umbilical cord was cut and parameters of umbilical cord were recorded. The mean GA at birth was 241.84 ± 20.06 days. The mean length, diameter, and circumference were 23.31 ± 7.66, 1.10 ± 0.18, and 3.56 ± 0.75 cm, respectively. The mean residual blood volume was 11.58 ± 4.99 mL or 0.50 ± 0.18 mL/cm. Total residual blood volume had a significant positive strong correlation with umbilical cord length (r = 0.720, p < .001). To reduce complications from blood overload, the appropriate blood volume for preterm infant should be calculated from birth weight and umbilical cord length.Impact statementWhat is already known on this subject? The World Health Organisation recommends delayed cord clamping for newborn infants which neonatal resuscitation was not indicated but the majority of preterm infants needed resuscitation. Umbilical cord milking is an alternative procedure providing blood to infants. A small volume transfusion (10-20 m/kg) is commonly used for replacement in preterm neonates. Although there is a concern about the blood volume transferred into infants, blood volume and proper length of umbilical cord have not been thoroughly investigated.What do the results of this study add? In this study, the mean residual blood volume was 0.5 mL/cm and total residual blood volume had a significant positive strong correlation with umbilical cord length. In subgroup of very low birth weight group, the mean residual blood volume was 0.41 mL/cm; however, there was no statistically significant difference from other birth weight groups.What are the implications of these findings for clinical practice and/or further research? The appropriate length of umbilical cord for milking can be calculated from the estimated foetal weight and the mean residual blood volume per length (0.5 mL/cm); nevertheless, the calculation should be used with caution. The further study should investigate in extremely preterm or very low birth weight infants.
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Affiliation(s)
- Woraphot Chaowawanit
- Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruk Koovimon
- Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Adjima Soongsatitanon
- Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Shirk SK, Manolis SA, Lambers DS, Smith KL. Delayed clamping vs milking of umbilical cord in preterm infants: a randomized controlled trial. Am J Obstet Gynecol 2019; 220:482.e1-482.e8. [PMID: 30786254 DOI: 10.1016/j.ajog.2019.01.234] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/26/2019] [Accepted: 01/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND It has been established that delayed umbilical cord clamping in preterm infants results in improvement in neonatal anemia, need for transfusion, incidence of necrotizing enterocolitis, and intraventricular hemorrhage by increasing neonatal circulating blood volume. However, the effects of umbilical cord milking as an alternative to delayed clamping in preterm infants are unclear. OBJECTIVE The primary objective of this study was to compare the effect of delayed clamping vs milking of the umbilical cord on the initial hematocrit concentration in preterm births (23-34 weeks gestation). In addition, we sought to compare the effects of delayed clamping vs milking on the incidences of intraventricular hemorrhage, necrotizing enterocolitis, and need for transfusion (secondary objectives). STUDY DESIGN The study was an unblinded randomized controlled trial of singleton preterm infants who were born 23 weeks 0 days to 34 weeks 6 days gestation and were assigned to 1 of 2 controlled study groups: delayed cord clamping for 60 seconds or milking of the cord towards the infant 4 times before clamping. Randomization occurred via block randomization with an allocation ratio of 1 to 1. The patients' third stage of delivery was standardized for route of delivery and randomization arm. All comparisons were preformed with an intent-to-treat analysis approach. The study was powered at 80% with a probability value of .05 for the primary outcome measure of a hematocrit difference of 3% between the 2 groups. RESULTS Of the 204 randomized patients, 104 were assigned to the delayed subgroup, and 100 were assigned to the milking subgroup. There were no significant differences in baseline maternal characteristics noted between groups. Though there was not any statistically significant difference in neonatal outcomes between the cord clamping and milking groups, the occurrences of transfusion (15.5% vs 9.1%; P=.24), necrotizing enterocolitis (5.8% vs 3.0%; P=.49), and intraventricular hemorrhage (15.5% vs 10.1%; P=.35) were all lower in the milking group. The milking group had higher initial hematocrit concentration compared with the delayed clamping group, although this was not significant (51.8 [6.2%] vs 49.9 [7.7%]; P=.07]. Peak bilirubin levels and need for phototherapy were similar between groups. CONCLUSION This study demonstrates that milking the umbilical cord may be an acceptable alternative to delayed cord clamping because there were similar effects on neonatal hematocrit concentrations and the need for neonatal transfusions and no increased risk for complications or neonatal morbidity. The present data support the concept that milking of the umbilical cord may offer an efficient and timely method of providing increased blood volume to the infant.
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Response to Dr. Kumar's letter. J Perinatol 2019; 39:597-598. [PMID: 30692616 DOI: 10.1038/s41372-019-0326-9] [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: 12/29/2018] [Accepted: 01/01/2019] [Indexed: 11/08/2022]
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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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Simonin A, Safarulla A, Farmer Z, Coleman J, Sutton D, Wheeler K, Waller J, Bhatia J. Cut umbilical cord milking: an ineffective method of placental transfusion in preterm infants? J Matern Fetal Neonatal Med 2019; 33:3132-3135. [PMID: 30714439 DOI: 10.1080/14767058.2019.1569616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To determine if umbilical cord milking performed on a cut umbilical cord segment increased the hemoglobin/hematocrit, with a reduction in the incidence of intraventricular hemorrhage, need for blood transfusions, and pressor requirement in infants with <35-weeks gestation.Study design: This was a single center, observational study in the NICU. One-hundred-six neonates received cut umbilical cord milking and two hundred ninety seven served as historical controls.Result: There were no statistically significant differences between the two groups in hemoglobin/hematocrit, peak bilirubin values, the incidence of intraventricular hemorrhage, need for blood transfusions, and the use of pressors.Conclusion: This is the first study using the cut umbilical cord milking technique that includes neonates with <35-weeks gestation. The procedure is safe but did not result in an increase in hemoglobin/hematocrit, nor did it reduce the incidence of intraventricular hemorrhage, need for blood transfusions, and pressor use.
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Affiliation(s)
- Ann Simonin
- Department of Pediatrics, Augusta University, Augusta, GA, USA.,Division of Neonatology, Augusta University, Augusta, GA, USA
| | - Azif Safarulla
- Department of Pediatrics, Augusta University, Augusta, GA, USA.,Division of Neonatology, Augusta University, Augusta, GA, USA
| | - Zachary Farmer
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Joshua Coleman
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Danielle Sutton
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Kelli Wheeler
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Jennifer Waller
- Division of Biostatistics, Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Jatinder Bhatia
- Department of Pediatrics, Augusta University, Augusta, GA, USA.,Division of Neonatology, Augusta University, Augusta, GA, USA
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Mercer JS, Erickson-Owens DA, Deoni SCL, Dean DC, Collins J, Parker AB, Wang M, Joelson S, Mercer EN, Padbury JF. Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial. J Pediatr 2018; 203:266-272.e2. [PMID: 30473033 PMCID: PMC6259583 DOI: 10.1016/j.jpeds.2018.06.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/22/2018] [Accepted: 06/01/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate whether placental transfusion influences brain myelination at 4 months of age. STUDY DESIGN A partially blinded, randomized controlled trial was conducted at a level III maternity hospital in the US. Seventy-three healthy term pregnant women and their singleton fetuses were randomized to either delayed umbilical cord clamping (DCC, >5 minutes) or immediate clamping (ICC, <20 seconds). At 4 months of age, blood was drawn for ferritin levels. Neurodevelopmental testing (Mullen Scales of Early Learning) was administered, and brain myelin content was measured with magnetic resonance imaging. Correlations between myelin content and ferritin levels and group-wise DCC vs ICC brain myelin content were completed. RESULTS In the DCC and ICC groups, clamping time was 172 ± 188 seconds vs 28 ± 76 seconds (P < .002), respectively; the 48-hour hematocrit was 57.6% vs 53.1% (P < .01). At 4 months, infants with DCC had significantly greater ferritin levels (96.4 vs 65.3 ng/dL, P = .03). There was a positive relationship between ferritin and myelin content. Infants randomized to the DCC group had greater myelin content in the internal capsule and other early maturing brain regions associated with motor, visual, and sensory processing/function. No differences were seen between groups in the Mullen testing. CONCLUSION At 4 months, infants born at term receiving DCC had greater ferritin levels and increased brain myelin in areas important for early life functional development. Endowment of iron-rich red blood cells obtained through DCC may offer a longitudinal advantage for early white matter development. TRIAL REGISTRATION ClinicalTrials.gov: NCT01620008.
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Affiliation(s)
- Judith S Mercer
- College of Nursing, University of Rhode Island, Kingston, RI; Pediatrics, Alpert School of Medicine, Brown University, Providence, RI; Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Debra A Erickson-Owens
- College of Nursing, University of Rhode Island, Kingston, RI; Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Sean C L Deoni
- Advanced Baby Imaging Lab, Memorial Hospital of Rhode Island, Pawtucket, RI; Department of Radiology, University of Colorado School of Medicine, Aurora, CO
| | | | - Jennifer Collins
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Ashley B Parker
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Meijia Wang
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Sarah Joelson
- Advanced Baby Imaging Lab, Memorial Hospital of Rhode Island, Pawtucket, RI
| | - Emily N Mercer
- Advanced Baby Imaging Lab, Memorial Hospital of Rhode Island, Pawtucket, RI
| | - James F Padbury
- Pediatrics, Alpert School of Medicine, Brown University, Providence, RI; Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
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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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42
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Blank DA, Polglase GR, Kluckow M, Gill AW, Crossley KJ, Moxham A, Rodgers K, Zahra V, Inocencio I, Stenning F, LaRosa DA, Davis PG, Hooper SB. Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition. Arch Dis Child Fetal Neonatal Ed 2018; 103:F539-F546. [PMID: 29208663 PMCID: PMC6278653 DOI: 10.1136/archdischild-2017-314005] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/31/2017] [Accepted: 11/05/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Umbilical cord milking (UCM) at birth may benefit preterm infants, but the physiological effects of UCM are unknown. We compared the physiological effects of two UCM strategies with immediate umbilical cord clamping (UCC) and physiological-based cord clamping (PBCC) in preterm lambs. METHODS At 126 days' gestational age, fetal lambs were exteriorised, intubated and instrumented to measure umbilical, pulmonary and cerebral blood flows and arterial pressures. Lambs received either (1) UCM without placental refill (UCMwoPR); (2) UCM with placental refill (UCMwPR); (3) PBCC, whereby ventilation commenced prior to UCC; or (4) immediate UCC. UCM involved eight milks along a 10 cm length of cord, followed by UCC. RESULTS A net volume of blood was transferred into the lamb during UCMwPR (8.8 mL/kg, IQR 8-10, P=0.01) but not during UCMwoPR (0 mL/kg, IQR -2.8 to 1.7) or PBCC (1.1 mL/kg, IQR -1.3 to 4.3). UCM had no effect on pulmonary blood flow, but caused large fluctuations in mean carotid artery pressures (MBP) and blood flows (CABF). In UCMwoPR and UCMwPR lambs, MBP increased by 12%±1% and 8%±1% and CABF increased by 32%±2% and 15%±2%, respectively, with each milk. Cerebral oxygenation decreased the least in PBCC lambs (17%, IQR 13-26) compared with UCMwoPR (26%, IQR 23-25, P=0.03), UCMwPR (35%, IQR 27-44, P=0.02) and immediate UCC (34%, IQR 28-41, P=0.02) lambs. CONCLUSIONS UCMwoPR failed to provide placental transfusion, and UCM strategies caused considerable haemodynamic disturbance. UCM does not provide the same physiological benefits of PBCC. Further review of UCM is warranted before adoption into routine clinical practice.
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Affiliation(s)
- Douglas A Blank
- Newborn Research, The Royal Women’s Hospital, Parkville, Victoria, Australia,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, New South Wales, Australia
| | - Andrew William Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Alison Moxham
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Karyn Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Ishmael Inocencio
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Fiona Stenning
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Domeic A LaRosa
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Peter G Davis
- Newborn Research, The Royal Women’s Hospital, Parkville, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
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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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Li J, Yu B, Wang W, Luo D, Dai QL, Gan XQ. Does intact umbilical cord milking increase infection rates in preterm infants with premature prolonged rupture of membranes? J Matern Fetal Neonatal Med 2018; 33:184-190. [PMID: 29886779 DOI: 10.1080/14767058.2018.1487947] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective: To investigate whether intact umbilical cord milking (I-UCM) can aggravate infection or result in other undesirable complications in preterm infants with premature prolonged rupture of membranes (PPROM).Methods: Neonates vaginally delivered between 28 and 37 weeks' gestation and complicated by PPROM before birth were randomly divided into two groups according to the cord clamping procedure: I-UCM before clamping and immediate cord clamping (ICC). Various parameters of the study participants were compared between the two groups.Results: Of 102 preterm infants, 48 and 54 were randomly allocated to the I-UCM and ICC groups, respectively. There were no significant differences between the two groups regarding hematological parameters (platelet count, white blood count, neutrophil ratio, and C-reactive protein) or neonatal outcomes (probable or certain neonatal infection, respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage) (p > .05). However, preterm neonates in the I-UCM group had higher serum hemoglobin and hematocrit levels (p < .05) and received fewer blood transfusions (p < .05) than those in the ICC group.Conclusion: Milking the umbilical cord to a preterm neonate with PPROM will not aggravate neonatal infection or result in other undesirable complications. This simple procedure will improve hemoglobin values and hematocrit levels and may lessen the need for transfusion during the neonatal period.
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Affiliation(s)
- Juan Li
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
| | - Bo Yu
- Department of Neonatal Intensive Care Unit (NICU), Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
| | - Wei Wang
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
| | - Dan Luo
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
| | - Qian-Ling Dai
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
| | - Xiao-Qin Gan
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital, Chengdu City, People's Republic of China
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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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Alzaree F, Elbohoty A, Abdellatif M. Early Versus Delayed Umbilical Cord Clamping on Physiologic Anemia of the Term Newborn Infant. Open Access Maced J Med Sci 2018; 6:1399-1404. [PMID: 30159064 PMCID: PMC6108792 DOI: 10.3889/oamjms.2018.286] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/22/2018] [Accepted: 06/23/2018] [Indexed: 12/16/2022] Open
Abstract
AIM Our study aims to make a comparison between the effects of milking of umbilical cord versus delayed cord clamping on Hemoglobin level at 6 weeks from delivery among term neonates and which method is more beneficial for them. DESIGN It was a randomised control study. Participants were randomised into 2 groups; Group 1: 125 women were assigned to delay cord clamping; Group 2: 125 women were assigned to milking of the umbilical cord 5 times before cutting. Student t-test was used to compare between the two groups for quantitative data, for qualitative data chi-square test and the Correlation coefficient was done to test the association between variables. SETTING This study was at El-Galaa Teaching Hospital, labour suite. Cairo, Egypt. PARTICIPANTS A group of 250 pregnant women starting from ≥ 37 weeks' gestational age. INTERVENTION In this study, we searched if the mechanism of milking or delayed cord clamping could give some of the positive benefits for neonates or not. RESULTS In this study, we found that milking of the umbilical cord five times as in group 1 was associated with higher hemoglobin levels at 6 weeks after birth, at physiological anemia of the fetus and significant but clinically there was no difference between the two groups (10.4 ± 0.5 and 10.6 ± 0.5 respectively, P < 0.001). Also, there was a positive correlation between haemoglobin of the mother and the newborn during the first day and after 6 weeks with r = 0.349 and 0.283 respectively and a P value < 0.001. Furthermore, there was a positive correlation between the haemoglobin of the fetus after the first day and fetus at 6 weeks with r = 0.534 and a P value < 0.001. For most other outcomes (including APGAR score, positive pressure ventilation, poor neonatal outcomes such as respiratory distress syndrome there were no significant differences between the two groups. Our study may recommend the use of umbilical cord milking in term babies when delayed cord clamping is unavailable. CONCLUSION Umbilical cord blood milking after its clamping improves some important haematological parameters for newborns, especially in countries with high incidence of anaemia in newborns and children.
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Affiliation(s)
- Fatma Alzaree
- National Research Center, Child Health Department, Eltahrir Street, Dokki, Guiza, Cairo 1234, Egypt
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Cervantes LL, Zuñiga JA. Strategies to Avoid Neonatal Blood Transfusions for Families of the Jehovah's Witness Faith. Nurs Womens Health 2018; 22:332-337. [PMID: 30077239 DOI: 10.1016/j.nwh.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/14/2018] [Accepted: 03/01/2018] [Indexed: 06/08/2023]
Abstract
Beliefs and restrictions regarding acceptance of blood products by members of the Jehovah's Witness faith often provoke discussion among health care professionals regarding alternative interventions. Establishing and maintaining an open dialog with women and families of the Jehovah's Witness faith regarding their beliefs on the use of blood and blood products are vital in creating a therapeutic relationship between families and the health care team. Such rapport facilitates the discussion of strategies to avoid blood transfusions for newborns and provides women and families multiple opportunities to develop of a holistic birth plan congruent with their beliefs.
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Katheria A, Mercer J, Brown M, Rich W, Baker K, Harbert MJ, Pierce B, Hassen K, Finer N. Umbilical cord milking at birth for term newborns with acidosis: neonatal outcomes. J Perinatol 2018; 38:240-244. [PMID: 29234144 DOI: 10.1038/s41372-017-0011-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/20/2017] [Accepted: 10/26/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if umbilical cord milking is detrimental in compromised term/near-term infants. STUDY DESIGN A retrospective analysis of infants with abnormal cord gases (cord arterial or venous pH of ≤ 7.1 or base deficit > -12). We collected maternal risk factors, cord management, birth, and neonatal outcomes during hospitalization. RESULT We found 157 infants who met the criteria for abnormal cord gases. Thirty-six of those had umbilical cord milking at delivery. There was no significant difference in neonatal outcomes, but fewer infants in the cord milking group needed resuscitation (38 vs. 56%, p = 0.07) and ongoing respiratory support (19 vs. 31%, p = 0.16) compared to the immediate clamping group. CONCLUSIONS While not significant, infants who received cord milking at birth needed less resuscitation and ongoing respiratory support. This study suggests that umbilical cord milking appears to be a safe therapy when acidosis is present and when resuscitation is needed.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
| | - Judith Mercer
- University of Rhode Island, Kingston, RI, USA.,Women and Infants Hospital and Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Melissa Brown
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Wade Rich
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Katie Baker
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - M J Harbert
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Brianna Pierce
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Kasim Hassen
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Neil Finer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
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Ghirardello S, Di Tommaso M, Fiocchi S, Locatelli A, Perrone B, Pratesi S, Saracco P. Italian Recommendations for Placental Transfusion Strategies. Front Pediatr 2018; 6:372. [PMID: 30560107 PMCID: PMC6287578 DOI: 10.3389/fped.2018.00372] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/13/2018] [Indexed: 12/13/2022] Open
Abstract
At delivery, if the cord is not clamped, blood continues to pass from the placenta to the newborn during the first minutes of life, allowing the transfer of 25-35 ml/kg of placental blood to the newborn, depending on gestational age, the timing of cord clamping, the position of the infant at birth, the onset of respiration, and administration of uterotonics to the mother. However, deriving benefits from delayed cord clamping (DCC) are not merely related to placental-to-fetal blood transfusion; establishing spontaneous ventilation before cutting the cord improves venous return to the right heart and pulmonary blood flow, protecting the newborn from the transient low cardiac output, and systemic arterial pressure fluctuations. Recent meta-analyses showed that delayed cord clamping reduces mortality and red blood cell transfusions in preterm newborns and increases iron stores in term newborns. Various authors suggested umbilical cord milking (UCM) as a safe alternative when delayed cord clamping is not feasible. Many scientific societies recommend waiting 30-60 s before clamping the cord for both term and preterm newborns not requiring resuscitation. To improve the uptake of placental transfusion strategies, in 2016 an Italian Task Force for the Management of Umbilical Cord Clamping drafted national recommendations for the management of cord clamping in term and preterm deliveries. The task force performed a detailed review of the literature using the GRADE methodological approach. The document analyzed all clinical scenarios that operators could deal with in the delivery room, including cord blood gas analysis during delayed cord clamping and time to cord clamping in the case of umbilical cord blood banking. The panel intended to promote a more physiological and individualized approach to cord clamping, specifically for the most preterm newborn. A feasible option to implement delayed cord clamping in very preterm deliveries is to move the neonatologist to the mother's bedside to assess the newborn's clinical condition at birth. This option could safely guarantee the first steps of stabilization before clamping the cord and allow DCC in the first 30 s of life, without delaying resuscitation. Contra-indications to placental transfusion strategies are clinical situations that may endanger mother 's health and those that may delay immediate newborn's resuscitation when required.
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Affiliation(s)
- Stefano Ghirardello
- Neonatal Intensive Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariarosaria Di Tommaso
- Health Sciences Department, University of Firenze, Careggi University Hospital, Florence, Italy
| | - Stefano Fiocchi
- Neonatology and Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Anna Locatelli
- Obstetrics and Gynecology Unit, School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Barbara Perrone
- Division of Neonatology and NICU, Salesi Children's Hospital, Ancona, Italy
| | - Simone Pratesi
- Neonatology Unit, Careggi University Hospital, Florence, Italy
| | - Paola Saracco
- Department of Pediatric Sciences, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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Abstract
"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.
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Affiliation(s)
- Deepak Sharma
- National Institute of Medical Science, Jaipur, Rajasthan India
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