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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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Li ZN, Wang SR, Wang P. Associations between low birth weight and perinatal asphyxia: A hospital-based study. Medicine (Baltimore) 2023; 102:e33137. [PMID: 37000089 PMCID: PMC10063296 DOI: 10.1097/md.0000000000033137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 04/01/2023] Open
Abstract
To investigate the associations between low birth weight (LBW) and perinatal asphyxia by a hospital-based study. The participants of this study were mothers who gave birth at our hospital in 2018. They were divided into case group and control group according to their children's asphyxia status. The bivariable and multivariable logistics regression were used to identify maternal and newborn factors with perinatal asphyxia. A total of 150 participants were enrolled in this study, including 50 participants in the case group and 100 participants in the control groups. The bivariate logistic regression analysis showed the significant relationship of LBW, the mother's age which was less than 20 years, and the gestational age with perinatal asphyxia (P < .05). The multivariate analysis was shown that LBW, male newborns, mothers who had preeclampsia/eclampsia, or mothers who were primipara or whose gestational age more than 37 weeks had higher risks of perinatal asphyxia (P < .05). However, there were no significant relationships of the age of mother or history of antenatal care with perinatal asphyxia. LBW of infants contributes to the higher risk of perinatal asphyxia.
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Affiliation(s)
- Zhao-na Li
- Neonatal Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Shu-rong Wang
- Neonatal Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Ping Wang
- Neonatal Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
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Cardiac Asystole at Birth Re-Visited: Effects of Acute Hypovolemic Shock. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020383. [PMID: 36832512 PMCID: PMC9955546 DOI: 10.3390/children10020383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.
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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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Ott F, Kribs A, Stelzl P, Kyvernitakis I, Ehlen M, Schmidtke S, Rawnaq-Möllers T, Rath W, Berger R, Maul H. Resuscitation of Term Compromised and Asphyctic Newborns: Better with Intact Umbilical Cord? Geburtshilfe Frauenheilkd 2022; 82:706-718. [PMID: 35815099 PMCID: PMC9262631 DOI: 10.1055/a-1804-3268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/18/2022] [Indexed: 10/27/2022] Open
Abstract
AbstractThe authors hypothesize that particularly severely compromised and asphyctic term infants in need of resuscitation may benefit from delayed umbilical cord clamping (after several minutes).
Although evidence is sparse, the underlying pathophysiological mechanisms support this assumption. For this review the authors have analyzed the available research. Based on these data they
conclude that it may be unfavorable to immediately clamp the cord of asphyctic newborns (e.g., after shoulder dystocia) although recommended in current guidelines to provide quick
neonatological support. Compression of the umbilical cord or thorax obstructs venous flow to the fetus more than arterial flow to the placenta. The fetus is consequently cut off from a
supply of oxygenated, venous blood. This may cause not only hypoxemia and consecutive hypoxia during delivery but possibly also hypovolemia. Immediate cord clamping may aggravate the
situation of the already compromised newborn, particularly if the cord is cut before the lungs are ventilated. By contrast, delayed cord clamping leads to fetoplacental transfusion of
oxygenated venous blood, which may buffer an existing acidosis. Furthermore, it may enhance blood volume by up to 20%, leading to higher levels of various blood components, such as red and
white blood cells, thrombocytes, mesenchymal stem cells, immunoglobulins, and iron. In addition, the resulting increase in pulmonary perfusion may compensate for an existing hypoxemia or
hypoxia. Early cord clamping before lung perfusion reduces the preload of the left ventricle and hinders the establishment of sufficient circulation. Animal models and clinical trials
support this opinion. The authors raise the question whether it would be better to resuscitate compromised newborns with intact umbilical cords. Obstetric and neonatal teams need to work
even closer together to improve neonatal outcomes.
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Affiliation(s)
- Friederike Ott
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
- Asklepios Medical School, Hamburg, Germany
| | - Angela Kribs
- Klinik für Neonatologie und pädiatrische Intensivmedizin, Universitätskinderklinik, Köln, Germany
| | - Patrick Stelzl
- Frauenklinik, Kepler Universitätsklinikum Linz, Linz, Austria
| | - Ioannis Kyvernitakis
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Michael Ehlen
- Klinik für Kinder- und Jugendmedizin, Marienhaus Klinikum Bendorf – Neuwied – Waldbreitbach, Neuwied, Germany
| | - Susanne Schmidtke
- Klinik für Neonatologie und pädiatrische Intensivmedizin, Asklepios Kliniken Barmbek und Nord-Heidberg, Hamburg, Germany
| | - Tamina Rawnaq-Möllers
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Werner Rath
- Universitätsfrauenklinik, Universitätsklinikum Schleswig Holstein, Kiel, Germany
| | - Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Holger Maul
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
- Asklepios Medical School, Hamburg, Germany
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Mercer J, Erickson-Owens D, Rabe H, Jefferson K, Andersson O. Making the Argument for Intact Cord Resuscitation: A Case Report and Discussion. CHILDREN 2022; 9:children9040517. [PMID: 35455560 PMCID: PMC9031173 DOI: 10.3390/children9040517] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/17/2022]
Abstract
We use a case of intact cord resuscitation to argue for the beneficial effects of an enhanced blood volume from placental transfusion for newborns needing resuscitation. We propose that intact cord resuscitation supports the process of physiologic neonatal transition, especially for many of those newborns appearing moribund. Transfer of the residual blood in the placenta provides the neonate with valuable access to otherwise lost blood volume while changing from placental respiration to breathing air. Our hypothesis is that the enhanced blood flow from placental transfusion initiates mechanical and chemical forces that directly, and indirectly through the vagus nerve, cause vasodilatation in the lung. Pulmonary vascular resistance is thereby reduced and facilitates the important increased entry of blood into the alveolar capillaries before breathing commences. In the presented case, enhanced perfusion to the brain by way of an intact cord likely led to regained consciousness, initiation of breathing, and return of tone and reflexes minutes after birth. Paramount to our hypothesis is the importance of keeping the umbilical cord circulation intact during the first several minutes of life to accommodate physiologic neonatal transition for all newborns and especially for those most compromised infants.
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Affiliation(s)
- Judith Mercer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA 92123, USA
- College of Nursing, University of Rhode Island, Kingston, RI 02881, USA;
- Correspondence:
| | | | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton BN2 5BE, UK;
| | - Karen Jefferson
- American College of Nurse-Midwives, Silver Spring, MD 20910, USA;
| | - Ola Andersson
- Department of Clinical Sciences Lund, Paediatrics, Lund University, 221 85 Lund, Sweden;
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Rabe H, Mercer J, Erickson-Owens D. What does the evidence tell us? Revisiting optimal cord management at the time of birth. Eur J Pediatr 2022; 181:1797-1807. [PMID: 35112135 PMCID: PMC9056455 DOI: 10.1007/s00431-022-04395-x] [Citation(s) in RCA: 2] [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: 11/03/2021] [Revised: 01/12/2022] [Accepted: 01/22/2022] [Indexed: 01/11/2023]
Abstract
A newborn who receives a placental transfusion at birth from delayed cord clamping (DCC) obtains about 30% more blood volume than those with immediate cord clamping (ICC). Benefits for term neonates include higher hemoglobin levels, less iron deficiency in infancy, improved myelination out to 12 months, and better motor and social development at 4 years of age especially in boys. For preterm infants, benefits include less intraventricular hemorrhage, fewer gastrointestinal issues, lower transfusion requirements, and less mortality in the neonatal intensive care unit by 30%. Ventilation before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the neonate. Hypovolemia, often associated with nuchal cord or shoulder dystocia, may lead to an inflammatory cascade and subsequent ischemic injury. A sudden unexpected neonatal asystole at birth may occur from severe hypovolemia. The restoration of blood volume is an important action to protect the hearts and brains of neonates. Currently, protocols for resuscitation call for ICC. However, receiving an adequate blood volume via placental transfusion may be protective for distressed neonates as it prevents hypovolemia and supports optimal perfusion to all organs. Bringing the resuscitation to the mother's bedside is a novel concept and supports an intact umbilical cord. When one cannot wait, cord milking several times can be done quickly within the resuscitation guidelines. Cord blood gases can be collected with optimal cord management. Conclusion: Adopting a policy for resuscitation with an intact cord in a hospital setting takes a coordinated effort and requires teamwork by obstetrics, pediatrics, midwifery, and nursing.
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Affiliation(s)
- Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
| | - Judith Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA USA ,College of Nursing, University of Rhode Island, Kingston, RI USA
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Nair J, Davidson L, Gugino S, Koenigsknecht C, Helman J, Nielsen L, Sankaran D, Agrawal V, Chandrasekharan P, Rawat M, Berkelhamer SK, Lakshminrusimha S. Sustained Inflation Reduces Pulmonary Blood Flow during Resuscitation with an Intact Cord. CHILDREN-BASEL 2021; 8:children8050353. [PMID: 33946658 PMCID: PMC8145980 DOI: 10.3390/children8050353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022]
Abstract
The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation-SI vs. positive pressure ventilation-V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with DCC improves gas exchange and hemodynamics in near-term lambs with asphyxial bradycardia. A total of 28 lambs were asphyxiated to a mean blood pressure of 22 mmHg. Lambs were randomized based on the timing of cord clamping (ECC-immediate, DCC-60 s) and mode of initial ventilation into five groups: ECC + V, ECC + SI, DCC, DCC + V and DCC + SI. The magnitude of placental transfusion was assessed using biotinylated RBC. Though an asphyxial bradycardia model, 2-3 lambs in each group were arrested. There was no difference in primary outcomes, the time to reach baseline carotid blood flow (CBF), HR ≥ 100 bpm or MBP ≥ 40 mmHg. SI reduced pulmonary (PBF) and umbilical venous (UV) blood flow without affecting CBF or umbilical arterial blood flow. A significant reduction in PBF with SI persisted for a few minutes after birth. In our model of perinatal asphyxia, an initial SI breath increased airway pressure, and reduced PBF and UV return with an intact cord. Further clinical studies evaluating the timing of cord clamping and ventilation strategy in asphyxiated infants are warranted.
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Affiliation(s)
- Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
- Correspondence: ; Tel.: +1-7163-230-260
| | - Lauren Davidson
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
- Buffalo Neonatology Associates, Sisters of Charity Hospital, Buffalo, NY 14214, USA
| | - Sylvia Gugino
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Deepika Sankaran
- Department of Pediatrics, University of California at Davis, Davis, CA 95616, USA; (D.S.); (S.L.)
| | - Vikash Agrawal
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
- Department of Pediatrics, Loma Linda University, Loma Linda, CA 92350, USA
| | - Praveen Chandrasekharan
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
| | - Sara K. Berkelhamer
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA; (L.D.); (S.G.); (C.K.); (J.H.); (L.N.); (V.A.); (P.C.); (M.R.); (S.K.B.)
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California at Davis, Davis, CA 95616, USA; (D.S.); (S.L.)
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Ancora G, Meloni C, Soffritti S, Sandri F, Ferretti E. Intrapartum Asphyxiated Newborns Without Fetal Heart Rate and Cord Blood Gases Abnormalities: Two Case Reports of Shoulder Dystocia to Reflect Upon. Front Pediatr 2020; 8:570332. [PMID: 33194898 PMCID: PMC7652761 DOI: 10.3389/fped.2020.570332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022] Open
Abstract
Our report covers two cases of severe hypoxic-ischemic encephalopathy in newborns whose birth was complicated by shoulder dystocia. In both cases, there were inconsistencies observed among cardiotocographic traces, baby's clinical conditions at birth, and umbilical cord blood gases. Namely, normal cardiotocographic monitoring and cord pH > 7, in spite of the fact that the newborns were severely depressed at birth and their blood gases evaluated within 1 h from birth showed a severe metabolic acidosis. Moreover, one of the two newborns displayed moderately low hemoglobin levels. Metabolic and infectious causes were ruled out. Both newborns developed severe hypoxic-ischemic encephalopathy and received therapeutic hypothermia for 72 h. Both survived, one with a severe dystonic cerebral palsy whereas the other developed only a mild developmental delay in language. Cardiac asystole theory could explain these two cases, reinforcing the need for specific resuscitation guidelines for infants experiencing a birth complicated by shoulder dystocia.
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Affiliation(s)
- Gina Ancora
- Neonatal Intensive Care Unit, Department of Maternal, Infant and Adolescent Health, Infermi Hospital, Azienda Unità Sanitaria Locale Romagna, Rimini, Italy
| | - Claudio Meloni
- Obstetrics and Gynecology Unit, Department of Maternal, Infant and Adolescent Health, Infermi Hospital, Azienda Unità Sanitaria Locale Romagna, Rimini, Italy
| | - Silvia Soffritti
- Neonatal Intensive Care Unit, Department of Maternal and Infant Health, Maggiore Hospital, Bologna, Italy
| | - Fabrizio Sandri
- Neonatal Intensive Care Unit, Department of Maternal and Infant Health, Maggiore Hospital, Bologna, Italy
| | - Emanuela Ferretti
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, The Ottawa General Hospital, University of Ottawa, Ottawa, ON, Canada
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