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Birkett R, Newar J, Sharma AM, Lin E, Blank L, Swaminathan S, Misharin A, Mestan KK. Development of a novel humanized mouse model to study bronchopulmonary dysplasia. Front Pediatr 2023; 11:1146014. [PMID: 37520051 PMCID: PMC10375491 DOI: 10.3389/fped.2023.1146014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Rationale The role of circulating fetal monocytes in bronchopulmonary dysplasia is not known. We utilized a humanized mouse model that supports human progenitor cell engraftment (MISTRG) to test the hypothesis that prenatal monocyte programming alters early lung development and response to hyperoxia. Methods Cord blood-derived monocytes from 10 human infants were adoptively transferred into newborn MISTRG mice at p0 (1 × 106 cells/mouse, intrahepatic injection) followed by normoxia versus hyperoxia (85% oxygen × 14 days). Lungs were harvested at p14 for alveolar histology (alveolar count, perimeter and area) and vascular parameters (vWF staining for microvessel density, Fulton's index). Human CD45 staining was conducted to compare presence of hematopoietic cells. Murine lung parameters were compared among placebo and monocyte-injected groups. The individual profiles of the 10 patients were further considered, including gestational age (GA; n = 2 term, n = 3 moderate/late preterm, and n = 5 very preterm infants) and preeclampsia (n = 4 patients). To explore the monocyte microenvironment of these patients, 30 cytokines/chemokines were measured in corresponding human plasma by multiplex immunoassay. Results Across the majority of patients and corresponding mice, MISTRG alveolarization was simplified and microvessel density was decreased following hyperoxia. Hyperoxia-induced changes were seen in both placebo (PBS) and monocyte-injected mice. Under normoxic conditions, alveolar development was altered modestly by monocytes as compared with placebo (P < 0.05). Monocyte injection was associated with increased microvessel density at P14 as compared with placebo (26.7 ± 0.73 vs. 18.8 ± 1.7 vessels per lung field; P < 0.001). Pooled analysis of patients revealed that injection of monocytes from births complicated by lower GA and preeclampsia was associated with changes in alveolarization and vascularization under normoxic conditions. These differences were modified by hyperoxia. CD45+ cell count was positively correlated with plasma monocyte chemoattractant protein-1 (P < 0.001) and macrophage inflammatory protein-1β (P < 0.01). Immunohistochemical staining for human CD206 and mouse F4/80 confirmed absence of macrophages in MISTRG lungs at P14. Conclusions Despite the inherent absence of macrophages in early stages of lung development, immunodeficient MISTRG mice revealed changes in alveolar and microvascular development induced by human monocytes. MISTRG mice exposed to neonatal hyperoxia may serve as a novel model to study isolated effects of human monocytes on alveolar and pulmonary vascular development.
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Affiliation(s)
- Rob Birkett
- Department of Pediatrics/Division of Neonatology, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Janu Newar
- Department of Pediatrics/Division of Neonatology, UC San Diego School of Medicine & Rady Children’s Hospital of San Diego, La Jolla, CA, United States
| | - Abhineet M. Sharma
- Department of Pediatrics/Division of Neonatology, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Erika Lin
- Department of Pediatrics/Division of Neonatology, UC San Diego School of Medicine & Rady Children’s Hospital of San Diego, La Jolla, CA, United States
| | - Lillian Blank
- Department of Pediatrics/Division of Neonatology, UC San Diego School of Medicine & Rady Children’s Hospital of San Diego, La Jolla, CA, United States
| | - Suchitra Swaminathan
- Department of Medicine/Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Alexander Misharin
- Department of Medicine/Division of Pulmonary & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Karen K. Mestan
- Department of Pediatrics/Division of Neonatology, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Pediatrics/Division of Neonatology, UC San Diego School of Medicine & Rady Children’s Hospital of San Diego, La Jolla, CA, United States
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Rabe H, Mercer J. Knowledge gaps in optimal umbilical cord management at birth. Semin Perinatol 2023:151791. [PMID: 37357042 DOI: 10.1016/j.semperi.2023.151791] [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] [Indexed: 06/27/2023]
Abstract
In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.
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Affiliation(s)
- Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, University of Sussex, 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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3
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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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4
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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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5
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Sharma AM, Birkett R, Lin ET, Ernst LM, Grobman WA, Swaminathan S, Abdala-Valencia H, Misharin AV, Bartom ET, Mestan KK. Placental dysfunction influences fetal monocyte subpopulation gene expression in preterm birth. JCI Insight 2022; 7:155482. [PMID: 35471950 PMCID: PMC9220934 DOI: 10.1172/jci.insight.155482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/22/2022] [Indexed: 02/03/2023] Open
Abstract
The placenta is the primary organ for immune regulation, nutrient delivery, gas exchange, protection against environmental toxins, and physiologic perturbations during pregnancy. Placental inflammation and vascular dysfunction during pregnancy are associated with a growing list of prematurity-related complications. The goal of this study was to identify differences in gene expression profiles in fetal monocytes - cells that persist and differentiate postnatally - according to distinct placental histologic domains. Here, by using bulk RNA-Seq, we report that placental lesions are associated with gene expression changes in fetal monocyte subsets. Specifically, we found that fetal monocytes exposed to acute placental inflammation upregulate biological processes related to monocyte activation, monocyte chemotaxis, and platelet function, while monocytes exposed to maternal vascular malperfusion lesions downregulate these processes. Additionally, we show that intermediate monocytes might be a source of mitogens, such as HBEGF, NRG1, and VEGFA, implicated in different outcomes related to prematurity. This is the first study to our knowledge to show that placental lesions are associated with unique changes in fetal monocytes and monocyte subsets. As fetal monocytes persist and differentiate into various phagocytic cells following birth, our study may provide insight into morbidity related to prematurity and ultimately potential therapeutic targets.
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Affiliation(s)
- Abhineet M. Sharma
- Department of Pediatrics/Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert Birkett
- Department of Pediatrics/Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Erika T. Lin
- Department of Pediatrics/Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Pediatrics, UCSD, La Jolla, California, USA
| | - Linda M. Ernst
- Department of Pathology & Laboratory Medicine, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - William A. Grobman
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine
| | | | | | | | - Elizabeth T. Bartom
- Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karen K. Mestan
- Department of Pediatrics/Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Pediatrics, UCSD, La Jolla, California, USA
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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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7
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Menon R, Dixon CL, Cayne S, Radnaa E, Salomon C, Sheller-Miller S. Differences in cord blood extracellular vesicle cargo in preterm and term births. Am J Reprod Immunol 2022; 87:e13521. [PMID: 35007379 DOI: 10.1111/aji.13521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/14/2021] [Accepted: 12/29/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study determined the cord plasma-derived extracellular vesicle (exosomes; 30-160 nm particles) proteomic profile in patients who had spontaneous preterm birth (PTB) or preterm premature rupture of membranes (pPROM), compared to those who delivered at term regardless of labor status. METHODS This is a cross-sectional analysis of a retrospective cohort that quantified and determined the proteomic cargo content of exosomes present in cord blood plasma samples in PTB or pPROM, and normal term in labor (TL) or term not in labor (TNIL) pregnancies. Exosomes were isolated by differential centrifugation followed by size exclusion chromatography. Exosomes were characterized by nanoparticle tracking analysis (quantity and size) and markers (dot blots for exosome markers). The exosomal proteomic profile was identified by liquid chromatography-mass spectrometry (LC-MS/MS). Ingenuity pathway analysis determined canonical pathways and biofunctions associated with dysregulated proteins. RESULTS Cord plasma exosomes have similar quantity and exhibit both tetraspanin and ESCRT protein markers specific of exosomes regardless of the conditions. Proteomics analysis exhibited several similar markers as well as very unique markers in exosomes from each condition; however, bioinformatics analysis revealed a generalized and non-specific inflammatory condition represented in exosomes from different condition that is not indicative of any specific underlying biological functions indicative of an underlying pathology. CONCLUSIONS Compared to maternal plasma and amniotic fluid exosomes, the value of cord plasma derived exosomes is limited. Quantity, character, and proteomic cargo contents in exosomes or the pathways and functions represented by differentially expressed proteins do not distinguish specific conditions regarding normal and abnormal parturition. The value of cord plasma exosome proteomic cargo has limited value as an indicator of an underlying physiology or as a biomarker of fetal well-being.
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Affiliation(s)
- Ramkumar Menon
- Division of Basic and Translation Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Christopher Luke Dixon
- Division of Basic and Translation Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Samir Cayne
- Division of Basic and Translation Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Enkhtuya Radnaa
- Division of Basic and Translation Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Carlos Salomon
- Exosome Biology Laboratory, Centre for Clinical Diagnostics, University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital, The University of Queensland, Brisbane, Australia.,Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepción, Concepción, Chile
| | - Samantha Sheller-Miller
- Division of Basic and Translation Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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8
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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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9
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Wood TR, Parikh P, Comstock BA, Law JB, Bammler TK, Kuban KC, Mayock DE, Heagerty PJ, Juul S. Early Biomarkers of Hypoxia and Inflammation and Two-Year Neurodevelopmental Outcomes in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. EBioMedicine 2021; 72:103605. [PMID: 34619638 PMCID: PMC8498235 DOI: 10.1016/j.ebiom.2021.103605] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In the Preterm Erythropoietin (Epo) NeUroproTection (PENUT) Trial, potential biomarkers of neurological injury were measured to determine their association with outcomes at two years of age and whether Epo treatment decreased markers of inflammation in extremely preterm (<28 weeks' gestation) infants. METHODS Plasma Epo was measured (n=391 Epo, n=384 placebo) within 24h after birth (baseline), 30min after study drug administration (day 7), 30min before study drug (day 9), and on day 14. A subset of infants (n=113 Epo, n=107 placebo) had interferon-gamma (IFN-γ), Interleukin (IL)-6, IL-8, IL-10, Tau, and tumour necrosis factor-α (TNF-α) levels evaluated at baseline, day 7 and 14. Infants were then evaluated at 2 years using the Bayley Scales of Infant and Toddler Development, 3rd Edition (BSID-III). FINDINGS Elevated baseline Epo was associated with increased risk of death or severe disability (BSID-III Motor and Cognitive subscales <70 or severe cerebral palsy). No difference in other biomarkers were seen between treatment groups at any time, though Epo appeared to mitigate the association between elevated baseline IL-6 and lower BSID-III scores in survivors. Elevated baseline, day 7 and 14 Tau concentrations were associated with worse BSID-III Cognitive, Motor, and Language skills at two years. INTERPRETATION Elevated Epo at baseline and elevated Tau in the first two weeks after birth predict poor outcomes in infants born extremely preterm. However, no clear prognostic cut-off values are apparent, and further work is required before these biomarkers can be widely implemented in clinical practice. FUNDING PENUT was funded by the National Institute of Neurological Disorders and Stroke (U01NS077955 and U01NS077953).
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Affiliation(s)
- Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Pratik Parikh
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Janessa B. Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Theo K. Bammler
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
| | - Karl C. Kuban
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Sandra Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - for the PENUT Trial consortium
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
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10
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Abstract
Keeping the umbilical cord intact after delivery facilitates transition from fetal to neonatal circulation and allows a placental transfusion of a considerable amount of blood. A delay of at least 3 minutes improves neurodevelopmental outcomes in term infants. Although regarded as common sense and practiced by many midwives, implementation of delayed cord clamping into practice has been unduly slow, partly because of beliefs regarding theoretic risks of jaundice and lack of understanding regarding the long-term benefits. This article provides arguments for delaying cord clamping for a minimum of 3 minutes.
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Affiliation(s)
- Ola Andersson
- Department of Clinical Sciences, Lund, Pediatrics, Lund University, SE-221 85 Lund, Sweden; Department of Neonatology, Skåne University Hospital, Jan Waldenströms gata 47, Malmö SE-214 28, Sweden.
| | - Judith S Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA; University of Rhode Island, Kingston, RI, USA
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11
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Placental transfusion: may the "force" be with the baby. J Perinatol 2021; 41:1495-1504. [PMID: 33850284 DOI: 10.1038/s41372-021-01055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/26/2021] [Accepted: 03/29/2021] [Indexed: 12/14/2022]
Abstract
Placental transfusion results in a significant decrease in the risk of death for extremely preterm infants. With immediate cord clamping (ICC), these infants can leave up to one-half of their normal circulating in utero blood volume in the placenta. Extremely preterm infants are at highest risk of harm from ICC yet are currently the most likely to receive ICC. Receiving a placenta transfusion provides infants with life-saving components and enhanced perfusion. We present some lesser-known but important effects of placental transfusion. New research reveals that enhanced vascular perfusion causes an organ's endothelial cells to release angiocrine responses to guide essential functions. High progesterone levels and pulmonary artery pressure in the first few hours of life assist with neonatal adaptation. We propose that lack of essential blood volume may be a major factor contributing to inflammation, morbidities, and mortality that preterm infants frequently encounter.
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12
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Franklin A, Yallapragada S, Birkett R, Grobman W, Ernst LM, Mestan K. The impact of placental pathology discordance in multiple gestation pregnancies on bronchopulmonary dysplasia-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910674. [PMID: 32215199 PMCID: PMC7065289 DOI: 10.1177/2045894020910674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/01/2020] [Indexed: 11/16/2022] Open
Abstract
Bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) may either be concordant or discordant between multiple gestation births. Abnormal placental development, particularly maternal vascular malperfusion, may account for discordance in BPD-PH through fetal programming mechanisms. Maternal vascular malperfusion is a placental histologic lesion associated with intrauterine growth restriction and BPD-PH. We conducted a retrospective longitudinal cohort study of infants born <29 weeks gestation with available placental histology at Prentice Women's Hospital in Chicago from 2005-2012. The primary outcome was discordant BPD-PH associated with placental maternal vascular malperfusion. We secondarily assessed whether the risk of BPD-PH and placental lesions was different among infants of multiple (compared to singleton) gestations. The cohort consisted of 135 multiple gestation infants and 355 singletons. In a separate cohort of 39 singletons and 35 multiples, associations between 12 cytokines and angiogenic growth factors in cord blood plasma for biomarker discordance, maternal vascular malperfusion, and bronchopulmonary dysplasia were explored. Among multiples, discordant maternal vascular malperfusion was not associated with BPD-PH (OR = 1.9 (0.52, 6.9); p = 0.33) in infants exposed to placental maternal vascular malperfusion. However, singleton infants were more likely to develop BPD-PH (compared to multiples) after adjusting for mode of delivery, chorioamnionitis, chronic hypertension, placental abruption, small-for-gestational age birth weight, and gestational age (aOR = 2.7 (1.2, 5.8); p = 0.038). Singletons were more likely to be small-for-gestational age (11% vs 4%, p = 0.025) and have placental lesions compared to their multiple-gestation counterparts (96% vs 81%, p < 0.001), principally severe maternal vascular malperfusion (17% vs 4%, p < 0.001) and chronic inflammation (32% vs 11%, p < 0.001). Increased risk of BPD-PH in singleton pregnancies <29 weeks gestation compared to multiples may be related to increased frequency of these histologic lesions. Placental pathology in singleton and multiple gestation pregnancies may serve as an early biomarker to predict BPD-PH.
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Affiliation(s)
- Andrew Franklin
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL, USA
| | | | - Robert Birkett
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William Grobman
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Karen Mestan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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