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Wang ZM, Zhou JY, Tang W, Jiang YY, Wang R, Wang LS. Effect of Placental Transfusion on Long-Term Neurodevelopmental Outcomes in Premature Infants: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pediatr Neurol 2024; 154:20-25. [PMID: 38452434 DOI: 10.1016/j.pediatrneurol.2024.01.018] [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: 09/03/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The pathophysiology and the potential risks of placental transfusion (PT) differ substantially in preterm infants, necessitating specific studies in this population. This study aimed to evaluate the safety and efficacy of PT in preterm infants from the perspective of long-term neurodevelopmental outcomes. METHODS We conducted a systematic literature search using placental transfusion, preterm infant, and its synonyms as search terms. Cochrane Central Register of Controlled Trials, Medline, and Embase were searched until March 07, 2023. Two reviewers independently identified, extracted relevant randomized controlled trials, and appraised the risk of bias. The extracted studies were included in the meta-analysis of long-term neurodevelopmental clinical outcomes using fixed-effects models. RESULTS A total of 5612 articles were identified, and seven randomized controlled trials involving 2551 infants were included in our meta-analysis. Compared with immediate cord clamping (ICC), PT may not impact adverse neurodevelopment events. No clear evidence was found of a difference in the risk of neurodevelopmental impairment (risk ratio [RR]: 0.89, 95% confidence interval [CI]: 0.76 to 1.03, P = 0.13, I2 = 0). PT was not associated with the incidence of cerebral palsy (RR: 1.23, 95% CI: 0.59 to 2.57, P = 0.79, I2 = 0). Analyses showed no differences between the two interventions in cognitive, language, and motor domains of neurodevelopment. CONCLUSIONS From the perspective of long-term neurodevelopment, PT at preterm birth may be as safe as ICC. Future studies should focus on standardized, high-quality clinical trials and individual participant data to optimize cord management strategies for preterm infants after birth.
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Affiliation(s)
- Zi-Ming Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Jia-Yu Zhou
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wan Tang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying-Ying Jiang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Wang
- Fudan University GRADE Center, Children's Hospital of Fudan University, Shanghai, China
| | - Lai-Shuan Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
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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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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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Koo J, Aghai ZH, Katheria A. Cord management in non-vigorous newborns. Semin Perinatol 2023:151742. [PMID: 37031034 DOI: 10.1016/j.semperi.2023.151742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Affiliation(s)
- Jenny Koo
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA
| | - Zubair H Aghai
- Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Anup Katheria
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA.
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Bitler CK, Rivera BK, Godavarthi S, Stehle CG, Smith CV, Halling C, Backes CH. Evaluating the evidence behind umbilical cord clamping practices in at-risk neonatal populations. Semin Perinatol 2023:151745. [PMID: 37012137 DOI: 10.1016/j.semperi.2023.151745] [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: 04/05/2023]
Abstract
Umbilical cord clamping practices impact nearly 140 million births each year. Current evidence has led professional organizations to recommend delayed cord clamping (DCC), as opposed to early cord clamping (ECC), as the standard of care in uncomplicated term and preterm deliveries. However, variability remains in cord management practices for maternal-infant dyads at higher risk of complications. This review examines the current state of evidence on the outcomes of at-risk infant populations receiving differing umbilical cord management strategies. Review of contemporary literature demonstrates members of high-risk neonatal groups, including those affected by small for gestational age (SGA) classification, intrauterine growth restriction (IUGR), maternal diabetes, and Rh-isoimmunization, are frequently excluded from participation in clinical trials of cord clamping strategies. Furthermore, when these populations are included, outcomes are often underreported. Consequently, evidence regarding optimal umbilical cord management in at-risk groups is limited, and further research is needed to guide best clinical practice.
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Affiliation(s)
- Chelsea K Bitler
- Pediatric Residency, Department of Pediatrics, The Ohio State University College of Medicine/Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian K Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Srikruthi Godavarthi
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Carolyn G Stehle
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Ohio Perinatal Research Network (OPRN), Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Cecilie Halling
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Ohio Perinatal Research Network (OPRN), Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA; The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
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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: 18] [Impact Index Per Article: 18.0] [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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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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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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9
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Okulu E, Haskologlu S, Guloglu D, Kostekci E, Erdeve O, Atasay B, Koc A, Soylemez F, Dogu F, Ikinciogullari A, Arsan S. Effects of Umbilical Cord Management Strategies on Stem Cell Transfusion, Delivery Room Adaptation, and Cerebral Oxygenation in Term and Late Preterm Infants. Front Pediatr 2022; 10:838444. [PMID: 35444969 PMCID: PMC9013943 DOI: 10.3389/fped.2022.838444] [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: 12/17/2021] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The umbilical cord blood contains a high concentration of stem cells. There is not any published study evaluating the amount of stem cells that have the potential to be transferred to the infant through placental transfusion methods as delayed cord clamping (DCC) and umbilical cord milking (UCM). The aim of this study is to measure the concentrations of endothelial progenitor cell (EPC) and CD34+ hematopoietic stem cell (HSC) in the placental residual blood volume (PRBV), and evaluate the delivery room adaptation and cerebral oxygenation of these infants. METHODS Infants with ≥36 gestational weeks were randomized to receive DCC (120 s), UCM, or immediate cord clamping (ICC). EPC and CD34+ HSC were measured by flow cytometry from the cord blood. PRBV was collected in the setup. The cord blood gas analysis and complete blood count were performed. The heart rate (HR), oxygen saturation (SpO2), and cerebral regional oxygen saturation (crSO2) were recorded. RESULTS A total of 103 infants were evaluated. The amount of PRBV (in ml and ml/kg) was higher in the ICC group (p < 0.001). The number of EPCs in the PRBV content (both ml and ml/kg) were the highest in the ICC group (p = 0.002 and p = 0.001, respectively). The number of CD34+ HSCs in PRBV content (ml and ml/kg) was similar in all groups, but nonsignificantly higher in the ICC group. The APGAR scores at the first and fifth min were lower in the ICC group (p < 0.05). The mean crSO2 values were higher at the 3rd and 10th min in the DCC group (p = 0.042 and p = 0.045, respectively). cFOE values were higher at the 3rd and 10th min in the ICC group (p = 0.011 and p < 0.001, respectively). CONCLUSION This study showed that placental transfusion methods, such as DCC and UCM, provide both higher blood volume, more stem cells transfer to the infant, and better cerebral oxygenation in the first minutes of life, whereas many lineages of stem cells is lost to the placenta by ICC with higher residual blood volume. These cord management methods rather than ICC do not require any cost or technology, and may be a preemptive therapeutic source for diseases of the neonatal period.
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Affiliation(s)
- Emel Okulu
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Sule Haskologlu
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Deniz Guloglu
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Kostekci
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Omer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Begum Atasay
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Acar Koc
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Feride Soylemez
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Figen Dogu
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aydan Ikinciogullari
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
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10
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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] [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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11
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[Effect of delayed cord clamping and umbilical cord milking on cerebral hemodynamics in preterm infants: a randomized double-blind controlled trial]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33840403 PMCID: PMC8050552 DOI: 10.7499/j.issn.1008-8830.2011158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To compare the effect of delayed cord clamping (DCC) versus umbilical cord milking (UCM) on cerebral blood flow in preterm infants. METHODS This was a single-center, prospective, double-blind, randomized controlled trial. A total of 46 preterm infants, with a gestational age of 30-33+6 weeks, who were born in Suining Central Hospital from November 2, 2018 to November 15, 2019 were enrolled and randomly divided into DCC group and UCM group, with 23 infants in each group. The primary outcome indexes included cerebral hemodynamic parameters[peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistance index (RI)] measured by ultrasound within 0.5-1 hour, (24±1) hours, (48±1) hours, and (72±1) hours after birth. Secondary outcome indexes included hematocrit, hemoglobin, red blood cell count, and serum total bilirubin levels on the first day after birth and the incidence rate of intraventricular hemorrhage during hospitalization. RESULTS A total of 21 preterm infants in the DCC group and 23 in the UCM group were included in the statistical analysis. There was no significant difference in PSV, EDV, and RI between the two groups at all time points after birth (P > 0.05). There was also no significant difference between the two groups in the hematocrit, hemoglobin, red blood cell count and total bilirubin levels on the first day after birth, and the incidence rate of intraventricular hemorrhage during hospitalization (P > 0.05). CONCLUSIONS DCC and UCM have a similar effect on cerebral hemodynamics in preterm infants with a gestational age of 30-33+6 weeks.
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Bruckner M, Katheria AC, Schmölzer GM. Delayed cord clamping in healthy term infants: More harm or good? Semin Fetal Neonatal Med 2021; 26:101221. [PMID: 33653601 DOI: 10.1016/j.siny.2021.101221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is recommended to delay cord clamping in healthy term infants for at least 60- and 180-s in high- and limited-resource environments, as delayed cord clamping lowers the incidence of anemia and iron deficiency and improves neurodevelopment. There are improvements in hemodynamic parameters such as peripheral arterial oxygen saturation, heart rate, cardiac output, and cerebral oxygenation. Historically, delayed cord clamping caused a higher rate of hyperbilirubinemia and phototherapy, but more recent evidence suggests this may no longer be the case. In limited-resource environments delayed cord clamping may reduce anemia and iron deficiency potentially improving neurodevelopmental outcomes. The use of delayed cord clamping in newborn infants with intrauterine growth restriction or monochorionic twins is limited and further evidence is needed before it can be formally recommended.
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Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States.
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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13
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The effect of umbilical cord milking on cerebral blood flow in very preterm infants: a randomized controlled study. J Perinatol 2021; 41:263-268. [PMID: 32782323 DOI: 10.1038/s41372-020-00780-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/10/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the effect of umbilical cord milking (UCM) vs. early cord clamping (ECC) on cerebral blood flow (CBF). METHOD Preterm infants <31 weeks' gestation were randomized to receive UCM or ECC at birth. Blood flow velocities and resistive & pulsatility indices of middle and anterior cerebral arteries were measured at 4-6 and 10-12 h after birth as an estimate of CBF. RESULTS Randomization allocated 37 infants to UCM and 36 to ECC. Maternal and antenatal variables were similar. There were no significant differences between groups in middle or anterior CBF velocities and resistive indices at either study time point. CBF variables were not correlated with mean blood pressure, systemic blood flow, or intraventricular hemorrhage. CONCLUSIONS In very preterm infants, UCM compared with ECC was not shown to change CBF indices during the first 12 h of age or correlate with other hemodynamic measures or with intraventricular hemorrhage. TRIAL REGISTRATION ClinicalTrials.gov: NCT01487187.
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14
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Sura M, Osoti A, Gachuno O, Musoke R, Kagema F, Gwako G, Ondieki D, Ndavi PM, Ogutu O. Effect of umbilical cord milking versus delayed cord clamping on preterm neonates in Kenya: A randomized controlled trial. PLoS One 2021; 16:e0246109. [PMID: 33497396 PMCID: PMC7837492 DOI: 10.1371/journal.pone.0246109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/13/2021] [Indexed: 01/15/2023] Open
Abstract
Background Delayed cord clamping (DCC) is a placental to new-born transfusion strategy recommended by obstetric and gynaecological societies. Though not widely adopted, umbilical cord milking (UCM) may achieve faster transfusion when DCC cannot be performed such as when a neonate requires resuscitation. Methods Pragmatic, two-arm, randomized clinical trial in which consenting women in spontaneous labour or provider-initiated delivery at 28 to less than 37 weeks at Kenyatta National Hospital in Nairobi, Kenya, were enrolled. At delivery, stable preterm infants were randomized to UCM (4 times) or DCC (60 seconds). Neonatal samples were collected for analysis at 24 hours after delivery. Maternal primary PPH (within 24 hours) and neonatal jaundice (within 1 week) were evaluated clinically. The primary outcome was the mean neonatal haemoglobin level at 24 hours after birth. Modified Intention to treat analysis was used for all outcomes. P-value was significant at p<0.05. Results Between March 2018 to March 2019, 344 pregnant women underwent screening, and 280 eligible participants were randomized when delivery was imminent. The intervention was not performed on 19 ineligible neonates. Of the remaining 260 neonates, 133 underwent UCM while 128 underwent DCC. Maternal and neonatal baseline characteristics were similar. The mean neonatal haemoglobin (17.1 vs 17.5 grams per decilitre, p = 0.191), haematocrit (49.6% vs 50.3%, p = 0.362), anaemia (9.8% vs 11.7%, p = 0.627), maternal PPH (2.3% vs 3.1%, p = 0.719) were similar between UCM and DCC respectfully. However, neonatal polycythaemia (2.3% vs 8.6%, p = 0.024) and neonatal jaundice (6.8% vs 15.6%, p = 0.024) were statistically significantly lower in UCM compared to DCC. Conclusion UCM compared to DCC for preterm neonates resulted in similar outcomes for neonatal haemoglobin, haematocrit, anaemia and maternal primary PPH and a lower proportion of neonatal polycythaemia and clinical jaundice. UCM offers a comparable method of placental transfusion compared to DCC and may be considered as an alternative to DCC in preterm neonates at 28 to <37 weeks’ gestation.
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Affiliation(s)
- Mandeep Sura
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
- * E-mail:
| | - Alfred Osoti
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
- Department of Global Health, The University of Washington, Seattle, Washington, United States of America
| | - Onesmus Gachuno
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Rachel Musoke
- Department of Pediatrics, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Frank Kagema
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - George Gwako
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Diana Ondieki
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Patrick M. Ndavi
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Omondi Ogutu
- Department of Obstetrics and Gynecology, College of Health Sciences, University of Nairobi, Nairobi, Kenya
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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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Variability and associated factors in the management of cord clamping and the milking practice among Spanish obstetric professionals. Sci Rep 2020; 10:1738. [PMID: 32015460 PMCID: PMC6997360 DOI: 10.1038/s41598-020-58641-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/17/2020] [Indexed: 11/15/2022] Open
Abstract
Clinical practice guides recommend delayed clamping of the umbilical cord. If this is not possible, some authors suggest milking as an alternative. The objective of this study was to determine the variability in professional practice in the management of umbilical cord clamping and milking and to identify factors or circumstances associated with the different methods. An observational cross-sectional study done on 1,045 obstetrics professionals in Spain in 2018. A self-designed questionnaire was administered online. The main variables studied were type of clamping and use of milking. Crude odds ratios (OR) and adjusted odds ratios (ORa) were estimated using binary logistic regression. 92.2% (964) performed delayed clamping. 69.3% (724) clamped the cord when it stopped beating. 83.8% (876) had heard of milking, and 55.9% (584) had never performed it. Professionals over 50 were less likely to perform delayed clamping, with an ORa of 0.24 (95% CI: 0.11–0.52), while midwives were more likely to perform delayed clamping than obstetricians, with an ORa of 14.05 (95% CI: 8.41–23.49). There is clinical variability in the management of umbilical cord clamping and the use of milking in normal births. Part of this variability can be attributed to professional and work environment factors.
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17
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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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18
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Bhargava S, Chen X, Howell H, Desai P. Optimal Timing and Methodology of Umbilical Cord Clamping in Preterm Infants: a Review. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00197-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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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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20
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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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Dempsey EM, Kooi EMW, Boylan G. It's All About the Brain-Neuromonitoring During Newborn Transition. Semin Pediatr Neurol 2018; 28:48-59. [PMID: 30522728 DOI: 10.1016/j.spen.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - E M W Kooi
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Geraldine Boylan
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland.
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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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24
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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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25
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McAdams RM, Fay E, Delaney S. Whole blood volumes associated with milking intact and cut umbilical cords in term newborns. J Perinatol 2018; 38:245-250. [PMID: 29234147 DOI: 10.1038/s41372-017-0002-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/08/2017] [Accepted: 10/04/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this study is to determine placental transfusion blood volumes with intact and cut umbilical cord milking in term newborns. STUDY DESIGN Sixty women at ≥37 weeks' gestation were enrolled. Following delivery, the umbilical cord was immediately clamped and cut to separate the newborn. Either intact umbilical cord milking (I-UCM) of the placental-umbilical cord unit or cut umbilical cord milking (C-UCM) of the cut umbilical cord segment was performed. For I-UCM, the cord underwent milking three or four times while being attached to placental circulation. For C-UCM, a 10, 20, or 30 cm cord segment was cut separately and milked four times. Blood volumes were compared between I-UCM and C-UCM methods. RESULTS Mean blood volume with I-UCM (×4) was increased compared to the 30 cm C-UCM technique (48.5 ± 19.0 vs. 24.8 ± 4.0 mL, P < 0.001). For C-UCM, blood volume increased proportionally to cord length and, by the second milking, 98.1 ± 4.5% of blood volume was delivered. CONCLUSION I-UCM provides a greater blood volume than C-UCM. With C-UCM, milking the cord more than twice offers no additional advantage.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Washington, Seattle, WA, USA. .,Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Emily Fay
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Shani Delaney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Katheria AC, Brown MK, Rich W, Arnell K. Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front Pediatr 2017; 5:1. [PMID: 28180126 PMCID: PMC5263890 DOI: 10.3389/fped.2017.00001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/06/2017] [Indexed: 01/18/2023] Open
Abstract
Over the past decade, there have been several studies and reviews on the importance of providing a placental transfusion to the newborn. Allowing a placental transfusion to occur by delaying the clamping of the umbilical cord is an extremely effective method of enhancing arterial oxygen content, increasing cardiac output, and improving oxygen delivery. However, premature and term newborns who require resuscitation have impaired transitional hemodynamics and may warrant different methods to actively provide a placental transfusion while still allowing for resuscitation. In this review, we will provide evidence for providing a placental transfusion in these circumstances and methods for implementation. Several factors including cord clamping time, uterine contractions, umbilical blood flow, respirations, and gravity play an important role in determining placental transfusion volumes. Finally, while many practitioners agree that a placental transfusion is beneficial, it is not always straightforward to implement and can be performed using different methods, making this basic procedure important to discuss. We will review three placental transfusion techniques: delayed cord clamping, intact umbilical cord milking, and cut-umbilical cord milking. We will also review resuscitation with an intact cord and the evidence in term and preterm newborns supporting this practice. We will discuss perceived risks versus benefits of these procedures. Finally, we will provide key straightforward concepts and implementation strategies to ensure that placental-to-newborn transfusion can become routine practice at any institution.
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Affiliation(s)
- Anup C. Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Melissa K. 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
| | - Kathy Arnell
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
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