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Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023; 402:2209-2222. [PMID: 37977169 DOI: 10.1016/s0140-6736(23)02468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. METHODS We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. FINDINGS We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. INTERPRETATION This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia.
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
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Tan-Koay AG, Libesman S, Kluckow M, Gill AW, de Waal K, Tarnow-Mordi W, Robledo KP, Seidler AL, Liley HG. Protocol for a Nested, Retrospective Study of the Australian Placental Transfusion Study Cohort. Cureus 2022; 14:e27693. [PMID: 36081962 PMCID: PMC9440991 DOI: 10.7759/cureus.27693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background Neonates, particularly if born preterm or with congenital anomalies, are among the pediatric patients most likely to need blood transfusion. However, they are also particularly vulnerable to adverse consequences of blood transfusion. Aiming to clamp the umbilical cord for at least a minute after birth is a simple safe procedure that is being increasingly adopted worldwide, although may be associated with increased rates of polycythemia and jaundice. It may also reduce the proportion of preterm babies who need a blood transfusion. The mechanisms for this are not fully understood. Potential mechanisms could include an increased volume of blood transfusion from the placenta to the baby after birth, and an overall reduction in the severity of illness in the first weeks after birth, which could lead to fewer blood tests and greater tolerance of anemia, or enhanced erythropoiesis. Objectives To investigate the mechanism behind the reduced need for blood transfusions after deferral of cord clamping. Methodology This protocol outlines the methods and data analysis plan for a study using nested retrospective data from a large randomized trial combined with additional data collected from patient medical and pathology records. The additional data items to be collected all relate to the receipt of transfusion and the factors that affect the risk for transfusion in preterm babies. The analysis will include all randomized babies from Australia and New Zealand for whom data are available. Causal mediation analysis is planned to estimate the effects of mediators on the relationship between the timing of cord clamping and the need for blood transfusion. The analysis is designed to discern whether initial severity of illness or the magnitude of placental transfusion mediates red blood cell transfusion dependence. Anticipated outcomes and dissemination We expect the study will identify potential strategies for reducing blood transfusions and associated negative outcomes in preterm infants. This will be relevant to researchers, clinicians, and parents. The results will be disseminated through publications, presentations, and inclusion in evidence-based guidelines.
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Brouwer E, Knol R, Kroushev A, Van Den Akker T, Hooper SB, Roest AA, te Pas AB. Effect of breathing on venous return during delayed cord clamping: an observational study. Arch Dis Child Fetal Neonatal Ed 2022; 107:65-69. [PMID: 34108193 PMCID: PMC8685611 DOI: 10.1136/archdischild-2020-321431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/06/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the effect of spontaneous breathing on venous return in term infants during delayed cord clamping at birth. METHODS Echocardiographic ultrasound recordings were obtained directly after birth in healthy term-born infants. A subcostal view was used to obtain an optimal view of the inferior vena cava (IVC) entering the right atrium, including both the ductus venosus (DV) and the hepatic vein (HV). Colour Doppler was used to assess flow direction and flow velocity. Recordings continued until the umbilical cord was clamped and were stored in digital format for offline analyses. RESULTS Ultrasound recordings were obtained in 15 infants, with a median (IQR) gestational age of 39.6 (39.0-40.9) weeks and a birth weight of 3560 (3195-4205) g. Flow was observed to be antegrade in the DV and HV in 98% and 82% of inspirations, respectively, with flow velocity increasing in 74% of inspirations. Retrograde flow in the DV was observed sporadically and only occurred during expiration. Collapse of the IVC occurred during 58% of inspirations and all occurred caudal to the DV inlet (100%). CONCLUSION Spontaneous breathing was associated with collapse of the IVC and increased antegrade DV and HV flow velocity during inspiration. Therefore, inspiration appears to preferentially direct blood flow from the DV into the right atrium. This indicates that inspiration could be a factor driving placental transfusion in infants.
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Affiliation(s)
- Emma Brouwer
- Neonatology, Leiden University Medical Center Willem Alexander Children's Hospital, Leiden, The Netherlands
| | - Ronny Knol
- Neonatology, Leiden University Medical Center Willem Alexander Children's Hospital, Leiden, The Netherlands,Neonatology, Erasmus MC, Rotterdam, The Netherlands
| | - Annie Kroushev
- Monash Women's, Monash Health, Clayton, Victoria, Australia
| | | | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia,Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Arno A Roest
- Pediatric Cardiology, Leiden University Medical Center Willem Alexander Children’s Hospital, Leiden, The Netherlands
| | - Arjan B te Pas
- Neonatology, Leiden University Medical Center Willem Alexander Children's Hospital, Leiden, The Netherlands
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Brouwer E, te Pas AB, Polglase GR, McGillick EV, Böhringer S, Crossley KJ, Rodgers K, Blank D, Yamaoka S, Gill AW, Kluckow M, Hooper SB. Effect of spontaneous breathing on umbilical venous blood flow and placental transfusion during delayed cord clamping in preterm lambs. Arch Dis Child Fetal Neonatal Ed 2020; 105:26-32. [PMID: 31092674 PMCID: PMC6961560 DOI: 10.1136/archdischild-2018-316044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 03/04/2019] [Accepted: 04/02/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION During delayed umbilical cord clamping, the factors underpinning placental transfusion remain unknown. We hypothesised that reductions in thoracic pressure during inspiration would enhance placental transfusion in spontaneously breathing preterm lambs. OBJECTIVE Investigate the effect of spontaneous breathing on umbilical venous flow and body weight in preterm lambs. METHODS Pregnant sheep were instrumented at 132-133 days gestational age to measure fetal common umbilical venous, pulmonary and cerebral blood flows as well as arterial and intrapleural (IP) pressures. At delivery, doxapram and caffeine were administered to promote breathing. Lamb body weights were measured continuously and breathing was assessed by IP pressure changes. RESULTS In 6 lambs, 491 out of 1117 breaths were analysed for change in body weight. Weight increased in 46.6% and decreased in 47.5% of breaths. An overall mean increase of 0.02±2.5 g per breath was calculated, and no net placental transfusion was observed prior to cord clamping (median difference in body weight 52.3 [-54.9-166.1] g, p=0.418). Umbilical venous (UV) flow transiently decreased with each inspiration, and in some cases ceased, before UV flow normalised during expiration. The reduction in UV flow was positively correlated with the standardised reduction in (IP) pressure, increasing by 109 mL/min for every SD reduction in IP pressure. Thus, the reduction in UV flow was closely related to inspiratory depth. CONCLUSIONS Spontaneous breathing had no net effect on body weight in preterm lambs at birth. UV blood flow decreased as inspiratory effort increased, possibly due to constriction of the inferior vena cava caused by diaphragmatic contraction, as previously observed in human fetuses.
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Affiliation(s)
| | | | - Graeme R Polglase
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia,Obstetrics and Gynaecology,
Monash University, Clayton, Victoria,
Australia
| | - Erin V McGillick
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia,Obstetrics and Gynaecology,
Monash University, Clayton, Victoria,
Australia
| | | | - Kelly J Crossley
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia,Obstetrics and Gynaecology,
Monash University, Clayton, Victoria,
Australia
| | - Karyn Rodgers
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia
| | - Douglas Blank
- Newborn Research, Royal
Women’s Hospital, Melbourne, Victoria,
Australia,The Ritchie Centre, Monash
Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Shigeo Yamaoka
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia
| | - Andrew William Gill
- Centre for Neonatal Research and
Education, University of Western Australia,
Perth, Western
Australia, Australia
| | - Martin Kluckow
- Department of Neonatology, St
Leonards, New South Wales,
Australia
| | - Stuart B Hooper
- The Ritchie Centre, The
Hudson Institute for Medical Research, Clayton, Victoria,
Australia,Obstetrics and Gynaecology,
Monash University, Victoria, Australia
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Di Tommaso M, Carotenuto B, Seravalli V, Magro Malosso ER, Pinzauti S, Torricelli M, Petraglia F. Evaluation of umbilical cord pulsatility after vaginal delivery in singleton pregnancies at term. Eur J Obstet Gynecol Reprod Biol 2019; 236:94-97. [PMID: 30901630 DOI: 10.1016/j.ejogrb.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To define the duration of umbilical cord pulsatility (UCP) after vaginal delivery and to evaluate its possible association with maternal characteristics and obstetric and neonatal variables. STUDY DESIGN Prospective observational study on women with a singleton pregnancy at term who had a vaginal delivery and cord clamping at the cessation of pulsations. The collection of UCP duration was performed through a stopwatch and by manual palpation of the umbilical cord. Maternal (age, BMI, parity, antepartum hemoglobin), obstetric (pregnancy characteristics, gestational age at delivery, induction of labor, duration of the first, the second and the third stage of labor, post-partum blood loss, umbilical cord length) and neonatal (birthweight, Apgar score, hematocrit, hemoglobin) variables were then compared between two groups: long-term vs. short-term UCP. RESULTS A total of 102 women were identified. The median duration of UCP after birth was 213 s (IQR 120, 420), corresponding to 3 min and 33 s. The long-term UCP group (n = 51) had a significantly longer duration of third stage of labor (median 12 vs. 8 min, p < 0.001) and a significantly higher birthweight (median 3530 g vs. 3250 g, p = 0.005) compared with the short-term UCP group (n = 51). No differences in the other variables were found between groups. CONCLUSION For the first time we have reported the duration of UCP after vaginal delivery. An increased duration of UCP is associated with a prolonged duration of third stage of labor and a higher birthweight.
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Affiliation(s)
| | - Bianca Carotenuto
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Viola Seravalli
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Serena Pinzauti
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Michela Torricelli
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Felice Petraglia
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
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