Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

Abstract

IMPORTANCEIt is unclear which umbilical cord management strategy is the best for preventing mortality and morbidities in preterm infants.OBJECTIVE To systematically review and conduct a network meta-analysis comparing 4 umbilical cord management strategies for preterm infants: immediate umbilical cord clamping (ICC), delayed umbilical cord clamping (DCC), umbilical cord milking (UCM), and UCM and DCC.DATA SOURCES PubMed, Embase, CINAHL, and Cochrane CENTRAL databases were searched from inception until September 11, 2020.STUDY SELECTION Randomized clinical trials comparing different umbilical cord management strategies for preterm infants were included.DATA EXTRACTION AND SYNTHESIS Data were extracted for bayesian random-effects meta-analysis to estimate the relative treatment effects (odds ratios [OR] and 95% credible intervals [CrI]) and surface under the cumulative ranking curve values. MAIN OUTCOMES AND MEASURESThe primary outcome was predischarge mortality. The secondary outcomes were intraventricular hemorrhage, severe intraventricular hemorrhage, need for packed red blood cell transfusion, and other neonatal morbidities. Confidence in network meta-analysis software was used to assess the quality of evidence and grade outcomes.RESULTS Fifty-six studies enrolled 6852 preterm infants. Compared with ICC, DCC was associated with lower odds of mortality (22 trials, 3083 participants; 7.6% vs 5.0%; OR, 0.64; 95% CrI, 0.39-0.99), intraventricular hemorrhage (25 trials, 3316 participants; 17.8% vs 15.4%; OR, 0.73; 95% CrI, 0.54-0.97), and need for packed red blood cell transfusion (18 trials, 2904 participants; 46.9% vs 38.3%; OR, 0.48; 95% CrI, 0.32-0.66). Compared with ICC, UCM was associated with lower odds of intraventricular hemorrhage (10 trials, 645 participants; 22.5% vs 16.2%; OR, 0.58; 95% CrI, 0.38-0.84) and need for packed red blood cell transfusion (9 trials, 688 participants; 47.3% vs 32.3%; OR, 0.36; 95% CrI, 0.23-0.53), with no significant differences for other secondary outcomes. There was no significant difference between UCM and DCC for any outcome. CONCLUSIONS AND RELEVANCECompared with ICC, DCC was associated with the lower odds of mortality in preterm infants. Compared with ICC, DCC and UCM were associated with reductions in intraventricular hemorrhage and need for packed red cell transfusion. There was no significant difference between UCM and DCC for any outcome. Further studies directly comparing DCC and UCM are needed.

Reply

“…2 Other peripartum factors associated with mortality and/or severe neurologic injury have included postnatal transfer from a nontertiary center, delayed cord clamping, and acuity score. 3,4 Regarding outcomes selection, we believe that survival is most critical when compared with other adverse outcomes: if there were a survival benefit to prophylactic indomethacin at the lowest gestations, one might accept slightly greater rates of other complications, such as spontaneous intestinal perforation in the presence of antenatal steroids.…”

Which infants should receive indomethacin prophylaxis: moving closer to individualized medicine in the neonatal intensive care unit

“…2 Other peripartum factors associated with mortality and/or severe neurologic injury have included postnatal transfer from a nontertiary center, delayed cord clamping, and acuity score. 3,4 Regarding outcomes selection, we believe that survival is most critical when compared with other adverse outcomes: if there were a survival benefit to prophylactic indomethacin at the lowest gestations, one might accept slightly greater rates of other complications, such as spontaneous intestinal perforation in the presence of antenatal steroids.…”

Prematürede anemi ve transfüzyon politikaları

“…Doğum sonrası göbek kordonunun klemplenme zamanı veya kordun sağılmasıyla ilgili çalışmalarda; geç kord klemplemenin Htc ve serum ferritin düzeylerini arttırdığı, mortaliyeti ve İVK riskini azalttığı, kan transfüzyonunda %10 azalma sağladığı, ancak kord sağmanın aşırı prematüre (<28 gebelik haftası) bebeklerde ciddi İVK riskini arttırdığı, hatta bazı çalışmalarda RDS riskini arttıryor gözüktüğü belirtilmekte olup, prematüre bebeklerde ideal kord uygulama yönteminin halen net olarak ne olduğununu bilinmediği, ancak erken kord klemplemenin (<30 sn) prematüre bebeklerde zararlı olabileceği nedeniyle bu bebeklere erken kord klemplemenin önerilmemesi gerektiği bildirilmektedir [6,[33][34][35][36][37][38][39][40]. Kord sağma işlemi prematüre bebeklerde serebrovasküler ve sistemik kan akımında fluktuasyonlara neden olabileceği için şu an önerilmemektedir [10].…”

“…Acil kord klempleme ile geç kord klemplemenin kıyaslandığı başka bir meta analizde (56 çalışma, n:6852 prematüre); geç kord klempleme ile İVK, eritrosit transfüzyon ihtiyacı ve moratalite azalmıştır. Umblikal kord sağmayla da İVK ve eritrosit transfüzyon ihtiyacının azaldığı görülmüş, geç kord klempleme ile kord sağma arasında bir farklılık bulunmamış olmakla birlikte bu konuda ek çalışmalara ihtiyaç duyulduğu belirtilmiştir [39]. Ancak, aşırı prematüre bebeklerde (<28 gebelik haftası) kord sağmanın ciddi İVK riskini arttırdığı saptanmıştır [40].…”