Haemoglobin discordances in twins: due to differences in timing of cord clamping?

Verbeek, Lianne; Zhao, Depeng; Middeldorp, Johanna M.; Oepkes, Dick; Hooper, Stuart B.; Pas, Arjan B. te; Lopriore, Enrico

doi:10.1136/archdischild-2016-311822

Cited by 13 publications

(10 citation statements)

References 17 publications

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“…We were unable to detect any placental transfusion using the PBCC strategy, which is consistent with our previous findings 33. Recent studies in twins (both monochorionic and dichorionic) have shown that when born vaginally, first-born twins have significantly lower haemoglobin levels (at 2 hours and 48 hours after birth) than their second-born twin 34 35. No differences were observed between first-born and second-born twins delivered by caesarean section, providing compelling evidence that placental transfusion may not occur in infants born by caesarean section.…”

Section: Discussionsupporting

confidence: 90%

Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

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Polglase

Kluckow

et al. 2017

Arch Dis Child Fetal Neonatal Ed

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ObjectiveUmbilical cord milking (UCM) at birth may benefit preterm infants, but the physiological effects of UCM are unknown. We compared the physiological effects of two UCM strategies with immediate umbilical cord clamping (UCC) and physiological-based cord clamping (PBCC) in preterm lambs.MethodsAt 126 days’ gestational age, fetal lambs were exteriorised, intubated and instrumented to measure umbilical, pulmonary and cerebral blood flows and arterial pressures. Lambs received either (1) UCM without placental refill (UCMwoPR); (2) UCM with placental refill (UCMwPR); (3) PBCC, whereby ventilation commenced prior to UCC; or (4) immediate UCC. UCM involved eight milks along a 10 cm length of cord, followed by UCC.ResultsA net volume of blood was transferred into the lamb during UCMwPR (8.8 mL/kg, IQR 8–10, P=0.01) but not during UCMwoPR (0 mL/kg, IQR −2.8 to 1.7) or PBCC (1.1 mL/kg, IQR −1.3 to 4.3). UCM had no effect on pulmonary blood flow, but caused large fluctuations in mean carotid artery pressures (MBP) and blood flows (CABF). In UCMwoPR and UCMwPR lambs, MBP increased by 12%±1% and 8%±1% and CABF increased by 32%±2% and 15%±2%, respectively, with each milk. Cerebral oxygenation decreased the least in PBCC lambs (17%, IQR 13–26) compared with UCMwoPR (26%, IQR 23–25, P=0.03), UCMwPR (35%, IQR 27–44, P=0.02) and immediate UCC (34%, IQR 28–41, P=0.02) lambs.ConclusionsUCMwoPR failed to provide placental transfusion, and UCM strategies caused considerable haemodynamic disturbance. UCM does not provide the same physiological benefits of PBCC. Further review of UCM is warranted before adoption into routine clinical practice.

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Section: Discussionsupporting

confidence: 90%

Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

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Polglase

Kluckow

et al. 2017

Arch Dis Child Fetal Neonatal Ed

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“…In their study, information on the timing of umbilical cord clamping was not available, but they hypothesized that the difference in hemoglobin concentration was because of differences in the timing of cord clamping. In our study, where almost all infants were delivered by CS, the post hoc subgroup analysis of the hematocrit level (in both the ICC and DCC groups) by birth order or chronicity did not yield any statistically significant differences between the groups, which is consistent with the results of Verbeek et al [4] (no significant inter-twin hemoglobin difference in infants born by CS). However, no further conclusion can be drawn due to our limited sample size, and the physiology of placental transfusion in these patients still needs to be elucidated.…”

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confidence: 82%

“…Verbeek et al [4] reported that second-born dichorionic twins vaginally delivered (VD) have higher hemoglobin levels at birth compared with ﬁrst-born twins. Their results also suggest that twins (monochorionic and dichorionic) delivered by cesarean section (CS) have no significant inter-twin hemoglobin difference.…”

mentioning

confidence: 99%

Reply to the Letter to the Editor “Delayed Cord Clamping in Twin Pregnancies: to Do or Not to Do?”

Ruangkit

Nuntnarumit

2019

Neonatology

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“…Various studies (86–88) showed that the second VD newborn twin had significantly higher hemoglobin concentration at birth and in the first days of life, compared to the first one, both in monochorionic and dichorionic pregnancies.…”

Section: Methodsmentioning

confidence: 99%

Italian Recommendations for Placental Transfusion Strategies

Ghirardello

Tommaso²,

Fiocchi

et al. 2018

Front. Pediatr.

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At delivery, if the cord is not clamped, blood continues to pass from the placenta to the newborn during the first minutes of life, allowing the transfer of 25–35 ml/kg of placental blood to the newborn, depending on gestational age, the timing of cord clamping, the position of the infant at birth, the onset of respiration, and administration of uterotonics to the mother. However, deriving benefits from delayed cord clamping (DCC) are not merely related to placental-to-fetal blood transfusion; establishing spontaneous ventilation before cutting the cord improves venous return to the right heart and pulmonary blood flow, protecting the newborn from the transient low cardiac output, and systemic arterial pressure fluctuations. Recent meta-analyses showed that delayed cord clamping reduces mortality and red blood cell transfusions in preterm newborns and increases iron stores in term newborns. Various authors suggested umbilical cord milking (UCM) as a safe alternative when delayed cord clamping is not feasible. Many scientific societies recommend waiting 30–60 s before clamping the cord for both term and preterm newborns not requiring resuscitation. To improve the uptake of placental transfusion strategies, in 2016 an Italian Task Force for the Management of Umbilical Cord Clamping drafted national recommendations for the management of cord clamping in term and preterm deliveries. The task force performed a detailed review of the literature using the GRADE methodological approach. The document analyzed all clinical scenarios that operators could deal with in the delivery room, including cord blood gas analysis during delayed cord clamping and time to cord clamping in the case of umbilical cord blood banking. The panel intended to promote a more physiological and individualized approach to cord clamping, specifically for the most preterm newborn. A feasible option to implement delayed cord clamping in very preterm deliveries is to move the neonatologist to the mother's bedside to assess the newborn's clinical condition at birth. This option could safely guarantee the first steps of stabilization before clamping the cord and allow DCC in the first 30 s of life, without delaying resuscitation. Contra-indications to placental transfusion strategies are clinical situations that may endanger mother ‘s health and those that may delay immediate newborn's resuscitation when required.

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Haemoglobin discordances in twins: due to differences in timing of cord clamping?

Cited by 13 publications

References 17 publications

Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

Reply to the Letter to the Editor “Delayed Cord Clamping in Twin Pregnancies: to Do or Not to Do?”

Italian Recommendations for Placental Transfusion Strategies

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