Hasty clamping of the umbilical cord may initiate neonatal intraventricular hemorrhage

Hofmeyr, G Justus; Bex, P.J.M.; Skapinker, R; Delahunt, T. A.

doi:10.1016/0306-9877(89)90157-6

Cited by 14 publications

(5 citation statements)

References 12 publications

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“…Fifty-six randomized clinical trials enrolling 6852 infants were included. The characteristics of the included studies are summarized in the Table . Eight studies were published in the Chinese language .…”

Section: Resultsmentioning

confidence: 99%

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Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

Jasani

Torgalkar

et al. 2021

JAMA Pediatr

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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.

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Section: Resultsmentioning

confidence: 99%

“…Thirty-one studies compared DCC with ICC, of which 1 study reported neurodevelopmental outcomes . Among these studies, the duration of DCC ranged from at least 30 seconds to more than 180 seconds.…”

Section: Resultsmentioning

confidence: 99%

Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

Jasani

Torgalkar

et al. 2021

JAMA Pediatr

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“…In this systematic review and meta-analysis of 221 trials that assessed 44 perinatal interventions, we found with moderate certainty that antenatal corticosteroids for lung maturation (small decrease) and indomethacin prophylaxis (moderate decrease) were associated with reduced risk of sIVH in preterm neonates. We also found low certainty evidence that volume-targeted ventilation (large decrease), early ESAs (moderate decrease), and prophylactic ethamsylate (moderate decrease) were associated with lower risk of sIVH, whereas UCM (moderate increase) were associated with higher risk of sIVH in preterm neonates.…”

Section: Discussionmentioning

confidence: 93%

“…We further determined the eligibility of 395 short-listed articles and excluded 174 articles for the reasons shown in eAppendix 4 in Supplement 1. A total of 221 RCTs were included in the final sample . These trials evaluated 44 interventions, which included 6 antenatal, 6 delivery room, and 32 neonatal interventions.…”

Section: Resultsmentioning

confidence: 99%

Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates

et al. 2023

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ImportanceInterventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials.ObjectiveTo evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates.Data SourcesMEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions.Study SelectionRandomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included.Data Extraction and SynthesisTwo co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis.Main Outcomes and MeasuresThe 3 prespecified outcomes were sIVH, cPVL, and severe brain injury.ResultsA total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], −1% [95% CI, −2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, −5% [95% CI, −8% to −3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, −9% [95% CI, −13% to −5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, −3% [95% CI, −4% to −1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, −4% [95% CI, −7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, −30 [95% CI, −368 to −16]).Conclusions and RelevanceResults of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.

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“…Current delivery room practice is to delay clamping and cutting the umbilical cord to allow for placental transfusion and hemodynamic stabilization. Supported by numerous randomized controlled trials 20 21 22 23 24 25 26 27 28 29 and meta-analyses, 30 31 this practice is endorsed by neonatal and obstetrical governing bodies. 32 33 34 Yet, data are very limited on optimal oxygenation during DCC in extremely preterm infants.…”

Section: Discussionmentioning

confidence: 99%

Differential Alveolar and Systemic Oxygenation during Preterm Resuscitation with 100% Oxygen during Delayed Cord Clamping

et al. 2021

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Objective Delayed cord clamping (DCC) and 21 to 30% O2 resuscitation is recommended for preterm infants but is commonly associated with low pulmonary blood flow (Qp) and hypoxia. 100% O2 supplementation during DCC for 60 seconds followed by 30% O2 may increase Qp and oxygen saturation (SpO2). Study Design Preterm lambs (125–127 days of gestation) were resuscitated with 100% O2 with immediate cord clamping (ICC, n = 7) or ICC + 30% O2, and titrated to target SpO2 (n = 7) or DCC + 100% O2 for 60 seconds, which followed by cord clamping and 30% O2 titration (n = 7). Seven preterm (23–27 weeks of gestation) human infants received continuous positive airway pressure (CPAP) + 100% O2 for 60 seconds during DCC, cord clamping, and 30% O2 supplementation after cord clamping. Results Preterm lambs in the ICC + 100% O2 group resulted in PaO2 (77 ± 25 mmHg), SpO2 (77 ± 11%), and Qp (27 ± 9 mL/kg/min) at 60 seconds. ICC + 30% O2 led to low Qp (14 ± 3 mL/kg/min), low SpO2 (43 ± 26%), and PaO2 (19 ± 7 mmHg). DCC + 100% O2 led to similar Qp (28 ± 6 mL/kg/min) as ICC + 100% O2 with lower PaO2. In human infants, DCC + CPAP with 100% O2 for 60 seconds, which followed by weaning to 30% resulted in SpO2 of 92 ± 11% with all infants >80% at 5 minutes with 100% survival without severe intraventricular hemorrhage. Conclusion DCC + 100% O2 for 60 seconds increased Qp probably due to transient alveolar hyperoxia with systemic normoxia due to “dilution” by umbilical venous return. Larger translational and clinical studies are warranted to confirm these findings. Key Points

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Hasty clamping of the umbilical cord may initiate neonatal intraventricular hemorrhage

Cited by 14 publications

References 12 publications

Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates

Differential Alveolar and Systemic Oxygenation during Preterm Resuscitation with 100% Oxygen during Delayed Cord Clamping

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