Neonatal outcomes in preterm multiples receiving delayed cord clamping

Abstract

ObjectiveTo compare neonatal outcomes in singletons versus multiples, first-born versus second-born multiples and monochorionic versus dichorionic/trichorionic multiples <33 weeks’ gestational age (GA) who received delayed cord clamping (DCC).DesignRetrospective, observational study of 529 preterm infants receiving ≥30 s DCC. Generalised estimating equations and mixed effects models were used to compare outcomes in singletons versus multiples and monochorionic versus dichorionic/trichorionic multiples. Wilcoxon signed-rank and McNemar tests were used to compare first-born versus second-born multiples.SettingLevel III neonatal intensive care unit, California, USA.Patients433 singletons and 96 multiples <33 weeks’ GA, born January 2008–December 2017, who received DCC.Results86% of multiples and 83% of singletons received DCC. Multiples had higher GA (31.0 weeks vs 30.6 weeks), more caesarean sections (91% vs 54%), fewer males (48% vs 62%) and higher 12–24 hour haematocrits (54.3 vs 50.5) than singletons. Haematocrit difference remained significant after adjusting for birth weight, delivery type and sex. Compared with first-born multiples, second-born multiples were smaller (1550 g vs 1438 g) and had lower survival without major morbidity (91% vs 77%). Survival without major morbidity was not significant after adjusting for birth weight. Compared with dichorionic/trichorionic multiples, monochorionic multiples had slightly lower admission temperatures (37.0°C vs 36.8°C), although this difference was not clinically significant. There were no other differences in delivery room, respiratory, haematological or neonatal outcomes between singletons and multiples or between multiples’ subgroups.ConclusionsNeonatal outcomes in preterm infants receiving DCC were comparable between singletons and multiples, first and second order multiples and monochorionic and dichorionic/trichorionic multiples.

What does the evidence tell us? Revisiting optimal cord management at the time of birth

“…It makes sense to provide them with more of their own blood through placental transfusion at birth [51,52]. Studies of multiple births have demonstrated feasibility of providing OCM to twins and triplets [53,54]. Thus, multiple births should not be routinely excluded.…”

Toward greater nuance in delayed cord clamping

“…There was no evidence for acute intertwin hemorrhage, and the observed difference was ascribed to differential clamping times [61]. A retrospective observational study showed that multiples less than 33 weeks gestation of mono/di/and tri chorionicity receiving DCC had similar outcomes to singletons receiving DCC [62]. In an RCT of preterm multiples between 28-36 weeks gestation, there was no difference in admission hematocrit between early and delayed clamping groups, but more frequent PPH in the DCC group, which contradicts other studies [63][64][65].…”

Achieving optimal cord management: a multidisciplinary quality improvement initiative

“…The safety profile of OCM in multiple births continues to be debated. Several studies support the practice in these infants, and national guidance suggests suitability should be assessed on a case-by-case basis rather than routine exclusion 13–15. However, in monochorionic twins where there is concern of placental vessel anastomoses (twin-to-twin transfusion syndrome or twin anaemia polycythaemia sequence), there is a risk of draining blood from one twin to the other during the procedure, thus these infants are often excluded from OCM.…”