Placental transfusion during neonatal resuscitation in an asphyxiated preterm model

Chandrasekharan, Praveen; Gugino, Sylvia F.; Koenigsknecht, Carmon; Helman, Justin; Nielsen, Lori; Bradley, Nicole; Nair, Jayasree; Sankaran, Deepika; Bawa, Mausma; Rawat, Munmun; Lakshminrusimha, Satyan

doi:10.1038/s41390-022-02086-9

Cited by 8 publications

(4 citation statements)

References 33 publications

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“…Although these findings may have been strengthened by a larger cohort of lambs than we have studied, we are satisfied that our findings were clear and consistent between subjects. Reassuringly, our observations of carotid blood flow are consistent with the recently published experiment conducted by Chandrasekharan and colleagues investigating UCM before and after ventilation in asphyxiate preterm lambs (23).…”

Section: Number Of Subjectssupporting

confidence: 92%

Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs

et al. 2023

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BackgroundUmbilical cord milking (UCM) at birth causes surges in arterial blood pressure and blood flow to the brain, which may explain the high risk of intraventricular haemorrhage (IVH) in extremely preterm infants receiving UCM. This high risk of IVH has not been reported in older infants.ObjectiveWe hypothesized that lung aeration before UCM, reduces the surge in blood pressure and blood flow induced by UCM.MethodsAt 126 days' gestation, fetal lambs (N = 8) were exteriorised, intubated and instrumented to measure umbilical, pulmonary, cerebral blood flows, and arterial pressures. Prior to ventilation onset, the umbilical cord was briefly (2–3 s) occluded (8 times), which was followed by 8 consecutive UCMs when all physiological parameters had returned to baseline. Lambs were then ventilated. After diastolic pulmonary blood flow markedly increased in response to ventilation, the lambs received a further 8 consecutive UCMs. Ovine umbilical cord is shorter than the human umbilical cord, with ∼10 cm available for UCMs. Therefore, 8 UCMs/occlusions were done to match the volume reported in the human studies. Umbilical cord clamping occurred after the final milk.ResultsBoth umbilical cord occlusions and UCM caused significant increases in carotid arterial blood flow and pressure. However, the increases in systolic and mean arterial blood pressure (10 ± 3 mmHg vs. 3 ± 2 mmHg, p = 0.01 and 10 ± 4 mmHg vs. 6 ± 2 mmHg, p = 0.048, respectively) and carotid artery blood flow (17 ± 6 ml/min vs. 10 ± 6 ml/min, p = 0.02) were significantly greater when UCM occurred before ventilation onset compared with UCM after ventilation.ConclusionsUCM after ventilation onset significantly reduces the increases in carotid blood flow and blood pressure caused by UCM.

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Section: Number Of Subjectssupporting

confidence: 92%

Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs

et al. 2023

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“…Data from a anesthetized preterm lamb model suggest UCM results in fluctuations in carotid artery blood flow, 9 which dissipates if the lambs are ventilated. 10 , 11 A randomized clinical trial stopped enrollment in the most preterm strata (23-27 weeks’ gestation) due to an associated increase in severe intraventricular hemorrhage. 12 There were no significant differences in short-term outcomes in the more mature group (28-32 weeks’ gestation).…”

Section: Introductionmentioning

confidence: 80%

Two-Year Outcomes of Umbilical Cord Milking in Nonvigorous Infants

Katheria,

El Ghormli,

Clark

et al. 2024

JAMA Netw Open

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ImportanceCompared with early cord clamping (ECC), umbilical cord milking (UCM) reduces delivery room cardiorespiratory support, hypoxic-ischemic encephalopathy, and therapeutic hypothermia in nonvigorous near-term and full-term infants. However, UCM postdischarge outcomes are not known.ObjectiveTo determine the 2-year outcomes of children randomized to UCM or ECC at birth in the Milking in Nonvigorous Infants (MINVI) trial.Design, Setting, and ParticipantsA secondary analysis to evaluate longer-term outcomes of a cluster-randomized crossover trial was conducted from January 9, 2021, to September 25, 2023. The primary trial took place in 10 medical centers in the US, Canada, and Poland from January 5, 2019, to June 1, 2021, and hypothesized that UCM would reduce admission to the neonatal intensive care unit compared with ECC; follow-up concluded September 26, 2023. The population included near-term and full-term infants aged 35 to 42 weeks’ gestation at birth who were nonvigorous; families provided consent to complete developmental screening questionnaires through age 2 years.InterventionUCM and ECC.Main Outcomes and MeasuresAges and Stages Questionnaire, 3rd Edition (ASQ-3) and Modified Checklist for Autism in Toddlers, Revised/Follow-Up (M-CHAT-R/F) questionnaires at ages 22 to 26 months. Intention-to-treat analysis and per-protocol analyses were used.ResultsAmong 1730 newborns from the primary trial, long-term outcomes were evaluated in 971 children (81%) who had ASQ-3 scores available at 2 years or died before age 2 years and 927 children (77%) who had M-CHAT-R/F scores or died before age 2 years. Maternal and neonatal characteristics by treatment group were similar, with median birth gestational age of 39 (IQR, 38-40) weeks in both groups; 224 infants (45%) in the UCM group and 201 (43%) in the ECC group were female. The median ASQ-3 total scores were similar (UCM: 255 [IQR, 225-280] vs ECC: 255 [IQR, 230-280]; P = .87), with no significant differences in the ASQ-3 subdomains. Medium- to high-risk M-CHAT-R/F scores were also similar (UCM, 9% [45 of 486] vs ECC, 8% [37 of 441]; P = .86).Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial among late near-term and full-term infants who were nonvigorous at birth, ASQ-3 scores at age 2 years were not significantly different between the UCM and ECC groups. Combined with previously reported important short-term benefits, this follow-up study suggests UCM is a feasible, no-cost intervention without longer-term neurodevelopmental risks of cord milking in nonvigorous near-term and term newborns.Trial RegistrationClinicalTrials.gov Identifier: NCT03631940

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“…As noted above, animal models suggest that adequate ventilation is protective against abnormal fluctuations in lambs receiving UCM (71). However, it is possible that UCM may stimulate spontaneous breathing in human neonates as contrasted to anesthetized lamb models.…”

Section: Hemodynamic Parameters Cerebral Oxygenation and Breathingmentioning

confidence: 99%

“…Anesthetized preterm lamb models delivered by C-section have demonstrated oscillations in the systemic arterial pressure and cerebral blood flow with UCM ( 12 , 31 , 92 ). However, asphyxiated preterm lamb models receiving UCM concurrently with ventilation exhibited a decrease in fluctuations of carotid and pulmonary blood flow as compared to UCM alone ( 71 ).…”

Section: Risks With Umbilical Cord Milkingmentioning

confidence: 99%

Umbilical cord milking-benefits and risks

2023

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The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.

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Placental transfusion during neonatal resuscitation in an asphyxiated preterm model

Cited by 8 publications

References 33 publications

Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs

Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs

Two-Year Outcomes of Umbilical Cord Milking in Nonvigorous Infants

Umbilical cord milking-benefits and risks

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