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Grand Rounds

What is the Optimal time of Cord Clamping in Preterm Newborns?

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BACKGROUND AND PURPOSE:

  • ACOG guidelines now call for waiting at least 30 to 60 seconds after birth before clamping the cord in preterm infants (see ‘Related ObG Topics’ below) if resuscitation unnecessary
  • Guidelines based on multiple studies showing benefit such as prevention of necrotizing enterocolitis and infection
  • Other guideline committees concur, however this practice is still not universal
  • Data limited with respect to mortality or incidence of neurodevelopmental disability
  • Mordi et al. (NEJM, 2017) determined the optimal timing for umbilical-cord clamping following delivery in preterm infants

METHODS:

  • Randomized controlled trial (RCT)
  • Australian Placental Transfusion Study (APTS)
  • Women expecting to delivery before 30 weeks gestation were randomized into
    • Immediate clamping of umblicial cord (≤10 seconds after delivery)
    • Delayed clamping (≥60 seconds after delivery)
  • The primary outcome was composite of death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age
  • Analyses were performed on an intention-to-treat basis

RESULTS:

  • 1566 liveborn < 30 weeks of gestation
    • 782 were assigned to immediate cord clamping (median time 5 seconds)
    • 784 were assigned to delayed cord clamping (median time 60 seconds)
  • There was no significant difference in composite of death or major morbidity between groups (37% delayed vs 37.2% immediate; P=0.96)
  • Mortality rate alone
    • Mortality was initially lower in the delayed group (6.4% vs 9.0%)
    • Adjusting for confounders, there was no significant difference
  • There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities

CONCLUSION:

  • Delayed cord clamping did not result in lower incidence of combined outcome of death or major morbidity in preterm infants at 36 weeks of gestation, compared to immediate clamping
  • The findings in this study differ from previous studies that did show less morbidity in the delayed clamping groups
    • Authors suggest that infants in the current study may have been less ill
    • A properly powered trial to assess mortality would require > 11,000 patients

Learn More – Primary Sources:

Delayed versus Immediate Cord Clamping in Preterm Infants

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Related ObG Topics:

Is There Benefit to 3 Minute Delay in Umbilical Cord Clamping?
ACOG Committee Opinion on Delayed Cord Clamping

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