Kelebogile C. Seloka Oswell Khondowe Kim Harper cord clamping... · 2013. 10. 29. · Clamping of...
Transcript of Kelebogile C. Seloka Oswell Khondowe Kim Harper cord clamping... · 2013. 10. 29. · Clamping of...
Kelebogile C. Seloka
Oswell Khondowe
Kim Harper
Clamping of the umbilical cord during birth isby far the oldest and most commoninterventions in humans (Hutton & Hassan2007).
Despite this, optimal cord clamping timeremains controversial (Van-Rheenen 2011).
The potential effect of time to cord clampinghas been reported.
Most practitioners in developed countriesclamp the cord immediately after birth(Hutton & Hassan 2007).
In developing countries the practice varieswidely (Van Rheenen & Brabin 2006).
In this review Early Cord Clamping (ECC)means; clamping within 30 seconds (Rabe,Reynolds & Diaz-Rossello 2004).
Delayed Cord Clamping (DCC); clamping donefrom 30 seconds and beyond (Rabe, Reynolds& Diaz-Rossello 2004).
Before the baby’s lungs start to fully function,the placental blood supplies the newbornwith oxygen for optimal survival.
The incidence of IVH is about 15-25% ininfants with low birth weight (Riskin et al2008) and is associated with neurologicalmorbidity and mortality (Ajayi & Nzeh 2003).
IVH originates in the germinal matrix, a veryhighly vascularised structure moresusceptible region to IVH (Vural et al 2007).
This periventricular region is selectivelyvulnerable to haemorrhage in LBW infants inthe first 48hrs of life (Ballahb 2010).
Grade I: Germinal matrix hemorrhage
Grade II: Bleeding inside the ventricles
Grade III: Ventricles enlarged by the blood
Grade IV: Bleeding into the brain tissuesaround the ventricles
10 to 15% in the Western world
43% in Africa
3rd leading cause of mortality and morbidity
AIM
To systematically appraise evidence on theeffects of DCC versus ECC on IVH among lowbirth weight infants
Secondary objective
To assess the risk of hyperbilirubinaemiabetween DCC versus ECC.
Eligibility criteria
Types of studies RCT’S
Types of participants •Infants with low birthweight (<2500g)regardless of gestationalage
Types of interventions •DCC versus ECC
Types of outcomemeasures
•Primary Outcomemeasures:IVH of all grades (i, ii, iiiand iv)
•Secondary outcomeMeasures:Hyperbilirubinaemia
Exclusion criteria
Trials that included women with multiplepregnancies
Studies that did not mention atleast oneoutcome of interest
Search methods for identification of studies
Electronic searches PubMed, CochraneRegister of ControlledTrials and CINAHL
Searching otherresources
Reference lists andexpert in the field
Selection of studies
Data extraction and management
Assessment of risk of bias in included studies
Measures of treatment effect
Dealing with missing data
Potentially relevant studies (n=344)
Studies excluded, after reading titles (n=300)
Studies detailed evaluation (n=44)
Potentially appropriate (n=20)
Studies included (n=5)
Studies excluded after reading abstracts(n=24).
Studies excluded (n=15)
Figure 1: The risk of Intraventricularhaemorrhage
Study or Subgroup
Hofmeyr, 1988
Mercer, 2003
Mercer, 2006
Oh, 2011
Rabe, 2000
Total (95% CI)
Total events
Heterogeneity: Chi² = 2.90, df = 4 (P = 0.57); I² = 0%
Test for overall effect: Z = 2.79 (P = 0.005)
Events
8
3
5
4
1
21
Total
24
16
36
16
20
112
Events
10
5
13
3
3
34
Total
14
16
36
17
20
103
Weight
34.6%
13.7%
35.6%
8.0%
8.2%
100.0%
M-H, Fixed, 95% CI
0.47 [0.24, 0.90]
0.60 [0.17, 2.10]
0.38 [0.15, 0.97]
1.42 [0.37, 5.37]
0.33 [0.04, 2.94]
0.52 [0.33, 0.82]
DCC ECC Risk Ratio Risk Ratio
M-H, Fixed, 95% CI
0.01 0.1 1 10 100Favours experimental Favours control
Figure 2: The risk of hyperbilirubinaemia
Study or Subgroup
Mercer 2003
Mercer 2006
Total (95% CI)
Heterogeneity: Chi² = 0.21, df = 1 (P = 0.64); I² = 0%
Test for overall effect: Z = 1.04 (P = 0.30)
Mean
8.2
10.1
SD
3
2.4
Total
16
36
52
Mean
8.1
9.5
SD
2.3
2.1
Total
16
36
52
Weight
24.0%
76.0%
100.0%
IV, Fixed, 95% CI
0.10 [-1.75, 1.95]
0.60 [-0.44, 1.64]
0.48 [-0.43, 1.39]
DCC ECC Mean Difference Mean Difference
IV, Fixed, 95% CI
-1 -0.5 0 0.5 1Favours experimental Favours control
There is a reduced risk of intraventricularhaemorrhage if cord clamping is delayed forat least 30 seconds or more in low birthweight infants compared to early cordclamping
These results are consistent with previousstudies conducted in low birth weight infants.
There was no difference inhyperbilirubinaemia between the twointerventions.
Only 2 studies reported on the outcome The evidence reported is not yet conclusive on
optimum timing of umbilical cord clamping. Growing evidence from recent studies indicates
that this vulnerable population of neonates canbenefit from delayed cord clamping.
However, due to small sample size of includedstudies, the results should be interpreted withcaution and need confirmation through largescale randomised controlled trials (RCTs).
Further research is warranted on timing of theumbilical cord particularly in developingcountries
Another thing very injurious to the child, isthe tying and cutting of the navel string toosoon; which should always be left till the childhas not only repeatedly breathed but till allpulsation in the cord ceases. As otherwise thechild is much weaker than it ought to be, aportion of the blood being left in theplacenta, which ought to have been in thechild.
Erasmus Darwin(12 December 1731 – 18 April 1802)
In 2012, the American College ofObstetricians and Gynecologists endorseddelaying clamping of the umbilical cord for30–60 seconds with the newborn in all casesof preterm delivery.
Many modern medical facilities worldwide stilluse ECC
Ajayi, O. & Nzeh, D.A. 2003. Intraventricular haemorrhage and periventricularleukomalacia in Nigerian infants of very low birth weight. West African Journal ofMedicine, 22(2):164-166.
Ballabh, P. 2010. Intraventricular haemorrhage in premature infants: Mechanismofdisease. Pediatric Research, 67(1):1-8.
Hofmeyr, G.J., Bolton, K.D., Bowen, D.C. & Govan, J.J. 1988.Periventricular /Intraventricular haemorrhage and umbilicalcord clamping: Findings andhypothesis, South African Medical Journal, 73:104-106.
Hutton, E. K. & Hassan, E. S. 2007. Late versus early clamping of the umbilical cord infull-term neonates: Systematic Review and Meta-Analysis of Controlled Trials. TheJournal of the American Medical Association, 297(11):1241-1252.
Mercer, J.S., McGrath, M.M., Hensman, A., Silver, H. & Oh, W.2003. Immediate anddelayed cord clamping in infants bornbetween 24 and 32 weeks: A pilot randomizedcontrolled trial. Journal of Perinatology, 23:466-472.
Mercer, J.S., Vohr, B.R., McGrath, M.M., Padbury, J.F.,Wallach, M. & Oh, W. 2006. Delayedcord clamping in very preterm infants reduces the incidence of intraventricularhaemorrhage and late-onset sepsis: A randomized, controlled trial. Pediatrics,117:1235-1242.
Oh, W., Fanaroff, A.A., Carlo, W.A., Donovan, E.F., McDonald,S.A. & Poole, W.K. 2011.Effects of delayed cord clamping invery-low-birth-weight infants. Journal ofPerinatology, 31:68-71.
Rabe, H., Reynolds, G. & Diaz-Rossello, J. 2004. Early versus delayed umbilical cord
clamping in preterm infants. Cochrane Database Systematic Review 18; (14) [CD – ROM003248]. [Online]. Last updated on 18 October 2008. Available:http://www.ncbi.nlm.nih.gov/pubmed. [2010, March 31].
Rabe, H., Wacker, A., Hülskamp, G., Hönig-Franz, I., Schulze-Everding, A., Cirkel, U.,Louwen, F., Witteler, R. & Schneider,H.P.G.2000. A randomised controlled trial of delayedcord clamping in very low birth weight preterm infants. European Journal of Pediatrics,159:775-777.
Riskin, A., Riskin-Mashiah, S., Bader, D., Kulgeman, A., Lerner-Geva, L., Boyko,V. &Reichman, B. 2008. Delivery mode and severe intraventricular haemorrhage in singlevery low birth weight, vertex infants. Obstetrics and Gynecology,112(1):21-28.
Van-Rheenen, P. 2011. Delayed cord clamping and improved infant outcomes. BritishMedical Journal, 343:Bmj.d7127.
Vural, M., Yimalz, I., Illikkan, B., Erginoz, E. & Perk. 2007. Intraventricular haemorrhagein preterm newborns: Risk factors and results from a university hospital in Istanbul, 8years after. Paediatrics International, 49:341-344.