“Delayed” cord clamping - UCSF CME Delayed” cord clamping: ... AMSTL Cord blood banking...
Transcript of “Delayed” cord clamping - UCSF CME Delayed” cord clamping: ... AMSTL Cord blood banking...
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Delayed cord clamping: Not just for preemies
6/17/2017
Kate Norman Frmeta, MS, CNMAssistant Professor, UCSF Division of Maternal-Fetal
Medicine
Nothing to disclose (kind of)
No financial ties Studied with Judith Mercer
*Drop the scissors*
Delayed cord clamping: Not just for preemies2
Do You Intentionally Delay Cord Clamping in Term Neonates?
A. Yes
B. No
6/17/2017Presentation Title and/or Sub Brand Name Here3Y e
s N o7%
93%
If You Delay, How Long Do You Delay?A. 3 minsD. Until the cord stops pulsing
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< 1 m i n
u t e1 - 3
m in u t
e s> 3
m in s
U n ti l t h
e c or d s
t o ps p .
. .
13%
42%
5%
40%
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Cord Clamping through time Traditionally the cord was not cut until after the delivery of the placenta First accounts of cutting the cord before delivery of the placenta from
the 17th century
Birthing in bed
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The cord, when it has ceased to pulsate be placed between the blades
First cord clamp: 1899 Magennis
cord clamp
Why Delay Cord Clamping?
Why Not???
What is the intervention?
Now in the position of finding evidence to justify our non-interventionwhen the intervention was never justified
Consent for an intervention with ICC? Placental transfusion
Volume of blood that remains in the placenta Immediate: 30% 60 seconds: 20% 3 minutes: 13%
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Where does the blood go? Newborn lung circulation:~10% in utero to ~50% ex utero
Also better perfusion, less hypothermia
fetal heart pumps:
In utero 110ml/k
Ex utero 90ml/k
Why Delay Cord Clamping? Preterm:
-improved blood pressure, increased cerebral oxygen index, reduced number of blood transfusions, less need for inotropic support, lower risk of necrotizing enterocolitis, nearly twofold reduction in risk for intracranial hemorrhage of all types
(ACOG recommended delay in 2012)
Rabe, Diaz-Rossello, Duley, & Dowswell, 2012
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Why Delay Cord Clamping?Term:
Up to 30% increase in blood volume
Less Anemia Higher hemoglobin levels at 24 to 48 hours of age increased serum ferritin levels (23-45% higher) at 4 to 6 months. Infants with ICC were twice as likely to be iron deficient at 3 to 6
months.
Results more pronounced in infants of anemic mothers Anemia reduced by 40% at 4 mos and 60% 8 mos.
Blouin, 2013, McDonald et al, 2013
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Why Do We Care About Iron Deficiency? Iron: essential for normal neurogenesis, differentiation of brain cells, brain
metabolism, neurotransmitter function, oligodendrogenesis, and myelination
Anemia: Reduced arborization of dendrites that decrease the complexity ofinterneural connections
Infants with DCC have increased myelin content at 4 month of age in brainregions associated with motor, visual and sensory processing/functioncompared with ICC.
Beard & Connor 2003; Brunette & Tran et al 2010; Georgieff & Rao 2011
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Why Do We Care About Iron Deficiency?
Iron deficiency in infancy associated with :
poor school performance,decreased cognitive abilities,less positive affectmore difficult to soothereduced level of engagement with examiners.lower IQs (more pronounced in lower
socioeconomic groups)
less favorable neurodevelopmental outcomesbehavioral problems out to 19 years of age.
*Even after correction*Lozoff et al, 2006; Lozoff et al, 2008; Lozoff et al 2010; Burden et al 2004; Pierano et al, 2010
Why do we care about Iron Deficiency? Anemia in the US: Anemia among participants in federally funded mat-child health and
nutrition programs (2010 data)
33.8% of all mothers
49.5% of all Non-Hispanic African-American mothers
By 6-12 mos 18% of all infants and 23.5% of AA were anemic.
Large state-to-state disparities as well.
Maternal anemia rates are higher than any region outside of Africa.
Dalenius, Brindley, Smith, Reinold, & Grummer-Strawn, 2012
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Stem Cells! 10x the amount of bone marrow Neuroprotection
Cotton et al (2014)
-Autologous stem cell transfusion in babies being head-cooled
>85 on Bayley scale: 74% transfused babies
41% control group
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Lack of Harm since 1980, NO published, randomized controlled trial has supported a
relationship between DCC and symptomatic polycythemia orhyperbilirubinemia.
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No difference (Term)Maternal
PP hemorrhage Mean blood loss Hgb pp Retained placenta Blood transfusions Duration of 3rd stage Need for uterotonicsMcDonald et al, 2013, Hutton and Hassan, 2007
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Neonatal
Apgars, need for resuscitation NICU admission Cord pH respiratory distress Clinical jaundice (no treatment) Polycythemia requiring treatment
Jaundice Requiring Treatment MacDonald and Middleton systematic review (Cochrane) included
weighted results of data from an unpublished dissertation from 1996for the outcome of bili light use.
2.7% increase in bili light use.
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Why Delay Cord Clamping at Term? Because your professional Organization told you to: WHO 2006, 2012, 2014 (1-3 mins) ACNM 2014 (2 mins below introitus, 5 mins skin- to-skin) ACOG 2016 (at least 30-60 secs) NICE 2012 (at least 60 secs) FIGO/ICM 2003 (until pulsations cease - include 1-3 mins of DCC in
AMTSL guidelines)
NRP 2015 (30-60 seconds in vigorous term and preterm infants)
Why Delay Cord Clamping? Because the family told you to
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How Long to Delay? Until the cord stops pulsing
Study of 15 infants during DCC using doppler u/s
Stopping of pulsations not correlated with stopping of blood flow.
Venous blood flowed for a median of 4.5 mins in 57% of infants andwas still flowing at 5.25 mins in 33% of infants
Boere et al, 2014
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How long to Delay?
Time to cord clamping was varied in studies anywhere from 1 -10 mins
Full transfusion by about 3 mins if below level of placenta but if skin-to-skin may take closer to 5 mins to get full transfusion
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Position of the Neonate Residual Placental Blood Volume (PRBV)with Skin-To-Skin Placement
ICC
DCC x 2
DCC x 5
CM
PRBV ml/kg
Erickson-Owens, Mercer & Thulier, 2012
181125
35
How long to Delay?At least 3 minutes at the perineum
At least 5 minutes on maternal abdomen
Wait for white
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Cord Milking A technique used to
accelerate placentaltransfusion when theclinical situationdoesnt allow time forDCC
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Cord Milking Use when time and speed are a factor Lower infant and milk cord 4 to 5 times (wait for cord to refill if
possible)
In term and preterm studies results same as DCC Higher H & H, better blood pressure
Higher ferritin levels at 6 weeks to 6 months
No increase in jaundice or symptomatic polycythemia
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Barriers to change Tight Nuchal Cord Cord gases AMSTL Cord blood banking
TRADITION Sit on your hands
? Resus
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Cord Blood Banking
ACOG Committee Opinion #399 (2008)collection should not alter routine practice for the timing of umbilical cord clamping
Babies arent allowed to be
blood donors!Delayed cord clamping: Not just for preemies32
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Take Home Messages
ICC is an interventionwithout any rationale or evidence to support it.
No longer not enoughevidence to justify
delayed cord clamping.
Delayed cord clamping: Not just for preemies33 Delayed cord clamping: Not just for preemies34
Delayed cord clamping: Not just for preemies35
Special thanks to Judith Bishop, CNM and Judy Mercer, CNM