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Placental Transfusion Strategies in Very Preterm Neonates: A Systematic Review and Meta-analysis

Backes, Carl H. MD; Rivera, Brian K. MS; Haque, Urbee MS; Bridge, Jeffrey A. PhD; Smith, Charles V. PhD; Hutchon, David J. R. MB, FRCOG; Mercer, Judith S. PhD, CNM, FACNM

doi: 10.1097/AOG.0000000000000324
Contents: Review

OBJECTIVE: To investigate the effects of interventions promoting placental transfusion at delivery (delayed cord clamping or umbilical cord milking) compared with early cord clamping on outcomes among premature neonates of less than 32 weeks of gestation.

DATA SOURCES: A systematic search was conducted of PubMed, Embase, and databases (January 1965 to December 2013) for articles relating to placental transfusion strategies in very preterm neonates.

METHODS OF STUDY SELECTION: Literature searches returned 369 articles with 82 considered in full. We only included data from studies with an average gestational age of less than 32 weeks of gestation enrolled in randomized trials of enhanced placental–fetal transfusion interventions (delayed cord clamping or umbilical cord milking) compared with early cord clamping.

TABULATION, INTEGRATION, AND RESULTS: We identified 12 eligible studies describing a total of 531 neonates with an average gestation of 28 weeks. Benefits of greater placental transfusion were decreased mortality (eight studies, risk ratio 0.42, 95% confidence interval [CI] 0.19–0.95, 3.4% compared with 9.3%, P=.04), lower incidence of blood transfusions (six studies, risk ratio 0.75, 95% CI 0.63–0.92, 49.3% compared with 66%, P<.01), and lower incidence of intraventricular hemorrhage (nine studies, risk ratio 0.62, 95% CI 0.43–0.91, 16.7% compared with 27.3%, P=.01). There was a weighted mean difference of −1.14 blood transfusions (six studies, 95% CI –2.01–0.27, P<.01) and a 3.24-mmHg increase in blood pressure at 4 hours of life (four studies, 95% CI 1.76–4.72, P<.01). No differences were observed between the groups across all available safety measures (5-minute Apgar scores, admission temperature, incidence of delivery room intubation, peak serum bilirubin levels).

CONCLUSIONS: Results of this meta-analysis suggest that enhanced placental transfusion (delayed umbilical cord clamping or umbilical cord milking) at birth provides better neonatal outcomes than does early cord clamping, most notably reductions in overall mortality, lower risk of intraventricular hemorrhage, and decreased blood transfusion incidence. The optimal umbilical cord clamping practice among neonates requiring immediate resuscitation remains uncertain.

Among very preterm neonates, enhanced placental transfusion at birth reduces overall mortality, risk of intraventricular hemorrhage, and incidence of transfusion compared with early cord clamping.Supplemental Digital Content is Available in the Text.

Departments of Pediatrics and Obstetrics and Gynecology, Center for Perinatal Research, the Heart Center at Nationwide Children's Hospital and the Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio; the Center for Developmental Therapeutics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, Washington; Darlington Memorial Hospital, Darlington, United Kingdom; the College of Nursing, University of Rhode Island, Kingston, and the Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Corresponding author: Carl H. Backes, MD, Department of Pediatrics, Department of Obstetrics and Gynecology, 700 Children's Drive, Columbus, OH 43205; e-mail:

© 2014 by The American College of Obstetricians and Gynecologists.