Timing of umbilical cord clamping among infants with congenital heart disease

Laura Marzec, Eli Zettler, Clifford L Cua, Brian K Rivera, Sara Pasquali, Anup Katheria, Carl H Backes, Laura Marzec, Eli Zettler, Clifford L Cua, Brian K Rivera, Sara Pasquali, Anup Katheria, Carl H Backes

Abstract

The optimal timing of clamping and cutting the umbilical cord at birth among infants with congenital heart disease (CHD) remains a subject of controversy and debate. The benefits of delayed umbilical cord clamping (DCC) among term infants without CHD are well described, but the evidence base for DCC among infants with CHD has not been characterized adequately. The goals of the present review are to: 1) compare outcomes of DCC versus early cord clamping (ECC) in term (≥37 weeks of gestation) infants; 2) discuss potential risk/benefit profiles in applying DCC among term infants with CHD; 3) use rigorous systematic review methodology to assess the quality and quantity of published reports on cord clamping practices among term infants with CHD; 4) identify needs and opportunities for future research and interdisciplinary collaboration. Our systematic review shows that previous trials have largely excluded infants with CHD. Therefore, the supposition that DCC is advantageous because it is associated with improved neurologic and hematologic outcome is untested in the CHD population. Given that CHD is markedly heterogeneous, to minimize unnecessary and potentially harmful cord clamping practices, identification of subgroups (single-ventricle, cyanotic lesions) most likely to benefit from optimal cord clamping practices is necessary to optimize risk/benefit profiles. The available evidence base suggests that contemporary, pragmatic, randomized controlled trials comparing DCC with ECC among infants with CHD are needed.

Keywords: congenital heart disease; delayed cord clamping.

Conflict of interest statement

Conflicts of interest The authors have no commercial of financial conflicts of interest to disclose.

Figures

Figure 1:
Figure 1:
Terms used in PubMed/Medline search and manuscript selection flowchart for systematic review.
Figure 2:
Figure 2:
Time-to-event curve showing the need for a transfusion during the first 28 days of life among preterm infants with congenital heart disease receiving delayed cord clamping (DCC) or early cord clamping (ECC) at birth. Log-rank (Mantel-Cox) comparison demonstrates significant differences in the curves (P=0.02). The corresponding Mantel-Haenszel hazard ratio (HR) for transfusion need in the ECC group versus the DCC group is 3.1 with a 95% confidence interval of 1.2 – 7.9. (Reproduced from Backes CH, et al., Journal of Perinatology, 2015:35;826–831.)”

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