65 - Cord management in extremely preterm infants. What works for below 28 weeks?

Publication Number: 2062.65

Aysuna Galandarova Ibrahimli, Cleveland Clinic Children's, Saint Louis, MO, United States; Hatem Eltaly, Cleveland Clinic Children’s, Cleveland, OH, United States; Mohamed A. Mohamed, Cleveland, Cleveland, OH, United States

Background: The optimal cord management or placental transfusion strategy for extremely preterm infants < 28 weeks' gestation remains debated. Delayed cord clamping (DCC) in vigorous infants has been shown to improve hemodynamic transition and hematologic stability. However, conflicting results have been associated with similar strategies in extremely preterm infants. In addition, the safety of the alternative strategy of cord milking (UCM whether intact (I) or cut (C)) followed by immediate cord cutting in these infants remain uncertain.

Objective: To compare neonatal outcomes of DCC < 60 s, DCC ≥60 s, UCM-I, and UCM-C versus early cord clamping (ECC) in infants extremely preterm infants < 28 weeks' gestational age (GA).

Design/Methods: Systematic review of 16 studies (2000-2025) including >12,000 infants < 28wk GA. Outcomes included mortality, severe intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), hematologic indices, transfusion need, and major morbidities.

Results: Both short ( < 60 s) and prolonged (≥60 s) DCC were associated with lower mortality, fewer transfusions, and better early hematologic indices than ECC, without increased severe morbidities. Severe IVH rates were lower or comparable to ECC across most studies, Table (1). UCM-I improved hematologic parameters but was linked to a higher risk of severe IVH, especially among infants 25-28 weeks, leading to early termination in some trials. UCM-C showed no clear advantage over ECC and, in one study, higher late-onset sepsis. Limited follow-up showed no significant neurodevelopmental differences among strategies.

Conclusion(s): For infants < 28 weeks' gestation, DCC for at least 30-60 seconds remains the most effective and safest placental transfusion approach, improving survival and hematologic stability without increasing major morbidities. UCM-I may enhance hematologic status but carries a higher risk of severe IVH, whereas UCM-C offers no proven benefit.

Table 1: Neonatal outcomes of cord management strategies in extremely preterm infants ( <28 weeks GA)
ECC: Early Cord Clamping; NS: No significant difference; IVH: Intraventricular Hemorrhage; NEC: Necrotizing Enterocolitis; ROP: Retinopathy of Prematurity; BPD: Bronchopulmonary Dysplasia.
* For Severe IVH, there was no significant difference between I-UCM and ECC. However, compared with DCC (≥60 s and <60 s), I-UCM was associated with a significant increase in Severe IVH, particularly in infants 25-28 weeks GA.
** Initial Hgb/Htc values were significantly higher with DCC <60s and I-UCM compared to ECC, but this difference was not sustained after 2 weeks.
*** For DCC <60s on Severe IVH, some studies reported no significant difference compared to ECC, while others reported a decrease.