Umbilical cord milking versus delayed cord clamping

A 2-center randomized controlled trial funded by the National Institutes of Health may make the case for using umbilical cord “milking” to improve blood flow in preterm infants who were delivered via cesarean.

In the trial, infants who were delivered by cesarean were randomly assigned to either undergo delayed cord clamping (lasting from 45 to 60 seconds) or umbilical cord milking, which consisted of 4 strippings. Infants delivered vaginally were separately randomly assigned to  receive either umbilical cord milking or delayed cord clamping. At one of the 2 centers, continuous hemodynamic measurements and echocardiography were performed.

Recommended: SMFM Consult on Delayed Umbilical Cord Clamping

Overall, there were 197 infants enrolled (mean gestational age 28 weeks ± 2 weeks), of whom 154 were delivered via cesarean. Umbilical cord milking was performed on 74 infants; delayed cord clamping was performed on 79 infants. Infants who received umbilical cord milking showed higher superior vena cava flow and right ventricular output in the first 12 hours of life. They also showed higher hemoglobin levels, delivery room temperature, and blood pressure in the first 15 hours; urine output in the first 24 hours of life was also higher. No differences were seen between the 2 methods among the 43 infants delivered vaginally.

The investigators concluded that umbilical cord milking may be a more efficient technique to improve blood volume in preterm infants born via cesarean delivery. They also stated that this was the first randomized controlled trial to demonstrate higher systemic blood flow with umbilical cord milking when compared with delayed cord clamping.

NEXT: Is the verdict in on mid-urethral slings?

Cochrane review: Longer-term data needed on sling surgery

A new Cochrane systematic review suggests that most women who have mid-urethral sling (MUS) surgery for urinary incontinence are still benefitting 5 years later. Data are limited, however, on outcomes further out, say the authors, underscoring a need for researchers to publish studies that illuminate longer-term results.

More than 12,000 women were represented in the data analyzed, which were from 81 trials of MUS procedures for stress urinary incontinence (SUI), urodynamic stress urinary incontinence, or missed urinary incontinence in women. The trials were found in CENTRAL, MEDLINE, MEDLINE in process, ClinicalTrials.gov, by handsearching of journals and conference proceedings, and in Embase and Embase Classic and WHO ICTRP. All were randomized or quasi-randomized trials with both arms involving a MUS operation.

More: Did surgeon inexperience result in iatrogenic injury?

For 36 of 55 reports comparing the transobturator route (TOR) and retropubic route (RPR), similar rates of subjective cure at up to 1 year were found for the two procedures (RR 0.98, 95% CI 0.96 to 1.00; moderate-quality evidence; range 62% to 98% for TOR versus 71% to 97% for RPR.) Short-term objective cure rates were similar (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Trials were fewer and the evidence was of lesser quality but rates of subjective cure were also similar at 1 to 5 years and >5 years (RR 0.97, 95% CI 0.87 to 1.09 and RR 0.95, 95% CI 0.80 to 1.12 for low-quality and moderate-quality evidence, respectively). At >5 years after surgery, subjective cure rates ranged from 43% to 92% in the women whose procedures were done by TOR versus 51% to 88% for those whose procedures were done by RPR.

Looking at morbidity of MUS, the Cochrane review authors found that the overall rate of adverse events was low but the rate of bladder perforation was higher after RPR (4.5% versus 0.6%; RR 0.13, 95% CI 0.08 to 0.20; moderate-quality evidence). TOR also had an advantage in lower rates of major vascular/visceral injury, mean operating time, operative blood loss, length of hospital stay, and postoperative voiding dysfunction.

Rates of vaginal tape erosion/exposure/extrusion, interestingly, were low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 165; 31 trials, 4743 women; moderate-quality evidence). Date were limited on the need for repeat incontinence surgery over the long term, but it was more likely when a procedure was done via TOR than via RPR (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women, low-quality evidence).

How the transobturator tape was passed (medial-to-lateral versus lateral-to-medial) made little difference to short- and medium-term cure rates (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate-quality evidence , and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate-quality evidence).

Regardless of the routes used, the authors said, MUS operations “are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term.” They underscored the need for longer-term data from existing trials, noting the information “would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.”