目的 评价脐带挤推对剖宫产分娩新生儿出生后相关结局指标的影响。 方法 计算机检索中英文数据库（包括中国知网、万方医学数据库、中国生物医学文献数据库、维普数据库、中华医学期刊全文数据库、PubMed、Embase、CINAHL、Web Of Science、the Cochrane Library、Google Scholar）及临床试验注册平台（ClinicalTrials.gov）中关于剖宫产分娩新生儿脐带挤推的随机对照研究，时间均从建库至2023年7月。纳入标准：研究类型为随机对照研究；研究对象为剖宫产分娩行脐带挤推后断脐的新生儿，种族不限；结局指标为出生后血红蛋白水平、红细胞压积、胆红素峰值、蓝光治疗、脐血pH值、脑室内出血、死亡、红细胞增多症、新生儿坏死性小肠结肠炎、Apgar评分；偏倚风险评估（risk of bias assessment tool 2.0）为低风险或可能存在风险。采用 RevMan5.3进行meta分析，并根据新生儿的胎龄进行亚组分析。采用推荐分级的评价、制订与评估（grades of recommendations assessment，development，and evaluation，GRADE）系统进行证据质量评级。 结果 最终纳入11篇文献，共计2 347例新生儿（包含足月儿1 322例和早产儿1 025例）。meta分析结果显示：（1）与立即断脐相比，脐带挤推能提高新生儿出生后24 h内血红蛋白水平（MD=1.40，95%CI：1.11~1.70，Z=9.32，P<0.01）、48~72 h血红蛋白水平（MD=0.86，95%CI：0.69~1.02，Z=10.02，P<0.01）、24 h内红细胞压积（MD=2.73，95%CI：0.18~5.29，Z=2.09，P=0.04）和48~72 h红细胞压积（MD=3.57，95%CI：2.29~4.85，Z=5.46，P<0.01），但对新生儿胆红素峰值、蓝光治疗、脐血pH值、1 minApgar评分和5 minApgar评分的影响均无统计学意义（P值均>0.05）；（2）与延迟脐带结扎相比，脐带挤推能提高新生儿出生后24 h内血红蛋白水平（MD=0.83，95%CI：0.75~0.91，Z=20.11，P<0.01）和红细胞压积（MD=2.34，95%CI：1.25~3.43，Z=4.20，P<0.01），对出生后48~72 h红细胞压积的影响无统计学意义（MD=－0.38，95%CI：－2.27~1.52，Z=0.39，P=0.70）；对胆红素峰值的影响无统计学意义（MD=－0.65，95%CI：－2.16~1.04，Z=0.69，P=0.49）。通过敏感性分析，足月剖宫产分娩的新生儿脐带挤推组胆红素峰值低于延迟脐带结扎组（MD=－1.30，95%CI：－2.26~0.34，Z=2.66，P<0.01）。脐带挤推对新生儿蓝光治疗、脑室内出血（Ⅰ~Ⅳ级）、死亡、红细胞增多症、新生儿坏死性小肠结肠炎、Apgar 1 min评分和Apgar 5 min评分的影响均无统计学意义（P值均>0.05）。 结论 脐带挤推能提高剖宫产分娩新生儿出生后短期的血红蛋白和红细胞压积水平，可能有益于预防新生儿出生后短期内贫血，但对胆红素峰值、蓝光治疗、红细胞增多症等发生风险影响不大，亦未增加剖宫产分娩新生儿的不良结局。但仍需更多高质量、大样本的随机对照研究进一步证实。 Objective To evaluate the effect of umbilical cord milking (UCM) on neonatal outcomes after cesarean section. Methods Chinese and English databases (including CNKI, Wanfang, China Biology Medicine Disc, VIP, Yiigle, PubMed, Embase, CINAHL, Web of Science, the Cochrane Library, and Google Scholar) and ClinicalTrials.gov were retrieved from the inception to July 2023. Randomized controlled trials regarding UCM in neonates from different races who were born by cesarean section were included. The outcomes were postnatal hemoglobin level, hematocrit value, peak serum bilirubin level, phototherapy, cord blood pH value, intraventricular hemorrhage, death, polycythemia, neonatal necrotizing enterocolitis, and Apgar score. The risk of bias among the included studies was confined to low or possible risk according to the Cochrane Risk of Bias Assessment Tool 2.0. RevMan5.3 was used for meta-analysis, and subgroup analysis was performed among neonates with different gestational ages. The certainty of evidence was evaluated using the grades of recommendations assessment, development, and evaluation (GRADE) framework. Results A total of 11 articles involving 2 347 neonates (1 322 full-term and 1 025 preterm infants) were included. Meta-analysis results showed that: (1) Compared with the immediate cord clamping, UCM increased the hemoglobin level within 24 h and 48-72 h after birth (MD=1.40, 95%CI: 1.11-1.70, Z=9.32 MD=0.86, 95%CI: 0.69-1.02, Z=10.02, both P<0.01), hematocrit value within 24 h and 48-72 h after birth (MD=2.73, 95%CI: 0.18-5.29, Z=2.09, P=0.04 MD=3.57, 95%CI: 2.29-4.85, Z=5.46, P<0.01). However, no significant differences were found in the peak bilirubin level, phototherapy, cord blood pH, and Apgar score at 1 and 5 min (allP>0.05). (2) Compared with delayed cord clamping, UCM increased the hemoglobin level (MD=0.83, 95%CI: 0.75-0.91, Z=20.11, P<0.01) and hematocrit value (MD=2.34, 95%CI: 1.25-3.43, Z=4.20, P<0.01) within 24 h after birth, but not in the hematocrit value at 48-72 h after birth (MD=－0.38, 95%CI:－2.27-1.52, Z=0.39, P=0.70) or the peak bilirubin level (MD=－0.65, 95%CI:－2.16-1.04,Z=0.69, P=0.49). Sensitivity analysis showed that for full-term neonates born by cesarean section, the peak bilirubin level in the UCM group was significantly lower than that in the delayed cord clamping group (MD=－1.30, 95%CI:－2.26-0.34, Z=2.66, P<0.01). Still, the incidence of phototherapy, intraventricular hemorrhage (grade Ⅰ-Ⅳ), death, polycythemia, neonatal necrotizing enterocolitis, and Apgar score at 1 min and 5 min showed no statistical differences (allP>0.05). Conclusions UCM could increase the short-term postnatal hemoglobin and hematocrit levels in neonates born by cesarean section, which might prevent neonatal anemia in the short term without increasing the adverse neonatal outcomes. Little effects were observed on the peak bilirubin level, phototherapy, polycythemia, etc. More high-quality and large-sample randomized controlled trials are needed in the future.
Umbilical cord milking on neonatal outcomes following cesarean section: a meta-analysis
Objective To evaluate the effect of umbilical cord milking (UCM) on neonatal outcomes after cesarean section. Methods Chinese and English databases (including CNKI, Wanfang, China Biology Medicine Disc, VIP, Yiigle, PubMed, Embase, CINAHL, Web of Science, the Cochrane Library, and Google Scholar) and ClinicalTrials.gov were retrieved from the inception to July 2023. Randomized controlled trials regarding UCM in neonates from different races who were born by cesarean section were included. The outcomes were postnatal hemoglobin level, hematocrit value, peak serum bilirubin level, phototherapy, cord blood pH value, intraventricular hemorrhage, death, polycythemia, neonatal necrotizing enterocolitis, and Apgar score. The risk of bias among the included studies was confined to low or possible risk according to the Cochrane Risk of Bias Assessment Tool 2.0. RevMan5.3 was used for meta-analysis, and subgroup analysis was performed among neonates with different gestational ages. The certainty of evidence was evaluated using the grades of recommendations assessment, development, and evaluation (GRADE) framework. Results A total of 11 articles involving 2 347 neonates (1 322 full-term and 1 025 preterm infants) were included. Meta-analysis results showed that: (1) Compared with the immediate cord clamping, UCM increased the hemoglobin level within 24 h and 48-72 h after birth (MD=1.40, 95%CI: 1.11-1.70, Z=9.32 MD=0.86, 95%CI: 0.69-1.02, Z=10.02, both P<0.01), hematocrit value within 24 h and 48-72 h after birth (MD=2.73, 95%CI: 0.18-5.29, Z=2.09, P=0.04 MD=3.57, 95%CI: 2.29-4.85, Z=5.46, P<0.01). However, no significant differences were found in the peak bilirubin level, phototherapy, cord blood pH, and Apgar score at 1 and 5 min (allP>0.05). (2) Compared with delayed cord clamping, UCM increased the hemoglobin level (MD=0.83, 95%CI: 0.75-0.91, Z=20.11, P<0.01) and hematocrit value (MD=2.34, 95%CI: 1.25-3.43, Z=4.20, P<0.01) within 24 h after birth, but not in the hematocrit value at 48-72 h after birth (MD=－0.38, 95%CI:－2.27-1.52, Z=0.39, P=0.70) or the peak bilirubin level (MD=－0.65, 95%CI:－2.16-1.04,Z=0.69, P=0.49). Sensitivity analysis showed that for full-term neonates born by cesarean section, the peak bilirubin level in the UCM group was significantly lower than that in the delayed cord clamping group (MD=－1.30, 95%CI:－2.26-0.34, Z=2.66, P<0.01). Still, the incidence of phototherapy, intraventricular hemorrhage (grade Ⅰ-Ⅳ), death, polycythemia, neonatal necrotizing enterocolitis, and Apgar score at 1 min and 5 min showed no statistical differences (allP>0.05). Conclusions UCM could increase the short-term postnatal hemoglobin and hematocrit levels in neonates born by cesarean section, which might prevent neonatal anemia in the short term without increasing the adverse neonatal outcomes. Little effects were observed on the peak bilirubin level, phototherapy, polycythemia, etc. More high-quality and large-sample randomized controlled trials are needed in the future.
万方数据
