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The Effect of Nuchal Cord on Perinatal Mortality and Long-Term Offspring Morbidity

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The Effect of Nuchal Cord on Perinatal Mortality and Long-Term Offspring Morbidity Journal of Perinatology https://doi.org/10.1038/s41372-019-0511-x ARTICLE The effect of nuchal cord on perinatal mortality and long-term offspring morbidity 1 1 2 1 Roee Masad ● Gil Gutvirtz ● Tamar Wainstock ● Eyal Sheiner Received: 28 May 2019 / Revised: 11 August 2019 / Accepted: 16 August 2019 © The Author(s), under exclusive licence to Springer Nature America, Inc. 2019 Abstract Objective To evaluate perinatal and long-term cardiovascular and respiratory morbidities of children born with nuchal cord. Study design A large population-based cohort analysis of singleton deliveries was conducted. Maternal and birth char- acteristics, as well as cardiovascular and respiratory morbidity incidence were evaluated. Kaplan–Meier survival curves were used to compare cumulative hospitalization incidence between groups. Cox regression models were used to control for possible confounders and follow-up length. Results 243,682 deliveries were included. Of them, 34,332 (14.1%) were diagnosed with nuchal cord. Perinatal mortality rate was comparable between groups (0.5 vs. 0.6%, p = 0.16). Kaplan–Meier survival curves demonstrated no significant p = p = 1234567890();,: 1234567890();,: differences in cumulative cardiovascular or respiratory morbidity incidence between groups (log rank 0.69 and 0.10, respectively). Cox regression models reaffirmed a comparable risk for hospitalization between groups (aHR = 0.99 (95% CI 0.85–1.14, p = 0.87) and aHR = 0.97 (95% CI 0.92–1.02, p = 0.28). Conclusions Nuchal cord is not associated with higher rate of perinatal mortality nor long-term cardiorespiratory morbidity. Introduction Controversy exists in the literature regarding the sig- nificance of nuchal cord. The majority of nuchal cord is Nuchal cord is an umbilical cord conformation, in which the transient and will undo on its own with no further impli- cord creates a loop around the fetal neck and is a relatively cations [4]. Nonetheless, nuchal cord has been associated in common finding at delivery [1–3]. The incidence of nuchal other studies with increased perinatal morbidity such as cord ranges from 15 to 34 percent at term, and as gestational increased risk for caesarian delivery [6], meconium aspira- age increases, so is the chance of a nuchal cord to occur tion [2] and birth asphyxia [7], low Apgar score [6, 8], and [1, 2]. The formation of a nuchal cord is probably random, even higher mortality rates [9]. and cannot be explained by a specific etiology [3, 4]. Some Whether there are long-term consequences of nuchal risk factors were described, including excessive movement cord at birth is under debate in the medical community for a of the fetus and a long umbilical cord [3]. Prenatal diagnosis long time. Some studies linked nuchal cord with neurolo- is made using ultrasound and Doppler imaging [2, 5]. gical or neurodevelopment sequela [7, 10] such as cerebral palsy although other studies challenged such an association [11]. Seizures, quadriplegia [12], and poor developmental performance [10] were also reported, all theoretically Supplementary information The online version of this article (https:// explained by asphyxiating events in delivery. Respiratory doi.org/10.1038/s41372-019-0511-x) contains supplementary and cardiovascular morbidities have not yet been described. material, which is available to authorized users. A significant portion of these studies were based on case * Roee Masad reports rather than a large data set, hence a clear link [email protected] between nuchal cord and the above outcomes, has yet been established. Moreover, these studies had a fairly short 1 Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer- follow-up and did not follow the children all the way to Sheva, Israel adulthood. 2 Department of Public Health, Faculty of Health Sciences, Ben- In this large population-based study, we sought to further Gurion University of the Negev, Beer-Sheva, Israel investigate the short-term and to focus on long-term (up to R. Masad et al. the age of 18) cardiovascular and respiratory morbidities of diagnoses made during a child hospitalization in the SUMC children born with nuchal cord entanglement. pediatric departments, and the computerized perinatal database of the obstetrics and gynecology department, containing perinatal information recorded immediately fol- Material and methods lowing delivery by an obstetrician. For both databases, experienced medical secretaries routinely review the infor- In this population-based retrospective cohort study, we mation prior to entering it into the database to ensure its included all singleton deliveries of women in a single maximal completeness and accuracy. Coding is performed medical center, between 1991 and 2014. The study was after assessing medical prenatal care records as well as conducted at the Soroka University Medical Center routine hospital documents. (SUMC), the sole tertiary medical center in the Negev (southern Israel), and the largest birth center in the country. Statistical analysis Thus, the study is based on nonselective population data. The institutional review board approved the study that Statistical analysis was performed using the SPSS package has been performed in accordance with the ethical standards 23rd ed. (IBM/SPSS, Chicago, IL). Categorical data are laid down in the 1964 declaration of helsinki and its later shown in counts and rates and the differences were assessed amendments (Helsinki Declaration 1975, revision 2013). by chi-square for general associations. Student’s t-test was The primary exposure was the presence of nuchal cord used for comparison of continuous variables with normal conformation around the newborn’s neck at birth. The distribution. For perinatal mortality outcome, a multi- diagnosis of nuchal cord was made by the attending mid- variable generalized estimating equation (GEE) analysis wife or obstetrician present during delivery, whether vagi- was constructed to account for siblings and other con- nal, operative or cesarean delivery. Indeed, the presence of founding factors such as preterm delivery and mode of nuchal cord is routinely recorded for all deliveries. delivery. For the long-term outcomes, Kaplan–Meier sur- We excluded multiple pregnancies and fetuses with vival curves were used to compare cumulative hospitaliza- congenital or chromosomal abnormalities. For the long-term tion incidences over time among the study groups. Only the analysis, perinatal mortality cases were also excluded. first admission with any cardiovascular or respiratory- A comparison was performed between children born with related condition for a given individual was included in the nuchal cord versus children born without nuchal cord. survival analysis. The differences between the curves were Outcomes assessment included mode of delivery (either assessed using the log-rank test. A Cox regression model vaginal, assisted, or cesarean section) and adverse perinatal was constructed to adjust for follow-up time and control for outcomes such as perinatal mortality, meconium stained possible confounders for the association between the pre- amniotic fluid, preterm delivery (<37 weeks’ gestation), low sence of nuchal cord at birth, and future incidence of car- birth weight (LBW = birthweight <2500 g), and low Apgar diovascular or respiratory-related hospitalizations of the scores at 1 and 5 min (<7) after birth. For cesarean deliveries offspring. These variables included: maternal age, gesta- (CD) we distinguished between elective CD and emergent tional age, maternal hypertensive disorders of pregnancy CD, based on their indication. Indications for an emergency (chronic hypertension, gestational or preeclampsia with or CD were: nonreassuring fetal heart rate tracing (NRFHR), without severe features), maternal diabetes (pregestational cord prolapse, labor dystocia (arrested labor during the first and gestational), and mode of delivery. Deliveries with no or second stage of labor), and placental abruption. nuchal cord were considered as reference. All analyses were For the long-term analysis, hospitalizations of the off- two-sided, and a p-value of ≤0.05 was considered statisti- spring up to the age of 18 years involving cardiovascular or cally significant. respiratory morbidities were also evaluated using diagnoses that were predefined by a set of ICD-9 codes detailed in the Supplementary Table. Results Follow-up was terminated if any of the following occurred: first hospitalization involving any of the cardio- During the study period, 243,682 deliveries meeting the vascular or respiratory morbidities, hospitalization resulting inclusion criteria occurred at the SUMC, of which 34 332 in death, end of the study period, or when the child reached (14.1%) were diagnosed with nuchal cord at birth. 18 years of age. Table 1 summarizes selective maternal characteristics. Data were collected from two databases that were cross- Mothers of children born with nuchal cord were slightly linked and merged: the computerized pediatric hospitaliza- older, compared with their counterparts. The likelihood to tion database of SUMC (“Demog-ICD9”), which includes be diagnosed with hypertensive disorders or diabetes mel- demographic information and ICD-9 codes for all medical litus were comparable between groups. The effect of nuchal cord on perinatal mortality and long-term offspring morbidity Table 1 Maternal characteristics of mothers whose babies had nuchal scores at 1 and 5 min and cesarean delivery rate in cord compared
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