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The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepae: http:!!"""#tan$%online#&om!loi!i'm%0
arl* +er,u, $ela*e$ &or$ &lampin: %%e&t, on hematoloi& ,tatu,n term in%ant,
.tu rte.in/ N# Nihan O$emir/ e.i Sahinolu/ 2u3a ur,o*/ Naan r3il r$al a*a
"ite t#is arti"le: A$ Akt%& 'rtekin, N$ Ni#an ()demir, *eki +a#ino&l%, !%&ba %rsoy,
)an 'rbil - 'rdal .aya /2015: 'arly vers%s delayed "ord "lamin&: 'e"ts on #ematolo&i" stat%s in term inants, !#e o%rnal o
aternal6etal - Neonatal 4edi"ine, D(7: 10$310891;05o%mal7normationB>o%malodeCi>m20
or
#hi
@iew rossmark data 6
http://www.tandfonline.com/loi/ijmf20http://www.tandfonline.com/loi/ijmf20http://dx.doi.org/10.3109/14767058.2015.1105951http://dx.doi.org/10.3109/14767058.2015.1105951http://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructionshttp://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructionshttp://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20http://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructionshttp://dx.doi.org/10.3109/14767058.2015.1105951http://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructionshttp://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructionshttp://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/doi/mlt/10.3109/14767058.2015.1105951http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20http://www.tandfonline.com/loi/ijmf20
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Taylor &.Francis
Taylor & Francis GroupJust Accepted by The Journal of Maternal-Fetal & Neonatal Medicine
THE JOURNAL OF
MATERNAL-FETAL
& NEONATALMEDICINE
EdHorc-nvChmf Gian Carlo Di Renzo DeMauli!
Coered inInde"Medici# andMED$NE
arl* +er,u, $ela*e$ &or$ &lampin: %%e&t, on hematoloi& ,tatu, interm in%ant,
A$ Akt%& 'rtekin, N$ Ni#an ()demir, *eki +a#ino&l%, !%&ba %rsoy, Na)an'rbil, 'rdal .aya
doi: 10$310891;05e"tive: e investi&ated t#e ee"ts o delayed and early "lamin& o t#e"ord on t#e #ematolo&i" stat%s o t#e baby at birt# and at t#e end ose"ond mont#$
4et#ods: Umbili"al "ord o babies were "lamed in t#e irst 30 se"onds/ro% 1 and ; were "lamed at 80120 se"onds /ro% 2$ Eevels o#emo&lobin, #emato"rit, iron and erritin were analysed rom t#e %mbili"al"ord blood at birt# and rom t#e veno%s samles at t#e end o se"ondmont#$
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Fes%lts: Gemo&lobin, #emato"rit, iron and erritin levels o "ord bloodwere similar in bot# &ro%s$ Gowever, t#eir levels ot#er t#an erritin were #ier in ro% 2 at t#e end ose"ond mont#$ !wo babies #ad resiratory distress and twelve neonates re"eived #otot#eray in ro% 2w#ereas only ive neonates re"eived #otot#eray in ro% 1$
on"l%sion: !erm babies to w#om delayed "ord "lamin& was erormed #ad imroved #ematolo&i"alarameters at t#e end o se"ond mont#$ !#ereore, delayin& "ord "lamin& in t#ese babies may be a avoriblearoa"# in reventin& anemia$
H 2015 !aylor - 6ran"is$ !#is rovisional ID6 "orresonds to t#e arti"le as it aeared %on a""etan"e$
6%lly ormatted ID6 and %ll te=t /G!4E versions will be made available soon$D7+EA74'F: !#e ideas and oinions e=ressed in t#e >o%rnalJs Just Accepted arti"les do not ne"essarily rele"t t#ose o !aylor - 6ran"is /t#e I%blis#er, t#e 'ditors or t#e
>o%rnal$ !#e I%blis#er does not ass%me any resonsibility or any in>%ry and9or dama&e to ersons or roerty arisin& rom or related to any %se o t#e material "ontained in t#esearti"les$ !#e reader is advised to "#e"k t#e aroriate medi"al literat%re and t#e rod%"t inormation "%rrently rovided by t#e man%a"t%rer o ea"# dr%& to be administered to veriy
t#e dosa&es, t#e met#od and d%ration o administration, and "ontraindi"ations$ 7t is t#e resonsibility o t#e treatin& #ysi"ian or ot#er #ealt# "are roessional, relyin& on #is or #er indeendent e=erien"e and knowled&e o t#e atient, to determine dr%& dosa&es and t#e best treatment or t#e atient$ Just Accepted arti"les #ave %nder&one %ll s"ientii"review b%t none o t#e additional editorial rearation, s%"# as "oyeditin&, tyesettin&, and rooreadin&, as #ave arti"les %blis#ed in t#e traditional manner$ !#ere may, t#ereore,be errors in Just Accepted arti"les t#at will be "orre"ted in t#e inal rint and inal online version o t#e arti"le$ Any %se o t#e Just Accepted arti"les is s%b>e"t to t#ee=ress %nderstandin& t#at t#e aers #ave not yet &one t#ro% t#e %ll K%ality "ontrol ro"ess rior to %bli"ation$
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Early verss delayed !ord !lam"in#: E$e!ts on %ematolo#i!stats in term in&ants
'('kt# Ertekin 1) *orres"ondin# at%or , Department of Health
Sciences, Uskudar University, Istanbul, Turkey
S! " #$% &'(
()**&+ a. "
#$% (+'&$/( E-
mail"
aaertekin01mail
2com
323ihan 45demir (, Department of 4bstetrics, 6eynep
7amil 8omen and Children9s Disease, Trainin1 and
:esearch Hospital, Istanbul, Turkey
S! " #$% &') +')&& E-mail "
nihanaslaner01mail2com
+eki ,a%ino#l 2) De"artment o& -erinatolo#y) *lini! o&
.bsteri!s and /yne!olo#y) 'nadol ealt% *enter) o!aeli)
rkeyS! " #$% &'( +/&/+
Email : 4eki(sa%ino#lanadolsa#lik(or#
Tu1ba ursoy ', Department of ;ediatrics, 7oc University
,!%ool o& 6edi!ine, Istanbul, Turkey
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mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]
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S! " #$% &'' &//&$// E-mail " t1ursoy0ku2edu2tr
3a5an Erbil /, Department of ;ediatrics, 6eynep 7amil
8omen and Children9s Disease, Trainin1 and :esearch
Hospital, Istanbul, Turkey S! " #$% &'( &('%)& E-
mail " erbilna5an0hotmail2com
mailto:[email protected]:[email protected]:[email protected]:[email protected]
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Erdal 7aya &, Department of 4bstetrics and ynecolo1y,
ective" 8e investi1ated the e?ects of delayed and early
clampin1 of the cord on the hematolo1ic status of the baby
at birth and at the end of second month2
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8omen andChildr
7
8
9
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!ethods" Umbilical cord of */ babies =ere clamped in the
@rst '% seconds Aroup B and *+ =ere clamped at $%-(%
seconds Aroup (B2 evels of hemo1lobin, hematocrit, ironand ferritin =ere analysed from the umbilical cord blood at
birth and from the venous samples at the end of second
month2
:esults" Hemo1lobin, hematocrit, iron and ferritin levels of
cord blood =ere similar in both 1roups2 Ho=ever, theirlevels other than ferritin =ere hi1her in roup ( at the end
of second month2 T=o babies had respiratory distress and
t=elve neonates received phototherapy in roup ( =hereas
only @ve neonates received phototherapy in roup 2
Conclusion" Term babies to =hom delayed cord clampin1
=as performed had improved hematolo1ical parameters at
the end of second month2 Therefore, delayin1 cord
clampin1 in these babies may be a favorible approach in
preventin1 anemia2
7ey=ords" early and delayed cord clampin1, hemo1lobin,
hematocrit, iron, ferritin2
;resented in oral format at the (%th 3ational 3eonatalo1y
Con1ress, pril &-), (%(,
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nemia is an important health problem all over the =orld,
especially in developin1 or lo= income countries amon1
ne=born infants or children and it is also associated =ith
poor neurodevelopment of the infant2 Iron in the blood is
essential for brain development, neurotransmitter function,
1lial and neuronal ener1y metabolism and myelination -
&F2 In youn1 children, iron de@ciency anemia is associated=ith behavioral and co1nitive de@cits, impaired motor
development and altered a?ective respondin1 +,*F2
;reventin1 infants and children from anemia is an
important health policy of the countries and for overcomin1
this problem there is no e.act consensus about early and
delayed cord clampin1 of the neonate or active and passive
mana1ement of the third sta1e of labor for preventin1
postpartum anemia in =omen2
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increase maternal morbidity and mortality2 nother lo1ic of
the use of uterotonic dru1s is to allo= more blood
transfusion from placenta to the baby =ith the contractions
of the uterus $F2 In delayed cord clampin1, appro.imately
)%-%% ml of blood can be transferred to the baby =hich
contributes (%-'% m1Gk1 of iron %,F2 In preterm
neonates, delayed cord clampin1 has also secondaryfavorable outcomes such as reduction in the incidence of
transfusion, respiratory support, intraventricular hemorrha1e
and sepsis (,'F2 There may be some adverse e?ects
=ith delayed cord clampin1, =hich are hyperbilirubinemia,
increased need for phototherapy, polycythemia and
respiratory symptoms/-*F2
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6et%ods
This prospective case-control study =as conducted in
6eynep 7amil !aternity and Children9s Disease, Trainin1
and :esearch Hospital, bet=een u1ust , (% and
3ovember '%, (%2 The study =as approved by the local
Ethics Committee2 The inclusin1 criteria =ere as follo=s
neonates born to sin1le and term pre1nancies A'* to / #+=eeksB, non-smokin1 and healthy mothers2 The e.clusion
criteria =ere preterm and multiple pre1nancies, operative
deliveries, neonates necessitatin1 recussitation, presence of
fetal anomalies, intrauterine 1ro=th restriction, maternal
diseases or dru1 use, placental anomalies and reuest for
cord blood bankin12
The primary outcome =as to investi1ate the e?ect of early
and delayed clampin1 of the umbilical cord on the
hematolo1ic status of the neonate at birth and at the end of
second month2 The secondary outcomes =ere to analyse
e?ect of delayed clampin1 on the incidence of maternal
blood loss, neonatal respiratory distress, hyperbilirubinemia,
phototherapy need, neonatal intensive care unit A3ICUB
admission and len1th of hospitalisation2
Informed consent =as obtained from the mothers =ho met
the inclusion criteria and =illin1 to participate in the study2
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!other and infant pairs =ere divided in ( 1roups, early
Aroup B and delayed Aroup (B cord clampin12 In roup
cord =as clamped in the @rst '% seconds and in roup (
cord =as clamped $% to (% seconds after delivery2
Delivery of the infant shoulder =as accepted as the 5ero
time and a sta? in all births recorded the clampin1 time
=ith a stop-=atch2 In cesarean and va1inal births, babies=ere put on a ne=born table in =hich the level of the baby
and uterus =as similiar in both 1roups and then the cord
=as clamped early or delayed2 fter clampin1 the umbilical
cord, venous blood =as obtained from the double clamped
umbilical cord of both 1roups for hemo1lobin, hematocrit,
iron and
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ferritin analyses and no blood was wit%drawn &rom t%e
"eri"%eral vein be!ase o& t%e stdy desi#n ma;or
!omment 2
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?eslts
The demo1raphic characteristics of the mother-infant pairs
and hematolo1ical parameters of the mothers did not di?erbet=een the 1roups ATable B2 Ho=ever, delivery by
cesareanne section =as si1ni@cantly hi1her in roup 2 =n
/ro" 1 and /ro" 2 avera#e !ord !lam"in# times were
20)5 and 101)1 se!onds) res"e!tively ma;or !omment 1
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2 ml &or dire!t and indire!t bilirbin) blood ty"e and
dire!t !oombs test ma;or !omment 5
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Dis!s
sion8orld Health 4r1anisation advises late cord clampin1
ho=ever there is a debate on the optimal time for cord
clampin1 )F2 If the cord clampin1 is deferred more than
+% seconds, blood Mo= bet=een the baby and placenta
continues and is usually completed by (% seconds and
named as placental transfusion2 This allo=s the transfusionof )%-%% ml of blood =hich constitutes about one third or
a uarter of the ne=borns total blood volume %F2 Even
thou1h not fully clear, placental transfusion could be
considered as a cause of some undesirable e?ects in the
ne=born and as =ell as in the mother such as polycytemia,
>aundice, respiratory symptoms, phototherapy need and
postpartum uterine hemorrha1e2 In this study, althou1h the
incidence of >aundice necessitatin1 phototherapy =as hi1her
in infants =hose cords =ere clamped late, this di?erence
did not reach statistical si1ni@cance A+,)L vs &,*L
pN%,%)B as con@rmed in the literature $-((F2 s
mentioned in the material- methods, =e paid attention to
put all the neonates on a ne=born table =hich =as
appro.imately at the same level =ith the uterus to facilitate
blood transmission from the placenta to the ne=born2
Ho=ever, in a multicenter trial at three university-aOliated
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Dis!s
sionhospitals in r1entina, the autors mentioned that position of
the ne=born baby before cord clampin1 does not seem to
a?ect volume of placental transfusion2 Therefore, mothers
could safely be allo=ed to hold their baby on their
abdomen or chest2 This chan1e in practice mi1ht increase
obstetric compliance =ith the procedure, enhance maternal-infant bondin1 and decrease iron de@ciency in infancy ('F2
8e found that delayin1 cord clampin1 up to $% to (%
seconds increases hemo1lobin, hematocrit and iron levels
si1ni@cantly at the second month2 lthou1h there =as no
di?erence of iron levels bet=een early and delayed cordclampin1 1roups at birth, a si1ni@cantly hi1her iron level
=as achieved at the second month of a1e in the delayed
clamped 1roup2 n increase of serum iron level rather than
hemo1lobin, allo=s more tissue
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o.y1enation, proper myelini5ation, improved hematolo1ic
parameters and less ventilator support (/,(&F2 Iron is an
essential trophic factor that is reuired for o.y1enconsumption and T; production2 The brain has a
relatively hi1h rate of o.y1en consumption compared to
other or1ans2 4li1odendrocytes are the principal cells in the
central nervous system that stain for iron under normal
conditions2 The timin1 of iron delivery to oli1odendrocytes
durin1 myelini5ation is essential because hypomyelination
and the associated neurolo1ical seuelae persist lon1 after
the systemic iron de@ciency has been corrected2 Due to the
hypomyelination, most common neurolo1ical si1ns of iron
de@ciency in children include poor school performance,
decreased co1nitive abilities and behavior problems (+F2
urthermore, these neurolo1ical seuelae persist even after
iron supplementation2
8hile prominent positive e?ects of delayed cord clampin1
on hemo1lobin, hematocrit and serum iron levels =ere =ell
established, clampin1 cord after the @rst breath of theneonate =as sho=n to have improvin1 e?ect on neonatal
cardiac and pulmonary functions $F2 In a study includin1
of &2&+' ne=borns outcomes in a rural hospital, the risk
of deathG3ICU admission =as consistently hi1her if cord
clampin1 occurred before spontaneous respiration (*F2
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8hile infants of birth =ei1ht P(&%% 1 =ere more likely to
die or be admitted at 3ICU, the risk of death or 3ICU
admission decreased by (%L for every %-second delay incord clampin1 after spontaneous respiration2 The authors
concluded that healthy self-breathin1 neonates =ere more
likely to die or be admitted if cord clampin1 occured
before or immediately after onset of spontaneous
respiration2 These clinical observations support the
e.perimental @ndin1s of an animal based study
demonstratin1 smoother cardiovascular transition =ith
delayed cord clampin1 after initiation of ventilation $F2
It =as kno=n that umbilical cord blood contains various
valuable stem cells such as haematopoietic stem cells,
endothelial cell precursors, mesenchymal pro1enitors and
multipotentGpluripotent linea1e stem cells2
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delayed cord clampin1, the merit of delayed cord clampin1
has been ma1ni@ed by reali5in1 @rst stem cell transfer2 In
vie= of this purpose, not only in preterm births, delayedcord clampin1 should be encoura1ed in term births too
()F2
8e conclude that delayed cord clampin1 in term babies
had no e?ect on hematolo1ic status at birth but had
improvin1 e?ects on hemo1lobin, hematocrit and iron levelsat the second month =ithout any serious complication2
Ho=ever, phototherapy need may be increased in delayed
1roup2
Delayed cord clampin1 could be considered an appropriate
and easy to perform approach in increasin1 iron levels,
circulatin1 blood volume and stem cells =hich seem to be
key factors in myelini5ation and smooth passa1e to
e.trauterine circulation in term neonates2 on1 term follo=
up studies should be performed to evaluate the e?ects of
hi1her iron levels on the neuroco1nitive outcome of the
babies2
'!knowled#ements
The authors report no ackno=led1ements2
De!laration o& interest
The authors report no declarations of interest
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?e&eren!es
2 o5o?
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*2 unnarsson
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$2 Dley G) Katey N( ."timal timin# o& mbili!al !ord
!lam"in# &or term and "reterm babies( Early man
Develo"ment 2013LBH:H05H0B(%2 @arrar D) 'irey ?) Gaw /) $nell D) *attle K)
Dley G( 6easrin# "la!ental trans&sion &or term birt%s:
wei#%in# babies wit% !ord inta!t( K./ 2011L11B:705(
2 6!Donald ,) 6iddleton -) Dowswell ) 6orris -,(
E$e!t o& timin# o& mbili!al !ord !lam"in# o& term in&ants
on maternal and neonatal ot!omes( *o!%rane Database
,yst ?ev 2013L7: *D00I07I(
(2 6er!er ) Mo%r K) 6!/rat% 6) -adbry ) alla!%
6) .% ( Delayed !ord !lam"in# in very "reterm in&ants
red!es t%e in!iden!e o& intraventri!lar %emorr%a#e and
late onset se"sis: a randomi4ed) !ontrolled trial( -ediatri!s
200AL117:1235I2(
'2 .% ) @anaro$ ') *arlo ) Donovan E) 6!Donald
,) -oole ( E$e!ts o& delayed !ord !lam"in# in verylow
birt%wei#%t in&ants( -erinatol 2011L31:,AB71(
/2 Yao '*) Gind ) Morenkoski M( E>"iratory #rntin#in t%e late !lam"ed normal neonate( -ediatri!s
1H71LIB:BA570(
&2 ,ai#al ,) Us%er ?( ,ym"tomati! neonatal "let%ora(
Kiol Neonate 1H77L32:A272(
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+2 Man ?%eenen -) Krabin K( Gate mbili!al !ord
!lam"in# as an intervention &or red!in# iron deJ!ien!y
anaemia in term in&ants in develo"in# and indstrialised!ontries: ' systemati! review( 'nn ro" -aediatr
200IL2I:31A(
*2 an# *G) 'nderson *) Geone ') ?i!% )
/ovindaswami K) @iner NN( ?ess!itation o& "reterm
neonates by sin# room air or 100C o>y#en( -ediatri!s
200BL121:10B3H(
)2 orld ealt% .r#ani4ation( *are in normal birt%: '
"ra!ti!al #ide( ,wit4erland: . ,a&e 6ot%er%ood
e!%ni!al orkin# /ro": /eneva 1HHAL"( 323(
$2 .>&ord 6idwives ?esear!% /ro"( ' stdy o& t%e
relations%i" between t%e delivery to !ord !lam"in# interval
and t%e time o& !ord se"aration( 6idwi&ery 1HH1L7: 1A7
7A(
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(%2 Emhamed !4, van :heenen ;,
ita H, Hosono , !inato!, 4kada T, Takahashi S, Harada 72 Umbilical cord
milkin1 reduces the need for red cell transfusions and
improves neonatal adaptation in infants born at less than ($
=eeks9 1estation" a randomi5ed control trial2 rch Dis Child
etal 3eonatal Ed (%%)$'"/-$2
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(&2 7rue1er !S, Eyal , ;eevy 7Q, Hamm C:,
8hitehurst :!, e=is D2 Delayed cord clampin1 =ith and
=ithout cord strippin1" prospective randomi5ed trial ofpreterm neonates2 m Q 4bstet ynecol (%& (("'$/ e-
'$/e&2
(+2 4ski , Honi1 S, Helu
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ables
Table I2 The demo1raphic characteristics and hematolo1icalparameters in both 1roups2
D o w n l o a d e d b y [ N e w
Y o r k U n
i v e r s i t y ] a t 1 2 : 0 7
1 3
N o
v e m b e r 2 0 1 5
roup n"
*/
roup ( n"*+p
1e Amean SDB (+,&&,( (+,$&,/ %,++
ravida ( A-'B ( A-'B %,
*ord !lam"in# 20)5OA 101)1OB)3 P0)001
se!onds) mean
!aternal Hb, 1Gdl ',,* ,+,/ %,/)
Amean SDB
!aternal Hct, L '/,*' '/,+/ %,)+
SDB
6a>imm 17(A 1(B 17(H 2(1 0(7level #FdG) mean
,D<
Delivery route, * A$&,$B &' A+$,*B P%,%%
birth, n ALB
-
8/19/2019 16. Journal of Maternal-Fetal and Neonatal -- Term Babies With Delayed Cor
26/26
Table II2 Hematolo1ical parameters of cord blood and at the
a1e of ( months of the infants in both 1roups2
Cord blood levels Second month blood
levels
n1Gml Amean SDBpP %2%&" statistically si1ni@cant
Download
edby[New
YorkUnive
rsity] at 12:07
13
November 2015
roup roup ( p
p
Hb, &,/ &,(,) %,& $,$%,$ %,'%,
Amean
SDB
Hct, /&,*/ /+,+ %,+ ($(,( '%,'(,
Amean
SDB
e, +,( /+&% %,% +),&(&,' *$,+(&
Amean
SDB
erriti (((( *,$ %,% (/%,'/ (',
%,%%'
0)00B
0)00
1
%,+)