Early versus delayed cord clamping of term births in Shatby Maternity University Hospital

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Fawzy, Azza A. Moustafa, Yasser S. El-Kassar, Manal S. Swelem, Ahmed S. El-Agwany, Dina A. Diab" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Abd El-Moneim A." "apellidos" => "Fawzy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Azza A." "apellidos" => "Moustafa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Yasser S." "apellidos" => "El-Kassar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Manal S." "apellidos" => "Swelem" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:4 [ "nombre" => "Ahmed S." "apellidos" => "El-Agwany" "email" => array:1 [ 0 => "Ahmedsamyagwany@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 5 => array:3 [ "nombre" => "Dina A." "apellidos" => "Diab" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Egypt" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pinzamiento precoz frente a pinzamiento tardío del cordón umbilical en nacimientos a término del Hospital Materno-Infantil de Shatby" ] ] "textoCompleto" => "IntroductionClamping and cutting of the umbilical cord at birth is by far the oldest and most prevalent in humans.<a class="elsevierStyleCrossRef" href="#bib0075">1</a> In spite of that, the optimal timing of cord clamping has been a controversial for decades.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>Active versus physiological management of the third stage is generally accepted as an evidence-based plan for women to avoid excessive blood loss; clamping and cutting the umbilical cord following birth has continued to be routine part of this focus.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>There are no formal practices guidelines, but most practitioners in western countries clamp and cut the cord immediately after birth, while the practice worldwide is variable. The active management of the third stage of labour includes: oxytocin administration, early cord clamping and controlled cord traction.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>Early cord clamping as a part of the active management is usually performed within the first 30s at birth, regardless of whether cord pulsations have ceased or not. Some researchers define “immediate” cord clamping as cutting the cord within 5 second, but this definition is not widely used.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>Advantages of early clamping are prevention of potential postpartum hemorrhage possibility for prompt treatment of the new born, and harvesting of stem cells, while the potential disadvantage of this approach is the increased likelihood of feto-maternal transfusion because early clamping may force blood back to the placenta and increase the likelihood of a D-antigen (rhesus) negative mother to be sensitized by her D-positive infant.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>Delayed clamping allows time for transfusion of placental blood to the newborn infant, which can provide the neonate with an additional 30% blood volume, thereby protecting him from anemia without increasing the risk of jaundice and complications related to hyper viscosity and polycythemia.<a class="elsevierStyleCrossRef" href="#bib0085">3</a>This – relatively – low cost intervention that can decrease the prevalence of iron deficiency anemia in childhood which is a serious worldwide problem affecting infants in developing countries.<a class="elsevierStyleCrossRef" href="#bib0090">4</a>In addition, circulation from the placenta persists for a few minutes after birth and the infant continues to get oxygen through umbilical cord. When oxygen-rich blood is allowed to course through the intact cord, the newly born infant is offered a protected time of adjustment to his new world and his new way of breathing.<a class="elsevierStyleCrossRef" href="#bib0095">5</a>On other hand delayed cord clamping has been identified as a cause of polycythemia which leads to hyperviscosity<a class="elsevierStyleCrossRef" href="#bib0095">5</a>; transient tachypnea of the newborn may occur as a result of delayed absorption of lung fluid caused by an increase in blood volume related to delayed cord clamping.<a class="elsevierStyleCrossRef" href="#bib0100">6</a>So the aim of this work was to compare the potential benefits and harms of early versus late umbilical cord clamping in Shatby Maternity Hospital, Alexandria University.MethodsA randomized study was carried on 100 pregnant women admitted to the obstetrics and gynecology department in Shatby Maternity University hospital from the June 2014, where the parents were informed about the trial and obtained informed consent before were obtained birth. The randomization was performed with a system of randomly prepared cards in sealed non-transparent envelopes containing early or delayed cord clamping when the birth was imminent. The inclusion criteria of this trial include primigravida, full term, non-complicated pregnancy, single, spontaneous delivery with average first and 2nd stage labor, optimums time of rupture of membrane and average fetal weight. While pregnancy with Rh−ve group mother, twins, history of postpartum hemorrhage, preterm, congenital anomalies, instrumental delivery, prolonged labor, patient under general anesthesia, cord around the neck necessitating early cutting and in need of early resuscitation were excluded from the trial. Fifty early cord clamped newborn infants within 30s (group I) were compared to fifty delayed cord clamping after cord stopped pulsation (group II), then Apgar score, Hb%, random blood sugar, O2 saturation by the oxymetry (Masimo SET® pulse oximetry) immediately after delivery and also bilirubin level after the 3rd day of delivery were assessed by the paediatrician. The data was collected and entered into personal computer. Statistical analysis was done using statistical package for social sciences (SPSS/version 20) software. Arithmetic mean standard deviation and the t-test were used for comparison between the two groups. The level of significant was 0.05.ResultsAfter analysis of the data of study, there was no statistically significant difference regarding baseline data or in mean value of the Apgar score at 1 and 5min (where P=0.425 and 0.565) respectively. Also, there was no statistically significant difference in mean hemoglobin or random blood sugar of newborn of both groups (where P=0.622 and 0.211) respectively. The comparison between the two studied groups regarding O2 saturation shows that there was statistical significance difference in mean value where (P=0.025), but no significant difference between both groups as regards serum bilirubin level where (P=0.123) (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionWith few exceptions, the umbilical cord of every newborn is clamped and cut at birth, yet the optimal timing for this intervention remains controversial.Trial evaluating a variety of definitions of early clamping and cutting ranging from immediately after delivery of the baby up to 30seconds after birth.The same confusion also exists as regards late or delayed cord clamping which applied when the mean delay 2–3min after birth or when cord pulsation has ceased.<a class="elsevierStyleCrossRef" href="#bib0105">7</a>Placental transfusion is defined as the amount of blood that flows from the placenta to the infant at birth. A 2011 study weighing babies with cord intact showed that the maximal mean volume of placental transfusion is between 24 and 312ml/kg of body weight or an additional 30–40% of blood volume, moreover, net placental flow appears to stop at two minutes. The quantity of blood transferred to the infant is thought to be influenced by several factors: the timing of umbilical cord clamping, gravity, the administration of uterotonic (such as oxytocin), and the milking of the cord.<a class="elsevierStyleCrossRef" href="#bib0110">8</a>In 2007, the World Health Organization recommended that “the cord should not be clamped earlier than necessary.<a class="elsevierStyleCrossRef" href="#bib0080">2</a> Also, in 2008, a Cochrane review showing the effect of the timing of clamping the umbilical cord on maternal and neonatal outcomes in term infants was published”.In response to this review, the American Congress of Obstetricians and Gynecologists deemed that “The evidence does not seem sufficient strong for a change in policy”, but it does encourage a relaxed approach to the timing of cord clamping.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>In 2009, The Society of Obstetricians and Gynecologists of Canada published a clinical practice guide line on the management of the third stage of labour, Which stated that for term newborn, the possible increase of neonatal jaundice requiring phototherapy must be weighed against the physiological benefits of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping.<a class="elsevierStyleCrossRef" href="#bib0115">9</a>In this study, neonatal Apgar score, hemoglobin, random blood sugar did not significantly differ (in spite of to be improved in DCC) between both groups possibly because the time interval between cord clamping and Apgar score and other variables was too brief to permit expression beneficial or adverse effects.Also this study showed significant changes (i.e. improvement) in blood gases, e.g. O2 saturation when the umbilical cord clamping at birth was delayed.Despite arise in the oxygen saturation when the newborn started to breathe, a trend towards a mixed respiratory and metabolic academia developed as characterized by decreases in PH, ↑PO2 and slight ↓PCO2. Subsequently, bicarbonate, the main buffer in the fetus and newborn, decreased over the whole periodA prospective observational study of vaginally delivered term newborn infants suggests a trend towards a mixed respiratory and metabolic acidosis when umbilical cord clamping is delayed, the authors of this study found a slight fall in arterial blood PH (by 0.03 units) and increase O2 saturation in DCC group. Although the statically significant of this finding is uncertain, a more recent RCT analyzing the acid–base status of both arterial venous cord blood showed no difference between ECC and DCC groups,<a class="elsevierStyleCrossRef" href="#bib0120">10</a> this agreed with this study but the small sample size may the cause of significant difference in O2 saturation.Regarding the bilirubin level jaundice is after attributed to delayed cord clamping with little evidence of causality. However, most studies did not show significant difference in bilirubin levels between early and late cord clamping in full term normal weight infants.<a class="elsevierStyleCrossRefs" href="#bib0130">12–14</a>This study agreed with these findings, no significant difference was found between DCC and ECC in total serum bilirubin levels at 72h, but the mean bilirubin concentrations were higher in DCC group, but did not reach the levels requiring phototherapy or exchange transfusion.In agreement with Cochrane review 2008, and recommendations of the Society of Obstetricians Gynecologists, our study proved that delayed cord clamping until the pulsations stop is a physiological way of treating the cord and is not associated with adverse effects, at least in term vaginal delivers. Even the overall available evidence that appears to suggest delayed cord clamping is likely to result in better neonatal out comes in term infants.<a class="elsevierStyleCrossRef" href="#bib0125">11</a> Even in areas where neonatal iron deficiency anemia is rare.<a class="elsevierStyleCrossRef" href="#bib0130">12</a> So delayed cord clamping is a safe simple procedure should be incorporated in a labor management.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres571494" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec588525" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres571493" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec588524" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-26" "fechaAceptado" => "2015-05-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec588525" "palabras" => array:3 [ 0 => "Early cord clamping" 1 => "Delayed cord clamping" 2 => "Umbilical cord" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec588524" "palabras" => array:3 [ 0 => "Pinzamiento precoz del cordón" 1 => "Pinzamiento tardío del cordón" 2 => "Cordón umbilical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe optimal timing for cord clamping; early versus delayed in the third stage of labour, is a controversial subject. There are no formed practice guidelines. ObjectiveTo compare the potential benefits and harms of early versus late clamping in term infants in Shatby Maternity Hospital. MethodsA randomized study was conducted on 100 primigravide full term single pregnancy admitted and delivered spontaneously at Shatby Maternity University Hospital. They were divided into two groups (each 50) where in the first group the umbilical cord was clamped immediately “early cord clamping” (ECC) and where the 2nd group the umbilical cord was clamped after pulsation had been ceased” delayed cord clamping” (DCC) and then Apgar score, Hemoglobin level, random blood sugar, oxygen saturation and bilirubin after 72h of labour of newborn were compared and analyzed. ResultsThere was no statistical significant difference between both groups as regards Apgar score, haemoglobin, Random blood sugar and bilirubin while, there was a statistical significant difference as regard O2 saturation. ConclusionDelayed cord clamping is likely to result in better neonatal outcome." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesEl momento óptimo para el pinzamiento del cordón umbilical, precoz frente al tardío durante el expulsivo del parto, es un tema polémico. No existen unas directrices prácticas formales. ObjetivoComparar los beneficios y daños potenciales del pinzamiento precoz frente al tardío en recién nacidos a término en el Hospital Materno-Infantil de Shatby. MétodosEstudio aleatorizado de 100 embarazos únicos a término en primigrávidas que ingresaron y dieron a luz de manera espontánea en el Hospital Materno-Infantil de Shatby. Quedaron divididas en 2 grupos (de 50 integrantes cada uno) en los que se realizó un pinzamiento precoz del cordón umbilical en el primero y un pinzamiento tardío del cordón umbilical en el segundo. A las 72h del parto se compararon y analizaron la puntuación de Apgar y los valores de hemoglobina, glucemia aleatoria, saturación de oxígeno y bilirrubina. ResultadosNo se apreció una diferencia estadística significativa entre ambos grupos con respecto a la puntuación en el test de Apgar, ni tampoco en los valores de hemoglobina, glucemia aleatoria y bilirrubina, si bien existió una diferencia estadísticamente significativa con respecto a la saturación de O2. ConclusiónUn pinzamiento tardío del cordón umbilical podría derivar en un mejor resultado neonatal." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group I \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Maternal age</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20–35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25–34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.423 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Gestational age at birth</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37–40 w \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38–41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.576 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Neonatal weight</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3000–4500g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3300–4000g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.912 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab931576.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison as regards baseline data." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">At 1min</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.425 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">At 5min</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.565 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Hb level</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.5–16.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.8–16.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.622 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Random blood sugar</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66–122 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70–128 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.211 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">O2saturation on the third day</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83–89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89–92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.025<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Bilirubin level on the 3rd day (mg/dl)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5–11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.123 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab931575.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => 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Eman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "JAMA" "fecha" => "2007" "volumen" => "397" "paginaInicial" => "1241" "paginaFinal" => "1252" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0135" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Committee Opinion No.543: Timing of umbilical cord clamping after birth" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Committee on Obstetric Practice, American College of Obstetricians and Gynecologists" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.AOG.0000423817.47165.48" "Revista" => array:5 [ "tituloSerie" => "Obstet Gynecol" "fecha" => "2012" "volumen" => "120" "paginaInicial" => "1522" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23168790" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0140" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.J. 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Original article

Pinzamiento precoz frente a pinzamiento tardío del cordón umbilical en nacimientos a término del Hospital Materno-Infantil de Shatby

Abd El-Moneim A. Fawzya, Azza A. Moustafab, Yasser S. El-Kassara, Manal S. Swelema, Ahmed S. El-Agwanya,

Corresponding author

Ahmedsamyagwany@gmail.com

Corresponding author.

, Dina A. Diabb

a Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Egypt

b Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clamping and cutting of the umbilical cord at birth is by far the oldest and most prevalent in humans&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> In spite of that&#44; the optimal timing of cord clamping has been a controversial for decades&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Active versus physiological management of the third stage is generally accepted as an evidence-based plan for women to avoid excessive blood loss&#59; clamping and cutting the umbilical cord following birth has continued to be routine part of this focus&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are no formal practices guidelines&#44; but most practitioners in western countries clamp and cut the cord immediately after birth&#44; while the practice worldwide is variable&#46; The active management of the third stage of labour includes&#58; oxytocin administration&#44; early cord clamping and controlled cord traction&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Early cord clamping as a part of the active management is usually performed within the first 30<span class="elsevierStyleHsp" style=""></span>s at birth&#44; regardless of whether cord pulsations have ceased or not&#46; Some researchers define &#8220;immediate&#8221; cord clamping as cutting the cord within 5 second&#44; but this definition is not widely used&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Advantages of early clamping are prevention of potential postpartum hemorrhage possibility for prompt treatment of the new born&#44; and harvesting of stem cells&#44; while the potential disadvantage of this approach is the increased likelihood of feto-maternal transfusion because early clamping may force blood back to the placenta and increase the likelihood of a D-antigen &#40;rhesus&#41; negative mother to be sensitized by her D-positive infant&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Delayed clamping allows time for transfusion of placental blood to the newborn infant&#44; which can provide the neonate with an additional 30&#37; blood volume&#44; thereby protecting him from anemia without increasing the risk of jaundice and complications related to hyper viscosity and polycythemia&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This &#8211; relatively &#8211; low cost intervention that can decrease the prevalence of iron deficiency anemia in childhood which is a serious worldwide problem affecting infants in developing countries&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition&#44; circulation from the placenta persists for a few minutes after birth and the infant continues to get oxygen through umbilical cord&#46; When oxygen-rich blood is allowed to course through the intact cord&#44; the newly born infant is offered a protected time of adjustment to his new world and his new way of breathing&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">On other hand delayed cord clamping has been identified as a cause of polycythemia which leads to hyperviscosity<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a>&#59; transient tachypnea of the newborn may occur as a result of delayed absorption of lung fluid caused by an increase in blood volume related to delayed cord clamping&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">So the aim of this work was to compare the potential benefits and harms of early versus late umbilical cord clamping in Shatby Maternity Hospital&#44; Alexandria University&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">A randomized study was carried on 100 pregnant women admitted to the obstetrics and gynecology department in Shatby Maternity University hospital from the June 2014&#44; where the parents were informed about the trial and obtained informed consent before were obtained birth&#46; The randomization was performed with a system of randomly prepared cards in sealed non-transparent envelopes containing early or delayed cord clamping when the birth was imminent&#46; The inclusion criteria of this trial include primigravida&#44; full term&#44; non-complicated pregnancy&#44; single&#44; spontaneous delivery with average first and 2nd stage labor&#44; optimums time of rupture of membrane and average fetal weight&#46; While pregnancy with Rh&#8722;ve group mother&#44; twins&#44; history of postpartum hemorrhage&#44; preterm&#44; congenital anomalies&#44; instrumental delivery&#44; prolonged labor&#44; patient under general anesthesia&#44; cord around the neck necessitating early cutting and in need of early resuscitation were excluded from the trial&#46; Fifty early cord clamped newborn infants within 30<span class="elsevierStyleHsp" style=""></span>s &#40;group I&#41; were compared to fifty delayed cord clamping after cord stopped pulsation &#40;group II&#41;&#44; then Apgar score&#44; Hb&#37;&#44; random blood sugar&#44; O<span class="elsevierStyleInf">2</span> saturation by the oxymetry &#40;Masimo SET<span class="elsevierStyleSup">&#174;</span> pulse oximetry&#41; immediately after delivery and also bilirubin level after the 3rd day of delivery were assessed by the paediatrician&#46; The data was collected and entered into personal computer&#46; Statistical analysis was done using statistical package for social sciences &#40;SPSS&#47;version 20&#41; software&#46; Arithmetic mean standard deviation and the <span class="elsevierStyleItalic">t</span>-test were used for comparison between the two groups&#46; The level of significant was 0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">After analysis of the data of study&#44; there was no statistically significant difference regarding baseline data or in mean value of the Apgar score at 1 and 5<span class="elsevierStyleHsp" style=""></span>min &#40;where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;425 and 0&#46;565&#41; respectively&#46; Also&#44; there was no statistically significant difference in mean hemoglobin or random blood sugar of newborn of both groups &#40;where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;622 and 0&#46;211&#41; respectively&#46; The comparison between the two studied groups regarding O<span class="elsevierStyleInf">2</span> saturation shows that there was statistical significance difference in mean value where &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;025&#41;&#44; but no significant difference between both groups as regards serum bilirubin level where &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;123&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">With few exceptions&#44; the umbilical cord of every newborn is clamped and cut at birth&#44; yet the optimal timing for this intervention remains controversial&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Trial evaluating a variety of definitions of early clamping and cutting ranging from immediately after delivery of the baby up to 30<span class="elsevierStyleHsp" style=""></span>seconds after birth&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The same confusion also exists as regards late or delayed cord clamping which applied when the mean delay 2&#8211;3<span class="elsevierStyleHsp" style=""></span>min after birth or when cord pulsation has ceased&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Placental transfusion is defined as the amount of blood that flows from the placenta to the infant at birth&#46; A 2011 study weighing babies with cord intact showed that the maximal mean volume of placental transfusion is between 24 and 312<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of body weight or an additional 30&#8211;40&#37; of blood volume&#44; moreover&#44; net placental flow appears to stop at two minutes&#46; The quantity of blood transferred to the infant is thought to be influenced by several factors&#58; the timing of umbilical cord clamping&#44; gravity&#44; the administration of uterotonic &#40;such as oxytocin&#41;&#44; and the milking of the cord&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In 2007&#44; the World Health Organization recommended that &#8220;the cord should not be clamped earlier than necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Also&#44; in 2008&#44; a Cochrane review showing the effect of the timing of clamping the umbilical cord on maternal and neonatal outcomes in term infants was published&#8221;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In response to this review&#44; the American Congress of Obstetricians and Gynecologists deemed that &#8220;The evidence does not seem sufficient strong for a change in policy&#8221;&#44; but it does encourage a relaxed approach to the timing of cord clamping&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In 2009&#44; The Society of Obstetricians and Gynecologists of Canada published a clinical practice guide line on the management of the third stage of labour&#44; Which stated that for term newborn&#44; the possible increase of neonatal jaundice requiring phototherapy must be weighed against the physiological benefits of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this study&#44; neonatal Apgar score&#44; hemoglobin&#44; random blood sugar did not significantly differ &#40;in spite of to be improved in DCC&#41; between both groups possibly because the time interval between cord clamping and Apgar score and other variables was too brief to permit expression beneficial or adverse effects&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Also this study showed significant changes &#40;i&#46;e&#46; improvement&#41; in blood gases&#44; e&#46;g&#46; O<span class="elsevierStyleInf">2</span> saturation when the umbilical cord clamping at birth was delayed&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Despite arise in the oxygen saturation when the newborn started to breathe&#44; a trend towards a mixed respiratory and metabolic academia developed as characterized by decreases in PH&#44; &#8593;PO<span class="elsevierStyleInf">2</span> and slight &#8595;PCO<span class="elsevierStyleInf">2</span>&#46; Subsequently&#44; bicarbonate&#44; the main buffer in the fetus and newborn&#44; decreased over the whole period</p><p id="par0115" class="elsevierStylePara elsevierViewall">A prospective observational study of vaginally delivered term newborn infants suggests a trend towards a mixed respiratory and metabolic acidosis when umbilical cord clamping is delayed&#44; the authors of this study found a slight fall in arterial blood PH &#40;by 0&#46;03 units&#41; and increase O<span class="elsevierStyleInf">2</span> saturation in DCC group&#46; Although the statically significant of this finding is uncertain&#44; a more recent RCT analyzing the acid&#8211;base status of both arterial venous cord blood showed no difference between ECC and DCC groups&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> this agreed with this study but the small sample size may the cause of significant difference in O<span class="elsevierStyleInf">2</span> saturation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Regarding the bilirubin level jaundice is after attributed to delayed cord clamping with little evidence of causality&#46; However&#44; most studies did not show significant difference in bilirubin levels between early and late cord clamping in full term normal weight infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">This study agreed with these findings&#44; no significant difference was found between DCC and ECC in total serum bilirubin levels at 72<span class="elsevierStyleHsp" style=""></span>h&#44; but the mean bilirubin concentrations were higher in DCC group&#44; but did not reach the levels requiring phototherapy or exchange transfusion&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In agreement with Cochrane review 2008&#44; and recommendations of the Society of Obstetricians Gynecologists&#44; our study proved that delayed cord clamping until the pulsations stop is a physiological way of treating the cord and is not associated with adverse effects&#44; at least in term vaginal delivers&#46; Even the overall available evidence that appears to suggest delayed cord clamping is likely to result in better neonatal out comes in term infants&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> Even in areas where neonatal iron deficiency anemia is rare&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> So delayed cord clamping is a safe simple procedure should be incorporated in a labor management&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2014-12-26"
    "fechaAceptado" => "2015-05-04"
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        0 => array:4 [
          "clase" => "keyword"
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            0 => "Early cord clamping"
            1 => "Delayed cord clamping"
            2 => "Umbilical cord"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Pinzamiento precoz del cord&#243;n"
            1 => "Pinzamiento tard&#237;o del cord&#243;n"
            2 => "Cord&#243;n umbilical"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The optimal timing for cord clamping&#59; early versus delayed in the third stage of labour&#44; is a controversial subject&#46; There are no formed practice guidelines&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To compare the potential benefits and harms of early versus late clamping in term infants in Shatby Maternity Hospital&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A randomized study was conducted on 100 primigravide full term single pregnancy admitted and delivered spontaneously at Shatby Maternity University Hospital&#46; They were divided into two groups &#40;each 50&#41; where in the first group the umbilical cord was clamped immediately &#8220;early cord clamping&#8221; &#40;ECC&#41; and where the 2nd group the umbilical cord was clamped after pulsation had been ceased&#8221; delayed cord clamping&#8221; &#40;DCC&#41; and then Apgar score&#44; Hemoglobin level&#44; random blood sugar&#44; oxygen saturation and bilirubin after 72<span class="elsevierStyleHsp" style=""></span>h of labour of newborn were compared and analyzed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There was no statistical significant difference between both groups as regards Apgar score&#44; haemoglobin&#44; Random blood sugar and bilirubin while&#44; there was a statistical significant difference as regard O<span class="elsevierStyleInf">2</span> saturation&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Delayed cord clamping is likely to result in better neonatal outcome&#46;</p></span>"
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            "identificador" => "abst0015"
            "titulo" => "Methods"
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            "titulo" => "Results"
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            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El momento &#243;ptimo para el pinzamiento del cord&#243;n umbilical&#44; precoz frente al tard&#237;o durante el expulsivo del parto&#44; es un tema pol&#233;mico&#46; No existen unas directrices pr&#225;cticas formales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Comparar los beneficios y da&#241;os potenciales del pinzamiento precoz frente al tard&#237;o en reci&#233;n nacidos a t&#233;rmino en el Hospital Materno-Infantil de Shatby&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio aleatorizado de 100 embarazos &#250;nicos a t&#233;rmino en primigr&#225;vidas que ingresaron y dieron a luz de manera espont&#225;nea en el Hospital Materno-Infantil de Shatby&#46; Quedaron divididas en 2 grupos &#40;de 50 integrantes cada uno&#41; en los que se realiz&#243; un pinzamiento precoz del cord&#243;n umbilical en el primero y un pinzamiento tard&#237;o del cord&#243;n umbilical en el segundo&#46; A las 72<span class="elsevierStyleHsp" style=""></span>h del parto se compararon y analizaron la puntuaci&#243;n de Apgar y los valores de hemoglobina&#44; glucemia aleatoria&#44; saturaci&#243;n de ox&#237;geno y bilirrubina&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">No se apreci&#243; una diferencia estad&#237;stica significativa entre ambos grupos con respecto a la puntuaci&#243;n en el test de Apgar&#44; ni tampoco en los valores de hemoglobina&#44; glucemia aleatoria y bilirrubina&#44; si bien existi&#243; una diferencia estad&#237;sticamente significativa con respecto a la saturaci&#243;n de O<span class="elsevierStyleInf">2</span>&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Un pinzamiento tard&#237;o del cord&#243;n umbilical podr&#237;a derivar en un mejor resultado neonatal&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Maternal age</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#8211;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;423&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Gestational age at birth</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#8211;40 w&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#8211;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;576&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top">Neonatal weight</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3000&#8211;4500<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3300&#8211;4000<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;912&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">At 1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;425&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">At 5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;565&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Hb level</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;5&#8211;16&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;8&#8211;16&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;622&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Random blood sugar</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#8211;122&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#8211;128&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;211&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">O</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">saturation on the third day</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#8211;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;025<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Bilirubin level on the 3rd day &#40;mg&#47;dl&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#8211;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#46;D&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">comparison between the two studied groups regarding main results&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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            7 => array:3 [
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            9 => array:3 [
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                  "contribucion" => array:1 [
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            10 => array:3 [
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            11 => array:3 [
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              "referencia" => array:1 [
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Article information

ISSN: 03045013
Original language: English

DOI:10.1016/j.pog.2015.05.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	35	2	37
2024 September	85	13	98
2024 August	62	7	69
2024 July	75	8	83
2024 June	67	9	76
2024 May	47	10	57
2024 April	61	7	68
2024 March	60	14	74
2024 February	73	6	79
2024 January	70	6	76
2023 December	60	9	69
2023 November	64	25	89
2023 October	119	29	148
2023 September	59	5	64
2023 August	71	6	77
2023 July	95	11	106
2023 June	52	4	56
2023 May	114	15	129
2023 April	102	2	104
2023 March	85	16	101
2023 February	63	3	66
2023 January	63	11	74
2022 December	60	15	75
2022 November	66	20	86
2022 October	51	18	69
2022 September	79	22	101
2022 August	85	15	100
2022 July	76	11	87
2022 June	68	14	82
2022 May	92	13	105
2022 April	75	8	83
2022 March	117	15	132
2022 February	132	13	145
2022 January	114	17	131
2021 December	83	28	111
2021 November	97	10	107
2021 October	88	19	107
2021 September	92	14	106
2021 August	50	6	56
2021 July	84	9	93
2021 June	40	9	49
2021 May	52	17	69
2021 April	164	50	214
2021 March	91	18	109
2021 February	94	18	112
2021 January	66	20	86
2020 December	63	18	81
2020 November	54	10	64
2020 October	62	17	79
2020 September	62	19	81
2020 August	44	11	55
2020 July	62	16	78
2020 June	68	20	88
2020 May	81	19	100
2020 April	51	19	70
2020 March	77	15	92
2020 February	56	18	74
2020 January	55	16	71
2019 December	53	10	63
2019 November	22	9	31
2019 October	8	17	25
2017 October	13	3	16
2017 September	19	4	23
2017 August	13	10	23
2017 July	17	20	37
2017 June	19	21	40
2017 May	31	14	45
2017 April	25	9	34
2017 March	12	20	32
2017 February	33	16	49
2017 January	23	8	31
2016 December	33	13	46
2016 November	40	15	55
2016 October	70	16	86
2016 September	67	14	81
2016 August	49	6	55
2016 July	49	5	54
2016 June	44	30	74
2016 May	41	22	63
2016 April	34	26	60
2016 March	46	30	76
2016 February	40	35	75
2016 January	23	15	38
2015 December	2	2	4
2015 November	3	10	13
2015 October	2	13	15

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