Postpartum umbilical cord blood collection for transplantation: a comparison of three methods

OBJECTIVE

This study was undertaken to compare 3 methods of collection of human umbilical cord blood.

STUDY DESIGN

Seventy-five women with uncomplicated vaginal deliveries were divided equally into 3 groups. One of 3 cord blood collection methods was applied to each woman. Method 1 was collection of cord blood into a standard donation blood bag. Methods 2 and 3 used a syringe to perform a sodium chloride solution flush and drain, which included withdrawal of cord blood by a syringe until the delivery of the placenta, followed by flushing through a catheter one of the umbilical arteries with sodium chloride solution and collection of the cord blood either into an open sterile container (method 2) or into a standard donation blood bag (method 3). Analyses included comparisons among the 3 groups of volume collected, total number of white blood cells, and bacterial contamination rates (positive culture results). In addition a correlation was made between the different variables and the collected cord blood nucleated cells.

RESULTS

Cord blood collection by the blood bag method (method 1), which is presently the standard clinical practice, resulted in a mean blood volume of 76.4 +/- 32.1 mL and a mean total white blood cell count of 835 +/- 507 x 10(6) cells. With collection methods 2 and 3, in which as much blood as possible was withdrawn by syringe while the placenta was still in utero followed by a second collection after infusion of the umbilical artery with sodium chloride solution, the mean volume collected was significantly higher (P <.05) at 174.4 +/- 42.8 mL and 173.7 +/- 41.3 mL, respectively, with significantly higher (P <.001) mean total white blood cell counts of 1624 +/- 887 x 10(6) cells and 1693 +/- 972 x 10(6) cells, respectively. A direct correlation was observed between the cord blood volume collected and placental weight, whereas no correlations were observed with maternal age, pregnancy duration, or the neonate's weight. Bacterial contamination was significantly higher (P =.04) in cord blood collections obtained by method 2 (48%) than by methods 1 (16%) and 3 (19%).

CONCLUSIONS

The syringe-assisted sodium chloride solution flush collection method with a blood bag (method 3) was found to be the most effective method for human umbilical cord blood collection. This method doubles the total white blood cells collected with respect to current yields, which may make cord blood transplantation applicable for adults.

Internalization of FimH+ Escherichia coli by the human mast cell line (HMC-1 5C6) involves protein kinase C

Rodent mast cells (MC) play critical roles in host defense against bacterial infection. However, bacteria-mediated signaling mechanisms in MC have not been studied. In addition, the response of human MC to bacteria is not fully investigated. This study examined the interaction between human MC and type 1 fimbriated Escherichia coli and the mechanisms involved using the human MC line HMC-1 5C6 and human cord blood-derived MC. These MC internalized significant numbers of FimH+ E. coli, but not its isogenic FimH- mutant. In HMC-1 cells, bacterial internalization was stimulated by protein kinase C (PKC) activation [short-term phorbol myristate acetate (PMA) treatment] and dramatically decreased by PKC inhibitors or PKC depletion (long-term PMA treatment). Moreover, bacterial internalization was accompanied by significant expression of PKCbeta1 and delta. Fluorescence microscopy demonstrated accumulation of PKCbeta1 on internalized bacteria. These data indicate that human MC has the capacity to internalize bacteria and PKC may be a critical intracellular mediator of this function.

Value of the comparative enzyme-linked immunofiltration assay for early neonatal diagnosis of congenital Toxoplasma infection

BACKGROUND

The transplacental transfer of specific maternal IgG antibodies makes the diagnosis of congenital Toxoplasma infection quite difficult in the neonate. The enzyme-linked immunofiltration assay (ELIFA), comparing at delivery the immunologic profile of the mother's antibody response and that of her child, allows discrimination between IgG antibodies of maternal origin and IgGs synthesized by the fetus.

OBJECTIVE

To evaluate the diagnostic reliability of the comparative ELIFA for diagnosing congenital Toxoplasma infection as well as the reliability of testing for IgM- and IgA-specific antibodies in cord blood.

METHODS

From November, 1991, to December, 1995, an ELIFA was prospectively performed at delivery on blood samples obtained from 227 women with primary Toxoplasma infection during pregnancy and from their infants. For each child the ELIFA result was evaluated in relation to the serologic follow-up: disappearance of specific anti-Toxoplasma gondii IgG antibodies in the absence of treatment before 12 months of age indicating an uninfected child, as opposed to persistence beyond 12 months of age indicative of a congenital infection.

RESULTS

Of 227 children 139 were lost to follow-up. Among the 88 children available for follow up, the ELIFA was negative in 70 infants, 69 of whom were confirmed to be uninfected. Thirteen of these 69 cord blood ELIFA-negative samples were positive for anti-T. gondii IgM and/or IgA detected by means of a conventional immunosorbent agglutination assay. Of the remaining 18 children (representing 75% of all new cases of congenital toxoplasmosis diagnosed during the study period at our institution), the ELIFA was positive in 16, negative in 1 and inconclusive in 1.

CONCLUSIONS

The ELIFA test is a valuable tool for diagnosing congenital T. gondii infection and in differentiating between true neonatal infection and cord blood contamination. In our experience the diagnostic sensitivity of the ELIFA test was 94.1% and the specificity was 98.6%. The cord blood was contaminated by specific maternal anti-T. gondii IgA and/or IgM in as many as 20% of the cases.

[Congenital syphilis: late diagnosis in spite of screening]

We report the case of an infant in whom congenital syphilis was diagnosed at the age of 5 weeks. The case is remarkable because of (a) the negative venereal disease laboratory test from the cord blood, (b) the incidental diagnosis of the disease in the fifth week of life, (c) pneumonia alba being one of the symptoms, (d) the occurrence of a mild Jarisch-Herxheimer reaction after initiation of penicillin therapy and (e) the successful treatment of infection related anaemia with recombinant human erythropoietin.

[Study of relation between ureaplasma urealyticum and fetal intrauterine growth retardation]

OBJECTIVE

To study the influences of Ureaplasma Urealyticum (UU) infection to fetal intrauterine growth.

METHODS

Polymerase Chain Reaction was used to detect UU in samples of cervical secretions, umbilical blood and placenta. The study group included 50 women with neonatal birth weight below 2,500 g, 50 women with newborns birth weight above 2,500 g served as control group.

RESULTS

Positive rate of UU in samples of cord blood and placenta and placental chorioamnionitis in study group were higher than that in the control group (P < 0.005 and P < 0.05). There was no significant difference of UU positive rate in cervical samples between two groups. The positive rate of UU in cases with chorioamnionitis was higher than that of cases with negative UU infection (P < 0.05).

CONCLUSION

UU may interfere fetal intrauterine growth through infecting umbilical blood and placenta.

Group B streptococcus infection, not birth asphyxia

This case illustrates 2 main points. Firstly, fetal infection can mimic exactly both the immediate and delayed signs of perinatal asphyxia. Secondly, the placenta may hold the key to the diagnosis of sepsis which may be made difficult in the neonate by labour ward practices such as the use of intrapartum and immediate newborn antibiotics. We strongly support the recommendation that newborn blood and fetal membrane cultures should always be obtained in babies with a diagnosis of 'intrapartum asphyxia and fetal distress' (1). To this we would add the recommendation that placental histology be performed in these circumstances.

Detection of Coxiella burnetii specific DNA in blood samples from Japanese patients with chronic nonspecific symptoms by nested polymerase chain reaction

The nested polymerase chain reaction (PCR) was used for direct species-specific detection of Coxiella burnetii in blood samples from 52 patients with chronic nonspecific symptoms, but no diagnostic or treatment history of Q fever. All patients had been in ill-health with general fatigue, muscle and joint pain, headache, etc., for one to more than 10 years. Seventeen (33%) showed evidence of C. burnetii infection, based on amplification of 438-bp fragments specific to C. burnetii by nested PCR, and 94% of positive patients reported close contact with animals. In contrast, five (9.6%) of 52 samples from healthy adult controls and two (2.8%) of 70 cord blood samples were positive by nested PCR. These data suggest a high prevalence of infection among adult patients with long term, nonspecific complaints who live in close contact with animals and the possible existence of a chronic post-acute Q fever syndrome in Japan.

Antibodies to group B streptococci in neonates and infants

Invasive group B streptococcal (GBS) infections are common in neonates but are rare after the 1st month of life. It is not known why GBS infections have this age distribution which differs from that of invasive infections caused by other encapsulated bacteria. The aim of this study was to test the possibility that serum antibodies against the GBS capsular polysaccharides (CPS) are acquired during the first months of life thereby preventing infections after the neonatal period. Cord sera were collected from 321 healthy term newborns. A second blood sample was collected at 2, 4, 8, 13 or 26 weeks of age. IgG CPS antibodies (measured by ELISA) against serotypes Ia, II and III were present in 98%-100% of all cord sera and decreased continuously during the first 6 months of life. No IgM antibodies against serotype III CPS were present in cord sera. Only 16%-17% of the children acquired IgM antibodies against serotype III CPS at 3 and 6 months of age.

CONCLUSION

Early acquisition of IgG or IgM antibodies against CPS of the most common GBS serotypes was not demonstrated and cannot explain the rare occurrence of invasive GBS infections in children after the 1st month of life.

Placental blood sampling: an aid to the diagnosis of neonatal sepsis

OBJECTIVE

To determine the usefulness of placental blood cultures in establishment of the diagnosis of early onset sepsis.

STUDY DESIGN

Babies born to mothers with suspected intraamniotic fluid infection had blood cultures obtained from a branch of the umbilical vein on the fetal surface of the placenta immediately after delivery. The babies at highest risk (n = 35) had subsequent neonatal blood cultured from a peripheral vein (group 1), whereas 26 newborns at a lower risk did not (group 2). A group of 20 term babies born after uncomplicated labor and vaginal delivery or by elective cesarean delivery served as control subjects.

RESULTS

Placental blood cultures were more often positive for pathogens in group 1 (7 of 35; 20%; 0.09 to 0.36) than in group 2 (0 of 26; 0 to 0.11) or control subjects (0 of 20; 0 to 0.14; p < 0.02). Within group 1, placental blood cultures were more often positive (7 of 35; 20%; 0.09 to 0.36) than subsequent neonatal blood cultures (1 of 35; 3%; 0 to 0.15; p < 0.05). Contaminants were cultured in 3 of 81 (4%; 01 to 0.11) placental samples (all from group 1) compared with 1 of 35 (3%; 0 to 0.11) neonatal samples (difference not significant).

CONCLUSIONS

A carefully obtained culture of placental blood may be a useful addition or substitute for neonatal blood culturing in newborns at risk for early-onset sepsis by virtue of maternal risk factors.

Feasibility of an obstetrician-based cord blood collection network for unrelated donor umbilical cord blood banking

The purpose of this study was to evaluate the feasibility of an obstetrician-based cord blood collection system for the purpose of banking cord blood for unrelated donor hematopoietic stem cell transplantation. Over 200 delivering physicians and 40 area obstetrical units were educated and became involved in the collection of cord blood during the third stage of labor. These products compared favorable with those obtained after placental delivery. Issues involved in the development of quality assurance for unrelated donor banking are discussed. An obstetrician-based cord blood collection network is feasible and advantageous in that cord blood can be collected from a wider variety of communities, thus enhancing the ethnic diversity of a bank.

Application of PCR for detection of mycoplasma DNA and pestivirus RNA in human live viral vaccines

PCR techniques were applied for the detection of mycoplasma DNA and pestivirus RNA to 43 lots of live viral vaccines (measles, mumps, rubella, and oral poliomyelitis) produced by six manufacturers in Japan. Although mycoplasma DNA was not detected in any of the vaccines tested, pestivirus RNA was detected in 12 lots (28%). The incidence of contamination among the four viral vaccines was in the range of 20 to 37%, and the incidence among the six manufacturers varied from 0 to 56%.

Application of a new perchloric acid treatment method to measure endotoxin in both amniotic fluid and cord blood by an endotoxin-specific chromogenic Limulus test in intra-amniotic infection

Endotoxin in both amniotic fluid and cord blood was measured to detect intra-amniotic fetal infection. Both amniotic fluid and cord blood plasma were pretreated by a perchloric acid treatment, and the endotoxin level was measured by Endospecy test. Cut off values for endotoxin in amniotic fluid and cord blood were 8.5 pg/mL and 7.6 pg/mL, respectively. Escherichia coli intra-amniotic infection caused respiratory distress syndrome (RDS)-mimicking pneumonia. Abnormally high values of endotoxin in both amniotic fluid and cord blood were detected. Intra-amniotic infection caused by Gram-positive bacteria (group B streptococci, Enterococcus fecalis) was shown to be endotoxin negative in both amniotic fluid and cord blood. In cases of negative amniotic fluid culture, measurement of the value of endotoxin in the amniotic fluid is useful in identifying intra-amniotic fetal infection.

Syphilis seroprevalence among pregnant women and its role as a risk factor for stillbirth in Maputo, Mozambique

OBJECTIVE

To elucidate the role of current syphilis as a risk factor for foetal death.

METHODS

Sera were obtained from 57 women with third trimester foetal death (cases) and 58 women with foetus alive (controls) matched for age and parity. All sera reactive in qualitative Rapid Plasma Reagin (RPR) analyses were tested with serial twofold dilutions to determine endpoint flocculation titres and tested with the micro-haemagglutination assay for Treponema pallidum (MHA-TP). Placental biopsies were sectioned and stained by haematoxylin-eosin and Warthin-Starry for light microscopy.

SETTING

Central Hospital, in Maputo, Mozambique, from January 1990 to June 1991.

RESULTS

The MHA-TP was reactive in 42% of cases and in 12% of controls (OR = 5.3; 95% CI: 1.9-15.4). The RPR card test was reactive at the dilution of 1.32 or greater in 28% of cases and in 7% of controls. All these results were confirmed by MHA-TP (OR = 5.3; 95% CI: 1.5-15.4). In 9/28 (32%) MHA-TP seroreactive women (7 cases and 2 controls) placental morphological changes indicated syphilitic infection.

CONCLUSION

MHA-TP seroreactivity and high titre RPR were associated with stillbirth. Morphological changes presumptive of syphilis infection were found in 32% placentas histologically studied. Syphilis is a risk factor for foetal death in Maputo, Mozambique.

Preterm prelabour amniorrhexis: relation to histological chorioamnionitis

Infection-mediated inflammation may be responsible for premature delivery in cases of preterm prelabour amniorrhexis. Histological examination of the cord and placenta was performed in 54 such pregnancies, in addition to amniocentesis and cordocentesis at presentation. Histological chorioamnionitis was more likely in those with positive amniotic fluid and/or fetal blood cultures, and in those cases with histological evidence of inflammation, the interval to delivery was short regardless of the culture results. Inflammation rather than infection per se may be the best indicator of preterm delivery in preterm prelabour amniorrhexis.

Amniotic fluid gram stain and leukocyte count in the prediction of intrauterine infection in preterm prelabour amniorrhexis

The purpose of the study was to examine the sensitivity and specificity of the amniotic fluid Gram stain and leukocyte count in the prediction of positive fetal blood and amniotic fluid cultures in 80 patients with preterm prelabour amniorrhexis. Amniocentesis and cordocentesis were performed and amniotic fluid and fetal blood were cultured for aerobic and anaerobic bacteria. Amniotic fluid was also cultured for Ureaplasma urealyticum and Mycoplasma hominis. The sensitivity of the Gram stain in the prediction of positive fetal blood and amniotic fluid cultures was 50 and 40% and the respective false positive rates were 12 and 4%. In the detection of aerobic or anaerobic infection of the amniotic fluid, the sensitivity and false positive rate of the Gram stain were 80 and 3% respectively. This compared favourably with the respective values of 66 and 35% for amniotic fluid leukocyte count > 30/mm3. Positive amniotic fluid Gram stain provides useful prediction of intra-uterine infection with aerobic or anaerobic organisms.

Lower genital tract swabs in the prediction of intrauterine infection in preterm prelabour rupture of the membranes

OBJECTIVE

To examine the genital tract flora in women with preterm prelabour rupture of the membranes and to determine the relationship of these microorganisms to those found in fetal blood and amniotic fluid.

DESIGN

Prospective study of 97 patients with preterm prelabour rupture of the membranes.

SETTING

Maternal-fetal medicine centre.

METHODS

High vaginal and endocervical swabs were taken for routine culture of aerobic and anaerobic bacteria and Ureaplasma urealyticum and Mycoplasma hominis. Cordocentesis and amniocentesis were performed and fetal blood and amniotic fluid were cultured for aerobic and anaerobic bacteria. Amniotic fluid was also cultured for Mycoplasma spp. The sensitivities and specificities of genital tract colonisation in the prediction of fetal blood and amniotic fluid infection were calculated.

RESULTS

Positive genital tract cultures for aerobic and anaerobic organisms predicted 40% of positive fetal blood and 53% of positive amniotic fluid cultures with false positive rates of 24% and 25%, respectively. The sensitivity and false positive rates for genital tract colonisation with Mycoplasma spp in the prediction of amniotic fluid infection with these organisms were 85% and 35%, respectively.

CONCLUSIONS

In preterm prelabour rupture of the membranes lower genital tract cultures provide poor prediction of intrauterine infection.

Intra-amniotic Chlamydia trachomatis infection

Chlamydia trachomatis is one of the most prevalent genital pathogens in pregnant women. Ascending, transcervical infection may reach fetal membranes creating chorioamnionitis or amniotic fluid infection. The aim of this study was to examine amniotic fluids obtained during cesarean section for the presence of chlamydial IgM- and IgG-specific antibodies, and for the presence of C. trachomatis antigen. Five of 52 (9.6%) amniotic fluid samples were seropositive. Two of 52 (3.8%) amniotic fluid samples had C. trachomatis antigen in the epithelial cells of the amnion. In conclusion, our data indicate that there is a high rate of transmission of C. trachomatis from mother to infant and that the pathogen can be identified in the amniotic fluid.

Autologous umbilical cord blood transfusion

The purpose of this study was to examine some aspects of umbilical cord blood collection for autologous transfusion in premature infants. All 120 microbacterial cultures (aerobic and anaerobic) of cord blood samples as well as 30 cultures of mycoplasma were treated. Cord prothrombin fragment (F 1 + 2) concentrations were quantified at one and 10 minutes after clamping of the cord. F 1 + 2 concentrations assessed on 25 newborn infants were similar and no linear association with time of clamping could be drawn. This means that cord blood thrombosis is not activated for at least 10 minutes following clamping of the cord. As far as is known, the first newborn infant to benefit from this method of transfusion is reported here. The premature infant received two portions of autologous blood (on days 5 and 7). No untoward effects were noted. Blood, collected from the umbilical cord, is a safe source for autotransfusion, provided that bacteriological testing has been carried out.

Fetal haematological response to intra-uterine infection in preterm prelabour amniorrhexis

The value of fetal haematological indices in the prediction of intra-uterine infection in 91 cases of preterm prelabour amniorrhexis was examined. Cordocentesis and amniocentesis were performed for the diagnosis of intra-uterine infection. The patients were subsequently divided into three groups, depending on the results of fetal blood and amniotic fluid cultures. In group 1 there were 53 patients with negative fetal blood and amniotic fluid cultures, group 2 consisted of 22 patients with negative fetal blood, but positive amniotic fluid cultures, and in group 3 there were 16 patients with positive fetal blood cultures. The mean leucocyte and neutrophil counts in all three groups were significantly higher than normal, and in group 3 the values were significantly higher than in group 1. The leucocyte and neutrophil counts were above the 95th centile of the normal range in 58% (22 cases) and 66% (25 cases), respectively, of the 38 cases with positive fetal blood and/or amniotic fluid cultures and in only 15% (8 cases) and 13% (7 cases), respectively, of the 53 patients with no infection. There were no significant differences between the groups, between the patients with amniorrhexis or for normal haemoglobin concentration, platelet count, or lymphocyte count. In the majority of the cases with positive fetal blood and/or amniotic fluid cultures, there is fetal leucocytosis. Since the results of the fetal leucocyte and neutrophil counts are available within a few minutes after cordocentesis, it would be reasonable to give antibiotics to all patients with a fetal leucocyte count above the 95th centile.

Maternal Lyme disease and congenital malformations: a cord blood serosurvey in endemic and control areas

This report describes a cohort study of over 5000 infants and their mothers who participated in a cord blood serosurvey designed to examine the relationship between maternal exposure to Lyme disease and adverse pregnancy outcome. Based on serology and reported clinical history, mothers of infants in an endemic hospital cohort are 5 to 20 times more likely to have been exposed to B. burgdorferi as compared with mothers of infants in a control hospital cohort. The incidence of total congenital malformations was not significantly different in the endemic cohort compared with the control cohort, but the rate of cardiac malformations was significantly higher in the endemic cohort [odds ratio (OR) 2.40; 95% confidence interval (CI) 1.25, 4.59] and the frequencies of certain minor malformations (haemangiomas, polydactyly, and hydrocele), were significantly increased in the control group. Demographic variations could only account for differences in the frequency of polydactyly. Within the endemic cohort, there were no differences in the rate of major or minor malformations or mean birthweight by category of possible maternal exposure to Lyme disease or cord blood serology. The disparity between observations at the population and individual levels requires further investigation. The absence of association at the individual level in the endemic area could be because of the small number of women who were actually exposed either in terms of serology or clinical history. The reason for the findings at the population level is not known but could be because of artifact or population differences.

Assessment of fetal activity and amniotic fluid volume in the prediction of intrauterine infection in preterm prelabor amniorrhexis

OBJECTIVE

Our purpose was to assess fetal activity, fetal heart rate patterns, and amniotic fluid volume in the prediction of intrauterine infection in pregnancies complicated by preterm prelabor amniorrhexis.

STUDY DESIGN

A prospective study was performed on 89 patients with preterm prelabor amniorrhexis undergoing fetal blood and amniotic fluid sampling for microbiologic investigations. Within 2 hours before cordocentesis and amniocentesis, computerized fetal heart rate monitoring was carried out and ultrasonographic examination was performed for assessment of biophysical profile and amniotic fluid volume.

RESULTS

In the pregnancies with microbiologic evidence of intrauterine infection compared with those with no infection, there was a tendency for a lower biophysical profile score and amniotic fluid index and an increased fetal heart rate. However, in the majority of pregnancies with positive amniotic fluid or fetal blood cultures the results of the various tests were normal.

CONCLUSION

In pregnancies complicated by preterm prelabor amniorrhexis assessment of fetal activity and amniotic fluid volume do not provide useful prediction of intrauterine infection.

Doppler studies of the placental and fetal circulation in pregnancies with preterm prelabor amniorrhexis

This study has investigated the effect of intrauterine infection on placental perfusion, fetal circulation and fetal oxygenation in patients with preterm prelabor amniorrhexis. In 69 pregnancies with preterm prelabor amniorrhexis, Doppler ultrasound studies of the uterine and umbilical arteries and the fetal middle cerebral artery and thoracic aorta were performed. Within 1 h after the Doppler studies, cordocentesis and amniocentesis were carried out for microbiological investigations and measurement of blood pO2 and pH. In the amniorrhexis group, there were no significant differences from the appropriate normal mean for gestation in any of the Doppler indices or blood gas results. Furthermore, there were no significant differences between the groups with positive fetal blood or amniotic fluid cultures and those with no evidence of infection. These data demonstrate that, in preterm prelabor amniorrhexis, microbial invasion of the amniotic cavity and fetal bacteremia are not associated with detectable changes in placental perfusion, fetal circulation or fetal oxygenation.

Sixty-six cases of intrauterine fetal death. A prospective study with an extensive test protocol

BACKGROUND

A prospective study was performed to elucidate the etiology of intrauterine fetal death and to evaluate diagnostic procedures.

METHODS

Sixty-six stillbirth cases with a gestational age of more than 25 complete weeks were studied, using an extensive test protocol. The validity of the cause of death was classified as certain, probable, possible and unexplained. The extent to which the diagnostic measures had been performed was classified: patients in whom none or only a few tests were performed, patients partially tested and patients completely tested.

RESULTS

The cause of death was certain in 57%, probable in 20%, and possible in 11% of the cases. In only 12% of the cases did the cause of death remain entirely unexplained. The principal causes of IUFD were infections, including premature rupture of the membranes (15%), anomalies (11%), preeclampsia-associated conditions (9%) and intrauterine growth retardation of unknown etiology (8%). In this series, less well-known conditions, such as circulating maternal autoantibodies and feto-maternal transfusion, also appeared to play an important role in causing intra-uterine fetal death.

CONCLUSIONS

An extensive and relevant test protocol provides information as to the cause of death in the majority of cases. Future protocols should include tests for autoimmune antibodies and feto-maternal transfusion.