ACOG Committee Opinion No. 771: Umbilical Cord Blood Banking

Hybrid umbilical cord blood banking: literature review

PURPOSE

Interest gaps between public and private umbilical cord blood banks have led to the introduction of hybrid banking options. Hybrid models combine features of private and public banks as well as interests of parents, children and of patients, in order to find an optimized solution. While several different models of hybrid banks exist, there is a lack of literature about this novel model of cord blood stem cell banking. Therefore, the aim of this literature review is to assess different options of umbilical cord blood banking and whether hybrid banking could be a valuable alternative to the existing public and private cord blood banking models.

METHODS

We performed a systematic literature search, using five main databases. Five hybrid models regarding their advantages as well as their challenges are discussed in this review.

RESULTS

We found that a wealth of literature exists about public cord blood banking, while private and hybrid banking are understudied. Different modalities of hybrid cord blood banking are being described in several publications, providing the basis to assess different advantages and disadvantages as well as practicability.

CONCLUSION

Hybrid banks, especially the sequential model, seem to have potential as an alternative to the existing banking models worldwide. A previously conducted survey among pregnant women showed a preference for hybrid banking, if such an option was available. Nevertheless, opinions among stakeholders differ and more research is needed to evaluate, if hybrid banking provides the expected benefits.

Beyond cord clamping: Complexities of umbilical cord management after birth

The benefits of delayed cord clamping have been investigated in multiple studies and supported by various professional associations. Other aspects of umbilical cord management strategies occurring after cord clamping have not been fully thoroughly analyzed. This article will explore and deliberate elements of umbilical cord nonseverance, vascular access management, and blood banking.

Umbilical Cord Blood Banking: An Update For Childbirth Educators

To make an informed decision on umbilical cord blood banking or donation during birth, families need evidence-based, quality information on this alternative. Cord blood banking often refers to private banking, while donation generally refers to public banking. Research has shown that expectant parents do not have sufficient understanding of the cord blood banking process, umbilical cord stem cell transplants, uses of these cells, or options. Research also shows that birthing families desire that information to come from a reliable healthcare provider resource, such as a childbirth educator. Therefore, this article will offer information for use by childbirth educators, nurses, or other birth workers to increase awareness and knowledge on the topic of umbilical cord blood banking and donation.

Evidence-based labor management: third stage of labor (part 5)

During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.

What does the evidence tell us? Revisiting optimal cord management at the time of birth

A newborn who receives a placental transfusion at birth from delayed cord clamping (DCC) obtains about 30% more blood volume than those with immediate cord clamping (ICC). Benefits for term neonates include higher hemoglobin levels, less iron deficiency in infancy, improved myelination out to 12 months, and better motor and social development at 4 years of age especially in boys. For preterm infants, benefits include less intraventricular hemorrhage, fewer gastrointestinal issues, lower transfusion requirements, and less mortality in the neonatal intensive care unit by 30%. Ventilation before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the neonate. Hypovolemia, often associated with nuchal cord or shoulder dystocia, may lead to an inflammatory cascade and subsequent ischemic injury. A sudden unexpected neonatal asystole at birth may occur from severe hypovolemia. The restoration of blood volume is an important action to protect the hearts and brains of neonates. Currently, protocols for resuscitation call for ICC. However, receiving an adequate blood volume via placental transfusion may be protective for distressed neonates as it prevents hypovolemia and supports optimal perfusion to all organs. Bringing the resuscitation to the mother's bedside is a novel concept and supports an intact umbilical cord. When one cannot wait, cord milking several times can be done quickly within the resuscitation guidelines. Cord blood gases can be collected with optimal cord management.   Conclusion: Adopting a policy for resuscitation with an intact cord in a hospital setting takes a coordinated effort and requires teamwork by obstetrics, pediatrics, midwifery, and nursing.

Cord Management of the Term Newborn

Keeping the umbilical cord intact after delivery facilitates transition from fetal to neonatal circulation and allows a placental transfusion of a considerable amount of blood. A delay of at least 3 minutes improves neurodevelopmental outcomes in term infants. Although regarded as common sense and practiced by many midwives, implementation of delayed cord clamping into practice has been unduly slow, partly because of beliefs regarding theoretic risks of jaundice and lack of understanding regarding the long-term benefits. This article provides arguments for delaying cord clamping for a minimum of 3 minutes.

Decreased Mortality in 1-Year Survivors of Umbilical Cord Blood Transplant vs. Matched Related or Matched Unrelated Donor Transplant in Patients with Hematologic Malignancies

Allogeneic hematopoietic stem cell transplantation (HCT) has the potential to cure hematologic malignancies but is associated with significant morbidity and mortality. Although deaths during the first year after transplantation are often attributable to treatment toxicities and complications, death after the first year may be due to sequelae of accelerated aging caused by cellular senescence. Cytotoxic therapies and radiation used in cancer treatments and conditioning regimens for HCT can induce aging at the molecular level; HCT patients experience time-dependent effects, such as frailty and aging-associated diseases, more rapidly than people who have not been exposed to these treatments. Consistent with this, recipients of younger cells tend to have decreased markers of aging and improved survival, decreased graft-versus-host disease, and lower relapse rates. Given that umbilical cord blood (UCB) is the youngest donor source available, we studied the outcomes after the first year of UCB transplantation versus matched related donor (MRD) and matched unrelated donor (MUD) transplantation in patients with hematologic malignancies over a 20-year period. In this single-center, retrospective study, we examined the outcomes of all adult patients who underwent their first allogeneic HCT through the Duke Adult Bone Marrow Transplant program from January 1, 1996, to December 31, 2015, to allow for at least 3 years of follow-up. Patients were excluded if they died or were lost to follow-up before day 365 after HCT, received an allogeneic HCT for a disease other than a hematologic malignancy, or received cells from a haploidentical or mismatched adult donor. UCB recipients experienced a better unadjusted overall survival than MRD/MUD recipients (log rank P = .03, median overall survival: UCB not reached, MRD/MUD 7.4 years). After adjusting for selected covariates, UCB recipients who survived at least 1 year after HCT had a hazard of death that was 31% lower than that of MRD/MUD recipients (hazard ratio, 0.69; 95% confidence interval, 0.47-0.99; P = .049). This trend held true in a subset analysis of subjects with acute leukemia. UCB recipients also experienced lower rates of moderate or severe chronic graft-versus-host disease (GVHD) and nonrelapse mortality, and slower time to relapse. UCB and MRD/MUD recipients experienced similar rates of grade 2-4 acute GVHD, chronic GHVD, secondary malignancy, and subsequent allogeneic HCT. UCB is already widely used as a donor source in pediatric HCT; however, adult outcomes and adoption have historically lagged behind in comparison. Recent advancements in UCB transplantation such as the implementation of lower-intensity conditioning regimens, double unit transplants, and ex vivo expansion have improved early mortality, making UCB an increasingly attractive donor source for adults; furthermore, our findings suggest that UCB may actually be a preferred donor source for mitigating late effects of HCT.

Identifying Barriers to Umbilical Cord Blood Banking in Jordan: A Cross-Sectional Survey of Obstetricians

Background: The expansion of umbilical cord blood (UCB) banking necessitates a greater understanding among obstetricians in order to responsibly inform parents about UCB collection and storage. Gaps in knowledge can compromise public UCB banking efforts and result in missed opportunities and public misguidance about UCB banking. Materials and Methods: A cross-sectional survey was disseminated among obstetricians in Amman, Jordan. The questionnaire aimed to evaluate obstetricians' knowledge of and attitude toward UCB storage and applications, as well as current practice patterns. Results: Ninety-six obstetricians responded (55% response rate), most of whom were Jordanian (71%), female (83%), resident physicians (59%), and working in either private (43%) or public (42%) hospitals, with an average of 6.5 years in practice. Only 26% had personal experience in UCB collection, and 20% had received education on UCB collection. Nearly 75% said their hospitals lacked standard operating procedures, guidelines, or infectious disease screening for UCB units. Overall knowledge about UCB was moderate, and the internet was the most common information source (54%). Overall attitudes were positive, especially in desire to expand personal knowledge about UCB, integrate information into medical residency curricula, and establish a public UCB bank in Jordan. However, many believed that ethical (61%) and religious (56%) controversies surround UCB donation. Conclusion: This study identifies deficiencies in quality control and experience in UCB collection in Jordan, as well as areas of inadequate knowledge and ethical controversies among obstetricians. These issues contribute to public misinformation and limit public UCB donation programs, and requires improved medical education on this topic.