Optimizing Umbilical Cord Blood Collection: Impact of Obstetric

Factors Versus Quality of Cord Blood Units

F. Mancinelli, A. Tamburini, A. Spagnoli, C. Malerba, G. Suppo, R. Lasorella, P. de Fabritiis,
and A. Calugi

ABSTRACT
Introduction. The main limitation factor for wide use of umbilical cord blood units
(UCBs) as a source of hematopoietic progenitors for transplantation is cell dose.
International standard guidelines recommend 2 ⫻ 107/kg as the minimal nucleated cell dose
for UCB transplantation for adults and 3.7 ⫻ 107/kg for children. Therefore it is important to
the optimize donor selection and the collection method so as to achieve high cell doses. In this
study our main purpose was to determine whether obstetric factors influence UCBs collected.
Study design. The study involved 304 UCBs collected from January to December 2004.
The UCBs were collected after donor selection based on international criteria for cord
blood banking. We analyzed UCB biological features such as collected volume, total
nucleated cells (TNC), and CD34-positive cells, and obstetric factors.
Results. First, our study showed by multivariate analysis that infant weight was the main
factor that influenced biologic features of UCB collected such as total volume (P ⫽ .000), TNC
(P ⫽ .000), CD34 total count (P ⫽ .003), and CFU-GM (P ⫽ .004). Placental weight ⬎ 600 g
produced a better volume (P ⫽ .007) and increased TNC (P ⫽ .056). Gestational age ⬎ 39
weeks enhanced CD34% (P ⫽ .016). Regarding route of delivery, we found that cesarean
section produced higher volume and reduced WBC count compared to vaginal delivery,
regarding cord length, it increased TNC (P ⫽ .037). And last, we noticed that female infants
increased WBC (P ⫽ .013) and CD34⫹ total count (P ⫽ .019) more than male ones.
Conclusions. Our results confirm that volume and TNC are influenced by several
obstetric factors, such as greater infant and placental weight, predicting a better collection.

T HE SMALL VOLUME of collection and poor cellu-

larity are today the main restrictions to placental
blood use as a source of hematopoietic progenitors for
transplants. Starting from our delivery room experience and
literature data, we pointed out that some obstetric factors
have a positive influence on placental blood collection. This
evidence encouraged us to start a study to verify the impact
of some of these factors. We focused on evaluating the
correlation between obstetric factors and collection param-
eters such as volume, total number of nucleated cells,
CD34⫹ cells, clonogenic potential; finally, we aimed to find
the limit value of the obstetric factors for a clear improve-
ment of the collection parameters.
MATERIALS AND METHODS
This is a retrospective study that involved 304 umbilical cord blood
units (UCBs) collected after donor selection based on international
criteria for cord blood banking. We considered the following obstet-
rics factors: infant weight, infant sex, 1- and 5-minute APGAR
scores; delivery mode (vaginal vs cesarean); collection method (in
uterus vs ex uterus); gestational age; number of deliveries; cord
length; placental weight; and presence of meconium. We also
considered other obstetric factors such as maternal race, age, and
time of delivery.
From the Department of Obstetrics and Gynecology (F.M.,
C.M., A.C.), and Cord Blood Bank, Department of Hematology
(A.T., A.S., G.S., R.L., P.D.F.), St. Eugenio Hospital-Tor Vergata
University, Rome, Italy.
Address reprint requests to Anna Tamburini, Università degli
Studi di Roma “Tor Vergata,” Ospedale S. Eugenio, Banca del
Sangue Placentare, Piazzale dell’Umanesimo 00144, Rome,
Italy. E-mail: cbbhutvrm@virgilio.it

0041-1345/06/$–see front matter © 2006 by Elsevier Inc. All rights reserved.

doi:10.1016/j.transproceed.2006.03.052 360 Park Avenue South, New York, NY 10010-1710

1174 Transplantation Proceedings, 38, 1174 –1176 (2006)

OPTIMIZING UMBILICAL CORD BLOOD COLLECTION
Placental Blood Collection
Placental blood was collected both after spontaneous delivery and
cesarean section; in uterus and ex uterus methods were used. The
cord was clamped as close as possible to the infant, within 30
seconds from birth, inserting the second clamp 5 cm from the first
and sectioning the cord between the two clamps. After a careful
disinfection of the cord before the first clamp with an iodine
solution, the umbilical vein was uncannulated and blood was
collected by gravity in bags with 21 mL of citrate-phosfo-dexstrose
as anticoagulant. At the same time another operator shook the bag
in order to prevent coagulation (otherwise the bag would be
rejected).
Units Characterization
UCBs were eligible for processing and cryopreservation if they met
certain criteria relative to volume and cell count. Then CD34⫹
count, CFUs, and sterility were evaluated. Finally, UCBs were
cryopreserved within 48 hours of collection.
Statistical Analysis
Continuous obstetric variables are expressed as median and range.
A general linear model was used to determine the obstetric
variables that influenced the biologic variables. A P value ⬍ .05 was
considered significant. For the calculation a statistical package
(SPSS Inc, Chicago, Ill, USA) was used.
RESULTS
UCBs were collected from January to December 2004 at St
Eugenio Hospital in Rome. Only 102 of 304 UCBs were
banked. Two hundred and two units were collected after
spontaneous delivery (in uterus), 76 after cesarean (21 in
uterus and 55 ex uterus). The median values and ranges of
some of the obstetric variables include: maternal age (33.38;
18 to 45); infant weight (3390 g; 2360 to 4580 g); placental
weight (572 g; 200 to 1000); gestational age (39 weeks; 35 to
42 weeks). First, our study showed by multivariate analysis
that infant weight was the main factor that influenced
biological features of UCBs collected, such as total volume
(P ⫽ .000), TNC (P ⫽ .000), CD34 total count (P ⫽ .003),
and CFU-GM (P ⫽ .004). Placental weight ⬎ 600 g
produced a better volume (P ⫽ .007) and increased TNC
(P ⫽ .056). Gestational age ⬎ 39 week increased CD34%
(P ⫽ .016). Concerning route of delivery, we found that
cesarean produced higher volume and reduced white blood
cell (WBC) count than vaginal delivery; regarding cord
length it increased TNC (P ⫽ .037). And last, we noticed
that female infants amplified WBCs more than male infants
(P ⫽ .013) and CD34⫹ cells (P ⫽ .019).
DISCUSSION
Up till now, the infused cellular dose and the favorable
phase of disease were the fundamental factors for trans-
plant success. The major limit of placental blood as an
alternative source to bone marrow is that of having a low
volume and a reduced cell content. Consequently apart
from aiming at the in vitro increase of placental cells, it
1175
is of the utmost importance to improve collection meth-
ods. Numerous studies have been carried out with the
aim of identifying the factors that influence a good
placental blood collection. Aufderhaar1 reported that
infant weight correlated with a better volume and an
increase in the number of CFUs and that cesarean
section increased the collection volume in comparison
with vaginal delivery. These results in part agree with
ours; in fact, after multivariate analysis we found that
cellular volume correlated with infant weight and placen-
tal weight and that collection after cesarean section was
greater. The fact that infant and placental weights pre-
dicted a good collection due to the existing correlation
with the fetal-placental blood volume is not surprising.
On the other hand, it is of interest to notice how after
cesarean section, the factor that positively influences
volume increase is the effect of gravity. In fact, the infant
is placed above the placenta before cord clamping; this
favors the downflow of blood into the placental cord and
consequently into the placental compartment. Another
hypothesis is that after cesarean section the placenta is
manually expelled more rapidly than after vaginal deliv-
ery, thus reducing the possibility of blood clot formation.
Our results demonstrate that the factors that positively
influence the number of WBCs are the type of delivery and
neonatal sex. Spontaneous delivery yields a major WBC
increase with respect to cesarean section. This could be due
to labor stress fetal response. As confirmed by Sparrow2
and considering that cesarean section results in volume
increase while spontaneous delivery results in WBC in-
crease, we can conclude that type of delivery does not
influence the number of TNC.
On the other hand, the fact that in female neonates a
greater number of WBC other than CD34⫹ total was found
is a very new datum, which has been reported only once in
the literature and the interpretation of which is unknown.
With regards to higher concentration of TNC, our results
coincided in part with Askari3 and Solves et al4, that
placental weight seems to be the determining factor. In
addition, according to our results neonatal weight and cord
length are correlated with higher TNC number.
According to our results, the fact that significantly
influences total CD34⫹, other than female sex and
neonatal weight, is gestational age. The influence of the
latter is most likely due to the fact that with increased
gestational age there is placental aging, and the fetus
encounters a progressive hypoxia resulting in defense
mechanisms that tend to increase hematopoietic cells
and circulating blood volume. Lasky5 investigated the in
utero and ex utero modalities to determine the best
collection yield, and they concluded that parameters
regarding volume, WBC, TNC, CD34⫹, and CFU-GM
are the same with both modalities. Our results are in
agreement with Lasky, with the exception that our data
show that only with in utero collection is the WBC count
significantly increased by neonatal weight, spontaneous
delivery, female sex, and cord length.
1176
Our final aim was to use these results to improve the
collection procedure; we think that above-mentioned ob-
stetric factors predict a good collection. This means daily
savings in resource such as time for anamnesis and collec-
tion, cost of each bag (20 €), time, and handling costs,
because we can focus on the supposed best collections. If we
have to choose between two collections, for example, in
case of simultaneous deliveries, we can count on these
factors. Hence optimizing the collection procedure is im-
portant so as to minimize the number of rejected CBUs.
The best ideal scenario is: infant weight ⬎ 3390 g; placental
weight ⬎ 600 g; cord length ⬎ 55 cm; female sex; gesta-
tional age ⬎ 39 weeks; in utero collection. We conclude that
the factors that could be best manipulated are: type of
collection (in utero preference); cord length (clamping at
the nearest fetal extremity); prolungation of gestational age
when possible.
MANCINELLI, TAMBURINI, SPAGNOLI ET AL
On the bases of our results we conclude that donor
selection and collection method optimization are the best
means of improving collection quality.
REFERENCES
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intrapartum factors on umbilical cord blood stem cell banking. J
Perinat Med 31:317, 2003
2. Sparrow RL, Cauchi JA, Ramadi LT, et al: Influence of mode
of birth and collection on WBC heels of umbilical cord blood units.
Transfusion 42: 2002
3. Askari S, Miller J, Chrysler G, et al: Impact of donor-and
collection-related variables of product quality in ex utero cord
blood banking. Transfusion 45:189, 2005
4. Solves P, Perales A, Moraga R, et al: Maternal, neonatal and
collection factors influencing the haematopoietic content of cord
blood units. Acta Haematol 113:241, 2005
5. Lasky LC, Lane TA, Miller JP, et al: In utero or ex utero cord
blood collection: which is better? Transfusion 42:1261, 2002