[Stem cells from cord blood: current status and future potential]

Umbilical cord blood is rich in hematopoietic stem cells. At birth, it can be collected, HLA-typed and stored. Cord blood is successfully used since over 10 years as source of transplantation of hematopoietic stem cells, in addition to bone marrow and mobilized peripheral blood stem cells. Allogeneic transplantations are performed between HLA-identical siblings and from HLA-matched unrelated donors. Most recipients of cord blood are children with Leukemia or genetic disorders, but also increasingly adolescents and adults. Based on the promising results, cord blood banks with kryopreserved, HLA-typed cord blood samples from anonymous donors are set up worldwide, ready to be used as allogeneic stem cell graft. In addition, so-called "private" cord blood banks have been set up, providing the possibility to store cord blood at birth from healthy children with no affected family member for a possible autologous stem cell transplantation in the future if the child later develops a disease such as Leukemia. For several reasons, however, this procedure has been scientifically as well as ethically challenged. To date, there is no established indication for an autologous cord blood transplantation. Nevertheless, the plasticity and multipotency of adult stem cells, which has been recently discovered, could lead to a possible autologous use of cord blood stem cells for different indications in the field of regenerative medicine (cell- and organ replacement/regeneration). So far, however, this remains speculatative. Research in the field of stem cell development and differentiation in the next decade will try to find some answers.

Split hand and foot malformation: ultrasound detection in the first trimester

The split hand split foot malformation is a rare disorder inherited in an autosomal dominant pattern with variable expression. In our case it was detected early by ultrasound in the twelfth week of gestation. To our knowledge, this is the earliest finding by ultrasound of this malformation. The sonographic findings were bilateral split hands and split foot. No other associated malformation was observed. The pathological findings were consistent with the diagnosis of split hand split foot malformation. Prenatal diagnosis, the genetic background, and the differential diagnosis are discussed.

[Prenatal stem cell transplantation: from bench to bedside]

Prenatal stem cell transplantation is a novel, promising therapeutic option for genetic disorders, which is now at the edge of moving from preclinical research into clinical application. The first clinical experience shows that inborn diseases, which lead to a severe immunodeficiency, can be treated successfully inutero. No therapeutic success has been achieved in genetic disorders which do not severely affect the immune system. Therefore, new strategies to improve the success are being developed, including e.g., graft modification, prenatal conditioning of the fetus, postnatal re-transplantation after prenatal induction of immune tolerance, and fetal gene therapy using autologous fetal stem cells. The use of non-hematopoietic (e.g. mesenchymal) or pluripotent stem cells will most probably lead to an expansion of the spectrum of indications in genetic diseases for this novel treatment. At the same time, however, ethical implications, in particular regarding fetal gene therapy and the use of pluripotent stem cells must be evaluated.

[Prenatal stem cell transplantation and gene therapy in treatment of genetic diseases]

Die vorgeburtliche Transplantation hämatopoietischer Stammzellen ist eine neue, vielversprechende Behandlungsmöglichkeit angeborener Krankheiten, welche früh in der Schwangerschaft diagnostiziert werden können. Kürzlich wurde über die ersten klinischen Erfolge berichtet. Bei vielen genetischen Krankheiten bestehen bisher noch einige Hindernisse, die einen durchschlagenden therapeutischen Effekt verhindern. Neuere Strategien zur Verbesserung dieser Therapie wie z.B. Manipulation des Transplantats, Konditionierung des Empfängers und der gentherapeutische Ansatz wurden nun entwickelt. Die Verwendung nicht-hämatopoietischer oder pluripotenter Stammzellen wird möglicherweise in naher Zukunft zu einer weiteren Entwicklung der Möglichkeiten dieser neuen, innovativen Therapiemethode führen. Ethische Aspekte insbesondere bezüglich der fetalen Gentherapie und der Verwendung pluripotenter Stammzellen müssen begleitend dazu schwerpunktmässig evaluiert werden.

[Management of patients with Type 2B von Willebrand's disease during delivery and puerperium]

Von Willebrand's disease (VWD) is the most common congenital haemorrhagic diathesis inherited as an autosomal dominant trait, with a prevalence estimated to be 1 - 2 %. In subtype 2B an abnormally structured von-Willebrand factor (VWF) leads to an increased binding of VWF molecules to normal platelets, which regularly results in thrombocytopenia in pregnancy. Only few systematic observations in patients with type 2B VWD in the perinatal period have been reported in the literature. Six spontaneous deliveries in two sisters with type 2B VWD are reported. The first patient did not show any bleeding complications in five vaginal deliveries without any factor replacement therapy. The second patient showed a massive haemorrhage on the third postpartum day after administration of factor VIII-VWF concentrate replacement therapy (Haemate(R) HS), only on the day of delivery. No neonatal complications were reported. The clinical management of pregnancy, delivery and puerperium in patients with type 2B VWD requires close collaboration of experienced obstetricians, haematologists, anaesthesiologists and paediatricians. During labour and delivery, but especially in puerperium, there is a significantly increased risk for haemorrhage. Vaginal delivery is generally safe, but the incidence of postpartum haemorrhage is 30 %. These bleedings may be extremely severe. The danger of postpartum bleeding complications cannot be predicted with certainty, neither by past history of bleeding episodes or haematological laboratory tests of VWF activity levels. Hence, in all patients factor VIII-VWF concentrate replacement therapy should be initiated already in the first stage of labour. Post partum replacement therapy along with effective uterotonic therapy should be continued at least for seven days. With this treatment bleeding problems may be largely prevented. The decision to perform epidural block in labour and delivery must be assessed depending on individual risk factors.

Fetal gender and aneuploidy detection using fetal cells in maternal blood: analysis of NIFTY I data. National Institute of Child Health and Development Fetal Cell Isolation Study

OBJECTIVES

The National Institute of Child Health and Human Development Fetal Cell Isolation Study (NIFTY) is a prospective, multicenter clinical project to develop non-invasive methods of prenatal diagnosis. The initial objective was to assess the utility of fetal cells in the peripheral blood of pregnant women to diagnose or screen for fetal chromosome abnormalities.

METHODS

Results of fluorescence in situ hybridization (FISH) analysis on interphase nuclei of fetal cells recovered from maternal blood were compared to metaphase karyotypes of fetal cells obtained by amniocentesis or chorionic villus sampling (CVS). After the first 5 years of the study we performed a planned analysis of the data. We report here the data from 2744 fully processed pre-procedural blood samples; 1292 samples were from women carrying singleton male fetuses.

RESULTS

Target cell recovery and fetal cell detection were better using magnetic-based separation systems (MACS) than with flow-sorting (FACS). Blinded FISH assessment of samples from women carrying singleton male fetuses found at least one cell with an X and Y signal in 41.4% of cases (95% CI: 37.4%, 45.5%). The false-positive rate of gender detection was 11.1% (95% CI: 6.1,16.1%). This was higher than expected due to the use of indirectly labeled FISH probes in one center. The detection rate of finding at least one aneuploid cell in cases of fetal aneuploidy was 74.4% (95% CI: 76.0%, 99.0%), with a false-positive rate estimated to be between 0.6% and 4.1%.

CONCLUSIONS

The sensitivity of aneuploidy detection using fetal cell analysis from maternal blood is comparable to single marker prenatal serum screening, but technological advances are needed before fetal cell analysis has clinical application as part of a multiple marker method for non-invasive prenatal screening. The limitations of the present study, i.e. multiple processing protocols, are being addressed in the ongoing study.

Prenatal diagnosis of an infratentorial subdural hemorrhage: case report

We report a case of a prenatally diagnosed infratentorial subdural hemorrhage. The hematoma located in the posterior cerebral fossa was detected by conventional ultrasound at 24 weeks of gestation. Intrauterine magnetic resonance imaging confirmed the diagnosis. Autopsy of the fetus revealed a well-circumscribed subdural hematoma. The prenatal findings of intracranial bleeding located in the posterior fossa and the prognosis of such cases are discussed.

[Pregnancy outcome in 1,252 fetuses after nuchal translucency measurement in the 1st trimester]

The measurement of the nuchal translucency is an important marker to detect a vast number of fetal anomalies. Lately the nuchal translucency has been used increasingly as a screening method to find chromosomal anomalies especially for trisomy 21. Beside a high incidence of chromosomal defects one assumes a high risk of rare syndromes and other associated anomalies such as heart defects, skeletal anomalies, cerebral anomalies, diaphragmatic hernias, as well as of an intrauterine death. In view of abortion rate, detection rate of chromosomal anomalies, other fetal anomalies and rare syndromes we evaluated in this study the pregnancy outcome after nuchal translucency measurement, and discuss a concept for its management.

Differentiation and management of endometrium abnormalities and leiomyomas by hydrosonography

Transvaginal sonography is an established method for numerous clinical indications in the assessment of endometrium pathology. The investigation of the endometrium consists of the measurement of the thickness, the visualization of the echogenity and echotexture and of the demonstration of focal masses. However, evaluation of the uterine cavity by transvaginal sonography is limited and an abnormal ultrasound of the endometrium may reflect benign or malignant conditions. Furthermore, small structures can be missed or overlooked. If indicated, hydrosonography offers various advantages compared to dilatation and curettage and hysteroscopy in terms of costs, availability and risks. Additional informations obtained after hydrosonography may influence the management before consideration of curettage or hysteroscopy.

[Screening for aneuploidy by first trimester nuchal translucency measurement: results from a prospective trial including 1980 cases in a single center in Switzerland]

AIM

The purpose of this study was to evaluate the efficiency of first trimester screening for chromosomal abnormalities using the sonographically determined thickness of nuchal translucency (NT) combined with maternal age.

PATIENTS AND METHODS

Risk screening was offered to all patients with a fetal crown rump length (CRL) between 45 and 84 mm after extensive counselling. For the risk assessment the software provided by the Fetal Medicine Foundation was used. In accordance with the recommendation of the Swiss Working Group on First Trimester Screening a cut-off risk of 1 : 400 was chosen.

RESULTS

A total of 1980 consecutive pregnancies participating in the risk screening programme with due dates prior to May 1, 2001 were included. Mean maternal age was 30.1 yrs and 522 (26.4 %) patients were 35 yrs or older. A positive risk screening result was obtained in a total of 219 (11.1 %) pregnancies including 33 of the 37 (1.9 %) cases with unbalanced chromosomal abnormalities.

CONCLUSIONS

The detection rate for unbalanced chromosome abnormalities in general (89.2 %) as well as the one for trisomy 21 (93.3 %) in particular are very high with a moderate false-positive rate (9.6 %) in this series. As a comparison in the series presented here, traditional "maternal age screening" (cut-off age 35 yrs) would have yielded detection rates of 64.9 % for all unbalanced chromosome abnormalities and 73.3 % for trisomy 21 at a false-positive rate of 25.0 %. Reducing the false-positive rate by raising the cut-off age to 38 yrs would yield detection rates of 40.5 % for all unbalanced chromosome abnormalities and 46.7 % for trisomy 21 at a false-positive rate of 8.9 %. The number of invasive procedures performed to detect one unbalanced chromosome count may be calculated as 21.75 using the cut-off age of 35 yrs as compared to 6.4 using NT measurement and maternal age. The outcome of this ongoing study is in good accordance with the earlier observation that the main benefit of the addition of first trimester NT measurements to the risk screening protocol is a very high detection rate at a moderate false-positive rate.

Cell-free DNA in urine: a marker for kidney graft rejection, but not for prenatal diagnosis?

Intrigued by the rapid clearance of free fetal DNA from the maternal circulation, we have investigated whether this fetal genetic material could be cleared via the kidney. For this purpose, we examined for the presence of Y chromosome-specific DNA sequences in urine samples obtained from 8 women pregnant with male fetuses. No male-specific sequences could be detected, despite the use of a very sensitive nested PCR assay nor a highly reproducible real-time PCR assay. We did, however, detect maternal DNA sequences. To determine if this cell-free DNA was derived from the kidney or another source, we next examined urine from female kidney transplant patients who had received male kidneys. Y chromosome-specific sequences were indeed detectable by both nested and real-time PCR in these samples, thereby confirming a recent report describing urinary DNA microchimerism. Quantitative analysis of serially obtained samples furthermore suggests that transplant-derived sequences are elevated during periods of graft rejection. These results imply that the measurement of graft-derived urinary DNA may serve as a new marker for kidney graft tolerance.

Large placental chorioangioma as a cause of sudden intrauterine fetal death. A case report

A giant placental chorioangioma was diagnosed in a fetus at 22 weeks of gestation by prenatal ultrasound screening and color Doppler imaging. Although no signs of fetal hydrops and cardiac decompensation were observed, the situation of the fetus deteriorated rapidly and in utero fetal death occurred at 26 weeks, attributed to bleeding from ruptured sinusoids within the tumor. Prenatal diagnosis of chorioangioma and treatment modalities are discussed.

Myomectomy during the first trimester associated with fetal limb anomalies and hydrocephalus in a twin pregnancy

OBJECTIVES

To present the complications of a twin pregnancy after first trimester myomectomy and to discuss the possible etiologic relationship.

CASE REPORT

A 44-year-old primigravida with a dichorionic-diamniotic twin pregnancy underwent myomectomy in another hospital at 12 weeks' gestational age. At 28 weeks the patient was referred to our unit because of ventriculomegaly and limb anomalies in the second twin. The patient underwent a Caesarean section at 37 weeks of gestation delivering twin A, a healthy female weighing 3235 g and twin B, a female weighing 2810 g with hydrocephalus and limb anomalies (clubfeet and hypoplasia of the nails and terminal phalanges). The placenta from twin A was normal, but in the placenta of twin B haemorrhage, thrombosis and infarction were noted.

CONCLUSIONS

Despite several reports of myomectomy in pregnancy without any problems for mother and fetus, the authors believe that myomectomy - especially in the first trimester - may be associated with the type of problems observed in the present case. The pathophysiological relationship between placental trauma and haemodynamic alterations as a possible cause of the malformations in twin B is discussed.

Bcl2-L-10, a novel anti-apoptotic member of the Bcl-2 family, blocks apoptosis in the mitochondria death pathway but not in the death receptor pathway

By GenBank database searches and PCR, we have identified a novel human Bcl2-like gene, Bcl2-L-10, which contains conserved BH4, BH1 and BH2 domains but lacks BH3 domain. The Bcl2-L-10 gene has been assigned to chromosome 15q21.2. Transfection experiments demonstrated that Bcl2-L-10 can block apoptosis induced by interleukin-3 withdrawal and Bax expression, by prevention of cytochrome C release, caspase-3 activation and mitochondrial membrane potential collapse. Bcl2-L-10 cannot block TNFalpha-induced apoptosis. Furthermore, both the BH4 domain and the transmembrane domain of Bcl2-L-10 are necessary for its suppressive action on cell death. Our results demonstrated that Bcl2-L-10 is a newly detected anti-apoptotic member of the Bcl-2 family and that it blocks apoptosis in the mitochondrial death pathway but not in the death receptor pathway.

Duplication dup(1)(q32q44) detected by comparative genomic hybridization (CGH): further delineation of trisomies 1q

Partial trisomy 1q is rare and mostly the result of an abnormal segregation of parental translocation chromosomes and their homologues. Only 31 cases have been described with pure partial trisomy 1q. In the fetus presented, chromosome analysis after amniocentesis had shown an unbalanced male karyotype with an aberrant chromosome 1. A de novo terminal duplication of the long arm was suspected but could not be verified by FISH in 1994. Five years after fetal death, retrospective identification of the additional material in 1q could finally be achieved by comparative genomic hybridization (CGH) using DNA extracted from formalin-fixed and paraffin-embedded fetal tissues. A direct duplication dir dup (1)(pter-->q44::q32.1-->qter) was found. Only 6 other individuals with duplication of this segment have been described so far. Comparative delineation of a dup1q phenotype with regard to size and origin of the dup (1q) segment evidenced that large duplications as well as proximal and interstitial duplications coincide with more severe visceral malformations, severe mental retar- dation and a short life span. Terminal duplications (1q32-->qter) concur with less severe malformations and longer periods of survival, but marked mental retardation. With small terminal duplications (1q42-->qter) dysmorphisms are usually mild and intellectual performance is mostly in the normal range.

Both maternal and fetal cell-free DNA in plasma fluctuate

Elevations in the concentration of cell-free fetal DNA in maternal plasma have recently been determined in various pregnancy-related disorders, including preeclampsia, preterm labor, and polyhydramnios. In addition, almost 2-fold increments in cell-free fetal DNA levels have been recorded in pregnancies with certain aneuploid fetuses, in particular trisomy 21. These findings have led to the speculation that quantitative assessment of circulatory fetal DNA may be useful in the noninvasive prenatal diagnosis of certain fetal genetic constellations or pregnancy-related disorders. A premise for any quantitative analysis is that the quantity of the analyte being assayed does not vary greatly over time. As this aspect has not been examined for circulatory DNA levels, we examined these in normal healthy individuals as well as in pregnant women. Our data indicate that severalfold alterations in circulatory DNA amounts do occur over short periods of time. Of particular note is that we observed almost 2-fold variations in free fetal DNA levels over a period of 3 days, which are in a similar range to the elevations noted in aneuploid pregnancies. Our results, therefore, imply that caution should be used when using small increments in circulatory fetal DNA concentrations for potential diagnostic applications.

Effect of preeclampsia on umbilical cord blood hematopoietic progenitor-stem cells

OBJECTIVE

The aim of the present study was to determine the influence of preeclampsia on cord blood hematopoietic progenitor-stem cells obtained at delivery because cord blood is increasingly used clinically for stem cell retrieval as an alternative to bone marrow.

STUDY DESIGN

Umbilical cord blood was collected from patients fulfilling the criteria for preeclampsia and from gestational age- and birth weight-matched control subjects at delivery (patient/control subjects ratio, 1:2). Cord blood volume and nucleated cell content were measured, and the number of hematopoietic progenitor-stem cells was determined by means of fluorescence-activated cell sorting with the CD34(+) epitope and by means of colony assays with different hematopoietic growth factors. In addition, the expression of adhesion molecules by CD34(+) progenitor-stem cells was examined.

RESULTS

In pregnancies affected by preeclampsia, volume and nucleated cell and total CD34(+) cell contents in the collected cord blood were significantly smaller compared with those of control subjects. Furthermore, there was a trend toward a smaller relative number of CD34(+) cells and colony-forming units per nucleated cell in cord blood samples from preeclamptic patients. No difference in the expression of the cell-adhesion molecules leukocyte function-associated antigen 1, very late activation antigen 4, and L-selectin by CD34(+) cells could be found.

CONCLUSION

This study shows that preeclampsia affects umbilical cord blood volume and nucleated cell and progenitor-stem cell numbers obtained at birth.

Circulatory fetal and maternal DNA in pregnancies at risk and those affected by preeclampsia

Elevations in fetal cell traffic as well as increased release of cell-free fetal DNA into the maternal periphery have previously been shown to occur in pregnancies affected by preeclampsia. Our own investigations have shown that manifestation of preeclampsia is associated with an increased accumulation of circulatory fetal DNA as well as cell-free maternal DNA in maternal plasma. We further established that the increments in these two molecular genetic analytes corresponded to the severity of the disease and to each other. This latter phenomenon was evident in preeclamptic pregnancies, but not in normal ones. As we had recently performed a prospective study to investigate fetal cell traffic prior to onset of preeclamptic symptoms, we examined the levels of cell-free fetal and maternal DNA in these samples. This analysis indicated that circulatory fetal DNA concentrations were significantly elevated prior to onset of the disease symptoms. No similar feature was observed for cell-free maternal DNA levels.

Fetal cells from cord blood as stem cell source: current status and possible implications in gynaecologic oncology

Umbilical cord blood is increasingly used as a source of hematopoietic stem cells for transplantation. Due to recent success, cord blood banks are being set up. We reviewed the currently available literature concerning cord blood collection, storage and transplantation, the impact of prenatal and perinatal factors and collection techniques on the quantity and quality of cord blood, and the ethical, legal and social questions related to cord blood transplantation. Possible implications in gynecologic oncology are reviewed and discussed. The emerging therapeutic use of cord blood for transplantation and transfusion implies new challenges for the speciality of gynecology and obstetrics.

[100 years ago: Oskar Kreis, a pioneer in spinal obstetric analgesia at the University Women's Clinic of Basel]

In 1900, Oskar Kreis (1872-1958), a gynecologist and obstetrician who received his training at the Basle University Women's Hospital, pioneered the use of spinal anaesthesia in six parturients for labour pain relief. Cocaine was used as a local anaesthetic, which had previously been shown to be effective for spinal anaesthesia by August Bier in 1898. This important advance in anaesthetic care was not widely acknowledged for a long period of time and it has only been during the past few decades that spinal anaesthesia was rediscovered as an important technique available for obstetric anaesthesia.

Medical and obstetric problems complicating pregnancy

The present review addresses several medical and obstetric factors/problems, and their interactions during pregnancy. These include the following: maternal age; morbidity and mortality during pregnancy; thromboembolism; gestational diabetes; haemolysis, elevated liver enzymes, low platelets syndrome; human immunodeficiency virus; hepatitis C; preterm labour; antenatal administration of corticosteroids; intrapartum surveillance; breech delivery; and caesarean section.