Rare event selection of fetal nucleated erythrocytes in maternal blood by flow cytometry

The isolation and analysis of fetal nucleated red blood cells using multifunctional microbeads with a nanostructured coating toward early noninvasive prenatal diagnostics

Prenatal diagnostics holds great significance for pregnant women desiring healthy babies. Fetal nucleated red blood cells (fNRBCs), bearing the complete genome of the fetus, have been regarded as an important biomarker for noninvasive prenatal diagnostics (NIPD). The high-performance detection and enrichment of fNRBCs from maternal blood, especially during early pregnancy, is urgently needed for NIPD, which, unfortunately, remains a big challenge for early-pregnancy fNRBC isolation. In this study, we developed an innovative platform based on silica microbeads for fNRBC isolation and release in early pregnancy. Microbeads were coated with self-assembled MnO₂ nanoparticles (SiO₂@MnO₂) and then modified with a specific antibody. Benefiting from the three-dimensional nanostructure of the MnO₂ nanoparticles, the isolation efficiency of the fNRBCs was enhanced. Subsequently, fNRBCs were released via dissolving the MnO₂-nanoparticle coating using oxalic acid. We successfully isolated fNRBCs from the maternal peripheral blood samples of 20 pregnant women in the early pregnancy period, ranging from 41 to 62 gestational days. More importantly, the fetal origin of isolated cells was confirmed via fluorescent in situ hybridization and short tandem repeat analysis. This platform based on SiO₂@MnO₂ microbeads has verified the existence of fNRBCs in early-pregnancy maternal blood and is a promising approach for NIPD in early pregnancy.

Nanostructured Substrates for Detection and Characterization of Circulating Rare Cells: From Materials Research to Clinical Applications

Circulating rare cells in the blood are of great significance for both materials research and clinical applications. For example, circulating tumor cells (CTCs) have been demonstrated as useful biomarkers for "liquid biopsy" of the tumor. Circulating fetal nucleated cells (CFNCs) have shown potential in noninvasive prenatal diagnostics. However, it is technically challenging to detect and isolate circulating rare cells due to their extremely low abundance compared to hematologic cells. Nanostructured substrates offer a unique solution to address these challenges by providing local topographic interactions to strengthen cell adhesion and large surface areas for grafting capture agents, resulting in improved cell capture efficiency, purity, sensitivity, and reproducibility. In addition, rare-cell retrieval strategies, including stimulus-responsiveness and additive reagent-triggered release on different nanostructured substrates, allow for on-demand retrieval of the captured CTCs/CFNCs with high cell viability and molecular integrity. Several nanostructured substrate-enabled CTC/CFNC assays are observed maturing from enumeration and subclassification to molecular analyses. These can one day become powerful tools in disease diagnosis, prognostic prediction, and dynamic monitoring of therapeutic response-paving the way for personalized medical care.

Frequency-enhanced transferrin receptor antibody-labelled microfluidic chip (FETAL-Chip) enables efficient enrichment of circulating nucleated red blood cells for non-invasive prenatal diagnosis

Fetal aneuploidy and other chromosomal aberrations affect 9 in 1000 live births. Unlike the invasive diagnosis with high risk of miscarriage, non-invasive prenatal diagnosis (NIPD) sampling from maternal blood becomes a promising way for fetal genetic screening. However, fetal cell-based NIPD has a major challenge due to the small number of fetal cells present in maternal blood. We designed a frequency-enhanced transferrin receptor antibody-labelled microfluidic chip (FETAL-Chip) for efficient enrichment and identification of circulating fetal cells, i.e., circulating nucleated red blood cells (cNRBCs) from maternal blood. The FETAL-Chip can dramatically enhance the interaction of fetal cells with antibody-coated microposts to increase the capture efficiency while minimizing nonspecific adsorption. With the help of immunostaining, we can identify cNRBCs from as little as 2 milliliter maternal blood. Various numbers of cNRBCs were detected from volunteers as early as 7 weeks after conception and throughout the entire pregnancy. Gene analysis was also carried out to confirm the fetal origin of captured cells. With easy, non-invasive and highly efficient enrichment of cNRBCs, the method presented here offers great potential for non-invasive prenatal diagnosis.

Non-invasive Prenatal Diagnosis of Chromosomal Aneuploidies and Microdeletion Syndrome Using Fetal Nucleated Red Blood Cells Isolated by Nanostructure Microchips

Detection of detached fetal nucleated red blood cells (fNRBCs) in the maternal peripheral blood may serve as a prospective testing method competing with the cell-free DNA, in non-invasive prenatal testing (NIPT). Methods: Herein, we introduce a facile and effective lab-on-a-chip method of fNRBCs detection using a capture-releasing material that is composed of biotin-doped polypyrrole nanoparticles. To enhance local topographic interactions between the nano-components and fNRBC, a specific antibody, CD147, coated on the nanostructured substrate led to the isolation of fNRBCs from maternal peripheral blood. Subsequently, an electrical system was employed to release the captured cells using 0.8 V for 15 s. The diagnostic application of fNRBCs for fetal chromosomal disorders (Trisomy 13/21/18/X syndrome, microdeletion syndrome) was demonstrated. Results: Cells captured by nanostructured microchips were identified as fNRBCs. Twelve cases of chromosomal aneuploidies and one case of 18q21 microdeletion syndrome were diagnosed using the fNRBCs released from the microchips. Conclusion: Our method offers effective and accurate analysis of fNRBCs for comprehensive NIPT to monitor fetal cell development.

The Effect of the Elapsed Time Between Blood Draw and Processing on the Recovery of Fetal Cells From Maternal Blood

OBJECTIVE

To test the hypothesis that a delay in initial fetal cell enrichment processing of maternal blood samples (defined as the time between blood draw and the initial density gradient centrifugation step) compromises the ability to recover fetal cells, we performed a randomized comparison of immediate (within 4 hours of draw) versus delayed (between 18-24 hours of draw) processing.

METHODS

Four centers participated: two centers utilized flow cytometry (FLOW), and two centers utilized magnetic-activated cell sorting (MACS) techniques. Each center collected 34 samples. The outcome was the percentage of gamma positive (gamma(+)) cells for FLOW or the number of nucleated red blood cells (NRBCs) for MACS, found in the final enriched cell population. Both outcomes reflect cell properties that are potentially fetal in origin, thus making them representative of the ability to recover fetal cells.

RESULTS

Our results did not support our hypothesis that delay in processing compromises fetal cell recovery. Instead, in MACS processing, we observed an increase in recovered NRBCs when blood sample processing was delayed compared with immediate processing. There was no significant difference in gamma(+) cells with FLOW.

CONCLUSION

Time-related changes in the density of target cells, perhaps associated with their progress towards apoptosis during the delay period, may result in increased intact fetal cells with the study methods utilized.

Lab-on-a-chip technology: impacting non-invasive prenatal diagnostics (NIPD) through miniaturisation

This paper aims to provide a concise review of non-invasive prenatal diagnostics (NIPD) to the lab-on-a-chip and microfluidics community. Having a market of over one billion dollars to explore and a plethora of applications, NIPD requires greater attention from microfluidics researchers. In this review, a complete overview of conventional diagnostic procedures including invasive as well as non-invasive (fetal cells and cell-free fetal DNA) types are discussed. Special focus is given to reviewing the recent and past microfluidic approaches to NIPD, as well as various commercial entities in NIPD. This review concludes with future challenges and ethical considerations of the field.

Unique monoclonal antibodies specifically bind surface structures on human fetal erythroid blood cells

BACKGROUND

Continuing efforts in development of non-invasive prenatal genetic tests have focused on the isolation of fetal nucleated red blood cells (NRBCs) from maternal blood for decades. Because no fetal cell-specific antibody has been described so far, the present study focused on the development of monoclonal antibodies (mAbs) to antigens that are expressed exclusively on fetal NRBCs.

METHODS

Mice were immunized with fetal erythroid cell membranes and hybridomas screened for Abs using a multi-parameter fluorescence-activated cell sorting (FACS). Selected mAbs were evaluated by comparative FACS analysis involving Abs known to bind erythroid cell surface markers (CD71, CD36, CD34), antigen-i, galactose, or glycophorin-A (GPA). Specificity was further confirmed by extensive immunohistological and immunocytological analyses of NRBCs from umbilical cord blood and fetal and adult cells from liver, bone marrow, peripheral blood, and lymphoid tissues.

RESULTS

Screening of 690 hybridomas yielded three clones of which Abs from 4B8 and 4B9 clones demonstrated the desired specificity for a novel antigenic structure expressed on fetal erythroblast cell membranes. The antigenic structure identified is different from known surface markers (CD36, CD71, GPA, antigen-i, and galactose), and is not present on circulating adult erythroid cells, except for occasional detectability in adult bone marrow cells.

CONCLUSIONS

The new mAbs specifically bind the same or highly overlapping epitopes of a surface antigen that is almost exclusively expressed on fetal erythroid cells. The high specificity of the mAbs should facilitate development of simple methods for reliable isolation of fetal NRBCs and their use in non-invasive prenatal diagnosis of fetal genetic status.

The promise of fetal cells in maternal blood

Delaying childbirth increases the proportion of advanced maternal age pregnancies. This increases the number of pregnancies requiring invasive prenatal testing. Prenatal diagnosis of chromosomal aneuploidies and monogenic disorders requires fetal cells obtained through invasive procedures (i.e. chorionic villus sampling and amniocentesis). These procedures carry a risk of fetal loss, which causes anxiety to at-risk couples. Intact fetal cells entering maternal circulation have raised the possibility of non-invasive prenatal diagnosis. Rarity of fetal cells, however, has made it challenging. Fetal nucleated red blood cells are ideal candidate target cells because they have limited lifespan, contain true representation of fetal genotype, contain specific fetal cell identifiers (embryonic and fetal globins), and allow interrogation with chromosomal fluorescence in-situ hybridisation and possibly with array comparative genomic hybridisation. The utility of fetal nucleated red blood cells in non-invasive prenatal diagnosis has not reached clinical application because of the inconsistencies in enrichment strategies and rarity of cells.

Ex vivo large-scale generation of human red blood cells from cord blood CD34+ cells by co-culturing with macrophages

We generated red blood cells (RBC) from cord blood (CB) CD34+ cells using a four-phase culture system. We first cultured CB CD34+ cells on telomerase gene-transduced human stromal cells in serum-free medium containing stem cell factor (SCF), Flt-3/Flk-2 ligand, and thrombopoietin to expand CD34+ cells (980-fold) and the total cells (10,400-fold) (first phase). Expanded cells from the first phase were liquid-cultured with SCF, interleukin-3 (IL-3), and erythropoietin (EPO) to expand (113-fold) and differentiate them into erythroblasts (second phase). To obtain macrophages for the next phase, we expanded CD34+ cells from a different donor using the same coculture system. Expanded cells from the first phase were liquid-cultured with granulocyte-macrophage colony stimulating factor, macrophage-colony stimulating factor (M-CSF), IL-3, and SCF to generate monocytes/macrophages (75-fold), which were incubated with type AB serum and M-CSF to fully differentiate them into macrophages. Erythroblasts were then co-cultured with macrophages in the presence of EPO to expand (threefold) and fully differentiate them (61% orthochromatic erythroblasts plus 39% RBC) (third phase). RBC were purified from erythroblasts and debris through a deleukocyting filter to generate 6.0 x 10(12) RBC from 1.0 unit of CB (3.0 transfusable units). Qualitatively, these RBC showed a hemoglobin content, oxygenation of hemoglobin, and in vivo clearance similar to those of adult peripheral RBC. Finally, an almost complete enucleation of orthochromatic erythroblasts (99.4%) was achieved by the cultivation method recently described by Miharada et al. in the absence of macrophages and cytokines (fourth phase). RBC were purified from remnant erythroblasts and debris by passage through a deleukocyting filter to generate 1.76 x 10(13) RBC from 1.0 unit of CB (8.8 transfusable units), the highest yield ever reported. Thus, this method may be useful for generating an alternative RBC supply for transfusions, investigating infectious agents that target erythroid cells, and as a general in vitro hematopoietic model system.

A microfluidics approach for the isolation of nucleated red blood cells (NRBCs) from the peripheral blood of pregnant women

OBJECTIVE

Nucleated red blood cells (NRBCs) have been identified in maternal circulation and potentially provide a resource for the monitoring and diagnosis of maternal, fetal, and neonatal health and disease. Past strategies used to isolate and enrich for NRBCs are limited to complex approaches that result in low recovery and less than optimal cell purity. Here we report the development of a high-throughput and highly efficient microfluidic device for isolating rare NRBCs from maternal blood.

MATERIAL AND METHODS

NRBCs were isolated from the peripheral blood of 58 pregnant women using a microfluidic process that consists of a microfluidic chip for size-based cell separation and a magnetic device for hemoglobin-based cell isolation.

RESULTS

The microfluidic-magnetic combination removes nontarget red blood cells and white blood cells at a very high efficiency (approximately 99.99%). The device successfully identified NRBCs from the peripheral blood of 58/58 pre-termination samples with a mean of 37.44 NRBC/mL (range 0.37-274.36 NRBC/mL). These results were compared with those from previous studies.

CONCLUSION

The microfluidic device results in an approximate 10- to 20-fold enrichment of NRBCs over methods described previously. The reliability of isolation and the purity of the NRBC product have the potential to enable the subsequent application of molecular diagnostic assays.

Biochip for separating fetal cells from maternal circulation

Isolation of fetal cells from maternal circulation is the subject of intense research to eliminate the need for currently used invasive prenatal diagnosis procedures. Fetal cells can be isolated using magnetic-activated cell sorting or fluorescence-activated cell sorting, however no technique to specifically isolate and use fetal cells for genetic diagnosis has reached routine clinical practice. This paper demonstrates the use of a micromachined device to separate fetal cells from maternal circulation based on differences in size and deformation characteristics. Nucleated fetal red blood cells range in diameter from 9 to 12 microm can deform and pass through a channel as small as 2.5 microm wide and 5 microm deep. Although the white blood cells range in diameter from 10 to 20 microm, they cannot deform and are retained by the 2.5 microm wide and 5 microm deep channels under our experimental conditions. Fetal cells were isolated from cord blood and DNA analysis confirmed their fetal origin with ruled out maternal contamination.

Prenatal genetic testing kits sold at your local pharmacy: promoting autonomy or promoting confusion?

Research groups around the world are developing non-invasive methods of prenatal genetic diagnosis, in which foetal cells are obtained by maternal blood test. Meanwhile, an increasing number of genetic tests are sold directly to the public. I extrapolate from these developments to consider a scenario in which PNGD self-testing kits are sold directly to the public. Given the opposition to over-the-counter genetic tests and the continuing controversy surrounding PNGD, it is reasonable to expect objections to PNGD self-testing kits. I focus on one potential objection, that PNGD self-testing kits would undermine the autonomy of potential test subjects. More specifically, that 'direct to the public' PNGD would fail to ensure that consumers exercise authority in the following PNGD-related choices: Should I use PNGD? Based on the results of the PNGD test, should I continue or terminate my pregnancy? Under the current system, PNGD is provided by health care practitioners, who are required to counsel women both before and after the test. In contrast, 'direct to the public' PNGD would allow women to make their PNGD-related decisions outside the context of the health care system. I compare these two decision-making contexts, arguing that the health care system is not unequivocally better at promoting the autonomy of potential test subjects. Therefore the promotion of autonomy does not constitute a strong argument against such test kits. Other objections may be more persuasive, so I do not offer an overall assessment of the acceptability of 'direct to the public' PNGD.

Quantification of all fetal nucleated cells in maternal blood in different cases of aneuploidies

We quantified all fetal nucleated cells (FNCs) per unit volume of maternal blood in different aneuploid pregnancies using molecular cytogenetic techniques. Seven cases of male trisomy 18, two triploidies (69,XXX), two 47,XXX, one 47,XXY, one 47,XYY, one male trisomy 13, and one case of 47,XY,r(22),+r(22) were analyzed. Whole blood samples were obtained from 15 women between 17 and 29 gestational weeks and harvested without using fetal cell enrichment procedures. Fluorescence in situ hybridization and primed in situ labeling were performed to identify the FNCs. All slides were manually scanned to quantify those cells. We have identified 4-20 FNCs/ml of maternal blood in the cases of trisomy 18; 10 and 25 FNCs/ml in the two cases of triploidy; 16 and 14 FNCs/ml, respectively, in the two X trisomies; 19 FNCs/ml in the 47,XXY; 26 FNCs/ml in the 47,XYY; nine FNCs/ml in the trisomy 13; and 10 FNCs/ml in the case of r(22). To detect all FNCs in all aneuploid pregnancies, we have used a very simple method that minimizes the manipulation steps to avoid losing fetal cells. The number of FNCs identified in aneuploid pregnancies was 2-5 times higher than in normal pregnancies. This higher number of FNCs will favor the design of a non-invasive pre-natal test.

Development of a rare cell fractionation device: application for cancer detection

Isolating rare cells from biological fluids including whole blood or bone marrow is an interesting biological problem. Characterization of a few metastatic cells from cancer patients for further study is desirable for prognosis/diagnosis. Traditional methods have not proven adequate, due to the compositional complexity of blood, with its large numbers of cell types. To separate individual cells based on their mechanical characteristics, we have developed a series of massively parallel microfabricated sieving device. These devices were constructed with four successively narrower regions of channels numbering approximately 1800 per region. As cells traversed the device, they encountered each region and stopped at a gap width that prohibited passage due to their size. Cultured neuroblastoma cells, when mixed with whole blood and applied to the device, were retained in the 10-microm-wide by 20-microm-deep channels. All other cells migrated to the output. A derivative of the same device was utilized to characterize migration of whole blood. Adult white blood cells were retained at the 2.5-microm-wide by 5-microm-deep channels, while red blood cells passed through these channels. Devices designed to capture rare cells in peripheral circulation for downstream analysis will provide an important tool for diagnosis and treatment.

Analysis of fetal DNA from maternal peripheral blood by lectin-polymerase chain reaction-single strand conformation polymorphism

Fetal nucleated cells in maternal peripheral blood are a non-invasive source of fetal DNA for prenatal genetic diagnosis. However, the number of fetal cells present in maternal peripheral blood is very small. Therefore, fetal cell enrichment is generally considered necessary to allow detection and subsequent genetic analysis of the rare fetal cells. In the study presented here, we performed fetal cell separation from maternal blood using galactose-specific lectin to concentrate fetal nucleated red blood cells (FNRBCs), and attempted paternal diagnosis using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP). Fetal cell separation was performed using galactose-specific lectin on a PV-MeA coated slide. Twenty cells consisting of an NRBC and its surrounding 19 maternal cells were collected using laser microdissection for stable DNA amplification. DNA analysis was performed using three sequence tagged site markers (D13S270, D17S5, and D18S474) by PCR-SSCP. All seven cases were informative because they showed heterozygosity at least one locus in D13S270, D17S5, or D18S474, and paternal-specific bands were detected in all cases. These results suggest that our proposed lectin-laser-micromanipulation-PCR-SSCP method may contribute to the development of prenatal diagnosis.

Isolation of fetal nucleated red blood cells from maternal blood in normal and aneuploid pregnancies

Fetal nucleated red blood cells (NRBC) have been widely reported in maternal blood during pregnancy. However, there is no consensus with regard to their presence in all pregnancies. Therefore, the usefulness of developing a fetal NRBC-based noninvasive method suitable for clinical prenatal diagnosis remains uncertain. Fluorescence in situ hybridization (FISH) method was used to evaluate the ability of one of our own monoclonal antibodies (mAb), 2B7.4, to isolate fetal NRBC from maternal blood by magnetic activated cell sorting (MACS). Our mAb was able to isolate from 25 to 822 NRBC from all of the 45 maternal blood samples included in this study. A correct diagnosis was achieved in 21 out of 24 pregnancies carrying trisomic fetuses (87.5%), with a fetal/maternal NRBC frequency of 8.4%. In contrast, a significantly lower percentage of fetal NRBC (0.2%) was observed in 22% of pregnancies carrying a chromosomally normal male fetus, that were correctly predicted. In conclusion, using 2B7.4 mAb we succeeded in isolating NRBC from the maternal blood samples, but most of the isolated cells were maternal in origin. Nevertheless, a higher number of fetal NRBC was found in the peripheral blood of pregnant women carrying aneuploid fetuses, which could allow development of a screening method for prenatal diagnosis of fetal aneuploidies.

Detection of gamma-globin mRNA in fetal nucleated red blood cells by PNA fluorescence in situ hybridization

OBJECTIVES

Fetal nucleated red blood cells (NRBC) that enter the peripheral blood of the mother are suitable for non-invasive prenatal diagnosis. The application of peptide nucleic acid (PNA) probes for tyramide amplified flow fluorescence in situ hybridization (FISH) detection of gamma-globin mRNA in fixed fetal NRBC is investigated.

METHODS

Hemin-induced K562 cells or nucleated blood cells (NBC) from male cord blood were mixed with NBC from non-pregnant women and analysed using both slide and flow FISH protocols. Post-chorionic villus sampling (CVS) blood samples from pregnant females carrying male fetuses were flow-sorted (2 x 10(6) NBC/sample). Y chromosome-specific PNA FISH was used to confirm that the identified gamma-globin mRNA stained cells were of fetal origin.

RESULTS

Flow FISH isolated gamma-globin mRNA positive NBCs showing characteristic cytoplasmic staining were all Y positive. The amplification system generated a population of false positive cells that were, however, easy to distinguish from the NRBCs in the microscope.

CONCLUSION

The gamma-globin mRNA specific PNA probes can be used for detection and isolation of fetal NRBCs from maternal blood. The method has additional potential for the study of gamma-globin mRNA levels or the frequency of adult NRBC (F cells) in patients with hemoglobinopathies.

Limited expression of Fas and Fas ligand in fetal nucleated erythrocytes isolated from first trimester maternal blood

OBJECTIVE

Intact fetal cells isolated from maternal blood can be used for non-invasive gender determination and genetic diagnosis. Recent studies demonstrating a large amount of cell-free fetal DNA in maternal plasma suggest that the circulating fetal DNA may result from fetal cells undergoing apoptosis. In the present study we evaluated the potential role of Fas and Fas ligand (FasL) cell surface expression with respect to apoptosis induction in fetal cells isolated from maternal blood.

METHODS

We flow sorted candidate fetal cells that were gamma chain-positive and Fas- or FasL-positive or -negative, and subsequently analysed them by fluorescence in situ hybridization (FISH) analysis using X and Y chromosome-specific probes.

RESULTS

Among all gamma hemoglobin-positive cells, there was a significant difference in the percent of cells expressing Fas versus FasL (4.4 and 12.3, respectively). We found no significant correlation between the total number of fetal nucleated red blood cells (NRBCs) and gestational age or the presence of Fas- and FasL-positive cells. From approximately 7 ml of maternal peripheral blood, most of the confirmed fetal (XY) cells were found in the Fas- and FasL-negative sorted population; the average numbers were 12.8 and 15.7, respectively.

CONCLUSION

We conclude that fetal NRBCs express FasL more than Fas, although most fetal NRBCs in first trimester maternal blood samples do not express Fas or FasL. This suggests the absence of a functional Fas/FasL apoptotic system in fetal NRBCs, and that programmed cell death in these cells, which may lead to circulating fetal DNA in maternal plasma, probably occurs by another pathway.

Screening

Historically, obstetrician/gynaecologists have utilized screening procedures as a major component of their routine clinical practice. The Papanicolaou (Pap) smear technique for cervical cancer is more than 50 years old and has saved countless lives by identifying who among the supposedly low-risk group of patients is in fact at high risk of cervical cancer. The introduction of alpha-fetoprotein screening for neural tube defects in the 1970s, low alpha-fetoprotein level for Down syndrome in the 80s, multiple markers in the 90s and now, after the millennium combined ultrasound and biochemistry for a more precise risk identification, has radically changed our approach towards optimizing the sensitivity, specificity and positive and negative predictive values of screening. As these techniques improve, old mainstays of attributable risks such as advanced maternal age will probably fade into oblivion as stand-alone criteria. The specifics of screening techniques will vary by disorder, but the general principles are important and can be applied to all new technologies as they come on line. In fact, the real 'take-home message' is that one must use these principles when looking at new technologies to understand their role in emerging practice.

Detection and relocation of cord blood nucleated red blood cells by laser scanning cytometry

BACKGROUND

Fetal nucleated red blood cells (NRBC) present in the peripheral blood of pregnant women at low frequency are a potential target for noninvasive prenatal diagnostics.

METHODS

CD71-enriched cells from male cord blood (CB) were stained for the gamma chain of HbF (Hb-gamma) and cytocentrifuged. Fluorescence in situ hybridization (FISH) was done for the Y chromosome. Following staining of the nucleus with TO-PRO-3, laser scanning cytometry was performed. Artificial mixtures of small volumes of male CB and blood drawn from nonpregnant females were analyzed.

RESULTS

In CB, 59% of events double positive for Hb-gamma and TO-PRO-3 were identified as CB-NRBC. In contamination studies, male fetal CB-NRBC were identified perfectly on the basis of morphologic characteristics and FISH reactivity following relocation and visual assessment. Mean recovery was 8.7%.

CONCLUSIONS

Laser scanning cytometry of preenriched fetal NRBC may offer a promising way for noninvasive prenatal diagnostics. This is because it provides a virtual enrichment step and the position on the slides of cells visually confirmed to correspond to fetal NRBC is known. Further experimental procedures on well-defined and located target cells may be feasible.

Enrichment of fetal cells from maternal blood by magnetic activated cell sorting (MACS) with fetal cell specific antibodies: one-step versus two-step MACS

We report here the results of fetal cell enrichment from maternal blood in 58 pregnant women by the use of magnetic activated cell sorting (MACS) with erythroblast-specific and/or maternal cell specific antibodies. Two approaches were compared; one-step MACS to enrich CD71+ (a membrane-bound marker) or GPA+ (another marker, glycophorin A) fetal cells versus two-step MACS to deplete CD14+ maternal cells and subsequently to enrich fetal (CD71+ or GPA+) cells. The existence of fetal cells was ensured by both FISH with Y-specific probes and karyotyping of respective amniotic and/or chorionic vullus cells, the results being applied for comparison of detection rate for XY fetuses between the two MACS procedures. In 24 (38.8%) of the 58 blood samples examined, Y-positive cells were observed by FISH, whereas there were 38 true XY fetuses later confirmed by karyotyping, including two cases of 47,XY,+21. On the other hand, in Y-negative cells by FISH, there were two cases of 47,XX,+18. The average number of cells sorted did not differ among one-step MACS procedures with anti-CD14, anti-CD71 and anti-GPA antibodies. With the latter, 12 (75%) of 16 Y-positive fetuses were detected, while only one (20%) of 5 Y-positive fetuses was detected by two-step MACS with anti-CD14/anti-GPA antibodies. The detection rate significantly varied (p = 0.0024) between the two procedures, although the numbers of cases examined were small. There was no statistical difference (p > 0.05) between one-step and two-step MACS with other combinations of antibodies. These findings indicate that one-step MACS using the anti-GPA antibody is more effective than two step MACS for enrichment of fetal cells from maternal blood.

Human erythroid cells produced ex vivo at large scale differentiate into red blood cells in vivo

New sources of red blood cells (RBCs) would improve the transfusion capacity of blood centers. Our objective was to generate cells for transfusion by inducing a massive proliferation of hematopoietic stem and progenitor cells, followed by terminal erythroid differentiation. We describe here a procedure for amplifying hematopoietic stem cells (HSCs) from human cord blood (CB) by the sequential application of specific combinations of growth factors in a serum-free culture medium. The procedure allowed the ex vivo expansion of CD34+ progenitor and stem cells into a pure erythroid precursor population. When injected into nonobese diabetic, severe combined immunodeficient (NOD/SCID) mice, the erythroid cells were capable of proliferation and terminal differentiation into mature enucleated RBCs. The approach may eventually be useful in clinical transfusion applications.

Magnetic field design for selecting and aligning immunomagnetic labeled cells

BACKGROUND

Recently we introduced the CellTracks cell analysis system, in which samples are prepared based on a combination of immunomagnetic selection, separation, and alignment of cells along ferromagnetic lines. Here we describe the underlying magnetic principles and considerations made in the magnetic field design to achieve the best possible cell selection and alignment of magnetically labeled cells. Materials and Methods Computer simulations, in combination with experimental data, were used to optimize the design of the magnets and Ni lines to obtain the optimal magnetic configuration.

RESULTS

A homogeneous cell distribution on the upper surface of the sample chamber was obtained with a magnet where the pole faces were tilted towards each other. The spatial distribution of magnetically aligned objects in between the Ni lines was dependent on the ratio of the diameter of the aligned object and the line spacing, which was tested with magnetically and fluorescently labeled 6 microm polystyrene beads. The best result was obtained when the line spacing was equal to or smaller than the diameter of the aligned object.

CONCLUSIONS

The magnetic gradient of the designed permanent magnet extracts magnetically labeled cells from any cell suspension to a desired plane, providing a homogeneous cell distribution. In addition, it magnetizes ferro-magnetic Ni lines in this plane whose additional local gradient adds to the gradient of the permanent magnet. The resultant gradient aligns the magnetically labeled cells first brought to this plane. This combination makes it possible, in a single step, to extract and align cells on a surface from any cell suspension.

Quantification of foetomaternal haemorrhage. An analysis of two cytometric techniques and a semiquantitative gel agglutination test

Traditional tests to screen for foetomaternal haemorrhage are time-consuming and difficult to perform. The Kleihauer test is widely used but difficult to standardize. We evaluated three techniques for quantifying foetomaternal haemorrhage: a semiquantitative gel agglutination test and two flow cytometric techniques. The gel agglutination test is based on the consumption of anti-D reagent by D+ cells, analysing the reaction of the supernatant against indicator cells in a Coombs-gel card. In the two colour direct immunofluorescent technique, the sample is incubated with Per-CP labelled anti CD45 antibody, fixed with glutaraldehyde and permeabilized by exposure to Triton X-100. An aliquot is stained with an antibody to foetal haemoglobin, conjugated with fluorescein isothiocyanate or phycoerythrin. The indirect immunofluorescent technique is based on the labelling of Rh (D) antigen with an anti D reagent, followed by the addition of an anti IgG antibody conjugated with phycoerythrin. Foetomaternal haemorrhage was not detected in 75 of the 85 samples analysed by the direct immunofluorescent technique. In the remaining 10 samples, the volume was very low. Thirty-five samples with Rh (D) antigen incompatibility were analysed in parallel by the indirect immunofluorescent technique and in 15 of the 35 samples, the gel agglutination technique was also carried out. The three techniques gave similar results. The gel agglutination test can be used to screen for foetomaternal haemorrhage, while greater volumes should be quantified by flow cytometric techniques.

Fetomaternal cellular and plasma DNA trafficking: the Yin and the Yang

In human pregnancy, multiple lines of evidence have indicated that there is trafficking of nucleated cells and cell-free DNA between the mother and fetus. Diagnostically, fetal cells in maternal blood and fetal DNA in maternal plasma offer a noninvasive source of fetal material for prenatal diagnosis. Through the developments of methods for fetal cell isolation and fetal DNA detection, many fetal genetic characteristics and chromosomal abnormalities have been detected from maternal blood. Large-scale clinical trials have been initiated that will facilitate the eventual application of these technologies. The presence of large quantities of cell-free fetal DNA in maternal plasma challenges the conventional belief that the fetal and maternal circulations are separate entities. In addition, the recent demonstration of the persistence of fetal cells following delivery also opens up a new field of investigation and raises new physiologic and pathogenic implications. Like the Yin and Yang in Chinese mythology, we believe that fetal cells and fetal DNA transfer are closely related and should be studied and applied in a synergistic manner.

Second-trimester biochemical screening

The past years have seen considerable progress in the area of biochemical screening. Increasing data have now clearly shown the advantages of multiple markers, particularly beta-hCG over AFP alone. There continues to be considerable controversy over the best mathematic algorithm and which markers are best (e.g., beta-HCG, uE3, and so forth). There seems to be a plateau of detection frequencies at about 65% to 70% with current methodologies. Further work needs to be done, however, including some new approaches, if there is to be substantial improvement of screening sensitivity. The combination of biochemical with biophysical parameters as discussed elsewhere in this issue represents the next level of sophistication in the attempt to identify the highest proportion of abnormalities with the fewest false-positives.

Current status of flow cytometry in cell and molecular biology

This review summarizes recent developments in flow cytometry (FC). It gives an overview of techniques currently available, in terms of apparatus and sample handling, a guide to evaluating applications, an overview of dyes and staining methods, an introduction to internet resources, and a broad listing of classic references and reviews in various fields of interest, as well as some recent interesting articles.

Optimization of nucleated red blood cell (NRBC) recovery from maternal blood collected using both layers of a double density gradient

The isolation of fetal nucleated red blood cells (NRBC) from maternal blood represents a promising approach to non-invasive prenatal diagnosis. However, the number of fetal NRBC in maternal circulation is quite low and therefore difficult to isolate. An enrichment procedure in which both layers from a double density 1.077/1.107 g/ml gradient are collected was optimized, followed by MACS selection using non-commercial monoclonal antibodies. The influence of the delay in processing maternal blood on the NRBC distribution in both interfaces of the gradient was also studied in cord blood and peripheral maternal blood samples. A significant increase in the number of NRBC isolated from maternal blood was achieved by collecting both layers of the double density gradient compared with the previous protocol in which only the lower layer was recovered. Cord blood samples showed significant differences in the number of NRBC recovered when processed at 24 instead of within 3 h. This effect was also observed in the number of NRBC collected only from the upper layer of peripheral maternal blood samples. Therefore, in order to minimize the target cell losses, it is advisable to process the maternal blood samples as soon as possible.

Genotyping fetal DNA by non-invasive means: extraction from maternal plasma

BACKGROUND AND OBJECTIVES

Identification of fetal DNA in maternal plasma may allow genetic analysis without the use of invasive techniques. The aim of this study was to extract DNA from maternal plasma, identify fetal material through the presence of SRY or RHD gene sequences and assess the reliability of these results.

MATERIALS AND METHODS

A polymerase chain reaction (PCR) method of a commercial kit was used with primers for SRY or exon 10 of the RHD gene sequence.

RESULTS

Multiple plasma samples were collected from 60 women who were evaluable for either SRY or RHD, or both, fetally derived DNA sequences. Fetal DNA was present in the plasma throughout the pregnancies and for some hours or days after delivery.

CONCLUSION

Fetal DNA can be reliably detected in maternal plasma from early in pregnancy and normally is cleared within days of delivery.

Fetal cells in the mother: from genetic diagnosis to diseases associated with fetal cell microchimerism

Fetal cells circulate in the blood of pregnant women. When the gestation is normal, fetal cells are low in number. Complications of pregnancy, such as pre-eclampsia, or fetal cytogenetic abnormalities, such as Down's syndrome, increase fetomaternal transfusion. The isolation of fetal cells from maternal blood is currently under active investigation as a non-invasive method for prenatal diagnosis. The fetal cells that are most commonly used for non-invasive genetic diagnosis, the nucleated erythrocyte and the trophoblast, are highly differentiated and do not persist post-partum. In the context of studying fetal cells in maternal blood it was discovered that fetal progenitor cells originating from a prior pregnancy could also be detected. This led to the appreciation that unlike fetal DNA in plasma, which is cleared almost immediately following delivery, fetal cells persist for decades post-partum. Following pregnancy, labor, and delivery, a woman becomes a chimera. Transfused fetal stem and progenitor cells appear to be capable of further differentiation and migration to maternal organs. A further research agenda is needed to explore the newly appreciated phenomenon of bi-directional fetomaternal cell trafficking. Any consideration of the fetus as a patient must also consider the fetus as a potential source of therapeutic stem cells for the mother.

Fetal cells in cervical mucus and maternal blood

Research in developing effective and accurate methods for non-invasive prenatal diagnosis has focused on two main techniques: the retrieval of trophoblast cells from the cervix and the enrichment of fetal erythroblasts from the blood of pregnant women. The isolation of fetal cells by both approaches has permitted the identification of fetal aneuploidies by the use of fluorescence in-situ hybridization (FISH) with appropriate probes, as well as fetal single gene disorders by polymerase chain reaction (PCR). In the latter instance, it has been shown that in order to attain the high degree of specificity required for prenatal diagnosis, it is necessary to analyse single fetal cells isolated by micromanipulation. This practice has permitted the successful characterization of fetal rhesus status, haemoglobinopathies, Duchenné's muscular dystrophy and spinal muscular atrophy, amongst others.Further developments include investigations into whether the diagnostic potential of fetal cells retrieved by either method can be expanded by the possible culturing of such cells, as well as the possibility of performing successive rounds of FISH and PCR by the recycling of isolated fetal cells.A novel observation that our group has made is that the traffic of fetal cells is enhanced in pregnancies affected by the pregnancy related disorder, pre-eclampsia. Our subsequent investigations have shown that this elevation in fetal cell traffic may serve as an early marker for those pregnancies at risk for this disorder.A very recent exciting discovery has been that free extracellular fetal DNA can be detected in the plasma and serum of pregnant women, which may permit the rapid and accurate detection of uniquely fetal loci, such as the fetal rhesus D gene in rhesus D negative pregnant women.

The clinical utility of fetal cell sorting to determine prenatally fetal E/e or e/e Rh genotype from peripheral maternal blood

OBJECTIVE

This study was undertaken to determine the fetal E/e or e/e Rh genotype prenatally from peripheral maternal blood by examining sorted fetal cells from alloimmunized and nonalloimmunized pregnancies.

STUDY DESIGN

Eighteen maternal peripheral venous blood samples were obtained before amniocentesis from 15 pregnant women who were homozygous for the e allele. Five were not alloimmunized and 10 were alloimmunized. The mononuclear cell layer was isolated from the maternal blood and enriched for fetal nucleated red blood cells by flow cytometry with monoclonal antibodies to CD36 or CD71 and to glycophorin A. Eight samples were treated with CD45 monoclonal antibody-coated magnetic beads before they were sorted to deplete the maternal sample of leukocytes (CD45(+) cells). We defined the positive fetal cell fractions as the monoclonal antibody positive-sorted cells derived from the maternal samples. These included sorted cells that were CD36(+)/glycophorin A(+), CD71(+)/glycophorin A(+) and CD45(-) cells that were sorted to become CD45(-)/CD36(+)/glycophorin A(+) or CD45(-)/CD71(+)/glycophorin A(+). The negative fractions were the cells that were negative for either CD36/glycophorin A or CD71/glycophorin A or were the CD45(+) cells. Deoxyribonucleic acid was isolated from all fractions and amplified by polymerase chain reaction with allele-specific primers for the E or e Rh genes. Gel electrophoresis was performed to detect fetal E/e or e/e Rh genotype. The fetal E/e or e/e Rh genotype was confirmed by serologic and deoxyribonucleic acid testing. The accuracy of E/e or e/e Rh genotype determination from the positive cell fractions was compared with that of E/e or e/e Rh genotype determination from the negative fractions.

RESULTS

Fetal E/e or e/e Rh genotype was determined correctly in 17 of 18 of the fetal cell enriched positive fractions (94%). Fetal E/e or e/e Rh genotype was determined correctly in 11 of 14 of the maternal samples in the negative unselected cell fractions (79%). Fetal E/e or e/e Rh genotype was determined correctly in 15 of 16 sample fractions that underwent magnetic bead separation with CD45 and were subsequently sorted into positive and negative fractions (94%). Fetal E/e or e/e Rh genotype was determined correctly in 13 of 13 of the samples obtained from the alloimmunized pregnancies (100%).

CONCLUSIONS

The use of monoclonal antibodies for cell sorting or for magnetic separation predicted fetal E/e or e/e Rh genotype from peripheral maternal blood correctly in as many as 100% of alloimmunized pregnancies. Thus noninvasive fetal E/e or e/e Rh genotyping can be performed by polymerase chain reaction amplification of the rare fetal cells in maternal blood. The correct prediction of fetal E/e or e/e Rh genotype from the cell population not selected by the monoclonal antibodies suggests that there are fetal cell types other than fetal nucleated erythrocytes that can also be used as a source of fetal deoxyribonucleic acid for noninvasive genetic diagnosis. Improved technology may provide methods less laborious than cell sorting to accurately determine fetal Rh type from different fetal cell types that circulate in maternal blood.

Comparison of fetal cell recovery from maternal blood using a high density gradient for the initial separation step: 1.090 versus 1.119 g/ml

The purpose of this study was to improve recovery of fetal nucleated erythrocytes (NRBCs) from maternal blood for non-invasive prenatal diagnosis. Peripheral blood samples were obtained from 27 women who had just undergone pregnancy termination at 6 to 23 weeks. Samples were split and mononuclear cells were isolated using Histopaque gradient at densities of 1.090 g/ml and 1.119 g/ml. CD45 depletion using magnetic activated cell-sorting, followed by flow-sorting with antibody to gamma-globin and fluorescence in situ hybridization (FISH) analysis, were used to evaluate the number of fetal NRBCs recovered. In samples separated with the 1.119 g/ml density gradient, the yield of true anti-gamma haemoglobin positive cells (median, 14. 9; range, 0-717.5) was significantly higher than that with the 1.090 g/ml density gradient (median, 4.9; range, 0-532.5). After FISH analysis, in the 14 samples in which the fetal karyotype differed from the mother, the median number of fetal NRBCs separated by the 1. 119 g/ml density gradient was 22.9 (2-717.5), which was significantly higher than that by the 1.090 g/ml gradient (median, 11.5; range, 0-532.5, p=0.022). Increased density of the gradient used for the initial enrichment of fetal cells results in improved fetal cell recovery in fresh post-termination blood samples, which may permit better non-invasive detection of fetal cells in maternal blood.

First trimester prenatal diagnosis: fetal cells in the maternal circulation

The recovery of fetal cells from the maternal circulation represents a promising approach to noninvasive prenatal diagnosis. Advances in techniques of sensitive molecular genetic analysis have enabled the conclusive demonstration of the presence of fetal cells in maternal blood. In most pregnancies, there are few fetal cells detectable. In some abnormal pregnancies, there appears to be increased fetomaternal transfusion, which facilitates recognition of aneuploid fetal cells. This review article describes general strategies of fetal cell isolation, current technical challenges, and clinical applications that are envisioned for the future. The increased appreciation of fetal cell microchimerism, and its association with complications of pregnancy and the postpartum development of autoimmune disease, is also discussed.

Fetal cells in maternal blood. An update from Basel

OBJECTIVE

The efficiency of two protocols for the enrichment of fetal cells from the blood of pregnant women was compared: a triple density gradient followed by twin magnetic separations (method A) versus a single density gradient and single magnetic separation (method B).

STUDY DESIGN

Blood samples were obtained from women prior to undergoing an invasive procedure. The processed samples, 87 by method A and 332 by method B, were examined for the presence of male cells by fluorescence in situ hybridisation.

RESULTS

The simpler protocol was found to be superior. The most critical component, however, is the ability of the reader to correctly evaluate the sample, where we observed large variations, with reader B attaining a sensitivity of 82.61% with a corresponding specificity of 86.96%.

CONCLUSION

A simpler enrichment protocol can be used from smaller blood samples to attain detection efficiencies which are similar to or superior to current noninvasive methods.

Photon-burst analysis in two-photon fluorescence excitation flow cytometry

We studied the use of a dramatically reduced testing zone in combination with two-photon excitation and photon-burst analysis in high-throughput rare-event detection simulation using a modified flow cytometer. Two-photon excitation measurements were performed with a mode-locked titanium:sapphire laser. Fluorescence emission was measured with a photon-counting avalanche photodiode. Measured signal was analysed offline by autocorrelation and burst detection methods. Test samples were composed of full blood and orange fluorescent polystyrene nanospheres mixed in full blood. Results show that two-photon fluorescence excitation and time-correlation analysis provide a good signal-to-noise ratio for rare-event particle detection in a turbid sample environment.

Quantitative flow cytometry for the analysis of T cell receptor Vbeta chain expression

Detailed characterisation of the T cell receptor (TCR) repertoire expressed by peripheral blood lymphocytes has been used to study specific T cell responses in disease conditions. The methods have mostly involved molecular biology analysis of transcribed gene products isolated from T cell subsets or individual clones. Extensive characterisation of the TCR Vbeta chain repertoire by flow cytometry is now possible due to the recently increased availability of specific monoclonal antibodies. However, there are major logistical problems inherent in this analysis relating to the number of cells required to obtain accurate results and the vast amounts of data generated. To reduce these factors to a practical level, we have performed a detailed study to define the limits of precision of cell subset analysis by flow cytometry. Maximal achievable precision was obtained by analysing 10(4) lymphocytes; no significant improvement was obtained by analysing greater numbers of cells up to 10(5) cells, even for cell subsets present at frequencies as low as 0.5%. Careful application of these precision profiles will also permit more effective use of clinical research samples for flow cytometry when the availability of cells is limited.

Strategies for rare-event detection: an approach for automated fetal cell detection in maternal blood

This article explores the feasibility of the use of automated microscopy and image analysis to detect the presence of rare fetal nucleated red blood cells (NRBCs) circulating in maternal blood. The rationales for enrichment and for automated image analysis for "rare-event" detection are reviewed. We also describe the application of automated image analysis to 42 maternal blood samples, using a protocol consisting of one-step enrichment followed by immunocytochemical staining for fetal hemoglobin (HbF) and FISH for X- and Y-chromosomal sequences. Automated image analysis consisted of multimode microscopy and subsequent visual evaluation of image memories containing the selected objects. The FISH results were compared with the results of conventional karyotyping of the chorionic villi. By use of manual screening, 43% of the slides were found to be positive (>=1 NRBC), with a mean number of 11 NRBCs (range 1-40). By automated microscopy, 52% were positive, with on average 17 NRBCs (range 1-111). There was a good correlation between both manual and automated screening, but the NRBC yield from automated image analysis was found to be superior to that from manual screening (P=.0443), particularly when the NRBC count was >15. Seven (64%) of 11 XY fetuses were correctly diagnosed by FISH analysis of automatically detected cells, and all discrepancies were restricted to the lower cell-count range. We believe that automated microscopy and image analysis reduce the screening workload, are more sensitive than manual evaluation, and can be used to detect rare HbF-containing NRBCs in maternal blood.

The application of individualised fetal growth curves

Individually adjusted or 'customised' growth charts aim to optimise the assessment of fetal growth by taking individual variation into account, and by projecting an optimal curve which delineates the potential weight gain in each pregnancy. This results in an increased detection rate of true growth restriction and a reduction in false positive diagnoses for IUGR. An adjustable standard can apply across geographical boundaries, as individual variation exceeds that between different maternity populations.

Isolation of yeast mutants defective for localization of vacuolar vital dyes

An application of flow cytometric sorting is used for isolation of Saccharomyces cerevisiae mutants that mislocalize vacuolar vital dyes. This screen is based on the ability of a lipophilic styryl compound, N-(3-triethylammoniumpropyl)-4-(6-(4-(diethylamino)phenyl)hexatrie nyl )pyridinium dibromide (FM4-64), to label endocytic intermediates from the plasma membrane to the vacuole membrane at 15 degreesC. Cells stained at 15 degreesC for both FM4-64 and carboxydichlorofluorescein diacetate (a vacuolar luminal vital stain), had a pronounced shift in red/green fluorescence from cells stained at 30 degrees or 38 degreesC. Flow cytometric selection based on this characteristic shift allowed the isolation of 16 mutants. These comprised 12 complementation groups, which we have designated SVL for styryl dye vacuolar localization. These groups were put into three classes. Class I mutants contain very large vacuoles; class II mutants have very fragmented vacuoles; and class III mutants show the strongest svl phenotype with punctate/diffuse FM4-64 staining. Limited genetic overlap was observed with previously isolated mutants, namely svl2/vps41, svl6/vps16, and svl7/fab1. The remaining svl mutants appear to represent novel genes, two of which showed temperature-sensitive vacuole staining morphology. Another mutant, svl8, displayed defects in uptake and sorting of phosphatidylcholine and phosphatidylethanolamine. Our flow cytometric strategy may be useful for isolation of other mutants where mislocalization of fluorescent compounds can be detected.

Optimized fixation and storage conditions for FISH analysis of single-cell suspensions

In our protocol to isolate and identify fetal cells in maternal peripheral blood, antibody (Ab)-stained cells are preserved with paraformaldehyde (PF) before batch flow cytometric sorting. However, PF fixation compromises the quality of subsequent interphase fluorescence in situ hybridization (FISH). We therefore examined the effect of PF concentrations and storage time in phosphate-buffered saline (PBS) on the quality of FISH signals. Cells were analyzed for changes in light scatter, morphology, and accessibility of target cell DNA. Fixation in 3% PF for 1 hr was ideal for both flow cytometry and subsequent FISH detection. However, beyond 10 days of storage, FISH quality deteriorated. (J Histochem Cytochem 46:971-973, 1998)

Prenatal diagnosis with use of fetal cells isolated from maternal blood: five-color fluorescent in situ hybridization analysis on flow-sorted cells for chromosomes X, Y, 13, 18, and 21

OBJECTIVE

Currently, prenatal diagnosis of chromosome abnormalities requires invasive techniques such as amniocentesis and chorionic villus sampling that carry small but finite risks of fetal loss. A noninvasive approach is to isolate fetal cells from maternal blood by flow sorting followed by genetic interphase analysis with fluorescence in situ hybridization. Because the ratio of fetal to maternal cells is relatively low after flow sorting and to detect 90% to 95% of fetal aneuploidies associated with serious birth defects, a 5-color fluorescent in situ hybridization strategy is necessary for simultaneous detection of chromosomes X, Y, 13, 18, and 21 in all flow-sorted nuclei recovered from a specimen.

STUDY DESIGN

Fetal nucleated red blood cells were isolated from maternal blood in 40 cases (10.4 to 27.0 weeks' gestation) by flow cytometry on the basis of positive selection of CD71+ (transferrin receptor), CD45-, and LDS751 staining. Each case was evaluated for 5-color fluorescent in situ hybridization efficiency by determining the percentage of flow-sorted nuclei containing 8 hybridization signals for chromosomes X, Y, 13, 18, and 21.

RESULTS

A total of 42,312 flow-sorted nuclei from maternal blood samples were analyzed. In 5 of 16 (31%) cases with a male fetus, 0.16% of nuclei scored were identified as fetal by the presence of 1 signal each for chromosomes X and Y. Fetal trisomy 21 nuclei were accurately detected in 2 cases with a female fetus, each of which was subsequently confirmed.

CONCLUSIONS

Five-color interphase fluorescent in situ hybridization analysis can be used to effectively analyze rare fetal aneuploid nuclei in enriched flow-sorted cells isolated from maternal blood.

Detection of anomalies: alternatives to ultrasound

Ultrasound and biochemical screening are complementary screening tests that each have limitations and advantages. The next several years will see variable progress in the evolution of these techniques, which, it is hoped, will result in an appropriate role for each to achieve a cost-effective, highly sensitive and specific screening approach that will allow couples the most comfort in detecting problems during pregnancy, as well as a high degree of confidence that normal results are accurate.