Media interest has raised the profile of cord blood collection and the possibility of life-saving properties of stem cells. As increasing numbers of parents request the collection of their baby’s cord blood, what are the main issues for midwives? Midwife and mother and baby consultant Sharon Trotter explains.
Midwives magazine:
August/September 2008
In January, Gordon Brown’s speech on NHS health screening (BBC, 2008) heralded its forthcoming 60th anniversary as a ‘great institution' with 'health care still free at the point of need’.
Changes in the way the NHS provides such a service evolve as new areas of diagnosis, treatment and the potential for further scientific advances become a reality. One such area is cord blood banking.
The uniqueness of cord blood as a source of stem cells is no longer in dispute. Its safe collection and potential uses continue to stimulate discussion, and media interest highlighting its potential benefits in life-saving or life-preserving applications has become more common.
While the author aims to provide a summary of this subject, in-depth analyses of the political or ethical issues are beyond the scope of this article. The implications and the associated legislation have been covered by the author (Trotter, 2008).
A brief history
It was in the early 1970s that Ende (1995) first observed that cord blood, like bone marrow, was a rich source of haematopoietic stem cells (HSC). These are master cells with the capacity to become any type of cell or tissue (pluripotent). In an embryo, these cells are known as true stem cells in that they retain an unlimited capacity for self renewal, whereas adult stem cells could be better described as progenitor cells as their capacity for unlimited renewal has not been conclusively demonstrated.
The main sources of stem cells are embryonic blood, bone marrow, peripheral and cord blood. Understandably, the use of embryos to harvest stem cells is emotive and while bone marrow transplants and peripheral blood stem cells work well, umbilical cord blood transplantation (UCBT) can be equally useful (Arcese et al, 2006).
The first successful UCBT was carried out in 1989 (Gluckman et al, 2004) confirming cord blood as an important and viable source of HSC. There have been thousands more successful transplants since then. Where the use of cord blood has become common practice, the number of cord blood banks (CBB) worldwide has continued to increase. Cord blood may have many potential uses. It has been postulated that stem cells could be used in the research and treatment of diseases such as Parkinson’s and Alzheimer’s (Edozien, 2006).
Collection and storage
UCB can be collected either in-utero or ex-utero. Both methods are straightforward to perform following appropriate training. It has been postulated that in-utero collection is quicker (two to five minutes against ten to 15 minutes for ex-utero), easier to perform and results in a larger volume of blood (Lasky et al, 2002), while others believe there is no significant difference (Warwick, 2004). Whichever method is used, infection control is vital.
Once collected, the red blood cells and plasma are removed, leaving a buffy coat of 20mls to 30mls maintaining the stem/proginator cells.
Concerns from the RCM and RCOG
The last position paper on CBB from the RCM was issued in 2002 (RCM, 2002). This advice has remained unchanged. While it supports the collection of UCB when medically indicated, the College does not support its commercial collection. Concerns include the:
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Possibility of future litigation due to problems during collection, storage and transportation
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Potential for increased risk of needle stick injury
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Need for more evidence to demonstrate its value
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Possibility of disruption around delivery
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Need for NHS debate on the ethical, legal and safety implications of commercial initiatives.
The RCOG have similar concerns, which have been addressed in their opinion paper (RCOG, 2006).
Recent developments
The Human Tissue Authority (HTA) announced new rules on 30 April. From 5 July, all maternity units that collect cord blood should act under the HTA license to ensure:
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Staff have training in collecting cord blood
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Procedures will help prevent medical attention being drawn away from mother or child
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A system exists to make sure the cord blood cells are traceable (Human Tissue Authority, 2008).
In the most recent amendment to the Human Fertilisation and Embryology Bill (Department of Health, 2008; BBC, 2008a), the House of Commons voted to allow limited research using human/animal embryos and the creation of ‘saviour siblings’.
The way forward
As awareness of CBB becomes more widespread, an increasing number of parents will ask about cord blood collection. This resource which, up until now has been discarded, can be stored in private banks as a potential autologous (donor use) or allogeneic (use by a family member) donation. While there has been opposition to the former type, due to the low odds of it being needed (1:2700 by the time a child is 18 years old (Johnson, 1997)), others have welcomed more altruistic ways of donating cord blood (Fisk, 2008).
Resources are over-stretched and the introduction of any service, except for ‘at risk’ cases could be seen as unnecessary. But parents have a right to an explanation of the pros and cons (Edozien, 2006). This can only be offered when guidelines are in place.
Whatever happens, there is a need for ongoing discussion between the companies providing this service and maternity units. As midwives, we will then be better prepared to answer the inevitable questions posed by parents.
References
Arcese W, Rocha V, Labopin M, et al. (2006) Unrelated cord blood transplants in adults with haematological malignancies. Haematologica 91(2): 223-30.
BBC News. (2008) In full: Brown speech on the NHS.See: http://news.bbc.co.uk/1/hi/uk_politics/7175083.stm (accessed 8 July 2008).
BBC News. (2008a) Embryology Bill: the key points.See: http://news.bbc.co.uk/1/hi/health/7391975.stm (accessed 8 July 2008).
Department of Health. (2008) Human Fertilisation and Embryology Bill 2007-8. See: http://services.parliament.uk/bills/2007-08/humanfertilisationandembryology.html (accessed 8 July 2008).
Edozien LC. (2006) NHS maternity units should not encourage commercial banking of umbilical cord blood. BMJ 333: 801-4.
Ende M. (1995) History of umbilical cord blood transplantation. Lancet 346: 1161.
Fisk NM. (2008) Public-private partnership in cord blood banking. BMJ 336: 642-4.
Gluckman E, Rocha V, Arcese W, et al. (2004) Factors associated with outcome of unrelated cord blood transplant: guidelines for donor choice. Exp Hematol 32(4): 397-407.
Human Tissue Authority. (2008) New rules for cord blood collection. See: www.hta.gov.uk/newsroom/media_releases.cfm?FaArea1=customwidgets.content
_view_1&cit_id=418 (accessed 8 July 2008).
Johnson FL. (1997) Placental blood transplantation and autologous banking – caveat emptor. Journal of Pediatric Haematology and Oncology 19(3): 183-6.
Lasky LC, Lane TA, Miller JP, et al. (2002) In utero and ex-utero cord blood collection: which is better? Transfusion 42(10): 1261-7.
RCM. (2002) Commercial cord blood collection. Guidance paper 1a and Position statement 1. RCM Midwives Journal 5(12): 422-4.
RCOG. (2006) Umbilical cord blood banking – Scientific Advisory Committee Opinion Paper 2. RCOG: London.
Trotter S. (2008) Cord blood banking and its implications for midwifery practice: time to review the evidence? Midirs Midwifery Digest 18(2): 159-64.
Warwick R, Armitage S. (2004) Cord blood banking: best practice and research. Clinical Obstetrics and Gynaecology 18(6): 995-1011.
