doi:10.1111/j.1447-0756.2011.01740.

J. Obstet. Gynaecol. Res. Vol. 38, No. 3: 490497, March 2012

Effects of preeclampsia on the yield of hematopoietic stem cells obtained from umbilical cord blood at delivery
Fadilah S. Abdul Wahid1,2, Mona Zaria Nasaruddin2, Mohd Razif Mohd Idris,1 Maiza Tusimin3, Nor Rafeah Tumian1,2 and Zaleha Abdullah Mahdy3
1

Cell Therapy Centre, and Departments of 2Medicine and 3Obstetrics and Gynecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
jog_1740 490..497

Abstract
Aim: To compare the numbers of cord blood CD34+ hematopoietic stem cells (HSC) between preeclampsia (PE) and control (non-PE) subjects and to determine the factors that may inuence this observation. Methods: Umbilical cord blood was collected from 28 PE and 19 non-PE subjects. Nucleated and CD34+ cell counts were derived using the Trucount tube-based stem cell enumeration kit on BD FACSCalibur. Results: The cord blood volume, nucleated and CD34+ cell counts were signicantly reduced in PE subjects compared to non-PE subjects. Among the PE subjects, systolic and diastolic blood pressure demonstrated a negative correlation with total nucleated and CD34+ cell counts. Gestational age at delivery inuenced cord blood volume and nucleated cell counts, but not CD34+ cell counts. Birth weight and placental weight correlated strongly with cord blood volume, and nucleated and CD34+ cell counts. There were no correlations observed between cord blood parameters and maternal age, maternal white cell count, gravidity, route of delivery or neonatal gender among PE subjects. Conclusion: Preeclampsia has a negative impact on the yield of HSC obtained from cord blood at delivery. Maternal blood pressure, neonatal birth weight and placental weight are important factors inuencing the numbers of cord blood HSC. These ndings should be taken into consideration when selecting cord blood units from mothers with PE for banking. Selecting the heaviest term neonate might improve the yield of cord blood HSC obtained from PE mothers. Key words: CD34+ hematopoietic stem cell, cord blood, cord blood banking, nucleated cell count, preeclampsia.

Introduction
Umbilical cord blood (UCB) has been used as an alternative source of hematopoietic stem cell transplantation for the treatment of hematological disorders, immunodeciency syndromes and metabolic disorders with over 6000 UCB transplantations having been performed worldwide. Its proliferative capacity is superior to that of cells in marrow or blood from adults. A 100-mL unit of UCB contains 1/10 the

number of nucleated cells (NC) and CD34+ hematopoietic stem cells (HSC) present in 1000 mL of bone marrow, but because they proliferate rapidly, the stem cells in a single unit of UCB can reconstitute the entire hematopoietic stem cell pool.1 Umbilical cord blood offers the advantages of easy procurement, absence of risk for the donor (mother), a reduced risk of transmitted infections, immediate availability of a graft and less stringent criteria for human leukocyte antigen matching without an unacceptably

Received: March 28 2011. Accepted: August 15 2011. Reprint request to: Professor Dr Fadilah S. Abdul Wahid, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Cheras 56000, Malaysia. Email: sfadilah@ppukm.ukm.my

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high incidence of graft versus host disease.2 However, insufcient numbers of HSC in a single unit of UCB resulting in delayed hematopoietic recovery has been the major limitation to the widespread use of UCB for allogeneic HSC transplantation for adults and large children.3 This is of particular importance because the outcome of cord blood transplantation has been shown to correlate with the number of total nucleated and CD34+ hematopoietic stem cells infused.1,4,5 Transplanted UCB grafts have been considered acceptable if they contain at least 1 107 to 3 107 NC count/kg recipient weight, with higher doses of cells infused correlating with a shorter time to engraftment.6 Results from more than 500 UCB transplants performed worldwide show that a low NC count (NCC) signicantly decreases post-transplant survival.1,4 Gluckman et al.,1 found that only 22% of patients who received <3.7 107 NCC/kg survived to one year, whereas those who received at least 3.7 107 NCC/kg had a 41% one-year survival rate. Transplantationrelated mortality was related to the number of NC and CD34+ HSC in the graft: patients who received a graft that contained <1.7 105 CD34+ cells/kg and 1 107 NC cells/kg had a higher probability of death.4,7 In accordance with these ndings, many UCB banks have established a policy of selecting units with high numbers of total nucleated and CD34+ cells.8,9 Studies performed on healthy pregnancies have shown that gestational and obstetric factors, including maternal age, parity, gestational age, length of labor, stress during labor, route of delivery, technique of UCB collection and positioning of the newborn after delivery can inuence the numbers of HSC in UCB obtained after delivery.1014 A younger maternal age, shorter gestational age and shorter time from collection to processing were associated with higher CD34+ HSC counts.14 Neonatal characteristics, including gender and weight of the newborn, may also inuence the numbers of HSC in UCB. Bigger babies had higher NCC, more CD34+ cells and colony-forming units granulocytemacrophage (CFU-GM).15 Male infants tend to have more CD34+ cells, but fewer nucleated cells and CFU-GM.9 Nakagawa et al. reported that delivery of a female infant and a longer gestational age were associated with a higher NCC.14 Most of the aforementioned studies examined UCB stem cells in normal pregnancies. Little information about the effect of common disorders complicating pregnancy is available. In particular, it is not known whether preeclampsia (PE) affects UCB HSC. Because

previous studies have shown that preeclamptic mothers have lower numbers of circulating endothelial progenitor cells and their fetuses have shown reduced hepatic hematopoiesis,16,17 the amount of circulating progenitor stem cells in UCB might be altered. Therefore, we have undertaken this study to determine if PE inuences the numbers of UCB HSC in order to address the question as to whether UCB units from mothers with PE are suitable for banking and future transplantation. We would also like to determine the factors that may inuence the numbers of UCB HSC obtained from PE subjects. The ndings from this study will be useful for counseling mothers with PE regarding UCB banking, and might provide valuable knowledge on the measures that can be taken to improve the yield of UCB HSC among PE subjects.

Patients and Methods

Patients and controls This was a prospective case control study involving 28 patients with PE and 19 apparently healthy pregnant women who were admitted for delivery to the Department of Obstetrics and Gynecology, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), between September 2009 and March 2010. Informed consent was obtained from all women and ethical approval was given by the hospitals the ethics committee. The diagnosis of PE was established in accordance with the denition of the American College of Obstetricians and Gynecologists.18 Patients were diagnosed with PE if their blood pressure (BP) was 140/90 mmHg or higher in two readings taken 4 h apart occurring after 20 weeks gestation and there was proteinuria of at least 300 mg/L in a 24-hour urine sample. The control group consisted of pregnant women with a similar age, parity and gestational age, but without signs of PE. Exclusion criteria were women with a maternal blood test positive for hepatitis B, hepatitis C, human immunodeciency virus 12, cytomegalovirus or syphilis, hematological disorders, genetic diseases, diabetes mellitus or gestational diabetes, chronic hypertension, autoimmune diseases, renal or liver impairment, multiple pregnancies and fetuses with congenital malformation or infection. Cord blood collection Umbilical cord blood samples were collected after delivery of the newborn, but before expulsion of the placenta. This was performed to avoid interfering with

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the delivery of the baby while still preserving the sterility of the UCB. A 16-gauge needle from a standard UCB collection bag set containing 22 mL of citrate phosphate dextrose anticoagulant was inserted into the umbilical vein; blood was allowed to ow by gravity and the needle was removed when the blood ow ceased. A similar method was applied for the cesarean section cases and the identical collection method was used for preeclamptic and control groups. After collection, UCB samples were sent to the laboratory and processed immediately. Any UCB samples collected during the night were stored at 4C and processed immediately the next day within 24 h.

Absolute number of nucleated cells per milliliter

No. of beads No. of CD45+ cell per TruCOUNT tube No. of beads counted sample volume Sample dilution factor Total nucleated cell count = Absolute number NC mL cord blood volume
Absolute CD34+ cells per microliter

Enumeration of UCB volume and nucleated and CD34+ cells The volume of collected UCB was dened as the total volume received in the laboratory, excluding the volume of anticoagulant (22 mL). The total volume was measured by weighing the collection bag and deducting the weight of the empty bag (8 g). One gram was taken as 1 mL. Analysis of UCB nucleated and CD34+ cells were performed on a FACS caliber analyzer (Becton Dickinson, Franklin Lakes, NJ, USA). CD45 antigen (a surrogate marker of NC) and CD34 antigen (a surrogate marker of HSC) staining was performed in Trucount tubes that contain a predispensed number of lyophilized 4.2 mm uorescent beads (BD Biosciences, San Jose, CA, USA), as described previously.19 Briey, 100 mL of UCB sample was incubated with 10 mL of uorescein isothiocyanate-conjugated anti-CD45 and 20 mL of phycoerythrin (PE)-conjugated anti-CD34 (clone 581; Beckman Coulter, Krefeld, Germany) for 20 min at 4C. 7-Amino actinomycin D (7-AAD) solution (a dye that discriminates between viable and nonviable cells) was added to the sample. After incubation, the remaining red blood cells in the sample tube were lysed for 10 min using a xative-containing the red blood cell lysis reagent FACSLyse (BD Biosciences). After incubation in the dark, the stained sample was analyzed immediately. Samples were acquired and analyzed by three-color ow cytometry using Cell Quest pro software (Becton Dickinson). A total of 75 000 events were acquired and subsequently analyzed. Cord blood NC (C45+ cells) and HSC (CD34+ cells) were enumerated using the ISHAGE gating strategy.20 The absolute and total numbers of NC (CD45+ cells) and CD34+ cells were calculated by the following formula:

No. of beads No. of CD34+ cell per TruCOUNT tube No. of beads counted sample volume Sample dilution factor

Total CD34+ cell count

Total CD 34 + cell count = Absolute CD 34 + cells L cord blood volume
A full blood count from the mothers serum was performed on the same day using Beckman Coulter LH755 hematology analyzer.

Statistical analysis The statistical software package SPSS version 16.0 was used to perform the data analysis. Data was tested for normality using the ShapiroWilk test. Normally distributed continuous data were analyzed using the independent-sample t-test, while categorical data were compared using the c2-test. Not normally distributed continuous data were analyzed using the Mann Whitney U-test. Pearsons product-moment correlation and Spearmans rank order correlation were used to study the relationship between maternal and neonatal factors and UCB parameters among PE subjects. A P-value < 0.05 was considered to be statistically signicant.

Results
The clinical characteristics of the PE and control groups are summarized in Table 1. Apart from the pronounced difference in the maximum systolic and diastolic BP, there was no signicant differences in maternal and neonatal characteristics, including maternal age, gravidity, gestational age at delivery, maternal white cell count and neonatal sex between the two groups. However, the rate of lower uterine segment cesarean section (LUSCS) was three times higher in the PE group compared to the control group (71.4% vs 28.6%,

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Table 1 Clinical characteristics of the preeclampsia and control groups Parameters Maternal age (years) Gestational age (weeks) Maternal leukocyte count (109/L) Systolic BP (mmHg) Diastolic BP (mmHg) Gravidity: 12 Route of delivery SVD LUSCS Birth weight (kg) Placental weight (g) Fetal sex Male Female Preeclampsia group (n = 28) 29.7 0.9 36.3 0.5 11.7 0.8 163.5 2.8 96.6 2.0 18 8 20 2.4 0.1 497.5 26.3 (2441) (3040) (6.324.4) (140190) (74120) (64.3%) (28.6%) (71.4%) (1.13.6) (200700) Control group (n = 19) 28.9 0.9 37.6 0.5 12.0 1.2 103.6 1.7 56.2 1.5 12 14 5 2.9 0.1 602.6 24.3 (2441) (3340) (8.222.4) (90120) (5070) (63.2%) (73.7%) (26.3%) (1.83.7) (450790) P-value 0.861 0.050 0.866 <0.0005 <0.0005 1.000 0.003 0.010 0.008 0.374

15 (53.6%) 13 (46.4%)

13 (68.4%) 6 (31.6%)

Values shown are mean SEM (range). P is signicant if <0.05. Blood pressure (BP) shown is the maximum BP. MannWhitney U-test. Fishers exact test. Independent-sample t-test. LUSCS, lower uterine segment caesarean section; SVD, spontaneous vaginal delivery.

Table 2 Cord blood parameters of the preeclampsia and control groups UCB parameters Volume (mL) Nucleated cell (106 cells/mL) Total nucleated cell (108 cells/mL) CD34+ (cells/mL) Total CD34+ (106 cells) UCB pH Preeclampsia group (n = 28) 110.1 6.1 6.5 0.6 7.5 1.0 24.2 3.6 2.9 0.5 7.3 0.0 (40.0192.5) (1.914.6) (1.526.1) (2.763.7) (0.211.1) (7.27.5) Control group (n = 19) 130.7 3.2 10.5 0.8 13.8 1.1 43.4 8.0 5.8 1.2 7.3 0.0 (104.4157.5) (4.616.4) (4.922.3) (9.2131.0) (1.120.6) (7.17.4) P-value 0.013 <0.0005 <0.0005 0.019 0.015 0.411

Values are mean SEM (range). P is signicant if <0.05. Independent-sample t-test.

P < 0.05). Additionally, the birth weight and placental weight obtained from PE mothers were lower compared to those in the control group. The UCB parameters, including the volume, NC and CD34+ cells counts, were signicantly reduced in the PE group compared to control group (Table 2). The mean volume of UCB obtained from PE mothers was smaller compared to the controls (110.0 6.1 mL vs 130.7 3.2 mL). The total and absolute NC and CD34+ cell counts were almost twice as low in UCB obtained from PE mothers compared to that from normotensive mothers. A total of approximately 7.5 1.0 108 nucleated cells and 2.9 0.5 106 CD34+ cells were obtained in the UCB from PE mothers, while a total of 13.8 1.1 108 nucleated cells and 5.8 1.2 106 CD34+ cells were obtained in the UCB from the controls. Next, we examined the relationship between UCB parameters and maternal and neonatal parameters among PE patients (Table 3). Maternal BP inuenced the cord blood volume, total NCC and CD34+ cell counts. We observed a negative correlation between

systolic BP/diastolic BP and cord blood volume, total NCC and CD34+ cell counts. High systolic and diastolic BP readings were associated with a lower cord blood volume, total NCC, CD34+ cell/mL and total CD34+ cell count. Among PE mothers, there was a signicant positive correlation between birth weight and placental weight with UCB volume, NCC and total CD34+ cell count. A reduced UCB volume, total NCC and total CD34+ cell count were observed in PE mothers who had neonates with lower birth and placental weights (Table 3). UCB obtained from newborns weighing <2.8 kg has signicantly lower volume and NC and CD34+ cell counts compared with UCB obtained from newborns weighing >2.8 kg. Of note, 70.8% (17 out of 24) of the newborns weighing <2.8 kg were from PE patients (Table 4). Among PE mothers, there was a positive correlation between the gestational age at delivery and the UCB volume and NCC; however, the gestational age did not inuence the UCB CD34+ cell counts in PE subjects. This might be explained by a small and non-signicant

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Table 3 Relationship between maternal and neonatal factors and cord blood parameters in the preeclampsia group Volume (mL) Systolic blood pressure (mmHg) P-value r value Diastolic blood pressure (mmHg) P-value r value Placental weight (g) P-value r value Birth weight (kg) P-value r value Gestational age (weeks) P-value r value Maternal age (years) P-value r value Maternal white cell count P-value r value Route of delivery Neonatal gender Gravidity 0.002 -0.570 0.010 -0.477 0.008 0.489 0.003 0.536 0.046 0.388 0.647 0.090 0.040 -0.390 0.684 0.695 0.666 Nucleated cells (106 cells/mL) 0.142 -0.285 0.165 -0.270 0.002 0.550 <0.0005 0.628 0.004 0.527 0.147 -0.282 0.305 -0.201 0.104 0.174 0.811 Total nucleated cells (108 cells/mL) 0.005 -0.513 0.010 -0.479 0.001 0.598 <0.0005 0.692 0.001 0.613 0.333 -0.190 0.121 -0.300 0.476 0.259 0.962 CD34+ (cells/mL) 0.010 -0.479 0.040 -0.391 0.012 0.470 0.086 0.331 0.575 0.113 0.824 -0.044 0.816 -0.046 0.170 0.222 0.565 Total CD34+ cells (106 cells/mL) 0.005 -0.513 0.033 -0.404 0.005 0.517 0.020 0.436 0.190 0.260 0.364 -0.178 0.236 -0.232 0.461 0.549 0.774

P is signicant if <0.05. Spearmans rank order correlation test. MannWhitney U-test. KruskalWallis test.

Table 4 Cord blood parameters of the <2.8 kg and >2.8 kg birth weight groups Cord blood parameters Volume (mL) Nucleated cells (106 cells/mL) Total nucleated cells (108 cells/mL) CD34+ (cells/mL) Total CD34+ (106 cells) <2.8 kg group (n = 24) (PE group: n = 17, 71%) 104.7 6.2 6.1 13.5 1.6 (88.4124.2) (4.110.2) (4.012.4) (10.236.8) (1.13.8) >2.8 kg group (n = 23) (PE group: n = 11, 47.8%) 135.5 8.9 12.3 32.0 4.4 (114.0146.7) (6.611.8) (8.314.3) (17.856.3) (2.46.4) P-value <0.0005 0.045 0.004 0.037 0.004

Values are median (interquartile). P is signicant if <0.05. KruskalWallis test. PE, preeclampsia.

difference in gestational age between PE mothers; hence, in PE patients a shorter gestational age was associated with a reduced UCB volume and NCC. No signicant effect of maternal age, maternal white cell count, gravidity, route of delivery or neonatal gender on the UCB parameters was observed.

Discussion
Recently, as a response to the initial encouraging clinical result of UCB transplants, several UCB banks have been established worldwide as well as in Malaysia. Commercialization of these private cord blood banking organizations has taken place here tremendously. Suc-

cessful outcomes of UCB transplantation has been strongly correlated with the NCC and CD34+ cell counts. As such, increasing numbers of studies have been performed in healthy pregnancies to examine the factors that might inuence the yield of NCC and HSC in UCB, including the inuence of maternal and neonatal factors, method of delivery and the technique of UCB collection. In contrast, there are few studies examining UCB HSCs in pregnancies complicated by disorders such as preeclampsia, which occurs in approximately 314% of all pregnancies worldwide.18 Apart from our study, there is only one other study that has examined the effects of PE on the yield of UCB HSC.20

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In this study, we showed that UCB parameters, including the volume and the numbers of NC and CD34+ cells, were signicantly smaller in pregnant patients affected by PE compared to the control group matched for maternal age, gestational age and parity. These ndings were consistent with the study performed by Surbek et al., which reported that there was a signicant and large difference in UCB volume, total NCC and CD34+ HSC, these being almost twice as low in the PE group compared with the non-PE control group matched for gestational age and birth weight.20 One possible explanation is the inuence of cytokine and growth factor patterns in fetuses affected by PE. The regulation of hematopoiesis in the fetus, including the physiological change of the predominant site of hematopoiesis from the liver to the bone marrow towards the end of gestation, depends on a complex interaction between the marrow microenvironment and circulating cytokine growth factors. Several studies have shown that the level of cytokines and growth factors in fetal blood are altered in PE and that a long term alteration of the patterns of cytokines and growth factors might have an inuence on hematopoietic activity in the progenitor cell population.16,21 In clinical practice, decisions as to processing and cryopreservation of freshly collected UCB units are generally made based on the volume of UCB and initial NCC because of the rapid availability of these parameters. We found that the volume of UCB obtained from PE mothers is signicantly lower compared to non-PE mothers. In addition, UCB obtained from PE mothers contained approximately 50% less absolute and total NC than that from non-PE mothers. A total of approximately 7.5 1.0 108 NC were obtained from the UCB of PE mothers and 13.8 1.1 108 from the UCB of non-PE mothers. Transplanted UCB grafts have been considered acceptable if they contain at least 1 107 to 3 107 NCC/kg recipient weight, as a low NC dose signicantly decreases post-transplant survival.4,9 Transplantationrelated mortality was related to the number of NC in the graft: patients who received no more than 1 107 NCC/kg had a 75% probability of death, whereas patients who received at least 3 107 NCC/kg had a 30% probability of death.10 Therefore, UCB units that have an initial total NCC greater than 10 108 are more likely to be used for transplantation than those with lower counts. Although not internationally standardized, many UCB banks require a minimum of 8 108 NC before processing and storage of

a UCB unit.11 Using this threshold, none of the UCB units collected from PE mothers in our study would meet the criteria for further processing and banking. We showed that UCB obtained from PE mothers contained signicantly smaller numbers of CD34+ HSC compared to normotensive mothers. Approximately 2.9 0.5 106 CD34+ cells were found in UCB obtained from our PE mothers. The dose of CD34+ cells was found to be signicantly associated with the rate of engraftment, transplantation-related mortality and survival after UCB transplantation. Wagner et al. reported on patients who had received a CD34+ cell dose of more than 2.7 105/kg and these had a transplantationrelated mortality of only 15% at one year; in contrast, patients who had received UCB grafts that contained 1.72.7 105 CD34+/kg and <1.7 105 CD34+/kg had higher rates of transplantation-related mortality (29% and 68%, respectively).4 It was suggested that UCB units containing <1.7 105 CD34+/kg recipient body weight should be considered inadequate for transplantation. Therefore, using this threshold for consideration of UCB transplantation, none of the UCB units collected from our PE mothers would be suitable for transplanting a recipient weighing more than 17 kg, suggesting that it is unlikely to be used in young adolescent or adult patients. Next we examined the factors that might inuence the numbers of UCB HSC among our PE mothers. We selected the factors that are known to inuence the yield of UCB stem cells in healthy pregnancies because factors inuencing UCB stem cells among PE subjects have never been determined systematically. We observed a signicant correlation between NCC and CD34+ cell count and maternal BP. We found that PE mothers with higher systolic and diastolic BP readings tended to have reduced total NCC, CD34+ cell/mL and total CD34+ cell counts. Of note, the numbers of total NC and total CD34+ cells in our PE patients (7.5 1.0 108 and 2.9 0.5 106, respectively) were higher compared to the numbers of total NC and total CD34+ cells reported in a previous study (4.6 0.8 108 and 1.1 0.3 106, respectively)20 that involves PE mothers with higher systolic and diastolic BP compared to PE mothers in our study (mean systolic BP: 174 5 vs 161 5 mmHg, mean diastolic BP:100 3 vs 96 2 mmHg, respectively). These ndings support our observation that the severity of maternal hypertension has a negative impact on UCB HPS. As there appears to be an inverse relationship between maternal BP and the UCB CD34+ cells, strict

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BP monitoring and control needs to be carried out among PE mothers who are interested in storing their UCB stem cells. In agreement with a previous study, we observed a signicant association between maternal BP and UCB volume.20 Of note, the PE mothers in our study produced a larger UCB volume than the PE mothers in that study (110.1 6.1 mL vs 37 6 mL, respectively). We also observed a strong relationship between both birth weight and placental weight with UCB parameters. PE mothers who delivered infants with a lower birth weight and placental weight tended to have a lower UCB volume, NC count/mL and CD34+ cell/mL. We showed that UCB obtained from a newborn weighing <2.8 kg had signicantly lower volume, NCC and CD34+ cell counts compared to UCB obtained from a newborn weighing >2.8 kg. Of note, 70.8% (17 out of 24) of the newborns weighing <2.8 kg were from PE patients. These ndings were consistent with prior reports in non-PE pregnancies where birth weight was the most signicant of all the neonatal parameters. Increasing birth weight itself was signicantly associated with increased UCB volume collected and all cell counts.9,15,21 Therefore, measures that could increase the fetal weight during the neonatal period might increase the numbers of CD34+ HSC obtained in the UCB of PE mothers. Previous reports showed that the alteration in fetal hematopoiesis are a consequences of PE itself rather than growth restriction alone as the UCB volume and numbers of HSC was smaller in PE than non-PE pregnancies, regardless of the infant birth weight.20,21 As the birth weight was smaller in PE mothers than in the controls, it should be assessed by using multivariate analysis if PE itself is an independent predictor of UCB volume, NC count and CD34 count. However, due to the small sample size in each subset, we were unable to perform multivariate analysis to determine if maternal BP alone is an independent predictor of UCB HSC among PE subjects. Gestational age appeared to inuence the UCB volume and NCC, but not CD34+ cells among our PE mothers. This nding was consistent with a previous study that showed a positive correlation between gestational age and NCC among healthy mothers.13,14 However, the relationship between gestational age and UCB CD34+ cells in healthy pregnancies appears to vary between published reports as some reports found no correlation between gestational age and UCB CD34+ cells,9 while others showed a reverse correlation.14 In our study, the lack of relationship between gestational age and UCB CD34+ cells in PE might be explained by

a small and non-signicant difference in gestational age between PE mothers. The route of delivery (caesarean delivery vs spontaneous vaginal delivery) did not inuence the UCB parameters among our PE mothers. The relationship between the route of delivery and CD34+ cells in healthy pregnancies appears to vary between published reports as some reports found no correlation between route of delivery and CD34+ cells,9 while others showed that caesarean delivery was associated with a higher UCB volume and CD34+ cells count, but a lower NC count.13,14 In agreement with previous studies performed in normal pregnancies,9,14 we did not observe any signicant effect of maternal age, maternal white cell count, gravidity or neonatal gender on the UCB parameters among our PE mothers. In conclusion, we showed that there is a signicant reduction in UCB CD34+ HSC in pregnancies complicated by PE. Importantly, the numbers of NCC and CD34+ cells in most of the UCB units collected from our PE mothers were below the threshold required for banking and are most likely inadequate for UCB transplantation in adolescent and adult patients. These ndings would provide guidance to mothers with PE and their health care providers in making the right decision regarding UCB stem cell collection and banking. Maternal BP and birth weight seems to have a strong inuence on the yield of UCB HSC. Hence, PE mothers who are interested in storing their UCB stem cells are advised to have their BP monitored and stabilized prior to delivery. In addition, selecting a good weight newborn and improving the UCB collection technique are among measures that may increase the likelihood of obtaining sufcient HSC in the UCB of PE mothers.

Acknowledgments
We gratefully acknowledge all the members of the Department of Obstetric and Gynecology, Universiti Kebangsaan Malaysia Medical Centre, for their assistance with cord blood collection. This work was supported by the Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Universiti Kebangsaan Malaysia.

Disclosure
None declared.

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