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Bacteriologic assessment of autologous cord blood for neonatal transfusion
Volume 149 Number 8
In the present patient osteolytic lesions in the skull and diabetes insipidus were first identified at the age of 3 years. Although the osteolytic lesions disappeared after radiation therapy, diabetes insipidus has remained in varying degrees throughout her life. Ten years after her first pregnancy she had grown 4 inches and was 4 feet, 11 inches tall. Although the fetus was term at the time of delivery, birth weight was 2680 gm, considerably less than her first child. Throughout hospitalization she continued to exhibit symptoms of polydipsia and polyuria. The major complications among women with HandSchiiller-Christian disease surviving to childbearing age appear to be diabetes insipidus (easily managed with Pitressin) and cephalopelvic disproportion. REFERENCES
1. MorrishJA, NewhallJF. Chronic histiocytosis-X associated with pregnancy. Obstet Gynecol 1965;26:504. 2. Ogburn PL, Cephalo RC, Nagel T, Okagaki T. Histiocytosis-X and pregnancy. Obstet Gynecol1981;58:513.
Bacteriologic assessment of autologous cord blood for neonatal transfusion Stephen M. Golden, Commander, MC, USN, Nancy Petit, Ensign; MC, USNR, Toby Mapes, Lieutenant Commander, MSC, USN, s; Edward Davis, Captain, PHS, and William P. Monaghan, Commander; MSC, USN Departments of Pediatrics, Laboratory Medicine, and Obstetrics and Gynecology, Naval Hospital, and Uniformed Services University of the Health Sciences, Bethesda, Maryland
Infants born in hypovolemic or septic shock often require expansion of the circulating intravascular volume to maintain adequate blood pressure and tissue perfusion. When compatible red cell concentrates or albumin/colloid-containing solutions are not available in the delivery room, autologous cord blood transfusion has been recommended for volume expansion. 1 • 2 In a previous assessment of autologous cord blood, we noted a high rate of in vitro bacteriologic growth following cord preparation with Betadine spray. 2 We therefore evaluated different techniques of umbilical cord surface preparation in order to decrease the risk of inadvertent baCterial colonization of newborn infants transfused with autologous cord blood. All autologous cord blood specimens were obtained from infants delivered from uncomplicated term pregThe opinions contained herein are those of the authors and do not reflect !he opinions of i:he Department of Defense or the Uniformed Services University of the Health Sciences. Reprint requests: Stephen M. Golden, M.D., Director of Neonatology, Overlook Hospital, 193 Morris Ave., Summit, NJ 07901.
Communications in brief 907
nancies with vaginal deliveries. The mothers were afebrile at the time of delivery and had not received antibiotic therapy. Following delivery, umbilical cords were sterilely clamped and severed. Two solutions commonly used for superficial skin sterilization were then compared: (1) Hibiclens (chlorhexidine gluconate, 4%, with 4% isopropyl alcohol, Stuart Pharmaceuticals, Wilmington, Delaware); (2) Frepp-sepp (2% iodine soap and 10% povidone-iodine solution, Marion Scientific Corporation, Kansas City, Missouri). Blood was obtained from the clamped umbilical cord immediately after delivery of the infant and prior to delivery of the placenta. To compare the two solutions in a controlled manner, two separate areas along the length of the umbilical cord were prepared, one with each solution. The area of the cord treated with Frepp-sepp was prepared as follows: (1) a brush containing the 2% iodine soap solution was used to scrub a selected area of the cord for 20 seconds; (2) the 10% iodine solution was then applied to the same area and scrubbed for approximately 10 seconds. The area of the cord prepared by Hibiclens was scrubbed for 30 seconds with a sterile gauze pad that had Hibiclens poured on it. After cleansing the two separate regions of the umbilical cord, blood was aspired from either the umbilical vein or artery with a sterile syringe and a No. 18-gauge needle. The needle was replaced with another sterile needle and then 5 ml aliquots of blood were inoculated into radiometric anaerobic and aerobic blood culture bottles (Bactec, Johnston Laboratories, Cockeysville, Maryland). Thirty-five sets of aerobic/anaerobic specimens from each prepared area were obtained for each solution. Aerobic and anaerobic cultures were sampled on days 0, 1, 2, 3, 5 and 7 and visually monitored on days 4 and 6. All aerobic cultures had a 12-hour subculture performed. In addition, cultures suspected of growth by radiometric indices were Gram stained and subcultured. All organisms isolated were identified. Two anaerobic cultures (5.7%) and no aerobic cultures were positive with the use of the Hibiclens preparation; one aerobic culture (2.8%) and no anaerobic cultures grew following Frepp-sepp preparation. The isolated aerobic organism was Staphylococcus epidermidis. One anaerobic culture yielded Gaffkya sp., an uncommon clinical isolate; the other anaerobic specimen could not be subcultured for identification. There were no statistically significant differences in growth frequencies between areas treated with Hibiclens and Frepp-sepp (X 2 test). Transfusion of banked whole blood or packed red blood cells is the technique most commonly employed to supply fresh blood to the newborn infant. The major advantage of autologous cord blood is its immediate availability in the delivery room in an unanticipated emergency situation requiring immediate transfusion, thereby avoiding the time delay inherent in the use of banked blood. Additional benefits of autologous cord blood are its immunologic compatibility, isotonic com-
908
Communications in brief
position, and the inherent oxygen-carrying and buffering capacity of hemoglobin. The low incidence of positive cuitures from autologous cord blood following the Frepp-sepp and Hibiclens applications compared to betadine spray indicates that both solutions are effective in reducing the risk of bacterial contamination after a brief cleansing of the umbilical cord surface. 2 The isolate of S. epidermidis found after Frepp-sepp preparation may represent superficial umbilical cord colonization or a laboratory contaminant, since the infant with this positive autologous cord blood culture was healthy. The growth of the nonpathogenic anaerobe, Gaffkya sp., in the Hibiclens preparation is unlikely to be a laboratory contaminant, since this organism is generally found as a transient on the skin and mucous membranes. Consequently, if autologous cord blood is required in an emergency situation, we recommend that it be infused immediately after collection to decrease the time for in vitro bacterial growth. The authors acknowledge the assistance of the resident and nursing staffs of the Department of Obstetrics and Gynecology and of the technical staff of the Division of Microbiology, Naval Hospital, Bethesda, Maryland. REFERENCES 1. Paxon CL. Collection and use of autologous fetal blood. AM 1 0BSTET GYNECOL 1979;134:708-10. 2. Golden SM, O'Brien WF, Lissner C, Cefalo RC, Monaghan WP, Schumacher H. Hematologic and bacteriologic assessment of autologous cord blood for neonatal transfusions. 1 Pediatr 1980;97:810-12.
Drainage of postabortion hematometra by Foley catheter Max Borten, M.D., and Emanuel A. Friedman, M.D., Sc.D. Department of Obstetrics and Gynecology, The Charles A. Dana Biomedical Research Institute, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts
Hematometra immediately following a suction curettage for pregnancy termination (postabortion syndrome) is usually diagnosed within hours of the original surgical procedure because of its characteristic manifestations. 1• 2 Hallmarks of this complication are uterine enlargement (frequently to a larger volume than preceding the evacuation) accompanied by exquisite suprapubic pain, which is constant in nature. Its physiopathologic mechanism appears to be uterine atony with rapid accumulation of blood and clots within the uterine cavity. Impediment to the outflow of
Reprint requests: Max Borten, M.D., Department of Obstetrics and Gynecology, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215.
August 15, 1984 Am. J. Obstet. Gynecol.
this blood seems to result from obstruction of the internal os by clotted blood. Bleeding within the uterus is self-limiting; once the uterus has become overdistended, the intrauterine pressure controls the bleeding. At the same time the pressure build-up causes the severe pain and syncopal symptoms. The currently accepted treatment regimen to alleviate this condition consists of repeat suction curettage. In our institution this entails returning the patient to the operating room from the recovery room or the ambulatory surgical unit facility. The discomfort and distress of the first procedure are further compounded by the fear and anxiety associated with having to go through it again, a psychologically traumatic event for most patients. We sought a means to resolve this complication without having to subject the patient to another surgical procedure. For this purpose, we utilized a Foley catheter of wide bore (No. 20 French) attached to a 60 ml plastic syringe with catheter tip to effect drainage of the uterine content. During the 7-year period of 1977 to 1983 a total of 3518 first-trimester abortions were performed. Among them, 12 were complicated by hematometra postoperatively (0.34%). Seven were selected for this trial. The patient was placed in the semifrog postion with elevation of the hips. A Graves speculum was inserted vaginally to visualize the cervix. Under direct vision in five cases, a soft, malleable No. 20 Foley catheter was inserted into the uterine Cavity, and a 60 ml plastic syringe was attached. In two instances we used a straight rubber catheter and syringe. The suction obtained was sufficient to drain 300 to 500 ml of retained clots and unclotted blood. Patients experienced immediate relief as soon as the blood was removed and the distention of the uterine cavity relieved. The concomitant administration of methylergonovine maleate, 0.2 mg intramuscularly, aided in accomplishing sustained uterine contraction and in preventing the reaccumulation of blood in the endometrial cavity. The catheter was removed upon relief of symptoms and firmness of the uterus obtained. All patients were observed for up to 3 hours and then discharged as previously planned without the need for operative evacuation or other treatment. None experienced any subsequent problems. The increase in the number of first-trimester pregnancy interruptions, as well as the recent acceptance of dilatation and evacuation for the termination of more advanced second-trimester gestations, suggests that the number of postabortion hematometras will increase. Although the number of cases is admittedly small, the success of this simple technique for evacuating retained blood via transcervical Foley catheter drainage encourages us to recommend it as the first line of treatment for the postabortion syndrome (hematometra). The advantages of this mode of therapy are that ( 1) no anesthesia is required, since the cervix is sufficiently dilated to accept the large catheter without additional stretching; (2) the procedure can be carried out with no delay
In the present patient osteolytic lesions in the skull and diabetes insipidus were first identified at the age of 3 years. Although the osteolytic lesions disappeared after radiation therapy, diabetes insipidus has remained in varying degrees throughout her life. Ten years after her first pregnancy she had grown 4 inches and was 4 feet, 11 inches tall. Although the fetus was term at the time of delivery, birth weight was 2680 gm, considerably less than her first child. Throughout hospitalization she continued to exhibit symptoms of polydipsia and polyuria. The major complications among women with HandSchiiller-Christian disease surviving to childbearing age appear to be diabetes insipidus (easily managed with Pitressin) and cephalopelvic disproportion. REFERENCES
1. MorrishJA, NewhallJF. Chronic histiocytosis-X associated with pregnancy. Obstet Gynecol 1965;26:504. 2. Ogburn PL, Cephalo RC, Nagel T, Okagaki T. Histiocytosis-X and pregnancy. Obstet Gynecol1981;58:513.
Bacteriologic assessment of autologous cord blood for neonatal transfusion Stephen M. Golden, Commander, MC, USN, Nancy Petit, Ensign; MC, USNR, Toby Mapes, Lieutenant Commander, MSC, USN, s; Edward Davis, Captain, PHS, and William P. Monaghan, Commander; MSC, USN Departments of Pediatrics, Laboratory Medicine, and Obstetrics and Gynecology, Naval Hospital, and Uniformed Services University of the Health Sciences, Bethesda, Maryland
Infants born in hypovolemic or septic shock often require expansion of the circulating intravascular volume to maintain adequate blood pressure and tissue perfusion. When compatible red cell concentrates or albumin/colloid-containing solutions are not available in the delivery room, autologous cord blood transfusion has been recommended for volume expansion. 1 • 2 In a previous assessment of autologous cord blood, we noted a high rate of in vitro bacteriologic growth following cord preparation with Betadine spray. 2 We therefore evaluated different techniques of umbilical cord surface preparation in order to decrease the risk of inadvertent baCterial colonization of newborn infants transfused with autologous cord blood. All autologous cord blood specimens were obtained from infants delivered from uncomplicated term pregThe opinions contained herein are those of the authors and do not reflect !he opinions of i:he Department of Defense or the Uniformed Services University of the Health Sciences. Reprint requests: Stephen M. Golden, M.D., Director of Neonatology, Overlook Hospital, 193 Morris Ave., Summit, NJ 07901.
Communications in brief 907
nancies with vaginal deliveries. The mothers were afebrile at the time of delivery and had not received antibiotic therapy. Following delivery, umbilical cords were sterilely clamped and severed. Two solutions commonly used for superficial skin sterilization were then compared: (1) Hibiclens (chlorhexidine gluconate, 4%, with 4% isopropyl alcohol, Stuart Pharmaceuticals, Wilmington, Delaware); (2) Frepp-sepp (2% iodine soap and 10% povidone-iodine solution, Marion Scientific Corporation, Kansas City, Missouri). Blood was obtained from the clamped umbilical cord immediately after delivery of the infant and prior to delivery of the placenta. To compare the two solutions in a controlled manner, two separate areas along the length of the umbilical cord were prepared, one with each solution. The area of the cord treated with Frepp-sepp was prepared as follows: (1) a brush containing the 2% iodine soap solution was used to scrub a selected area of the cord for 20 seconds; (2) the 10% iodine solution was then applied to the same area and scrubbed for approximately 10 seconds. The area of the cord prepared by Hibiclens was scrubbed for 30 seconds with a sterile gauze pad that had Hibiclens poured on it. After cleansing the two separate regions of the umbilical cord, blood was aspired from either the umbilical vein or artery with a sterile syringe and a No. 18-gauge needle. The needle was replaced with another sterile needle and then 5 ml aliquots of blood were inoculated into radiometric anaerobic and aerobic blood culture bottles (Bactec, Johnston Laboratories, Cockeysville, Maryland). Thirty-five sets of aerobic/anaerobic specimens from each prepared area were obtained for each solution. Aerobic and anaerobic cultures were sampled on days 0, 1, 2, 3, 5 and 7 and visually monitored on days 4 and 6. All aerobic cultures had a 12-hour subculture performed. In addition, cultures suspected of growth by radiometric indices were Gram stained and subcultured. All organisms isolated were identified. Two anaerobic cultures (5.7%) and no aerobic cultures were positive with the use of the Hibiclens preparation; one aerobic culture (2.8%) and no anaerobic cultures grew following Frepp-sepp preparation. The isolated aerobic organism was Staphylococcus epidermidis. One anaerobic culture yielded Gaffkya sp., an uncommon clinical isolate; the other anaerobic specimen could not be subcultured for identification. There were no statistically significant differences in growth frequencies between areas treated with Hibiclens and Frepp-sepp (X 2 test). Transfusion of banked whole blood or packed red blood cells is the technique most commonly employed to supply fresh blood to the newborn infant. The major advantage of autologous cord blood is its immediate availability in the delivery room in an unanticipated emergency situation requiring immediate transfusion, thereby avoiding the time delay inherent in the use of banked blood. Additional benefits of autologous cord blood are its immunologic compatibility, isotonic com-
908
Communications in brief
position, and the inherent oxygen-carrying and buffering capacity of hemoglobin. The low incidence of positive cuitures from autologous cord blood following the Frepp-sepp and Hibiclens applications compared to betadine spray indicates that both solutions are effective in reducing the risk of bacterial contamination after a brief cleansing of the umbilical cord surface. 2 The isolate of S. epidermidis found after Frepp-sepp preparation may represent superficial umbilical cord colonization or a laboratory contaminant, since the infant with this positive autologous cord blood culture was healthy. The growth of the nonpathogenic anaerobe, Gaffkya sp., in the Hibiclens preparation is unlikely to be a laboratory contaminant, since this organism is generally found as a transient on the skin and mucous membranes. Consequently, if autologous cord blood is required in an emergency situation, we recommend that it be infused immediately after collection to decrease the time for in vitro bacterial growth. The authors acknowledge the assistance of the resident and nursing staffs of the Department of Obstetrics and Gynecology and of the technical staff of the Division of Microbiology, Naval Hospital, Bethesda, Maryland. REFERENCES 1. Paxon CL. Collection and use of autologous fetal blood. AM 1 0BSTET GYNECOL 1979;134:708-10. 2. Golden SM, O'Brien WF, Lissner C, Cefalo RC, Monaghan WP, Schumacher H. Hematologic and bacteriologic assessment of autologous cord blood for neonatal transfusions. 1 Pediatr 1980;97:810-12.
Drainage of postabortion hematometra by Foley catheter Max Borten, M.D., and Emanuel A. Friedman, M.D., Sc.D. Department of Obstetrics and Gynecology, The Charles A. Dana Biomedical Research Institute, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts
Hematometra immediately following a suction curettage for pregnancy termination (postabortion syndrome) is usually diagnosed within hours of the original surgical procedure because of its characteristic manifestations. 1• 2 Hallmarks of this complication are uterine enlargement (frequently to a larger volume than preceding the evacuation) accompanied by exquisite suprapubic pain, which is constant in nature. Its physiopathologic mechanism appears to be uterine atony with rapid accumulation of blood and clots within the uterine cavity. Impediment to the outflow of
Reprint requests: Max Borten, M.D., Department of Obstetrics and Gynecology, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215.
August 15, 1984 Am. J. Obstet. Gynecol.
this blood seems to result from obstruction of the internal os by clotted blood. Bleeding within the uterus is self-limiting; once the uterus has become overdistended, the intrauterine pressure controls the bleeding. At the same time the pressure build-up causes the severe pain and syncopal symptoms. The currently accepted treatment regimen to alleviate this condition consists of repeat suction curettage. In our institution this entails returning the patient to the operating room from the recovery room or the ambulatory surgical unit facility. The discomfort and distress of the first procedure are further compounded by the fear and anxiety associated with having to go through it again, a psychologically traumatic event for most patients. We sought a means to resolve this complication without having to subject the patient to another surgical procedure. For this purpose, we utilized a Foley catheter of wide bore (No. 20 French) attached to a 60 ml plastic syringe with catheter tip to effect drainage of the uterine content. During the 7-year period of 1977 to 1983 a total of 3518 first-trimester abortions were performed. Among them, 12 were complicated by hematometra postoperatively (0.34%). Seven were selected for this trial. The patient was placed in the semifrog postion with elevation of the hips. A Graves speculum was inserted vaginally to visualize the cervix. Under direct vision in five cases, a soft, malleable No. 20 Foley catheter was inserted into the uterine Cavity, and a 60 ml plastic syringe was attached. In two instances we used a straight rubber catheter and syringe. The suction obtained was sufficient to drain 300 to 500 ml of retained clots and unclotted blood. Patients experienced immediate relief as soon as the blood was removed and the distention of the uterine cavity relieved. The concomitant administration of methylergonovine maleate, 0.2 mg intramuscularly, aided in accomplishing sustained uterine contraction and in preventing the reaccumulation of blood in the endometrial cavity. The catheter was removed upon relief of symptoms and firmness of the uterus obtained. All patients were observed for up to 3 hours and then discharged as previously planned without the need for operative evacuation or other treatment. None experienced any subsequent problems. The increase in the number of first-trimester pregnancy interruptions, as well as the recent acceptance of dilatation and evacuation for the termination of more advanced second-trimester gestations, suggests that the number of postabortion hematometras will increase. Although the number of cases is admittedly small, the success of this simple technique for evacuating retained blood via transcervical Foley catheter drainage encourages us to recommend it as the first line of treatment for the postabortion syndrome (hematometra). The advantages of this mode of therapy are that ( 1) no anesthesia is required, since the cervix is sufficiently dilated to accept the large catheter without additional stretching; (2) the procedure can be carried out with no delay