Barbara Barrano

No association between apolipoprotein E polymorphisms and recurrent pregnancy loss.

Our study does not support the reported association between APOE and recurrent pregnancy loss (RPL) than the clinical management of these patients should not be influenced by the presence or not of APO E polymorphisms.

Unexplained infertility and inherited thrombophilia

Approximately 15%–30% of couples (1) will be diagnosed with unexplained infertility after their diagnostic workup, as suggested in guidelines (2), fails to reveal any abnormality. The treatment for unexplained infertility is therefore, by definition, empiric because it does not address a specific defect or functional impairment (1). The principal treatments for unexplained infertility include expectant observation with timed intercourse and lifestyle changes, clomiphene citrate (CC) and IUI, controlled ovarian hyperstimulation (COH) with IUI, and IVF. In addition, the likelihood of pregnancy without treatment among couples with unexplained infertility is less than that of fertile couples but greater than zero. It is possible that unexplained infertility represents the lower extreme of the normal distribution of fertility with no defect present. Recently a possible association between unexplained infertility and genetic thrombophilia gene mutations have been reported (3), with a significant statistically association with MTHFR C677T polymorphisms. We have examined 32 couples with unexplained infertility compared with a control group of 130 couples with recurrent pregnancy loss referred to our Centre for genetic counseling. The infertile couples had been trying to achieve a successful pregnancy for more than 1 year without success and known causes of infertility were excluded (semen anomalies, karyotype abnormalities, uterine malformations, tubal occlusion, hormonal dysfunctions, and celiac disease). In the recurrent pregnancy loss group all pregnancy losses were registered in the first trimester of pregnancy, anatomical anomalies of the uterus, chromosomal, immunologic risk factors (including antiphospholipid antibodies, antinuclear antibodies, antithyroid antibodies, and lupus anticoagulant), and celiac disease were excluded. Genetic evaluation included factor V (G1691ALeiden and H1299R); factor II prothrombin (G20210A), and methylenetetrahydrofolate reductase (MTHFR) with C677T and A1298C mutations that represent the most common, clinically significant, inherited thrombophilias. The other gene mutations included in the thrombophilic diagnostic tests were performed but were excluded for this analysis. Our results showed a statistically significant association between the two groups for factor VH1299R mutation heterozygosity (P1⁄4.001) and for MTHFR C677T homozygosity (P1⁄4.02). No significant associations were found for factor V-Leiden, MTHFR-A1298C homozygosity, compound heterozigosity for C677T and A1298C, and heterozigosity for C677T or A1298C. Inherited thrombophilia is believed to

Isolated congenital amastia: a subclavian artery supply disruption sequence?

Isolated Congenital Amastia: A Subclavian Artery Supply Disruption Sequence? Sebastiano Bianca,* Maria Licciardello, Barbara Barrano, and Giuseppe Ettore Centro di Consulenza Genetica e di Teratologia della Riproduzione, Dipartimento Materno Infantile, ARNAS Garibaldi Nesima, Catania, Italy Dipartimento di Pediatria, Universit a di Catania, Italy U.O.C. Ginecologia e Ostetricia, Dipartimento Materno Infantile, ARNAS Garibaldi Nesima, Catania, Italy

Mosaic trisomy 20: Considerations for genetic counseling

Trisomy 20 is one of the most common types of mosaic trisomy detected on prenatal diagnosis, whether by amniocentesis or chorionic villus sampling. Many of the prenatally detected cases are not fetal trisomy as the trisomic cells found on amniocentesis or chorionic villus sampling in these cases, originate from and are restricted to the placenta or other extra embryonic tissue. Even if few cases with congenital abnormalities have been reported, more than 90% of cases were associated with healthy babies. Factors predictive of outcome in the case of prenatally diagnosed trisomy 20 mosaicism have been proposed and include the presence of uniparental disomy (UPD), origin and level of trisomy. Moreover, firm conclusions for genetic counseling are not evident. Recently, Willis et al. [2008] reported three patients with mosaic trisomy 20, two of whom were identified prenatally and suggest that with long term follow up a subtle phenotype does exist and includes spinal abnormalities (spinal stenosis, vertebral fusion, and kyphosis), hypotonia, lifelong constipation, sloped shoulders, and significant learning disabilities despite normal intelligence. Some of these findings may be overlooked on routine history and physical exam or assumed to be standard pediatric problems. No dysmorphic features have been reported. On the basis of these observations, we think that, in the absence of specific guidelines for prenatal genetic counseling, some considerations may be useful for genetic management. Based on available literature and personal experience we have proposed [Bianca et al., 2005] that in the cases of prenatally detected trisomy 20, it is important to tell the parents that: (1) a second invasive sample to confirm the presence of a true fetal mosaicism does not provide conclusive remarks and risks spontaneous abortion; (2) fetal blood sampling is not helpful, as the trisomic cells do not appear in blood even in the cases with abnormal outcome; (3) UPD study is not useful because UPD cases do not differ substantially with trisomy mosaicism; (4) trisomy mosaicism levels do not influence the outcome; (5) second-level ultrasonography at 20–22 gestational weeks may exclude severe congenital anomalies and intrauterine growth retardation (IUGR) and may be useful, when normal, in providing some reassurance to parents. Thus, in absenceof severe structural anomalies and even though a mild phenotype cannot be excluded as suggested by Willis et al. [2008], it is important to reassure the parents about the unlikelihood of severe mental retardation and dysmorphic appearance, findings that often are the most important components in the decision of voluntary termination the pregnancy in the absence of structural anomalies on prenatal ultrasonography. Finally we agree with Willis et al. [2008] in the opportunity to long term follow up mosaic trisomy 20 patients with special attention to spinal evaluation even if in the majority

Familial nuchal cystic hygroma without fetal effects: Genetic counselling and further evidence for an autosomal recessive subtype.

Nuchal cystic hygroma (NCH) is a congenital malformation in which distended fluid-filled spaces develop typically in the region of the fetal neck at incidences of 1/6000 at birth and 1/750 among spontaneous abortions (Chen et al. 1996). Prenatal diagnosis by ultrasound is based on the demonstration of a bilateral, mostly symmetric, cystic structure located in the occipitocervical region with the lesion either septated by internal trabeculae (septated) or not (nonseptated). Septated NCH may result from complete obstruction in the cervical lymphatic sacs preventing communication with the jugular venous system and causing large multilocular cysts. In contrast, it is believed that nonseptated NCH result from a temporary accumulation of lymphatic fluid due to incomplete obstruction of lymphatic drainage (Brumfield et al. 1996). Increased pressure in the lymphatic system may sometimes overcome the incomplete obstructions, thus explaining the spontaneous resolution of these lesions (Bernstein et al. 1991). Differential diagnosis is made with nuchal translucency (NT), which is defined as measurement of the size of the translucent space behind the neck of the fetus using ultrasound at between 10 and 14 weeks of pregnancy, reflecting the amount of fluid that has accumulated under the skin of the fetus. Increased NT is associated with an increased risk of chromosomal abnormality and is a marker for major cardiac defects, noncardiac structural defects, and rare genetic syndromes. When cystic hygroma appears septated, the prognosis is considered even worse than the nonseptated form. Fetuses with NCH are at high risk for adverse outcome and detailed prenatal diagnosis, including invasive procedures, should be offered because the condition has been reported to be associated with normal chromosomes in 20–40% of cases, and is frequently associated with chromosomal aberrations such as X monosomy and trisomy 21, 18, and 13. It is also known to be associated with cardiac anomalies and no immune hydrops fetalis. Compared with simple increased NT, cystic hygroma has five-fold, 12-fold, and six-fold increased risks of aneuploidy, cardiac malformation, and perinatal death, respectively (Malone et al. 2005). Moreover, to determine fetal outcome in NCH cases with normal karyotypes, detailed sonography should be concentrated beside the exclusion of fetal heart defects and existence of hydrops fetalis, on the skeletal, urogenital and craniofacial anomalies, as these might cause severe morbidity (Tanriverdi et al. 2005). Interestingly, in utero resolution of NCH with advancing gestational age has been described both in chromosomally normal (Bronshtein et al. 1989) and abnormal (Rodis et al. 1988) fetuses with resolution of the cystic hygroma in the 10% of the aneuploid cases and 17.6% of the euploid cases (Ganapathy et al. 2004). NCH has often a very poor fetal outcome (Tanriverdi et al. 2001); however, it can resolve spontaneously and isolated NCH with a normal karyotype and no other suspicious sonographic findings has a moderately good prognosis and most pregnancies with normal evaluation at the completion of the second trimester result in a healthy infant with a normal pediatric outcome (Malone et al. 2005). Knowledge of the natural history of this condition has implications in counseling, invasive testing and follow-up of fetuses diagnosed with this condition. Familial cases have been described suggesting a genetic basis of the condition with possible Mendelian inheritance. Dallapiccola et al. (1984) described two sib fetuses with NCH and normal chromosomes and suggested the existence of an autosomal recessive type of cystic hygroma. Tricoire et al. (1993) reported eight cases of familial cystic hygroma concerning three families with parental consanguinity. Watson et al. (1990) described a patient who had three consecutive fetuses with cystic hygroma and hydrops, two of which had documentation of normal karyotype. Rotmensch et al. (2004) described 18 families in which 18 pairs of siblings were affected by transient nonseptated cystic hygromata. We have observed two families in which there was a recurrence of septated NCH in two consecutive pregnancies. In all four fetuses the karyotypes were normal and no other known causes were detected (such as associated anomalies or infection). The first couple decided to voluntary terminate the pregnancies in the second trimester. Fetal autopsy showed no congenital anomalies other than those detected by ultrasound. In the second family prenatal diagnosis of septated NCH was made in two consecutive pregnancies and after evidence of no abnormalities (karyotype, ultrasound and infections) the couple decided to continue the pregnancies with the birth of two healthy babies; NCH decreased in the late second trimester and disappeared progressively. Even if an autosomal recessive pattern of inheritance has been postulated, cystic hygroma may also occur in association with a variety of syndromes, like Noonan syndrome, some of which have other patterns of inheritance. Prenatal diagnosis is often made in the first or early in the second trimester, and it is frequently very difficult for prenatal genetic counseling to give a fetal prognosis in the absence of anomalies or to give a recurrence risk for future pregnancies after a voluntary terminated pregnancy in the second trimester without evidence of known etiologies. Malone et al. (2005) have proposed a step-by-step prenatal counseling based on a standardized diagnostic algorithm when a diagnosis of septated cystic hygroma in the first trimester is made. Initial counseling should occur immediately after sonographic diagnosis, and an overall risk of fetal aneuploidy of one in two should be quoted. After confirmation of a normal fetal karyotype, a second counseling session should be provided. At that time, prospective parents should be given a residual risk of one in two of a major structural fetal abnormality or spontaneous fetal death. After completion of detailed fetal anatomic sonography and echocardiography by 16–20 weeks of gestation, patients with normal findings can then be quoted a 95% chance of a normal pediatric outcome. Our case of recurrence without neonatal anomalies and the other two cases without evidence of a recognizable cause confirm the suggested existence (Rotmensch et al. 2004) of an inconsequential genetic syndrome without fetal effects related presumably to lymphatic development with an autosomal recessive inheritance pattern. The existence of this possible genetic subtype may be included in prenatal genetic counseling of NCH fetus without known etiology. doi:10.1111/j.1741-4520.2010.00273.x Congenital Anomalies 2010; 50, 139–140 139

Fetal upper limb amelia with increased nuchal translucency

Embryogenesis of the upper extremity commences four weeks after fertilization, with formation of the upper limb bud on the lateral wall of the embryo, and ends at eight weeks of gestation. In animal models three signaling centers of limb development have been discovered. The apical ectodermal ridge is obligated for limb development in a proximal-to-distal direction. The zone of polarizing activity functions as a signaling center for anterior-to-posterior (radioulnar) limb development. The Wnt signaling center resides in the dorsal ectoderm and secretes factors that induce the underlying mesoderm to adopt dorsal-to-ventral axis configuration. Abnormalities within one signaling center indirectly prohibit adequate functioning of the other two remaining centers and affect limb formation (Bamshad et al. 1999). Amelia, the absence of upper and/or lower limbs, represents a longitudinal failure of formation with an absent intervening segment of the extremity (intercalary aplasia). Amelia may be unilateral or bilateral, with different levels of severity in relationship with embryogenesis disruption and may present as an isolated or associated finding, often inherited as part of a genetic syndrome. The isolated form is often sporadic, moreover an autosomal recessive inheritance (OMIM 601360) was supposed by Michaud et al. (1995). Nuchal translucency (NT) is defined as a measurement of the size of the translucent space behind the neck of the fetus using ultrasound between 10 and 14 weeks of pregnancy, reflecting the amount of fluid that has accumulated under the skin of the fetus. Increased NT is associated with an increased risk of chromosomal abnormality and is a marker for major cardiac defects, noncardiac structural defects, and rare genetic syndromes, including skeletal dysplasias in chromosomally normal fetuses (Snijders et al. 1998; Hyett et al. 1999). The association between upper limb amelia and increased NT has been reported only by Souter et al. (2002) in a case of monochorionic, diamniotic twin pregnancy. The patient was referred to us at 13 weeks of gestation in her first pregnancy. There was no history of teratological exposure or family genetic condition; maternal age was 35 years and paternal age was 40. Ultrasonographic evaluation with 2D and 4D demonstrated an NT value of 3 mm and upper limb amelia (Fig. 1). Fetal karyotype was 46,XY. After genetic counseling the couple decided to perform voluntary termination of pregnancy. Fetal examination and X-ray confirmed the upper limb amelia (Fig. 2) without additional anomalies at fetal autopsy. The pathophysiological mechanisms of increased NT are not clear and may vary with the underlying condition. These include over-expression of collagen VI and increased hyaluronan in the skin of fetuses with trisomy 21 (Von Kaisenberg et al. 1998; Bohlandt et al. 2000). Mediastinal compression due to narrowing of the fetal chest and alterations in the composition of the dermis have been postulated as possible causes of increased NT in fetuses with skeletal dysplasias (Makrydimas et al. 2001). Moreover pathophysiological mechanisms underlying increased NT in the presence of upper limb phocomelia are not clear. In conclusion, the present case adds to the body of literature supporting an association between increased NT and skeletal abnormalities. It also serves as a reminder of the value of looking for fetal structural abnormalities on sonography when increased NT is detected in the first trimester of pregnancy.

Congenital perineal hernia in a fetus with X monosomy

Congenital defects in the pelvis and perineal area, which are derived from defective development of the cloacal membrane, urorectal septum, mesonephric and paramesonephric (Müllerian) ducts, and urogenital sinus, have been described. Congenital pelvic floor hernias are extremely rare and most published cases involve adults and have occurred after surgery or in individuals with a weak pelvic floor; only a small number of cases of congenital perineal hernia in children have been described (Mohta and Bhargava 2004). Perineal hernias are divided into anterior and posterior, depending upon their relationship with the transverse perinei muscle. The anterior type emerges through the urogenital diaphragm in the triangle formed by the transverse perineal, ischiocavernous and bulbospongiosus muscles. These occur almost exclusively in women. The posterior type is less common and emerges through a defect in the levator ani muscle or between the levator ani and coccygeus muscles. Congenital defects causing primary hernia are extremely rare. The etiology of congenital perineal hernia is thought to be the persistence of a cul-de-sac descending into the perineum during embryonic life. A perineal hernia protrudes through the pelvic floor formed by the levator ani and coccygeus muscles along with their fascia. A woman was referred to us at 15 weeks of gestation in her first pregnancy. There was no history of teratological exposure or familial genetic condition. The maternal age was 25 years and the paternal age was 30 years. Ultrasonographic evaluation demonstrated the presence of nuchal cystic hygroma. The fetal karyotype was 45,X. After genetic counseling the couple decided to perform voluntary termination of the pregnancy. Fetal examination showed a perineal prolapse of multiple bowel loops (Fig. 1) without additional anomalies at fetal autopsy. The perineal defect was located between the vaginal orifice and the anus. The urinary bladder, vagina, and rectum were intact without fistulae. The herniated bowel consisted of small and large intestines. Turner syndrome (TS), occurs in approximately 50 per 100 000 girls, and is defined by a partially or completely absent X chromosome (Gravholt 2004). The majority of TS patients have a 45,X karyotype. Short or long arm deletion, ring X, isochromosome and mosaicism have been reported. Cardinal features include growth retardation and reduced adult height, with or without additional features, such as minor facial dysmorphism, associated anomalies, gonadal insufficiency and infertility (Gravholt 2004). Fetal perineal hernia has been recently reported for the first time in a fetus with trisomy 18 by Steffensen et al. (2009). Our case constitutes the first published case associated with monosomy X. The perineal defect, which led to bowel herniation may have been secondary to pressure necrosis of the perineal skin. As supposed by Steffensen et al. (2009) in a trisomy 18 fetus, a defect in the formation of the secondary perineum may be the etiological explanation of the reported congenital defect and may be the same etiological mechanism in our observed case.

Prenatal diagnosis of 45,X/46,XY mosaicism with cleft lip and epispadias

Introduction45,X/46,XY mosaicism is an uncommon chromosomal anomaly with a range of phenotypes from normal males to cases of multiple congenital anomalies.Materials and methodsWe report a case with associated cleft lip and epispadias prenatally diagnosed with autopsy evidences.ConclusionOur case, with an uncommon association of congenital anomalies, stresses the difficulty of prenatal counselling regarding 45,X/46,XY mosaicism and discuss the possible role of sex chromosome genes that may be involved in the pathogenesis of both types of midline defect.

Craniorachischisis and heterotaxia with heart disease in twins: link or change nature?

Craniorachischisis is a rare neural tube defect in which both acrania and a complete schisis of the vertebral column are present. Heterotaxy results from failure to establish normal left-right asymmetry during embryonic development and is characterized by a variable group of congenital anomalies that include complex cardiac malformations and situs inversus or situs ambiguous. We report a diamniotic twin pregnancy with two malformed fetuses affected one by craniorachischisis and the other by heterotaxya with paired right-sided viscera, asplenia, and complex congenital heart disease. The occurrence of severe congenital anomalies in both members of the twin pair implies a strong influence of genetic factors. At present, the genetic basis determining the different phenotypes observed in our twins is unknown. Our case with the simultaneous presence of both midline and laterality defects in twins supports the hypothesis that the midline plays a critical role in establishing left-right asymmetry in the body and that a mutation in a gene responsible for both heterotaxy and midline defects may be strongly supposed.

Clinical management of Rendu-Osler-Weber syndrome and genetic thrombophilia.

Rendu-Osler-Weber syndrome or hereditary haemorragic telangectasia (HHT) is an autosomal dominant disorder. The four clinical diagnostic criteria include epistaxes, telangiectasia, visceral lesions, and family history. HHT diagnosis can be made if three criteria are present and cannot be established in patients with only two criteria, but should be recorded as possible or suspected in order to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although, children of affected individuals should be considered at risk in view of age-related penetrance in this disorder [1]. Genetic heterogeneity was indicated by the results of linkage studies, moreover, mutations in endoglin (ENG) and activin receptor-like kinase 1 (ALK1) genes were reported [2]. The coexistence of HHT and thrombophilia, two genetic disorders that theoretically may have the opposite actions on hemostasis has been rarely reported [3,4]. Such states pose a difficult management problem when occurring together in one patient. We have observed a 45-year-old man, who was referred to our centre for genetic counselling. He was affected by HHT characterized by spontaneous, recurrent epistaxis (onset childhood), nasal mucosa, finger pad telangiectases and, three transient ischemic attack (TIA) with hemiparesis which subsided completely within few weeks. A similar clinical situation was reported for the patient’s father who died of a stroke at 58 years. Testing for acquired thrombophilia showed normal values. Genetic test for inherited thrombophilia showed that the patient was heterozygous for Factor V-Leiden mutation, homozygous for C677T mutation of methylenetetrahydrofolate reductase (MTHFR) gene and, homozygous for 4Gallele polymorphism of plasminogen activator inhibitor (PAI-1) gene. Cyclic aspirin treatment after TIA was reported complicated by nasal haemorrhages treated with tranexamic acid. Biochemical test for homocysteinemia revealed hyperhomocysteinemia that was treated with