M Häusler

Quantitative fluorescence polymerase chain reaction for the rapid prenatal detection of common aneuploidies and fetal sex

OBJECTIVE We have developed a quantitative fluorescence multiplex polymerase chain reaction assay for the rapid detection of sex and aneuploidies involving chromosomes 21, 18, and 13. STUDY DESIGN Samples of deoxyribonucleic acid (n = 85) extracted from amniotic fluid, fetal tissues, and blood were investigated by multiplex polymerase chain reaction amplification of polymorphic small tandem repeat markers specific for chromosomes 21, 18, 13, and X. RESULTS Quantitative analysis of the polymerase chain reaction products allowed us to distinguish between normal samples and samples with autosomal trisomies while sexing was performed simultaneously. From 85 samples only three produced unsatisfactory results with one of the two chromosome 13-specific markers. In these three cases the amplification of the other chromosome 13 marker always resulted in a correct normal pattern. CONCLUSION Quantitative fluorescence multiplex polymerase chain reaction is a reliable and rapid method that allows prenatal diagnosis of the major numeric chromosomal abnormalities to be performed within 24 hours.

Absent or reversed end-diastolic blood flow in the umbilical artery and abnormal Doppler cerebroplacental ratio--cognitive, neurological and somatic development at 3 to 6 years.

UNLABELLED The objective of this study was to examine the cognitive, neurological and somatic developments of children who had in utero an absent or reversed end-diastolic blood flow (ARED) in the umbilical artery or an abnormal cerebroplacental ratio (ABF). METHODS 16 children with ARED blood flow and 15 children with ABF were each matched to children with the same gestational age, appropriate for gestational age, the same sex and born within 4 months. Data were assessed at the age of 3-6 years. Children with asphyxia, neonatal infection, malformation or major surgical interventions in the neonatal period were excluded. Each child underwent a neuropediatrical examination; furthermore, a Kaufman Assessment Battery for Children, a Snijders-Oomen Intelligence Scale for Children and a Man-Drawing Test were used to evaluate cognitive development. The socioeconomic status was also assessed. RESULTS Children in the ARED group remained lighter and had a higher frequency of microcephaly. In the Kaufman Assessment Battery for Children and the Snijders-Oomen Intelligence Scale for Young Children, cognitive development was impaired in the ARED and the ABF groups compared to the control group. The ARED and the ABF groups, however, showed no differences. The Man-Drawing Test and the Denver Development Test did not show any differences. DISCUSSION ARED blood flow and ABF showed impaired cognitive development. The degree of impairment was the same in the ARED and the ABF groups. Long-term follow-up studies until adulthood are necessary to see if impaired cognitive development remains significant in these groups of patients.

Cell-Free DNA Testing for Fetal Chromosomal Anomalies in clinical practice: Austrian-German-Swiss Recommendations for non-invasive prenatal tests (NIPT)

1. cfDNA testing should be offered only after, or in conjunction with, a qualified ultrasound and following appropriate counseling about the nature, scope and significance of the test. 2. cfDNA tests are screening tests. A high-risk cfDNA testing result should always be confirmed by an invasive diagnostic test (Chorionic villous sampling, amniocentesis), before a clinical consequence is drawn from the findings. 3. cfDNA testing can be used as secondary screening test for trisomy 21 (Down syndrome) for the reduction of invasive procedures after a high or intermediate risk result from First-trimester combined test (1 in 1,000 or > 1: 500 (FMF-D)). It should be noted that, even when cfDNA testing is used as a secondary screening, invasive diagnostic testing (Chorionic villous sampling, amniocentesis) is still the method of choice when the adjusted risk for trisomy 21 after the combined test is > 1:10 or the fetal nuchal translucency thickness is > 3.5mm or a fetal malformation is present. 4. cfDNA tests can also be used as a primary screening method for fetal trisomy 21 in pregnant women of every age and risk group. 5. In general, it should be noted that the performance of cfDNA screening for trisomy 18 (Edwards syndrome) and trisomy 13 (Patau syndrome) is lower than that for trisomy 21. 6. Based on the available evidence the use of cfDNA tests to screen for aneuploidy of sex chromosomes and microdeletion syndroms can currently not be recommended without reservation. Correspondence Österreich: Ass. Prof. Priv. Doz. Dr. med. Maximilian Schmid, Universitätsklinik für Frauenheilkunde Wien, E-Mail: maximilian. schmid@meduniwien.ac.at, Assoz. Prof. Priv.-Doz. Dr. Philipp Klaritsch, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz (Austria), E-Mail: philipp. klaritsch@medunigraz.at Deutschland: Prof. Dr. Bernd Eiben, MVZ Institut für Labormedizin und Klinische Genetik Rhein/Ruhr GmbH, E-Mail: eiben@eurogen.de Schweiz: Prof. Dr. med. Sevgi Tercanli, Ultraschall FreieStrasse Basel, E-Mail: sevgi. tercanli@unibas.ch Recommendation 507

Quality Requirements for the early Fetal Ultrasound Assessment at 11-13(+6) Weeks of Gestation (DEGUM Levels II and III)

The early fetal ultrasound assessment at 11 - 13(+6) weeks of gestation remains the cornerstone of care despite the progress in diagnosing fetal chromosomal defects using cell-free fetal DNA (cffDNA) from the maternal circulation. The measurement of nuchal translucency (NT) allows the risk calculation for the fetal trisomies 21, 18 and 13 but also gives information on those fetal chromosomal defects which are at present unable to be detected using cffDNA. Nuchal translucency is the only auditable parameter at 11 - 13(+6) weeks and gives thus information on the quality of the first trimester anomaly scan. In addition it gives indirect information on the risks for fetal defects and for cardiac anomalies. Also the chances for a healthy live baby can be estimated. As experience with first trimester anomaly scanning increases, and the resolution of the ultrasound equipment has increased substantially, more and more details of the fetal anatomy become accessible at the first trimester scan. Therefore fetal anatomical defects and complex anomalies have become amenable to examination in the first trimester. This guideline describes compulsory and optional parameters for investigation at the first trimester scan and outlines a structured method of examining a first trimester fetus at 11 - 13(+6) weeks of gestation.

Management of Bartholin's cyst and abscess using the Word catheter: implementation, recurrence rates and costs

OBJECTIVE Bartholins cysts and abscesses occur in about 2% of women. None of the surgical or conservative treatment approaches have been proven to be superior. The Word catheter is an outpatient treatment option, but little is known about aspects of implementing this therapy in an office setting. The present studys focus is on recurrence rates and organizational requirements of implementing outpatient treatment of Bartholins cyst and abscess and compares costs of Word catheter treatment and marsupialization. STUDY DESIGN Between March 2013 and May 2014 30 women were included in the study. We measured time consumed for treatment and follow-up and analyzed costs using the Word catheter and marsupialization under general anesthesia. We also assessed the ease of use of the Word catheter for application and removal using a standardized visual analog scale (VAS 1-10). RESULTS Word catheter treatment was successful in 26/30 cases (87%). Balloon loss before the end of the 4-week treatment period occurred in 11/26 cases with a mean residence time of 19.1 (±10.0) days. None of the patients with early catheter loss developed recurrent cyst or abscess. Recurrence occurred in 1/26 cases (3.8%). Difficulty-score of application was 2 [1-10] and of removal 1 [1], respectively. Costs were € 216 for the treatment in the clinic as compared with € 1584/€ 1282 for surgical marsupialization with a one-night stay or daycare clinic, respectively. CONCLUSIONS The present study indicates that the Word catheter is an easy to handle, low cost outpatient procedure with acceptable short-term recurrence rates. Treatment costs are seven times lower than for marsupialization.

Severe primary pulmonary lymphangiectasis in a premature infant: Management and follow up to early childhood

Primary pulmonary lymphangiectasis (PPL) is a rare congenital developmental abnormality of the lung with a generally poor prognosis. Only a limited number of patients with neonatal‐onset PPL have been reported to survive. We present the case of a male preterm infant (gestational age 34 weeks 6 days) with histologically confirmed PPL, complicated by hydrops fetalis, bilateral hydrothorax (treated in utero with pleuro‐amniotic shunts), and immediate respiratory distress at birth. He survived after extensive neonatal intensive care therapy and was discharged home at the age of 7 months. At last follow up he was 3 years 7 months old, still requiring assisted ventilation via tracheostomy, having recurrent episodes of wheezing and had mild global developmental delay. This case demonstrates that survival beyond the neonatal period is possible even with severe PPL but long‐term morbidity may be relevant, and multidisciplinary management and close follow up are essential.

Quality of life and sexual activity during treatment of Bartholin's cyst or abscess with a Word catheter

OBJECTIVES Cysts and abscesses of the Bartholin glands are a common occurrence in gynecologic or general practice. Little is known about restrictions in patients daily life and sexual activity during treatment of Bartholins cysts in general and especially with the Word catheter. This study is to assess the Quality of Life and Sexual Activity during treatment of Bartholin cysts and abscesses with the Word-catheter. STUDY DESIGN Between March 2013 and May 2014 30 women were included in the study. Pain before treatment and during catheter insertion and removal was assed using a standardized VAS scale. Health-related quality of life was assessed with the Short-Form-12-Health-Survey. Fallowfields Sexual Activity Questionnaire was administered to investigate sexual limitations. During treatment patient self-reported to a pain-diary (VAS 0-10). RESULTS Pain levels decreased from a 3 [0-10] on day 1 to 0 [0-6] on day 6 with the median staying at 0 for the remaining treatment period. Discomfort and pain during sexual activity decreased significantly from initial presentation to end of treatment. The mental component summary score of the SF 12 increased significantly from 46.94±10.23 before treatment to 50.58±7.16 after treatment (p=0.016); the physical component summary score did not change significantly. CONCLUSIONS The Word catheter is well tolerated for the treatment of Bartholins cysts and abscesses with few and no serious side effects and little impingement of sexual health. A more relevant informed consent ahead of treatment, specifically with regard to pain in the first few days after catheter placement, might further increase acceptance of the catheter and adjust patient expectations.

Endothelial indoleamine 2,3-dioxygenase-1 regulates the placental vascular tone and is deficient in intrauterine growth restriction and pre-eclampsia

Indoleamine 2,3-dioxygenase-1 (IDO1) mediates the degradation of L-tryptophan (L-Trp) and is constitutively expressed in the chorionic vascular endothelium of the human placenta with highest levels in the microvasculature. Given that endothelial expression of IDO1 has been shown to regulate vascular tone and blood pressure in mice under the condition of systemic inflammation, we asked whether IDO1 is also involved in the regulation of placental blood flow and if yes, whether this function is potentially impaired in intrauterine growth restriction (IUGR) and pre-eclampsia (PE). In the large arteries of the chorionic plate L-Trp induced relaxation only after upregulation of IDO1 using interferon gamma and tumor necrosis factor alpha. However, ex vivo placental perfusion of pre-constricted cotyledonic vasculature with L-Trp decreases the vessel back pressure without prior IDO1 induction. Further to this finding, IDO1 protein expression and activity is reduced in IUGR and PE when compared to gestational age–matched control tissue. These data suggest that L-Trp catabolism plays a role in the regulation of placental vascular tone, a finding which is potentially linked to placental and fetal growth. In this context our data suggest that IDO1 deficiency is related to the pathogenesis of IUGR and PE.