Variability in the phenotypic expression of fryns syndrome: A report of two sibships

We report on two sibships with four fetuses of 12, 15, 17, and 20 weeks of gestation, respectively, and 1 preterm baby of 31 weeks of gestation affected by a multiple congenital disorder with manifestation suggestive of Fryns syndrome. In addition to the characteristic malformation pattern in Fryns syndrome, they presented with fetal hydrops, cystic hygroma, and multiple pterygias, allowing prenatal ultrasound diagnosis as early as in the 11th week of gestation. The two affected fetuses of family 1 showed severe craniofacial anomalies with bilateral cleft lip and palate, acral hypoplasia, postaxial oligodactyly, persistent truncus arteriosus, and interrupted aortic arch, asplenia sequence, and complex central nervous system midline malformations. In family 2 with three affected sibs, ear anomalies with atresia of the auditory canals, postaxial hexadactyly, intestinal atresias, callosal defects, and eye colobomas were the most outstanding features. On the basis of the present findings and former reports, the inter- and intrafamiliar phenotypic variability in Fryns syndrome, possible pathogenetic mechanisms, and the value of prenatal diagnosis are discussed. In the pathogenetic discussion, a special emphasis is put on the neural crest cell developmental field.

Fluctuation of maternal and fetal free extracellular circulatory DNA in maternal plasma

OBJECTIVE

To examine whether concentrations of free extracellular fetal circulatory DNA in maternal plasma are stable or fluctuate.

METHODS

Consecutive blood samples were drawn from 13 healthy nonpregnant volunteers and from 16 healthy pregnant women over 3 days. DNA was isolated from the plasma fraction and quantified by real-time polymerase chain reaction (PCR).

RESULTS

In nonpregnant controls the total amount of cell free DNA fluctuated by an average of 13.5-fold. In samples obtained from pregnant women the amount of maternal cell free DNA varied by an average of 21.5-fold. Because ten of those women were pregnant with male fetuses, the concentration of free fetal DNA in these cases was determined by a real-time PCR assay for the Y chromosome. The mean variation in free fetal DNA levels in male fetuses was 2.2-fold.

CONCLUSION

The degree of variation in free fetal DNA concentrations observed in this study was similar to published values, so these results imply that care should be exercised when considering quantitation of this fetal material for potential diagnostic or screening purposes.

Increased nuchal translucency in a case of long-chain 3-hydroxyacyl- coenzyme A dehydrogenase deficiency

We present a case where the embryo showed an increased nuchal edema and a metabolic disorder. At 31 weeks of gestation the fetus developed a cardiomegaly and a hydrops. In this case, a long-chain 3-hydroxacyl-coenzyme A dehydrogenase deficiency (LCHAD deficiency) was confirmed by biochemical investigations in cultured chorionic villus cells and by DNA analysis. This metabolic disease causes a reduced production of mitochondrial trifunctional proteins and is a very rare autosomal-recessive disease.

Assessing the chromosome copy number in metaphase II oocytes by sequential fluorescence in situ hybridization

PURPOSE

Aneuploidy in oocytes is the main cause of failed embryo implantation and of miscarriage. At present, only limited data on the prevalence of aneuploidy in freshly collected human oocytes are available and all studies have been performed with conventional methods for karyotyping. In this feasibility study, multiple-hybridization fluorescence in situ hybridization (FISH) was evaluated as an alternative method to determine the number of chromosomes in oocytes.

METHODS

Fifty-two spare oocytes were collected from 23 patients treated with gonadotropins for intrauterine insemination or intracytoplasmic sperm injection. A conventional dual color FISH approach using mixtures of chromosome-specific standard alpha-satellite probes was applied consecutively to the chromosomes of the same metaphase II oocyte. Mixtures of three to six probes were designed in order to allow chromosome identification based on signal color and centromeric index.

RESULTS

One hybridization cycle was possible in 52 uninseminated metaphase II oocytes, two hybridizations in 43 oocytes (82.7%), three hybridizations in 30 oocytes (57.6%), four hybridizations in 27 oocytes (51.9%), and five hybridizations in 15 oocytes (28.8%). Altogether, 591 chromosomes could be marked (47.4% of the entire chromosome complement, 11.4 chromosomes per oocyte). The most important single factor contributing to technical failure was loss of the oocyte from the slide.

CONCLUSION

This feasibility study demonstrates that multiple-hybridization FISH can be used for the assessment of a larger proportion of the chromosome complement in oocyte as compared to previous studies based on FISH.

Developmental changes in adhesion molecule expressions in umbilical cord blood CD34 hematopoietic progenitor and stem cells

OBJECTIVE

The purpose of this study was to determine whether expressions of the cell adhesion molecules LFA-1 (CD11a), VLA-4 (CD49d), and L -selectin (CD62L ) on CD34(+) stem and progenitor cells in umbilical cord blood change during gestation.

STUDY DESIGN

In a prospective observational study 3-color fluorescence-activated cell sorting was used to assess the levels of expression of CD11a, CD49d, and CD62L on CD34(+) cells in fresh cord blood samples collected at delivery between 22 and 42 weeks' gestation.

RESULTS

The relative number of CD34(+) cells decreased as gestational age increased (r = -0.71; P<.001). Conversely, we found significant increases in cell adhesion molecule expression by CD34(+) cells during gestation (LFA-1, r = 0.47; P =.001; VLA-4, r = 0.33, P =.031; L -selectin, r = 0.61; P<.001). Comparisons between grouped samples from early preterm (22-32 weeks' gestation), late preterm (33-37 weeks' gestation), and term (38-42 weeks' gestation) infants confirmed this correlation and revealed that the major increases occurred between early and late preterm gestation.

CONCLUSION

These results suggest a role for cell adhesion molecule expression in the process of migration and homing of circulating stem cells to the fetal bone marrow toward the end of pregnancy. The findings may have implications for the use of preterm cord blood for hematopoietic stem cell transplantation and also for prenatal gene therapy.

Complications of lost needle after suture of vaginal tear following delivery

We present a case of a lost broken needle during repair of a vaginal tear following delivery. The woman was not informed at that time. Only twenty years later a pelvic X-ray visualised the fragment by chance. From that day on she complained about lower abdominal chronic pain and insisted on a hysterectomy. The case considers moving of foreign bodies and as a cause of chronic pain and relates to open information even 20 years later.

Fetal DNA in maternal plasma is elevated in pregnancies with aneuploid fetuses

Current non-invasive screening methods for the prenatal diagnosis of fetal aneuploidies are hampered by low sensitivities and high false positive rates. Attempts to redress this situation include the enrichment of fetal cells from maternal blood, or the use of fetal DNA in the plasma of pregnant women. By the use of real-time quantitative polymerase chain reaction (PCR) it has recently been shown that circulatory male fetal DNA in maternal plasma is elevated in pregnancies with trisomy 21 fetuses. In this independent study we confirm and extend upon these results by showing that the levels of fetal DNA are also elevated in pregnancies with other chromosomal aneuploidies (mean=185.8 genome equivalents/ml; range=62.2-471.7) when compared to pregnancies with normal male fetuses (mean=81.9 genome equivalents/ml; range=28.8-328.9), p=0.005. This elevation was greatest for fetuses with trisomy 21, whereas it was not significant for fetuses with trisomy 18, p=0.356. These data suggest that a quantitative analysis of such fetal DNA levels may serve as an additional marker for certain fetal chromosomal abnormalities, in particular for trisomy 21.

Inv(11)(p13p15) and myf-3(MyoD1) in a malignant extrarenal rhabdoid tumor of a premature newborn

We present a premature newborn of 32 wk of gestation with a congenital malignant extrarenal rhabdoid tumor (MERT) on the right shoulder with generalized metastases. Standard histologic, immunohistochemical, molecular and cytogenetic methods were used in the evaluation of diagnostic material. Biopsy of a skin lesion showed the histologic features of a malignant rhabdoid tumor. Cytogenetic analysis of the tumor cells revealed an inv(11)(p13p15) and additionally, an increased expression of myf-3 (myogenic determination factor, MyoD1) and PAX3 was detected. These results suggest an origin of the neoplasm derived from a pluripotent cell with the potential of myogenic differentiation. Tumor suppressor genes located on chromosome 11p13 and 11p15 may play an important role for malignant rhabdoid tumor development and progression.

High levels of fetal erythroblasts and fetal extracellular DNA in the peripheral blood of a pregnant woman with idiopathic polyhydramnios: case report

Abnormal amniotic fluid volume can be associated with increased maternal risk as well as perinatal morbidity and mortality. Polyhydramnios is often indicative of fetal, placental or maternal problems. In a large proportion of patients the aetiology of the disorder is unclear. Here we report on a case in which numerous fetal erythroblasts and large quantities of extracellular fetal DNA were found in the peripheral blood of a pregnant woman with idiopathic polyhydramnios bearing a male fetus. Following enrichment of erythroblasts by magnetic separation (MACS) and anti-CD71 antibodies, approximately 45-fold more erythroblasts were determined per ml peripheral maternal blood than in matched controls (231 versus 5). Single cell multiplex polymerase chain reaction (PCR) of individually micromanipulated erythroblasts showed that approximately 122 of these were of fetal origin. The concentration of extracellular fetal circulatory DNA in maternal plasma was determined by real-time quantitative PCR and shown to be almost double that of the control group (749.2 versus 404 fetal genome equivalents per ml maternal plasma). It can be speculated that the increased intrauterine pressure in polyhydramnios leads to an enhanced influx of fetal cells and free extracellular fetal DNA into the maternal circulation. This hypothesis will have to be tested with further cases.

Resistance of pelvic arteries and plasma lipids in postmenopausal women: comparative study of tibolone and continuous combined estradiol and norethindrone acetate replacement therapy

OBJECTIVE

We sought to compare vascular resistance and plasma lipids in postmenopausal women assigned to tibolone (a synthetic estrogen replacement steroid) therapy or continuous combined hormone replacement therapy.

STUDY DESIGN

Pulsatility and resistance indexes in pelvic arteries (color Doppler transvaginal ultrasonography) and lipids were monitored in this double-blind 1-year trial of 100 women randomized to either 2.5 mg tibolone or 2 mg 17beta-estradiol plus 1 mg norethindrone acetate daily.

RESULTS

Both indexes of the arcuate arteries (uterine arteries) were significantly reduced beyond 3 and 6 months (12 months) from baseline, respectively, by the combined regimen compared with tibolone alone. Tibolone increased the resistance index of arcuate arteries but did not affect uterine arteries. There was no effect of either regimen on the internal iliac arteries. The medians of the percentage changes from baseline of high-density lipoprotein cholesterol (triglycerides) were significant between groups after 1 year, as follows: -17% (-16%) in the tibolone group and -4% (+15%) in the combined group, respectively. Both regimens similarly reduced total and low-density lipoprotein cholesterol and lipoprotein Lp(a).

CONCLUSION

Hormone replacement therapy may induce different or opposite changes of both vascular resistance and lipids. It is unknown whether these findings may modify cardiovascular risk.

Prenatal diagnosis and obstetric management of Larsen's syndrome in a patient with an unrecognized family history of the disease

We report the third case of a prenatal diagnosis of Larsen's syndrome, which is the first report affecting both a 37-year-old primiparous caucasian woman and her fetus not considered to have Larsen's syndrome until the finding of bilateral clubfeet was demonstrated on screening ultrasound at 23 weeks of gestation. History and physical examination of the pregnant woman revealed severe impairment in the mobility of hip, elbow and knee joints starting in early childhood. Additional findings were spatulate thumbs and a flat nasal bridge. The mother of the pregnant woman demonstrated similar joint symptoms. The differential diagnosis of Larsen's syndrome was considered for the first time in both women. The patient wished to terminate her pregnancy, as the potential early onset of the same disorder was suggested by the finding of clubfeet. An intraamniotic instillation of ethacridinic acid was performed. On pathological examination including radiography of the male stillborn, various anomalies of the face, and upper and lower extremities were demonstrated compatible with Larsen's syndrome.

Maternal cerebral hemodynamics in pregnancy-related hypertension. A prospective transcranial Doppler study

AIM

To compare maternal cerebral hemodynamics, as assessed by transcranial Doppler studies, with the clinical and radiological findings in different types of pregnancy-related hypertension and to determine their pathophysiology.

METHODS

A prospective study of 66 consecutive pregnant women with hypertensive disorders (eclampsia, n = 3; pre-eclampsia, n = 41; isolated hemolysis, elevated liver enzymes, and low platelet count (HELLP)-syndrome, n = 12; pre-eclampsia superimposed on chronic hypertension, n = 5; chronic hypertension, n = 5) and 21 women with uncomplicated pregnancies. Mean blood flow velocities (Vmean) were assessed serially by means of transcranial Doppler in all basal arteries and correlated with changes in mean arterial blood pressure (MABP) and the clinical course.

RESULTS

Patients with the pre-eclampsia/eclampsia syndrome showed significantly elevated Vmean values as compared to controls. In the course of the illness Vmean over the whole length of all insonated basal arteries rose simultaneously. The three eclamptic patients showed the highest Vmean values (156, 182, 192 cm/s, respectively), of the middle cerebral artery (MCA) while MABP was 135, 135, and 150 mmHg, respectively. In pre-eclamptic patients the maximal Vmean MCA ranged from 80 (67, 93) to 145 (114, 151) cm/s [median (25th, 75th percentile)] depending on the severity of clinical presentation. In patients with isolated HELLP-syndrome changes in Vmean were either mild (5/12 cases) or absent (7/12 cases).

CONCLUSIONS

Considerable differences in cerebral hemodynamics were observed in the various types of pregnancy-related hypertensive disorders examined in this study. Our findings in patients with pre-eclampsia/eclampsia syndrome suggest a breakdown of autoregulation with hyperperfusion and vasogenic edema being the most probable pathophysiological mechanism.

Fetal cells in cervical mucus and maternal blood

Research in developing effective and accurate methods for non-invasive prenatal diagnosis has focused on two main techniques: the retrieval of trophoblast cells from the cervix and the enrichment of fetal erythroblasts from the blood of pregnant women. The isolation of fetal cells by both approaches has permitted the identification of fetal aneuploidies by the use of fluorescence in-situ hybridization (FISH) with appropriate probes, as well as fetal single gene disorders by polymerase chain reaction (PCR). In the latter instance, it has been shown that in order to attain the high degree of specificity required for prenatal diagnosis, it is necessary to analyse single fetal cells isolated by micromanipulation. This practice has permitted the successful characterization of fetal rhesus status, haemoglobinopathies, Duchenné's muscular dystrophy and spinal muscular atrophy, amongst others.Further developments include investigations into whether the diagnostic potential of fetal cells retrieved by either method can be expanded by the possible culturing of such cells, as well as the possibility of performing successive rounds of FISH and PCR by the recycling of isolated fetal cells.A novel observation that our group has made is that the traffic of fetal cells is enhanced in pregnancies affected by the pregnancy related disorder, pre-eclampsia. Our subsequent investigations have shown that this elevation in fetal cell traffic may serve as an early marker for those pregnancies at risk for this disorder.A very recent exciting discovery has been that free extracellular fetal DNA can be detected in the plasma and serum of pregnant women, which may permit the rapid and accurate detection of uniquely fetal loci, such as the fetal rhesus D gene in rhesus D negative pregnant women.

Prenatal diagnosis of a partial trisomy 19q

Phenotypic anomalies due to a genetic imbalance of chromosome 19 have been reported in very rare postnatal cases. Here a case of partial trisomy 19 diagnosed prenatally by ultrasonography and cytogenetic analysis is presented. Detailed evaluation by sonography showed major anomalies which could be correlated to the typical appearance of this chromosomal anomaly. Termination of pregnancy at 21 weeks of gestation was performed, and the prenatal diagnosis was confirmed postnatally by autopsy. The syndrome in this case was caused by a duplication of the long arm of chromosome 19 (46,XY, dup(19) (q13.1-->qter).

Preterm birth and the availability of cord blood for HPC transplantation

BACKGROUND

Cord blood from deliveries at term can be used for HPC transplantation. The objective of this study was to determine the amounts of cord blood nucleated cells (NCs) and HPCs that were collectable from preterm deliveries.

STUDY DESIGN AND METHODS

Cord blood collected from preterm deliveries between 22 and 36 weeks of gestation was compared with regard to volume, NC count (/mL), CD34+ cell count (/mL), and the NC and CD34+ cell counts per cord blood sample and at different gestational ages.

RESULTS

A correlation was found between gestational age and NC count (r = 0.52, p<0.001), and an inverse relation was found between gestational age and CD34+ cell count (r = - 0.68, p<0.001). The CD34+ cell count per cord blood sample was independent of gestational age (r = - 0.13, p = NS), and no significant difference between early (22-32 week) and late (33-36 week) preterm deliveries was found (p = 0.870). Comparison with published data from cord blood transplantations revealed that up to one-third of preterm samples contained at least as many NCs (or CD34+ cells) as the median cell dose transplanted (calculated for the median recipient weight) in the respective study. Furthermore, 77 percent of all preterm samples contained at least 1 x 10(7) NCs (and 42% at least 1 x 10(5) CD34+ cells) per kg for transplantation in a recipient of 20-kg body weight, which corresponds to the lower threshold of cells per kg in the graft recommended by Eurocord.

CONCLUSION

Preterm delivery should not be a reason to exclude cord blood collection if allogeneic cord blood transplantation in a sibling is planned.

Umbilical cord blood collection before placental delivery during cesarean delivery increases cord blood volume and nucleated cell number available for transplantation

OBJECTIVE

We sought to determine whether umbilical cord blood collection during cesarean delivery can be improved by collecting cord blood before delivery of the placenta.

STUDY DESIGN

Patients undergoing cesarean delivery were randomly assigned to cord blood collection before or after placental delivery. Closed sterile collection systems were used for blood sampling. Cord blood characteristics and maternal outcome parameters were compared between the 2 groups.

RESULTS

A total number of 40 patients were available for analysis. No differences in maternal and neonatal characteristics were found. A larger amount of cord blood volume (mean +/- SEM, 93 +/- 7.5 vs 66 +/- 6.6 mL; P =.013) and total nucleated cell number (11.1 +/- 1.2 vs 7.4 +/- 0.8 x 10(8) cells; P =.026) was obtained in the samples collected before compared with those collected after placental delivery. Similarly, there was a trend toward higher total CD34(+) cell number in samples collected in situ (30.0 +/- 6.0 vs 17.4 +/- 2.4 x 10(5) cells; P =.076). Estimated intraoperative blood loss, difference between prepartum and postpartum hemoglobin values, operating time, and puerperal infection rates were similar in both groups.

CONCLUSION

If a cesarean delivery is performed, cord blood sampling is more efficacious if performed before delivery of the placenta. This collection method seems beneficial and safe and might therefore be preferably used for related, as well as unrelated, cord blood stem cell banking and transplantation.

Detection of fetal Rhesus D and sex using fetal DNA from maternal plasma by multiplex polymerase chain reaction

OBJECTIVE

To test the sensitivity, specificity and reproducibility using fetal DNA obtained from plasma of pregnant women by polymerase chain reaction for the simultaneous detection of both fetal sex and Rhesus D genotype.

METHOD

Blood samples were obtained from 22 Rhesus D negative pregnant women about to undergo an invasive procedure. DNA was extracted from the plasma fraction and analysed by a multiplex nested polymerase chain reaction using Y chromosome-and Rhesus D-specific primers. The results of this experimental procedure were compared with those obtained from the analysis performed on material gained by the invasive procedure.

RESULTS

The sensitivity of the plasma polymerase chain reaction-based method was surprisingly high, with both fetal genotypes being correctly determined in almost 100% of the cases examined. In only one instance was a false positive result for the detection of Rhesus D recorded, which on subsequent analysis was negative.

CONCLUSIONS

The ease and rapidity with which the plasma polymerase chain reaction-based method can be performed makes it a promising method for the analysis of multiple fetal loci, such as Rhesus D and sex.

Prenatal diagnosis of beta-thalassaemia using fetal erythroblasts enriched from maternal blood by a novel gradient

We have assessed a new technique for the isolation of fetal erythroblasts from maternal blood for the non-invasive prenatal diagnosis of pregnancies at risk of beta-thalassaemia. This method relies on the separation of erythroblasts from maternal nucleated cells by a novel step gradient and high speed centrifugation. In four of the six cases examined, single erythroblasts were identified by immunohistochemistry for zeta (zeta) globin. These were individually micromanipulated and analysed by single cell polymerase chain reaction (PCR) and subsequent sequencing of the region of beta-globin locus where the mutations most common to the region of Puglia, Italy, are clustered. In each of the four instances where fetal erythroblasts were identified by antibody staining, the fetal beta-globin genotype was correctly determined. To date, this represents the largest series of non-invasive prenatal diagnoses performed for this haemoglobinopathy.

Transabdominal first trimester embryofetoscopy as a potential approach to early in utero stem cell transplantation and gene therapy

OBJECTIVE

To explore the potential of embryofetoscopy for early diagnosis and for access to the fetal circulation in the first trimester of gestation.

DESIGN

Transabdominal embryofetoscopy was performed in 14 patients scheduled for termination of pregnancy using a 1-mm semirigid fibreoptic telescope with a 18 gauge examination sheath and a single-chip digital camera. A 25 gauge needle was inserted through an additional 21 gauge side port to access the fetal circulation.

RESULTS

Fetal head, face, abdomen, complete upper and lower limbs could be visualized in over 80% of cases. On the contrary, the fetal back and external genitalia could be examined in detail only in some cases (35.7% and 64.3%, respectively). Injection of 10-20 ml saline improved visibility in 43% of cases. Funipuncture was successful in two of three attempts.

CONCLUSIONS

Our experience suggests that embryofetoscopy is a useful tool for early diagnosis in the first trimester of pregnancy. Funipuncture is possible thus providing the means for an early intravascular stem cell application.

An examination of different Percoll density gradients and magnetic activated cell sorting (MACS) for the enrichment of fetal erythroblasts from maternal blood

OBJECTIVE

To increase the yield of fetal erythroblasts from the blood of pregnant women by optimising and simplifying the enrichment procedure.

METHODS

By using an experimental system whereby cord blood was mixed with normal adult blood, we evaluated the recovery of fetal erythroblasts using different single or double percoll density gradients with or without subsequent enrichment by Magnetic Activated Cell Sorting (MACS).

RESULTS

The recovery of erythroblasts on single density gradients increased from 3%-68% of the input erythroblasts with an increase in the density of percoll from 1075 g/l-1098 g/l. Although the use of a double density gradient did eliminate most lymphocytes, it was accompanied by a significant loss of erythroblasts. The combination with MACS enrichment, however, lead to a almost 200 fold increase in the purity of erythroblasts.

CONCLUSIONS

Erythroblasts are preferentially retained by higher density gradients. To enhance their purity a subsequent more specific enrichment step, such as MACS is advisable.

Multiplex and real-time quantitative PCR on fetal DNA in maternal plasma. A comparison with fetal cells isolated from maternal blood

Fetal DNA has recently been detected in maternal plasma by PCR and has shown promise for the prenatal determination of fetal sex or rhesus D. In order to obtain the maximum amount of information from this fetal genetic material, we have devised a sensitive multiplex PCR method to permit simultaneous analysis for both the SRY locus and the rhesus D gene. Our studies show that this technique is very sensitive and specific. In the 22 cases from rhesus D negative women examined, we were able to determine both fetal genotypes correctly. In the parallel enrichment for fetal cells, fetal erythroblasts were only detected in 14 of the 19 cases. Our data also indicate that fetal DNA from rhesus D positive fetuses is present in maternal plasma even after prophylactic anti-D treatment. Furthermore, since fetal cells have been reported to be elevated in pregnancies with aneuploid fetuses, we have quantified the amount of fetal DNA present in the maternal plasma of 10 such affected pregnancies by real-time PCR. Our results indicate that fetal DNA is elevated under such circumstances when compared to gestationally matched normal pregnancies (mean of 7% in aneuploid samples versus 3.5% in normal pregnancies). These results indicate that the quantification of fetal DNA in maternal plasma may be an additional screening tool for pregnancies at risk of bearing an aneuploid fetus.