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Iskrov G, Angelova V, Bochev B, Valchinova V, Gencheva T, Dzhuleva D, Dichev J, Nedkova T, Palkova M, Tyutyukova A, Hristova M, Hristova-Atanasova E, Stefanov R. Prospects for Expansion of Universal Newborn Screening in Bulgaria: A Survey among Medical Professionals. Int J Neonatal Screen 2023; 9:57. [PMID: 37873848 PMCID: PMC10594438 DOI: 10.3390/ijns9040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 09/21/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Determining the scope of a newborn screening program is a challenging health policy issue. Our study aimed to explore the attitudes of specialists in pediatrics, neonatology, medical genetics, and biochemistry regarding the prospects for expanding the panel of diseases for universal newborn screening in Bulgaria. We conducted an online survey in March-May 2022. The questionnaire listed 35 disorders that could potentially be included in the Bulgarian panel for universal newborn screening. If endorsing a specific condition, participants had to justify their position by judging its performance against the ten principles of Wilson and Jungner. We found a high degree of knowledge about the current universal newborn screening program in Bulgaria. An overwhelming majority (97.4%) supported the expansion of the panel to include more conditions. Four disorders obtained more than 50% approval for inclusion: cystic fibrosis (87.0%), thalassemia (72.7%), spinal muscular atrophy (65.6%), and classical galactosemia (59.1%). The perception of the condition as an important health problem was the most significant factor in this support. The costs of diagnosis and treatment appeared to be the main source of concern. We recommend country-specific economic evaluations and research on the views of other stakeholders, including the government, payers, and patient organizations, to better understand and manage the complex nature of newborn screening policymaking.
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Affiliation(s)
- Georgi Iskrov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (G.I.); (R.S.)
- Institute for Rare Diseases, 22 Maestro G. Atanasov St., 4017 Plovdiv, Bulgaria
| | - Vyara Angelova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Boyan Bochev
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Vaska Valchinova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Teodora Gencheva
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Desislava Dzhuleva
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Julian Dichev
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Tanya Nedkova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Mariya Palkova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Anelia Tyutyukova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Maria Hristova
- Faculty of Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (V.A.); (B.B.); (V.V.); (T.G.); (D.D.); (J.D.); (T.N.); (M.P.); (A.T.); (M.H.)
| | - Eleonora Hristova-Atanasova
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (G.I.); (R.S.)
- Institute for Rare Diseases, 22 Maestro G. Atanasov St., 4017 Plovdiv, Bulgaria
| | - Rumen Stefanov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., 4002 Plovdiv, Bulgaria; (G.I.); (R.S.)
- Institute for Rare Diseases, 22 Maestro G. Atanasov St., 4017 Plovdiv, Bulgaria
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Yaneva N, Baycheva M, Kostova P, Papochieva V, Mileva S, Miteva D, Savov A, Petrova G. Preventable Hazards from in Vitro Fertilization - A Case Series of CF Patients from Bulgaria. Balkan J Med Genet 2023; 26:83-88. [PMID: 37576787 PMCID: PMC10413990 DOI: 10.2478/bjmg-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Pre-implantation genetic diagnosis (PGD) is not often performed when donor gametes are used, due to its high cost. This is with the presumption that the donors are healthy. We report on five cases of babies with confirmed cystic fibrosis (CF), being the result from in vitro fertilization (IVF) with donor (4 cases) or own gametes (one case). There has been no family history for CF in any of the families affected. The clinical presentation in the children ranged from meconium ileus to recurrent respiratory infections and severe nasal polyposis. The age of diagnosis also varied from birth until 9 years. Since one of the presented cases was discovered in a very renowned private IVF clinic, the clinic changed their own protocol, and currently they test every donor for CF carriership. The percentage of CF carriers in the donor population is roughly the same as the one predicted in the general population of Bulgaria - 1/33. Although PGD is costly, the costs for proper care for a CF patient are currently much higher. The more economical option would to screen every donor for CF carriership. IVF requires a lot of physical and psychological stamina. The couples that go through this procedure also require a great deal of hope. It is essential to be more preconscious for possible congenital diseases. We advocate every IVF center to test the donors for CF carriership or to provide PGD for their clients.
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Affiliation(s)
- N Yaneva
- National genetic laboratory- Maichin dom, Sofia, Bulgaria
| | - M Baycheva
- Medical University Sofia, Pediatric department, Sofia, Bulgaria
- Department of Gastroenterology and Hepatology, University Children’s Hospital “Prof Ivan Mitev”, Sofia, Bulgaria
| | - P Kostova
- Medical University Sofia, Pediatric department, Sofia, Bulgaria
- University Hospital Alexandrovska, Pediatric clinic, Sofia, Bulgaria
| | - V Papochieva
- University Hospital Alexandrovska, Pediatric clinic, Sofia, Bulgaria
| | - S Mileva
- Medical University Sofia, Pediatric department, Sofia, Bulgaria
- University Hospital Alexandrovska, Pediatric clinic, Sofia, Bulgaria
| | - D Miteva
- Medical University Sofia, Pediatric department, Sofia, Bulgaria
- University Hospital Alexandrovska, Pediatric clinic, Sofia, Bulgaria
| | - A Savov
- National genetic laboratory- Maichin dom, Sofia, Bulgaria
- Medical University Sofia, Department of obstetrics and gynecology, Sofia, Bulgaria
| | - G Petrova
- Medical University Sofia, Pediatric department, Sofia, Bulgaria
- University Hospital Alexandrovska, Pediatric clinic, Sofia, Bulgaria
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Clinical and Genetic Characterisation of Cystic Fibrosis Patients in Latvia: A Twenty-Five-Year Experience. Diagnostics (Basel) 2022; 12:diagnostics12112893. [PMID: 36428953 PMCID: PMC9689702 DOI: 10.3390/diagnostics12112893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Cystic fibrosis (CF) is the most common life-limiting genetic disorder in European descent populations. It is caused by pathogenic variants in the CFTR gene, and inheritance is autosomal recessive. This study provides an up-to-date, comprehensive estimation of the distribution of CFTR pathogenic variants in Latvia and their phenotypic characteristics. It also reports the first results of the CF newborn screening programme following its implementation in 2019. We analysed the clinical and molecular data of CF patients treated at the only tertiary hospital in Latvia providing specialised healthcare for the disorder. Between 1997 and 2022, 66 CF patients from 62 families were diagnosed based on symptoms or a molecular confirmation (six patients were diagnosed through the CF newborn screening programme). F508del was identified in 70.5% of all CF chromosomes. Known variants were identified in more than one family: dele2,3, R1006H, L1335P, W57R, R553X, 2143delT and 3849+10kb C>T (legacy names used). Furthermore, two novel variants were identified, namely, c.503C>A p.(Ser168Ter) and c.(743+1_744-1)_(1584+1_1585-1)del p.(?). The available follow-up results indicated that Latvian CF patients demonstrated similar tendencies to CF patients worldwide. The oldest age at diagnosis prior to the implementation of the CF newborn screening programme was 14 years. We provide here, for the first time, a comprehensive description of Latvian CF patients. An improvement in the healthcare of CF patients over time, including access to diagnosis, is evident. Two novel CF-causing variants are reported, and F508del is the most frequently occurring variant in the population, thus suggesting that F508del screening should be followed by the testing of the full CFTR gene.
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Petrova N, Balinova N, Marakhonov A, Vasilyeva T, Kashirskaya N, Galkina V, Ginter E, Kutsev S, Zinchenko R. Ethnic Differences in the Frequency of CFTR Gene Mutations in Populations of the European and North Caucasian Part of the Russian Federation. Front Genet 2021; 12:678374. [PMID: 34220950 PMCID: PMC8242336 DOI: 10.3389/fgene.2021.678374] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
Cystic fibrosis (CF) is a common monogenic disease caused by pathogenic variants in the CFTR gene. The distribution and frequency of CFTR variants vary in different countries and ethnic groups. The spectrum of pathogenic variants of the CFTR gene was previously studied in more than 1,500 CF patients from different regions of the European and North Caucasian region of Russia and the spectrum of the most frequent pathogenic variants of the CFTR gene and ethnic features of their distribution were determined. To assess the population frequency of CFTR gene mutations some of the common variants were analyzed in the samples of healthy unrelated individuals from the populations of the European part of the Russian Federation: 1,324 Russians from four European regions (Pskov, Tver, Rostov, and Kirov regions), representatives of five indigenous ethnic groups of the Volga-Ural region [Mari (n = 505), Udmurts (n = 613), Chuvash (n = 780), Tatars (n = 704), Bashkirs (n = 517)], and six ethnic groups of the North Caucasus [Karachay (n = 324), Nogais (n = 118), Circassians (n = 102), Abazins (n = 128), Ossetians (n = 310), and Chechens (n = 100)]. The frequency of common CFTR mutations was established in studied ethnic groups. The frequency of F508del mutation in Russians was found to be 0.0056 on average, varying between four regions, from 0.0027 in the Pskov region to 0.0069 in the Rostov region. Three variants W1282X, 1677delTA, and F508del were identified in the samples from the North Caucasian populations: in Karachay, the frequency of W1282X mutation was 0.0092, 1677delTA mutation - 0.0032; W1282X mutation in the Nogais sample - 0.0127, the frequency of F508del mutations was 0.0098 and 1677delTA - 0.0098 in Circassians; in Abazins F508del (0.0039), W1282X (0.0039) and 1677delTA (0.0117) mutations were found. In the indigenous peoples of the Volga-Ural region, the maximum frequency of the F508del mutation was detected in the Tatar population (0.099), while this mutation was never detected in the Mari and Bashkir populations. The E92K variant was found in Chuvash and Tatar populations. Thus, interethnic differences in the spectra of CFTR gene variants were shown both in CF patients and in healthy population of the European and North Caucasian part of Russia.
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Affiliation(s)
- Nika Petrova
- Research Centre for Medical Genetics, Moscow, Russia
| | | | | | | | | | | | | | - Sergey Kutsev
- Research Centre for Medical Genetics, Moscow, Russia
| | - Rena Zinchenko
- Research Centre for Medical Genetics, Moscow, Russia
- N.A. Semashko National Research Institute of Public Health, Moscow, Russia
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Current Status of Genetic Diagnosis Laboratories and Frequency of Genetic Variants Associated with Cystic Fibrosis through a Newborn-Screening Program in Turkey. Genes (Basel) 2021; 12:genes12020206. [PMID: 33572515 PMCID: PMC7910984 DOI: 10.3390/genes12020206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Cystic fibrosis (CF) is the most common worldwide, life-shortening multisystem hereditary disease, with an autosomal recessive inheritance pattern caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The national newborn screening (NBS) program for CF has been initiated in Turkey since 2015. If the immunoreactive trypsinogen (IRT) is elevated (higher than 70 μg/L in the second control) and confirmed by sweat test or clinical findings, genetic testing is performed. The aims of this study are to emphasize the effect of NBS on the status of genetic diagnosis centers with the increasing numbers of molecular testing methods, and to determine the numbers and types of CFTR mutations in Turkey. Methods: The next-generation sequencing (NGS) and multiplex ligation-dependent probe amplification (MLPA) results of 1595 newborns, who were referred to Cukurova University Adana Genetic Diseases Diagnosis and Treatment Center (AGENTEM) for molecular genetic testing, were evaluated with positive CF NBS program results since 2017. Results: According to the results; 560 (35.1%) of the 1595 patients carried at least 1 (one) CF-related variant, while 1035 patients (64.9%) had no mutation. Compound heterozygosity for two mutations was the most common in patients, while two detected variants were homozygote in 14 patients. A total of 161 variants were detected in 561 patients with mutations. Fifteen novel variants that have not been previously reported were found. Moreover, p.L997F was identified as the most frequent pathogenic mutation that might affect the IRT measurements used for the NBS. The distribution of mutation frequencies in our study showed a difference from those previously reported; for example, the well-known p.F508del was the third most common (n = 42 alleles), rather than the first. The most striking finding is that 313 cases had a pathogenic variant together with the V470M variant, which might have a cumulative effect on CF perpetuation. Conclusion: This study is the first to determine the mutational spectrum of CFTR in correlation with the NBS program in the Turkish population. NBS for CF raises issues regarding screening in diverse populations, both medical and non-medical benefits, and carrier identification. Through the lens of NBS, we focused on the integrated diagnostic algorithms and their effect on the results of genetic testing.
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Koracin V, Mlinaric M, Baric I, Brincat I, Djordjevic M, Drole Torkar A, Fumic K, Kocova M, Milenkovic T, Moldovanu F, Mulliqi Kotori V, Nanu MI, Remec ZI, Repic Lampret B, Platis D, Savov A, Samardzic M, Suzic B, Szatmari I, Toromanovic A, Zerjav Tansek M, Battelino T, Groselj U. Current Status of Newborn Screening in Southeastern Europe. Front Pediatr 2021; 9:648939. [PMID: 34026686 PMCID: PMC8138576 DOI: 10.3389/fped.2021.648939] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/08/2021] [Indexed: 12/30/2022] Open
Abstract
Significant part of Southeastern Europe (with a population of 76 million) has newborn screening (NBS) programs non-harmonized with developed European countries. Initial survey was conducted in 2013/2014 among 11 countries from the region (Albania, Bulgaria, Bosnia and Herzegovina (BIH), Croatia, Kosovo, Macedonia, Moldova, Montenegro, Romania, Serbia, and Slovenia) to assess the main characteristics of their NBS programs and their future plans. Their cumulative population at that time was ~52,5 million. At that time, none of the countries had an expanded NBS program, while phenylketonuria screening was not introduced in four and congenital hypothyroidism in three of 11 countries. We repeated the survey in 2020 inviting the same 11 countries, adding Cyprus, Greece, Hungary, and Malta (due to their geographical position in the wider region). The aims were to assess the current state, to evaluate the change in the period, and to identify the main obstacles impacting the implementation of expanded NBS and/or reaching a wider population. Responses were collected from 12 countries (BIH-Federation of BIH, BIH-Republic of Srpska, Bulgaria, Croatia, Greece, Hungary, Kosovo, North Macedonia, Malta, Montenegro, Romania, Serbia, Slovenia) with a population of 68.5 million. The results of the survey showed that the regional situation regarding NBS only modestly improved in this period. All of the surveyed countries except Kosovo screened for at least congenital hypothyroidism, while phenylketonuria was not screened in four of 12 countries. Croatia and Slovenia implemented an expanded NBS program using tandem mass spectrometry from the time of last survey. In conclusion, the current status of NBS programs in Southeastern Europe is very variable and is still underdeveloped (or even non-existent) in some of the countries. We suggest establishing an international task-force to assist with implementation and harmonization of basic NBS services where needed.
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Affiliation(s)
| | - Matej Mlinaric
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivo Baric
- Department of Pediatrics, School of Medicine, University Hospital Center Zagreb and University of Zagreb, Zagreb, Croatia
| | | | - Maja Djordjevic
- Department of Metabolism and Clinical Genetics, Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia
| | - Ana Drole Torkar
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ksenija Fumic
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mirjana Kocova
- Department of Endocrinology and Genetics, University Pediatric Clinic, Skopje, Macedonia
| | - Tatjana Milenkovic
- Department of Pediatric Endocrinology, Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia
| | - Florentina Moldovanu
- Department of Pediatrics, National Institute for Mother and Child Health, Alessandrescu-Rusescu, Bucharest, Romania
| | | | - Michaela Iuliana Nanu
- Department of Pediatrics, National Institute for Mother and Child Health, Alessandrescu-Rusescu, Bucharest, Romania
| | - Ziga Iztok Remec
- Clinical Institute for Special Laboratory Diagnostics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbka Repic Lampret
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Clinical Institute for Special Laboratory Diagnostics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dimitrios Platis
- Department of Neonatal Screening, Institute of Child Health, Athens, Greece
| | - Alexey Savov
- National Genetic Laboratory, University Hospital of Obstetrics and Gynecology, Medical University Sofia, Sofia, Bulgaria
| | - Mira Samardzic
- Institute for Sick Children, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Biljana Suzic
- Children Hospital Banja Luka, Banja Luka, Bosnia and Herzegovina
| | | | - Alma Toromanovic
- Department of Pediatrics, University Clinical Center, Tuzla, Bosnia and Herzegovina
| | - Mojca Zerjav Tansek
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Petrova G, Yaneva N, Hrbková J, Libik M, Savov A, Macek M. Identification of 99% of CFTR gene mutations in Bulgarian-, Bulgarian Turk-, and Roma cystic fibrosis patients. Mol Genet Genomic Med 2019; 7:e696. [PMID: 31245908 PMCID: PMC6687650 DOI: 10.1002/mgg3.696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/30/2019] [Accepted: 04/07/2019] [Indexed: 01/25/2023] Open
Abstract
Background The spectrum and frequencies of CFTR mutations causing Cystic fibrosis (CF) varies among different populations in Europe, and beyond. Methods We identified 98.9% of all CFTR mutations in a representative cohort of 140 CF patients comprising 107 Bulgarian‐ (BG), 17 BG Turk‐, and 16 BG Roma cases. The compiled clinical and genotype dataset includes 110 previously analyzed patients with 30 cases currently analyzed for rare CFTR variants by massively parallel sequencing of the entire CFTR coding region and adjacent introns combined with the analysis of intra‐CFTR rearrangements. Results Altogether 53 different mutations, of which 15 newly identified in the BG CF population, were observed. Comparison of clinical and laboratory data between individual BG ethnic groups proved that BG Roma have a more severe nutritional status and are younger than other CF patients, as well as that the spectrum mutations differs between them. Conclusion This collaborative study improves genetic counselling in BG, facilitates introduction of multitier CF neonatal screening and fosters public health measures for improvement of care in the Roma CF population.
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Affiliation(s)
- Guergana Petrova
- Pediatric Clinic, University Hospital Alexandrovska, Sofia, Bulgaria.,Pediatric Department, Medical University Sofia, Sofia, Bulgaria
| | - Nadezhda Yaneva
- University Specialized Hospital for Active Treatment in Obstetrics and Gynecology, 'Maichin dom', National Genetic Laboratory, Sofia, Bulgaria.,Medical University Sofia, Sofia, Bulgaria
| | - Jana Hrbková
- Department of Biology and Medical Genetics, University Hospital Motol, Prague, Czech Republic.,Faculty of Medicine of Charles University, Prague, Czech Republic
| | - Malgorzata Libik
- Department of Biology and Medical Genetics, University Hospital Motol, Prague, Czech Republic.,Faculty of Medicine of Charles University, Prague, Czech Republic
| | - Alexey Savov
- University Specialized Hospital for Active Treatment in Obstetrics and Gynecology, 'Maichin dom', National Genetic Laboratory, Sofia, Bulgaria.,Medical University Sofia, Sofia, Bulgaria
| | - Milan Macek
- Department of Biology and Medical Genetics, University Hospital Motol, Prague, Czech Republic.,Faculty of Medicine of Charles University, Prague, Czech Republic
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