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Barrozo ER, Racusin DA, Jochum MD, Garcia BT, Suter MA, Delbeccaro M, Shope C, Antony K, Aagaard KM. Discrete placental gene expression signatures accompany diabetic disease classifications during pregnancy. Am J Obstet Gynecol 2024:S0002-9378(24)00596-9. [PMID: 38763341 DOI: 10.1016/j.ajog.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/06/2024] [Accepted: 05/11/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Gestational diabetes mellitus affects up to 10% of pregnancies and is classified into subtypes gestational diabetes subtype A1 (GDMA1) (managed by lifestyle modifications) and gestational diabetes subtype A2 (GDMA2) (requiring medication). However, whether these subtypes are distinct clinical entities or more reflective of an extended spectrum of normal pregnancy endocrine physiology remains unclear. OBJECTIVE Integrated bulk RNA-sequencing (RNA-seq), single-cell RNA-sequencing (scRNA-seq), and spatial transcriptomics harbors the potential to reveal disease gene signatures in subsets of cells and tissue microenvironments. We aimed to combine these high-resolution technologies with rigorous classification of diabetes subtypes in pregnancy. We hypothesized that differences between preexisting type 2 and gestational diabetes subtypes would be associated with altered gene expression profiles in specific placental cell populations. STUDY DESIGN In a large case-cohort design, we compared validated cases of GDMA1, GDMA2, and type 2 diabetes mellitus (T2DM) to healthy controls by bulk RNA-seq (n=54). Quantitative analyses with reverse transcription and quantitative PCR of presumptive genes of significant interest were undertaken in an independent and nonoverlapping validation cohort of similarly well-characterized cases and controls (n=122). Additional integrated analyses of term placental single-cell, single-nuclei, and spatial transcriptomics data enabled us to determine the cellular subpopulations and niches that aligned with the GDMA1, GDMA2, and T2DM gene expression signatures at higher resolution and with greater confidence. RESULTS Dimensional reduction of the bulk RNA-seq data revealed that the most common source of placental gene expression variation was the diabetic disease subtype. Relative to controls, we found 2052 unique and significantly differentially expressed genes (-22 thresholds; q<0.05 Wald Test) among GDMA1 placental specimens, 267 among GDMA2, and 1520 among T2DM. Several candidate marker genes (chorionic somatomammotropin hormone 1 [CSH1], period circadian regulator 1 [PER1], phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit beta [PIK3CB], forkhead box O1 [FOXO1], epidermal growth factor receptor [EGFR], interleukin 2 receptor subunit beta [IL2RB], superoxide dismutase 3 [SOD3], dedicator of cytokinesis 5 [DOCK5], suppressor of glucose, and autophagy associated 1 [SOGA1]) were validated in an independent and nonoverlapping validation cohort (q<0.05 Tukey). Functional enrichment revealed the pathways and genes most impacted for each diabetes subtype, and the degree of proximal similarity to other subclassifications. Surprisingly, GDMA1 and T2DM placental signatures were more alike by virtue of increased expression of chromatin remodeling and epigenetic regulation genes, while albumin was the top marker for GDMA2 with increased expression of placental genes in the wound healing pathway. Assessment of these gene signatures in single-cell, single-nuclei, and spatial transcriptomics data revealed high specificity and variability by placental cell and microarchitecture types. For example, at the cellular and spatial (eg, microarchitectural) levels, distinguishing features were observed in extravillous trophoblasts (GDMA1) and macrophages (GDMA2). Lastly, we utilized these data to train and evaluate 4 machine learning models to estimate our confidence in predicting the control or diabetes status of placental transcriptome specimens with no available clinical metadata. CONCLUSION Consistent with the distinct association of perinatal outcome risk, placentae from GDMA1, GDMA2, and T2DM-affected pregnancies harbor unique gene signatures that can be further distinguished by altered placental cellular subtypes and microarchitectural niches.
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Affiliation(s)
- Enrico R Barrozo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Diana A Racusin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael D Jochum
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Brandon T Garcia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX; Genetics & Genomics Graduate Program, Baylor College of Medicine, Houston, TX
| | - Melissa A Suter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Melanie Delbeccaro
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Cynthia Shope
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Kathleen Antony
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Kjersti M Aagaard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
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Shiraishi W, Tateishi T, Hayashida S, Tajima G, Tsumura M, Isobe N. [A case of very long chain acyl-CoA dehydrogenase deficiency diagnosed due to a trigger of hyperemesis gravidarum during pregnancy]. Rinsho Shinkeigaku 2023; 63:656-660. [PMID: 37779023 DOI: 10.5692/clinicalneurol.cn-001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
A 25-year-old Japanese woman with a history of repeated episodes of rhabdomyolysis since the age of 12 presented with rhabdomyolysis caused by hyperemesis gravidarum. Blood tests showed an elevated serum CK level (11,755 IU/l; normal: 30-180 IU/l). Carnitine fractionation analysis revealed low levels of total carnitine (18.3 μmol/l; normal: 45-91 μmol/l), free carnitine (13.1 μmol/l; normal: 36-74 μmol/l), and acylcarnitine (5.2 μmol/l; normal: 6-23 μmol/l). Tandem mass spectrometry showed high levels of C14:1 acylcarnitine (0.84 nmol/ml: normal: <0.4 nmol/ml) and a high C14:1/C2 ratio of 0.253 (normal: <0.013), indicating a potential diagnosis of very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. Enzyme activity measurement in the patient's peripheral blood lymphocytes confirmed the diagnosis of VLCAD deficiency, with low palmitoyl-CoA dehydrogenase levels (6.5% of normal control value). With the patient's informed consent, acyl-CoA dehydrogenase very long-chain (ACADVL) gene analysis revealed compound heterozygous mutations of c.1332G>A in exon 13 and c.1349G>A (p.R450H) in exon 14. In Japan, neonatal mass screening is performed to detect congenital metabolic diseases. With the introduction of tandem mass screening in 2014, fatty acid metabolism disorders, including VLCAD deficiency, are being detected before the onset of symptoms. However, it is important to note that mass screening cannot detect all cases of this disease. For patients with recurrent rhabdomyolysis, it is essential to consider congenital diseases, including fatty acid metabolism disorders, as a potential diagnosis.
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Affiliation(s)
- Wataru Shiraishi
- Department of Neurology, Kokura Memorial Hospital
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Takahisa Tateishi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine
| | - Shotaro Hayashida
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Go Tajima
- Division of Neonatal Screening, Research Institute, National Center for Child Health and Development
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences
| | - Miyuki Tsumura
- Division of Neonatal Screening, Research Institute, National Center for Child Health and Development
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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3
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Shakerdi LA, McNulty J, Gillman B, McCarthy CM, Ivory J, Sheerin A, O'Byrne JJ, Donnelly JC, Treacy EP. Management of pregnancy in a patient with long-chain 3-hydroxyacyl CoA dehydrogenase deficiency. JIMD Rep 2022; 63:265-270. [PMID: 35822088 PMCID: PMC9259390 DOI: 10.1002/jmd2.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is a rare mitochondrial defect of β-oxidation of long-chain fatty acids. Patients may present with muscle pain, hypotonia, peripheral neuropathy, cardiomyopathy, recurrent rhabdomyolysis and sudden death. Dietary management of LCHADD aims at preventing prolonged fasting and decreasing energy production from long-chain fatty acids compensated by an increase in medium-chain triglyceride fat. Herein, we present medical and dietetic management of a successful pregnancy in a LCHADD female patient and the delivery of a healthy baby boy.
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Affiliation(s)
- Loai A. Shakerdi
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
| | - Jenny McNulty
- National Centre for Inherited Metabolic DisordersChildren's Health Ireland (CHI)DublinIreland
| | - Barbara Gillman
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
| | | | - Jessica Ivory
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
| | - Alison Sheerin
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
| | - James J. O'Byrne
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
| | | | - Eileen P. Treacy
- National Centre for Inherited Metabolic DisordersMater Misericordiae University HospitalDublinIreland
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4
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Akar HT, Çağan M, Yıldız Y, Sivri HS. Complicated peripartum course in a patient with very long-chain acyl-coenzyme A dehydrogenase (VLCAD) deficiency. Neuromuscul Disord 2021; 31:566-569. [PMID: 33965301 DOI: 10.1016/j.nmd.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/22/2021] [Accepted: 03/31/2021] [Indexed: 11/28/2022]
Abstract
Very long-chain acyl-coenzyme A (CoA) dehydrogenase (VLCAD) deficiency is an autosomal recessive fatty acid oxidation disorder characterized by rhabdomyolysis, hypoglycemia and cardiomyopathy. The general treatment approach in adult patients is based on the prevention of catabolism. High carbohydrate, low fat diet and supplementation of medium-chain triglycerides are essential in the treatment. There is little experience with pregnancy follow-up in this patient group. We present a complicated peripartum course and successful management in a patient with VLCAD deficiency. Although high-dose glucose infusion was initiated, creatine kinase levels significantly increased in the immediate postpartum period, but the patient remained asymptomatic and rhabdomyolysis resolved rapidly after increasing the glucose infusion rate.
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Affiliation(s)
- Halil Tuna Akar
- Department of Pediatrics, Pediatric Metabolism and Nutrition Unit, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Murat Çağan
- Department of Obstetrics and Gynecology, Perinatology Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yılmaz Yıldız
- Department of Pediatrics, Pediatric Metabolism and Nutrition Unit, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - H Serap Sivri
- Department of Pediatrics, Pediatric Metabolism and Nutrition Unit, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey.
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5
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Zagorda B, Camdessanché JP, Féasson L. Pregnancy and myopathies: Reciprocal impacts between pregnancy, delivery, and myopathies and their treatments. A clinical review. Rev Neurol (Paris) 2021; 177:225-234. [PMID: 33648783 DOI: 10.1016/j.neurol.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/07/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022]
Abstract
During pregnancy, women undergo physical and physiological changes, which can impact the neuromuscular disease course, but also delivery and fetus health. Generally, there is little impact on the disease course, but sometimes an impairment is noticed, which could be attributed to pregnancy and not to disease progression. Cardiac and respiratory functions have to be assessed at the beginning of pregnancy and a close follow-up is mandatory in case of disorder. Labour and delivery are often impacted. Labour is prolonged because of muscle weakness that is an increased risk of instrumental delivery or Cesarean sections. Patients with myotonic dystrophy are at risk of postpartum hemorrhage. Fetal loss can be associated with fetal disease in myotonic dystrophy, and is at high risk for patients with active inflammatory myopathy only.
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Affiliation(s)
- B Zagorda
- Service de médecine physique et de réadaptation, Hôpital Bellevue, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France
| | - J-P Camdessanché
- Service de neurologie, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France
| | - L Féasson
- Unité de myologie, service de physiologie clinique et de l'exercice, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France.
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6
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Van Calcar SC, Sowa M, Rohr F, Beazer J, Setlock T, Weihe TU, Pendyal S, Wallace LS, Hansen JG, Stembridge A, Splett P, Singh RH. Nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD): An evidence- and consensus-based approach. Mol Genet Metab 2020; 131:23-37. [PMID: 33093005 DOI: 10.1016/j.ymgme.2020.10.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/31/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022]
Abstract
The nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD) is the fourth in a series of web-based guidelines focusing on the diet treatment for inherited metabolic disorders and follows previous publication of guidelines for maple syrup urine disease (2014), phenylketonuria (2016) and propionic acidemia (2019). The purpose of this guideline is to establish harmonization in the treatment and monitoring of individuals with VLCAD of all ages in order to improve clinical outcomes. Six research questions were identified to support guideline development on: nutrition recommendations for the healthy individual, illness management, supplementation, monitoring, physical activity and management during pregnancy. This report describes the methodology used in its development including review, critical appraisal and abstraction of peer-reviewed studies and unpublished practice literature; expert input through two Delphi surveys and a nominal group process; and external review from metabolic physicians and dietitians. It includes the summary statements of the nutrition management recommendations for each research question, followed by a standardized rating based on the strength of the evidence. Online, open access of the full published guideline allows utilization by health care providers, researchers and collaborators who advise, advocate and care for individuals with VLCAD and their families and can be accessed from the Genetic Metabolic Dietitians International (https://GMDI.org) and Southeast Regional Genetics Network (https://southeastgenetics.org/ngp) websites.
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Affiliation(s)
| | - M Sowa
- CHOC Children's, Orange, CA, USA
| | - F Rohr
- Met Ed Co, Boulder, CO, USA; Children's Hospital of Boston, Boston, MA, USA
| | - J Beazer
- National PKU News, How Much Phe, LLC, Helena, MT, USA
| | - T Setlock
- Shodair Children's Hospital, Helena, MT, USA
| | - T U Weihe
- Children's Mercy, Kansas City, MO, USA
| | - S Pendyal
- Duke University Health System, Durham, NC, USA
| | - L S Wallace
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - J G Hansen
- Oregon Health & Science University, Portland, OR, USA
| | | | - P Splett
- University of Minnesota, St. Paul, MN, USA
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7
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Fatehi F, Okhovat AA, Nilipour Y, Mroczek M, Straub V, Töpf A, Palibrk A, Peric S, Rakocevic Stojanovic V, Najmabadi H, Nafissi S. Adult-onset very-long-chain acyl-CoA dehydrogenase deficiency (VLCADD). Eur J Neurol 2020; 27:2257-2266. [PMID: 32558070 DOI: 10.1111/ene.14402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Very-long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a hereditary disorder of mitochondrial long-chain fatty acid oxidation that has variable presentations, including exercise intolerance, cardiomyopathy and liver disease. The aim of this study was to describe the clinical and genetic manifestations of six patients with adult-onset VLCADD. METHODS In this study, the clinical, pathological and genetic findings of six adult patients (four from Iran and two from Serbia) with VLCADD and their response to treatment are described. RESULTS The median (range) age of patients at first visit was 31 (27-38) years, and the median (range) age of onset was 26.5 (19-33) years. Parental consanguinity was present for four patients. Four patients had a history of rhabdomyolysis, and the recorded CK level ranged between 67 and 90 000 IU/l. Three patients had a history of exertional myalgia, and one patient had a non-fluctuating weakness. Through next-generation sequencing analysis, we identified six cases with variants in the ACADVL gene and a confirmed diagnosis of VLCADD. Of the total six variants identified, five were missense, and one was a novel frameshift mutation identified in two unrelated individuals. Two variants were novel, and three were previously reported. We treated the patients with a combination of L-carnitine, Coenzyme Q10 and riboflavin. Three patients responded favorably to the treatment. CONCLUSION Adult-onset VLCADD is a rare entity with various presentations. Patients may respond favorably to a cocktail of L-carnitine, Coenzyme Q10, and riboflavin.
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Affiliation(s)
- F Fatehi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - A A Okhovat
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Nilipour
- Pediatric Pathology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Mofid Children Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Mroczek
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - V Straub
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Töpf
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Palibrk
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - S Peric
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - V Rakocevic Stojanovic
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - H Najmabadi
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - S Nafissi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Manta-Vogli PD, Schulpis KH, Dotsikas Y, Loukas YL. Nutrition and medical support during pregnancy and lactation in women with inborn errors of intermediary metabolism disorders (IEMDs). J Pediatr Endocrinol Metab 2020; 33:5-20. [PMID: 31804959 DOI: 10.1515/jpem-2019-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The establishment of expanded newborn screening (NBS) not only results in the early diagnosis and treatment of neonates with inborn errors of intermediary metabolism disorders (IEMDs) but also helps the affected females to reach the reproductive age under medical and dietetic support, as well as to give birth to normal infants. In this review, we aimed to focus on laboratory investigation tests, dietetic management and medical support for most known IEMD pregnant and lactating women, such as those suffering from aminoacidopathies, carbohydrate metabolic diseases and fatty acid (FAO) oxidation disorders.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition and Dietetics, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Yannis Dotsikas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274696, Fax: +30 210 7274039
| | - Yannis L Loukas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274224, Fax: +30 211 1826131
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9
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Stone J, Reed D. Maternal genetic diseases: potential concerns for mother and baby. Hum Genet 2019; 139:1173-1182. [PMID: 31729547 DOI: 10.1007/s00439-019-02086-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022]
Abstract
With advances in medical care, many women with genetic conditions previously known to decrease life expectancy are reaching childbearing age. Thus, it is important to understand the management of patients in the preconception, antepartum, and postpartum periods as they pose a unique challenge to the obstetrician. Most rare disorders lack well-established clinical guidelines for management in pregnancy. Existing data stem from case reports, case series, and expert opinion. We aim to summarize these recommendations and develop a clinical reference for managing reproductive age women with these conditions. We review recommendations for women with inborn errors in metabolism, connective tissue disorders, skeletal dysplasia, and selected single gene disorders. In all cases, it is crucial to employ a multidisciplinary team to optimize care for patients with rare disease before, during, and immediately after their pregnancies. The emphasis on expert consensus recommendations in the guidance of obstetric care is a signal that more studies are needed to determine best practices.
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Affiliation(s)
- Julie Stone
- Tufts Medical Center, 800 Washington Center, Boston, MA, 02111, USA
| | - Dallas Reed
- Tufts Medical Center, 800 Washington Center, Boston, MA, 02111, USA.
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10
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Yamada K, Matsubara K, Matsubara Y, Watanabe A, Kawakami S, Ochi F, Kuwabara K, Mushimoto Y, Kobayashi H, Hasegawa Y, Fukuda S, Yamaguchi S, Taketani T. Clinical course in a patient with myopathic VLCAD deficiency during pregnancy with an affected baby. JIMD Rep 2019; 49:17-20. [PMID: 31497477 PMCID: PMC6718132 DOI: 10.1002/jmd2.12061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 11/08/2022] Open
Abstract
Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is an autosomal recessive mitochondrial fatty acid oxidation disorder that manifests in three clinical forms: (a) severe, (b) milder, and (c) myopathic. Patients with the myopathic form present intermittent muscular symptoms such as myalgia, muscle weakness, and rhabdomyolysis during adolescence or adulthood. Here, the clinical symptoms and serum creatine kinase (CK) levels of a pregnant 31-year-old woman with the myopathic form of VLCAD deficiency were reduced during pregnancy. Clinical symptoms rarely appeared during pregnancy, although she had sometimes suffered from muscular symptoms before pregnancy. When ritodrine was administered for threatened premature labor at 35 weeks of gestation, her CK level was elevated to over 3900 IU/L. She delivered a full-term baby via cesarean section but suffered from muscle weakness with elevated CK levels soon after delivery. It has been reported that an unaffected placenta and fetus can improve maternal β-oxidation during pregnancy. However, in our case, the baby was also affected by VLCAD deficiency. These suggest that the clinical symptoms of a woman with VLCAD deficiency might be reduced during pregnancy even if the fetus is affected with VLCAD deficiency.
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Affiliation(s)
- Kenji Yamada
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Keiichi Matsubara
- Department of Obstetrics and GynecologyEhime University School of MedicineToonEhimeJapan
| | - Yuko Matsubara
- Department of Obstetrics and GynecologyEhime University School of MedicineToonEhimeJapan
| | - Asami Watanabe
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Sanae Kawakami
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
| | - Fumihiro Ochi
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Kozue Kuwabara
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Yuichi Mushimoto
- Department of Pediatrics, Graduate School of Medical SciencesKyushu UniversityHigashi‐kuFukuokaJapan
| | - Hironori Kobayashi
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Yuki Hasegawa
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Seiji Fukuda
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Seiji Yamaguchi
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Takeshi Taketani
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
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Abstract
Once based mainly in paediatrics, inborn errors of metabolism (IEM), or inherited metabolic disorders (IMD) represent a growing adult medicine specialty. Individually rare these conditions have currently, a collective estimated prevalence of >1:800. Diagnosis has improved through expanded newborn screening programs, identification of potentially affected family members and greater awareness of symptomatic presentations in adolescence and in adulthood. Better survival and reduced mortality from previously lethal and debilitating conditions means greater numbers transition to adulthood. Pregnancy, once contraindicated for many, may represent a challenging but successful outcome. Successful pregnancies are now reported in a wide range of IEM. Significant challenges remain, given the biological stresses of pregnancy, parturition and the puerperium. Known diagnoses allow preventive and pre-emptive management. Unrecognized metabolic disorders especially, remain a preventable cause of maternal and neonatal mortality and morbidity. Increased awareness of these conditions amongst all clinicians is essential to expedite diagnosis and manage appropriately. This review aims to describe normal adaptations to pregnancy and discuss how various types of IEM may be affected. Relevant translational research and clinical experience will be reviewed with practical management aspects cited. Based on current literature, the impact of maternal IEM on mother and/or foetus, as well as how foetal IEM may affect the mother, will be considered. Insights gained from these rare disorders to more common conditions will be explored. Gaps in the literature, unanswered questions and steps to enhance further knowledge and systematically capture experience, such as establishment of an IEM-pregnancy registry, will be summarized.
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Affiliation(s)
- Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, M6 8HD, UK.
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Yamamoto H, Tachibana D, Tajima G, Shigematsu Y, Hamasaki T, Tanaka A, Koyama M. Successful management of pregnancy with very-long-chain acyl-coenzyme A dehydrogenase deficiency. J Obstet Gynaecol Res 2015; 41:1126-8. [DOI: 10.1111/jog.12672] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/01/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Hiroko Yamamoto
- Department of Obstetrics and Gynecology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Go Tajima
- Department of Pediatrics; Hiroshima University Graduate School of Biomedical and Health Sciences; Hiroshima Japan
| | | | - Takashi Hamasaki
- Department of Pediatrics; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Akemi Tanaka
- Department of Pediatrics; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology; Osaka City University Graduate School of Medicine; Osaka Japan
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Mendez-Figueroa H, Chien EK, Ji H, Nesbitt NL, Bharathi SS, Goetzman E. Effects of labor on placental fatty acid β oxidation. J Matern Fetal Neonatal Med 2012; 26:150-4. [PMID: 22928498 DOI: 10.3109/14767058.2012.722721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To measure the effect labor exerts on fatty acid (FA) oxidation in term human placentas, and to compare enzymes expression and activity between placenta and liver. METHODS Placental samples were collected: (a) scheduled non-labored cesarean section and (b) normal vaginal delivery at or beyond 37 weeks. Long and medium-chain FA oxidation were measured using (3)H-labeled FA, ATP concentration was measured via commercial kit. Activity and expression levels of 11 FA enzymes were measured and results compared to both human and mouse liver. RESULTS Placentas undergoing labor had significantly decreased palmitate oxidation and ATP levels. Octanoic acid oxidation was 10-fold higher than palmitic acid oxidation. No difference in expression or activity level was detected between the groups. CONCLUSION Term human placentas express all the enzymes required to oxidize FA, at a rate 20-fold lower than liver. FA Oxidation is not likely an important placental energy source during labor. Further work is needed to determine the functionality of this pathway in placenta.
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Affiliation(s)
- Hector Mendez-Figueroa
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Women and Infants' Hospital of Brown University, Providence, Rhode Island 02903, USA.
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