Genetic diagnosis in the fetus

Evaluation of a perinatal palliative care program by SWOT analysis

BACKGROUND

Perinatal Palliative Care (PPC) is individualized medical-nursing care aimed at improving the quality of life of newborns with life-limiting conditions and to support their families. This study draws on the analysis of the experience gained over ten years by a service of PPC called the "Percorso Giacomo" (PG).

METHODS

We employed a SWOT analysis to identify the strengths, weaknesses, opportunities, and threats of the PG through a systematic retrospective review of 48 cases followed by the program over the course of 10 years, 21 unsolicited parents' narrative and 27 experts' point of view.

RESULTS

Main strengths of the program were communication and parents' involvement in shared decision-making. Main weaknesses included lack of knowledge of the presence and the role of the PG and lack of resources. For opportunities, the PG proved to be an innovative choice for pregnancies with a fetal life-limiting diagnosis, however threats were identified such as lack of knowledge of PPC and delayed referrals.

CONCLUSION

The analysis by SWOT method of the 10-year experience of the PG allowed the identification of limitations and areas of improvement, however demonstrated that the PG provided beneficial services to women faced with fetal life-limiting diagnoses.

IMPACT

Perinatal Palliative Care (PPC) practice and literature on this subject is still limited. This study offers features of the 10-year experience of the Percorso Giacomo (PG), a service of PPC, through a SWOT analysis. By identifying strengths, weaknesses, opportunities and threats of the PG, the study shows limitations and areas of improvement but also benefits of a PPC service to women with fetal diagnosis of life-limiting condition and may allow replication in other institutions.

The Impact of Chromosomal Mosaicisms on Prenatal Diagnosis and Genetic Counseling-A Narrative Review

Genetic disorders represent a high-impact diagnosis for both patients and their families. Prenatal screening methods and, when recommended, genetic testing allow parents to make informed decisions about the course a pregnancy is going to take. Although offering certainty about the potential evolution and prognosis of the pregnancy, and then the newborn, is usually not possible, genetic counseling can offer valuable insights into genetic disorders. Chromosomal mosaicisms are genetic anomalies that affect only some cell lines in either the fetus or the placenta or both. They can affect autosomal or heterosomal chromosomes, and they can be either numerical or structural. The prognosis seems to be more severe if the genetic alterations are accompanied by malformations visible in ultrasounds. Several genetic techniques can be used to diagnose certain mosaicisms, depending on their nature. A novel approach in prenatal care is non-invasive prenatal screening (NIPS), also known as non-invasive prenatal testing (NIPT), which, although it does not always have diagnostic value, can provide valuable information about potential genetic anomalies, especially numerical, with high sensitivity (Se).

Examination of Risk of Depression and Perception of Social Support in Pregnant Women Undergoing Intrauterine Intervention

BACKGROUND

Interventions during pregnancy might increase the risk of depression becausethey may cause anxiety and stress in the mother. In these cases, it is important to provide social support to pregnant women.

AIM

This study aimed to determine the relationship between the risk of depression and the perception of social support in pregnant women who had undergone intrauterine intervention (IUI).

METHODS

The population of this descriptive study consisted of all pregnant women (n = 267) who attended a state hospital in Izmir between March and September 2022 and who had undergone IUI. Data were obtained using a sociodemographic data form, the Beck Depression Inventory (BDI), and the Multidimensional Scale of Perceived Social Support (MSPSS). Descriptive statistics and the Chi-square test were used in the study.

RESULTS

In this study, of the women, 42.7% had ≥3 pregnancies; the gestational week of 93.6% of the pregnant women was between 13-24 weeks. The mean scores of the pregnant women were 11.12 ± 8.04 on the BDI and 61.06 ± 19.84 on the MSPSS. According to the results of the correlation analysis, there was a weak (<0.05) negative reverse correlation between the scales.

CONCLUSIONS

In the results of this study, it has been determined that as perceived social support increases in pregnant women, symptoms of depression are less likely to occur. This result is important in terms of indicating the need for providing social support to pregnant women. Women should be able to identify depression risk factors during this process to receive appropriate care and support.

Genomic medicine in neonatal care: progress and challenges

During the neonatal period, many genetic disorders present and contribute to neonatal morbidity and mortality. Genomic medicine-the use of genomic information in clinical care- has the potential to significantly reduce morbidity and mortality in the neonatal period and improve outcomes for this population. Diagnostic genomic testing for symptomatic newborns, especially rapid testing, has been shown to be feasible and have diagnostic and clinical utility, particularly in the short-term. Ongoing studies are assessing the feasibility and utility, including personal utility, of implementation in diverse populations. Genomic screening for asymptomatic newborns has also been studied, and the acceptability and feasibility of such an approach remains an active area of investigation. Emerging precision therapies, with examples even at the "n-of-1" level, highlight the promise of precision diagnostics to lead to early intervention and improve outcomes. To sustainably implement genomic medicine in neonatal care in an ethical, effective, and equitable manner, we need to ensure access to genetics and genomics knowledge, access to genomic tests, which is currently limited by payors, feasible processes for ordering these tests, and access to follow up in the clinical and research realms. Future studies will provide further insight into enablers and barriers to optimize implementation strategies.

De novo variants of dominant monogenic disorders in Vietnam detected by a noninvasive prenatal test: a case series

Background: Noninvasive prenatal tests for monogenic diseases (NIPT-SGG) have recently been reported as helpful in early-stage antenatal screening. Our study describes the clinical and genetic features of cases identified by NIPT-SGG. Materials & methods: In a cohort pregnancy with abnormal sonograms, affected cases were confirmed by invasive diagnostic tests concurrently, with NIPT-SGG targeting 25 common dominant single-gene diseases. Results: A total of 13 single-gene fetuses were confirmed, including Noonan and Costello syndromes, thanatophoric dysplasia, achondroplasia, osteogenesis imperfecta and Apert syndrome. Two novel variants seen were tuberous sclerosis complex (TSC2 c.4154G>A) and Alagille syndrome (JAG1 c.3452del). Conclusion: NIPT-SGG and standard tests agree on the results for 13 fetuses with monogenic disorders. This panel method of screening can benefit high-risk Vietnamese pregnancies, but further research is encouraged to expand on the causative gene panel.

Developing and validating noninvasive prenatal testing for de novo autosomal dominant monogenic diseases in Vietnam

Background: Over 60% of single-gene diseases in newborns are autosomal dominant variants. Noninvasive prenatal testing for monogenic conditions (NIPT-SGG) is cost-effective and timesaving, but not widely applied. This study introduces and validates NIPT-SGG in detecting 25 monogenic conditions. Methods: NIPT-SGG with a 30-gene panel applied next-generation sequencing and trio assays to confirm de novo variants. Diagnostic tests confirmed NIPT-detected cases. Results: Among 93 pregnancies with ultrasound findings, 11 (11.8%) fetuses were screened and diagnosed with monogenic diseases, mostly with Noonan syndrome. NIPT-SGG determined >99.99% of actual positive and negative cases, confirmed by diagnostic tests. No false-negatives or false-positives were reported. Conclusion: NIPT-SGG effectively identifies the fetuses affected with monogenic diseases, which is a promisingly safe and timely antenatal screening option for high-risk pregnancies.

Genetic Implications in High-Risk Pregnancy and Its Outcome: A 2-Year Study

OBJECTIVE

The aim of this study is to evaluate high-risk pregnant females' offspring as regard the presence of any medical condition, hereditary disorder, or major anomaly as well as to document parental sociodemographic characteristics and compliance with follow-up schedules of fetal medicine and clinical genetic clinics.

STUDY DESIGN

This prospective 2-year cohort study of neonates and infants reported the referral indications, investigations, and diagnoses obtained through prenatal and postnatal examinations. It also reported their parental follow-up vigilance.

RESULTS

Of the 811 infants of high risk females referred 460 (56.7%) came for assessment. Mean parental consanguinity and endogamy were 67 and 71.3%, respectively. All pregnant mothers underwent first-trimester biochemical testing (plasma protein-A, α-fetoprotein [AFP], human chorionic gonadotropin [hCG]) and serial ultrasound examinations. Seventy mothers needed second-trimester biochemical testing (AFP, hCG, and estriol). Sixty-two mothers underwent amniocentesis where G-banding karyotype, fluorescence in situ hybridization and targeted molecular testing for the specific gene mutation of single gene disorders were conducted according to suspected disorders. High quality fetal ultrasound was performed when brain malformations were suspected, while 16 fetuses required brain MRI examination. Mean age of newborns at first examination was 26.5 days. They were grouped according to the maternal indication for referral. Upon examination, 18 neonates had confirmed congenital malformations/genetic disorders. Five of them were diagnosed prenatally. In four other fetuses with single gene disorder, the molecular diagnosis of their affected siblings was not established prior to this pregnancy; thus, prenatal diagnosis was not possible. The remaining nine cases were diagnosed postnatally.

CONCLUSION

Parental consanguinity and endogamy were increased among high-risk pregnancies. Public awareness about potential adverse effects of consanguineous marriages and the importance of genetic testing are imperative. A structured multidisciplinary team of specialists in fetal medicine, clinical genetics, and neonatology provides good genetic services. Expansion and financial support of these services are urgently required.

KEY POINTS

· A multidisciplinary team provides good genetic services in high-risk pregnancies.. · Parental consanguinity and endogamy are increased among high-risk pregnancies.. · Increased public awareness about genetic testing importance and financial support are imperative..

The Role of Genome Sequencing in Neonatal Intensive Care Units

Genetic diseases disrupt the functionality of an infant's genome during fetal-neonatal adaptation and represent a leading cause of neonatal and infant mortality in the United States. Due to disease acuity, gene locus and allelic heterogeneity, and overlapping and diverse clinical phenotypes, diagnostic genome sequencing in neonatal intensive care units has required the development of methods to shorten turnaround times and improve genomic interpretation. From 2012 to 2021, 31 clinical studies documented the diagnostic and clinical utility of first-tier rapid or ultrarapid whole-genome sequencing through cost-effective identification of pathogenic genomic variants that change medical management, suggest new therapeutic strategies, and refine prognoses. Genomic diagnosis also permits prediction of reproductive recurrence risk for parents and surviving probands. Using implementation science and quality improvement, deployment of a genomic learning healthcare system will contribute to a reduction of neonatal and infant mortality through the integration of genome sequencing into best-practice neonatal intensive care.

Genetic testing for unexplained perinatal disorders

PURPOSE OF REVIEW

Perinatal disorders include stillbirth, congenital structural anomalies, and critical illnesses in neonates. The cause of these is often unknown despite a thorough clinical workup. Genetic diseases cause a significant portion of perinatal disorders. The purpose of this review is to describe recent advances in genetic testing of perinatal disorders of unknown cause and to provide a potential diagnostic strategy.

RECENT FINDINGS

Exome and genome sequencing (ES and GS) have demonstrated that significant portions of perinatal disorders are caused by genetic disease. However, estimates of the exact proportion have varied widely across fetal and neonatal cohorts and most of the genetic diagnoses found in recent studies have been unique to individual cases. Having a specific genetic diagnosis provides significant clinical utility, including improved prognostication of the outcome, tailored therapy, directed testing for associated syndromic manifestations, referral to appropriate subspecialists, family planning, and redirection of care.

SUMMARY

Perinatal disorders of unknown cause, with nonspecific presentations, are often caused by genetic diseases best diagnosed by ES or GS. Prompt diagnosis facilitates improved clinical care. Improvements in noninvasive sampling, variant interpretation, and population-level research will further enhance the clinical utility of genetic testing.

VIDEO ABSTRACT

http://links.lww.com/MOP/A61.

Acute Perinatal Infection and the Evidenced-Based Risk of Intrauterine Diagnostic Testing: A Structured Review

BACKGROUND

The prevalence of perinatal infection from maternal exposure is increasing. The prevalence of acute maternal infections identifies cytomegalovirus, parvovirus B19, toxoplasmosis, and varicella as the most common organisms and in the order of frequency. Maternal informed consent and understanding is required before intrauterine testing for fetal infectious and possible genetic risk assessment.

METHODS

This structured review of the reproductive published literature focuses on the risks of amniocentesis and cordocentesis diagnostic procedure-related fetal loss rates and fetal vertical transmission (VT) rates from published infected pregnant cohorts.

RESULTS

The total postprocedure fetal loss rate for diagnostic amniocentesis procedures, in limited infectious cohorts, is 1.5% and does not appear to be increased compared to "noninfected" amniocentesis cohorts using an estimated background spontaneous fetal loss rate (no procedure) of 0.65%. The "pooled" unintended fetal loss rate is from small infected population cohorts, but can be used for counseling purposes. Postcordocentesis fetal loss risk, in an infected cohort, is not possible to estimate due to limited data. The "biological spontaneous fetal loss rate" risk with a perinatal infection (positive or negative fetal anomalies) and no diagnostic procedure before 20 weeks of gestation is reviewed. The risk of VT in acute infection cohorts as a result of the intra-amniotic diagnostic procedure is not found to be increased.

CONCLUSION

The unintended "fetal loss" rate after amniocentesis for perinatal infected cohorts is similar to that of noninfected cohorts, but the estimate is based on limited infected cohorts. There was no procedure-based risk of fetal VT in the infected cohorts, but identification of postprocedure maternal bleeding into the amniotic cavity increases the potential risk. Maternal knowledge translation and an informed consent process with risk-benefit maternal/fetal risk counseling are required prior to any diagnostic amniocentesis procedure.