Current concepts in genetics. Congenital malformations

Adverse maternal outcomes associated with major fetal malformations after singleton live birth

BACKGROUND

Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity.

OBJECTIVE

This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations.

STUDY DESIGN

This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders.

RESULTS

Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90).

CONCLUSION

Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

The effect of extended cryo-storage following vitrification on embryo competence: a systematic review and meta-analysis

PURPOSE

Few studies explored whether prolonged cryo-storage after vitrification affects embryo competence and perinatal outcomes. This systematic review and meta-analysis aims at highlighting any putative impact of cryo-storage duration on cryo-survival, miscarriage, live birth and major malformations.

METHODS

A systematic review was performed using MEDLINE (PubMed), ISI Web of Knowledge, Scopus and Embase databases up to June 2021. Data were combined to obtain a pooled OR, and meta-analysis was conducted using a random effects model. Out of 1,389 screened abstracts, 22 papers were assessed for eligibility, and 5 studies were included (N = 18,047 embryos). Prolonged cryo-storage was defined as > 12 months (N = 3389 embryos). Subgroup analysis was performed for untested vitrified cleavage stage embryos (N = 1739 embryos) and for untested and euploid vitrified blastocysts (N = 13,596 and 2712 embryos, respectively).

RESULTS

Survival rate, miscarriage, live birth and major malformation rates were all similar in the two groups.

CONCLUSION

These data further support the safety of long-term cryo-storage of human embryos beyond 12 months. This is reassuring for good prognosis patients with surplus embryos, couples seeking a second child from supernumerary embryos and women postponing the transfer for clinical or personal reasons.

Safety of components and platforms of COVID-19 vaccines considered for use in pregnancy: A rapid review

BACKGROUND

Rapid assessment of COVID-19 vaccine safety during pregnancy is urgently needed.

METHODS

We conducted a rapid systematic review, to evaluate the safety of COVID-19 vaccines selected by the COVID-19 Vaccines Global Access-Maternal Immunization Working Group in August 2020, including their components and their technological platforms used in other vaccines for pregnant persons. We searched literature databases, COVID-19 vaccine pregnancy registries, and explored reference lists from the inception date to February 2021 without language restriction. Pairs of reviewers independently selected studies through COVIDENCE, and performed the data extraction and the risk of bias assessment. Discrepancies were resolved by consensus. Registered on PROSPERO (CRD42021234185).

RESULTS

We retrieved 6757 records and 12 COVID-19 pregnancy registries from the search strategy; 38 clinical and non-clinical studies (involving 2,398,855 pregnant persons and 56 pregnant animals) were included. Most studies (89%) were conducted in high-income countries and were cohort studies (57%). Most studies (76%) compared vaccine exposures with no exposure during the three trimesters of pregnancy. The most frequent exposure was to AS03 adjuvant, in the context of A/H1N1 pandemic influenza vaccines, (n = 24) and aluminum-based adjuvants (n = 11). Only one study reported exposure to messenger RNA in lipid nanoparticles COVID-19 vaccines. Except for one preliminary report about A/H1N1 influenza vaccination (adjuvant AS03), corrected by the authors in a more thorough analysis, all studies concluded that there were no safety concerns.

CONCLUSION

This rapid review found no evidence of pregnancy-associated safety concerns of COVID-19 vaccines or of their components or platforms when used in other vaccines. However, the need for further data on several vaccine platforms and components is warranted, given their novelty. Our findings support current WHO guidelines recommending that pregnant persons may consider receiving COVID-19 vaccines, particularly if they are at high risk of exposure or have comorbidities that enhance the risk of severe disease.

Safety of COVID-19 vaccines, their components or their platforms for pregnant women: A rapid review

BACKGROUND

Pregnant women with COVID-19 are at an increased risk of severe COVID-19 illness as well as adverse pregnancy and birth outcomes. Many countries are vaccinating or considering vaccinating pregnant women with limited available data about the safety of this strategy. Early identification of safety concerns of COVID-19 vaccines, including their components, or their technological platforms is therefore urgently needed.

METHODS

We conducted a rapid systematic review, as the first phase of an ongoing full systematic review, to evaluate the safety of COVID-19 vaccines in pregnant women, including their components, and their technological platforms (whole virus, protein, viral vector or nucleic acid) used in other vaccines, following the Cochrane methods and the PRISMA statement for reporting (PROSPERO-CRD42021234185).We searched literature databases, COVID-19 and pregnancy registries from inception February 2021 without time or language restriction and explored the reference lists of relevant systematic reviews retrieved. We selected studies of any methodological design that included at least 50 pregnant women or pregnant animals exposed to the vaccines that were selected for review by the COVAX MIWG in August 2020 or their components or platforms included in the COVID-19 vaccines, and evaluated adverse events during pregnancy and the neonatal period.Pairs of reviewers independently selected studies through the COVIDENCE web software and performed the data extraction through a previously piloted online extraction form. Discrepancies were resolved by consensus.

RESULTS

We identified 6768 records, 256 potentially eligible studies were assessed by full-text, and 37 clinical and non-clinical studies (38 reports, involving 2,397,715 pregnant women and 56 pregnant animals) and 12 pregnancy registries were included.Most studies (89%) were conducted in high-income countries. The most frequent study design was cohort studies (n=21), followed by surveillance studies, randomized controlled trials, and registry analyses. Most studies (76%) allowed comparisons between vaccinated and unvaccinated pregnant women (n=25) or animals (n=3) and reported exposures during the three trimesters of pregnancy.The most frequent exposure was to AS03 adjuvant in the context of A/H1N1 pandemic influenza vaccines (n=24), followed by aluminum-based adjuvants (n=11). Aluminum phosphate was used in Respiratory Syncytial Virus Fusion candidate vaccines (n=3) and Tdap vaccines (n=3). Different aluminum-based adjuvants were used in hepatitis vaccines. The replication-deficient simian adenovirus ChAdOx1 was used for a Rift Valley fever vaccine. Only one study reported exposure to messenger RNA (mRNA) COVID-19 vaccines that also used lipid nanoparticles. Except for one preliminary report about A/H1N1 influenza vaccination (adjuvant AS03) - corrected by the authors in a more thorough analysis, all studies concluded that there were no safety concerns.

CONCLUSION

This rapid review found no evidence of pregnancy-associated safety concerns of COVID-19 vaccines that were selected for review by the COVAX MIWG or of their components or platforms when used in other vaccines. However, the need for further data on several vaccine platforms and components is warranted given their novelty. Our findings support current WHO guidelines recommending that pregnant women may consider receiving COVID-19 vaccines, particularly if they are at high risk of exposure or have comorbidities that enhance the risk of severe disease.

Characteristics and outcomes among pregnant women with end-stage renal disease on hemodialysis

PURPOSE

Pregnancy among women with end-stage renal disease (ESRD) has risen in frequency, which may be attributed to improvements in hemodialysis care. Our objective was to describe baseline characteristics and pregnancy outcomes among women with ESRD on hemodialysis.

METHODS

Using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we created a cohort of women with ESRD on hemodialysis who gave birth between 2005 and 2015. We determined the proportion of adverse maternal and neonatal outcomes among this cohort. Then, we created a composite measure of vascular-mediated adverse pregnancy outcomes. Women who experienced at least one of either preeclampsia, intrauterine growth restriction, or intrauterine fetal death were categorized as having the composite measure. Then, multivariate regression models were used to estimate the associations between maternal baseline demographic and clinical characteristics and the composite measure.

RESULTS

Among 8,765,973 deliveries between 2005 and 2015, 307 were to women with ESRD on hemodialysis. Over the study period, the incidence of pregnancies to women with ESRD increased from 0.47 to 5.76/100,000 births. An estimated 28% of pregnancies were complicated by preeclampsia, 8% by placental abruption, 58% delivered by cesarean, and in the postpartum, 28% required blood transfusions and 6% experienced sepsis. About 45% of babies were born preterm and 14% had IUGR. The composite measure of adverse events was not found to be associated with any baseline maternal characteristics.

CONCLUSIONS

The frequency of pregnant women with ESRD on hemodialysis has risen, with adverse pregnancy complications for both mother and fetus. Transfer to high-risk centers is suggested for women with ESRD.

Confined placental mosaicism and the association with pregnancy outcome and fetal growth: a review of the literature

BACKGROUND

Chromosomal mosaicism can be detected in different stages of early life: in cleavage stage embryos, in blastocysts and biopsied cells from blastocysts during preimplantation genetic testing for aneuploidies (PGT-A) and later during prenatal testing, as well as after birth in cord blood. Mosaicism at all different stages can be associated with adverse pregnancy outcomes. There is an onward discussion about whether blastocysts diagnosed as chromosomally mosaic by PGT-A should be considered safe for transfer. An accurate diagnosis of mosaicism remains technically challenging and the fate of abnormal cells within an embryo remains largely unknown. However, if aneuploid cells persist in the extraembryonic tissues, they can give rise to confined placental mosaicism (CPM). Non-invasive prenatal testing (NIPT) uses cell-free (cf) DNA released from the placenta in maternal blood, facilitating the detection of CPM. In literature, conflicting evidence is found about whether CPM is associated with fetal growth restriction (FGR) and/or other pregnancy outcomes. This makes counselling for patients by clinicians challenging and more knowledge is needed for clinical decision and policy making.

OBJECTIVE AND RATIONALE

The objective of this review is to evaluate the association between CPM and prenatal growth and adverse pregnancy outcomes. All relevant literature has been reviewed in order to achieve an overview on merged results exploring the relation between CPM and FGR and other adverse pregnancy outcomes.

SEARCH METHODS

The following Medical Subject Headings (MESH) terms and all their synonyms were used: placental, trophoblast, cytotrophoblast, mosaicism, trisomy, fetal growth, birth weight, small for gestational age and fetal development. A search in Embase, PubMed, Medline Ovid, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases was conducted. Relevant articles published until 16 July 2020 were critically analyzed and discussed.

OUTCOMES

There were 823 articles found and screened based on their title/abstract. From these, 213 articles were selected and full text versions were obtained for a second selection, after which 70 publications were included and 328 cases (fetuses) were analyzed. For CPM in eight different chromosomes (of the total 14 analyzed), there was sufficient evidence that birth weight was often below the 5th percentile of fetal growth standards. FGR was reported in 71.7% of CPM cases and preterm birth (<37 weeks of delivery) was reported in 31.0% of cases. A high rate of structural fetal anomalies, 24.2%, in cases with CPM was also identified. High levels of mosaicism in CVS and presence of uniparental disomy (UPD) were significantly associated with adverse pregnancy outcomes.

WIDER IMPLICATIONS

Based on the literature, the advice to clinicians is to monitor fetal growth intensively from first trimester onwards in case of CPM, especially when chromosome 2, 3, 7, 13, 15, 16 and 22 are involved. In addition to this, it is advised to examine the fetuses thoroughly for structural fetal anomalies and raise awareness of a higher chance of (possibly extreme) premature birth. Despite prematurity in nearly a fifth of cases, the long-term follow-up of CPM life borns seems to be positive. More understanding of the biological mechanisms behind CPM will help in prioritizing embryos for transfer after the detection of mosaicism in embryos through PGT-A.

Periconception glycemic control and congenital anomalies in women with pregestational diabetes

INTRODUCTION

To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes.

RESEARCH DESIGN AND METHODS

This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003-2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses.

RESULTS

Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%-9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9).

CONCLUSION

In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.

Variant Anatomy and Its Terminology

Variant anatomy, which is an integral part of anatomical science, is related to abnormalities in the human body structure. Our understanding of variant anatomy is based on thousand years of anatomical experience. These abnormalities generally do not interfere with the function of the human body and do not typically manifest as pathological nosological units. However, under certain conditions, these abnormalities can worsen existing pathological states or even evoke new ones. Understanding variant anatomy is a basic skill not only of mere anatomists, but also of clinicians who work in fields involving both diagnostic techniques and therapeutic interventions. To gain and retain a good knowledge of the most frequent and clinically relevant anatomical variations, a simple, clear, and exactly defined nomenclature of variant structures is needed. A list of items comprising variant anatomy, which have been incorporated into the internationally accepted nomenclatures Terminologia Anatomica (1998) and Terminologia Neuroanatomica (2017), is described and analyzed. Examples of the most common anatomical variations related to terminology are mentioned, and variant anatomy as a whole and its role in understanding current anatomy are discussed.

Audit of level II scans in a tertiary center of a middle-income country (MIC)

Context:

Significant anomalies are those that are lethal or those that require prolonged follow-up and unaffordable treatments. Detection of these anomalies allows early termination or the support systems necessary for pregnancies with these diagnoses. Anxiety associated with overdiagnosis makes the woman a victim of modern imaging technology. However, accurate detection of significant anomalies in a busy scan room of a developing country with the need to cater to large numbers is particularly challenging.

Aims:

The aim was to audit the diagnostic accuracy in a busy scan room.

Settings and Design:

Retrospective cohort in a tertiary center.

Methods and Materials:

Audit of significant anomalies identified at the 20-week scan was performed after the expected date of confinement. Anomalies that were missed or overdiagnosed were noted.

Statistical Analysis Used:

All the categorical variables in this research were summarized using counts and percentages.

Results:

Twenty-eight thousand women underwent morphology ultrasound during the study period. 963 (3.4%) women were detected to have anomalies at birth. Multiple anomalies were seen in 285 (30%) cases and isolated ones in 678 (70%) cases. Anomalies of the genitourinary system were the commonest followed by the anomalies of central nervous system. Only 53 (0.2%) anomalies were missed. They were mainly syndromes and anomalies of the cardiovascular system. The most significant anomalies that were identified could be diagnosed with a basic ultrasound machine.

Conclusions:

910/963 (95%) of significant anomalies can be identified even in busy centers if a systematic assessment approach is ensured.

Selective Progesterone Receptor Modulators-Mechanisms and Therapeutic Utility

Selective progesterone receptor modulators (SPRMs) are a new class of compounds developed to target the progesterone receptor (PR) with a mix of agonist and antagonist properties. These compounds have been introduced for the treatment of several gynecological conditions based on the critical role of progesterone in reproduction and reproductive tissues. In patients with uterine fibroids, mifepristone and ulipristal acetate have consistently demonstrated efficacy, and vilaprisan is currently under investigation, while studies of asoprisnil and telapristone were halted for safety concerns. Mifepristone demonstrated utility for the management of endometriosis, while data are limited regarding the efficacy of asoprisnil, ulipristal acetate, telapristone, and vilaprisan for this condition. Currently, none of the SPRMs have shown therapeutic success in treating endometrial cancer. Multiple SPRMs have been assessed for efficacy in treating PR-positive recurrent breast cancer, with in vivo studies suggesting a benefit of mifepristone, and multiple in vitro models suggesting the efficacy of ulipristal acetate and telapristone. Mifepristone, ulipristal acetate, vilaprisan, and asoprisnil effectively treated heavy menstrual bleeding (HBM) in patients with uterine fibroids, but limited data exist regarding the efficacy of SPRMs for HMB outside this context. A notable class effect of SPRMs are benign, PR modulator-associated endometrial changes (PAECs) due to the actions of the compounds on the endometrium. Both mifepristone and ulipristal acetate are effective for emergency contraception, and mifepristone was approved by the US Food and Drug Administration (FDA) in 2012 for the treatment of Cushing's syndrome due to its additional antiglucocorticoid effect. Based on current evidence, SPRMs show considerable promise for treatment of several gynecologic conditions.

Neonatal outcomes and its association among gestational diabetes mellitus with and without depression, anxiety and stress symptoms in Malaysia: A cross-sectional study

OBJECTIVE

Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia.

DESIGN

This was a cross-sectional study.

SETTING

Tertiary hospitals in Malaysia.

PARTICIPANTS

Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia.

MEASUREMENTS

Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined.

FINDINGS

Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21).

KEY CONCLUSIONS

The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus.

IMPLICATIONS FOR PRACTICE

It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions.

US FDA Breast Implant Postapproval Studies: Long-term Outcomes in 99,993 Patients

OBJECTIVE

To analyze the long-term safety and efficacy outcomes of patients with breast implants.

SUMMARY BACKGROUND DATA

Research is ongoing regarding the safety of silicone breast implants. Despite the number of patients with breast implants followed by United States Food and Drug Administration large postapproval studies (LPAS), this database has not been thoroughly analyzed or reported.

METHODS

This is a multicentered, cohort study. LPAS prospectively monitor long-term implant-related outcomes and systemic harms for silicone/saline implants from 2 manufacturers (Allergan and Mentor) placed for primary/revision augmentation/reconstruction. Systemic harms, self-harm, and reproductive outcomes are compared with normative data. Implant-related complications are analyzed by implant composition and operative indication in the short and long terms.

RESULTS

LPAS data includes 99,993 patients, 56% of implants were silicone for primary augmentation. Long-term magnetic resonance imaging surveillance is under 5%. Compared with normative data, silicone implants are associated with higher rates of Sjogren syndrome (Standardized incidence ratio [SIR]8.14), scleroderma (SIR 7.00), rheumatoid arthritis (SIR5.96), stillbirth (SIR4.50), and melanoma (SIR3.71). One case of BI-ALCL is reported. There is no association with suicide. In the short term, rupture is higher for saline (2.5% vs. 0.5%, P < 0.001), and capsular contracture higher for silicone (5.0% vs. 2.8%, P < 0.001). At 7 years, reoperation rate is 11.7% for primary augmentation, and 25% for primary/revision reconstruction. Capsular contracture (III/IV) occurs in 7.2% of primary augmentations, 12.7% primary reconstructions, and is the most common reason for reoperation among augmentations.

CONCLUSIONS

This is the largest study of breast implant outcomes. Silicone implants are associated with an increased risk of certain rare harms; associations need to be further analyzed with patient-level data to provide conclusive evidence. Long-term safety and implant-related outcomes should inform patient and surgeon decision-making when selecting implants.

Intracytoplasmic sperm injection (ICSI) in extreme cases of male infertility

INTRODUCTION

Severely compromised spermatogenesis typical of men with virtual azoospermia or non-obstructive azoospermia requires an extreme search for spermatozoa. Our goal was to evaluate the usefulness of a meticulous search carried out in ejaculated or surgically retrieved specimens in achieving pre- and post-implantation embryo development.

PATIENTS AND METHODS

In a retrospective cohort study carried out in an academic institution, intracytoplasmic sperm injection (ICSI) outcomes were reviewed as a function of length of microscopic sperm search in ejaculated and surgically retrieved specimens. Couples whose male partner presented with either virtual or non-obstructive azoospermia were treated by ICSI and categorized according to the time spent in identifying and retrieving enough spermatozoa to inject all the oocyte cohort. Semen parameter, fertilization, pregnancies, deliveries, and child welfare in relation to increasing search time were analyzed and compared.

RESULT(S)

The maternal and paternal ages were comparable in both ejaculated and testicular sperm extraction (TESE) groups along with the oocytes retrieved. The fertilization rates for both ejaculated and TESE progressively decreased with increasing time (P<0.0001). Clinical pregnancies in the ejaculated cohort remained satifactory. In the TESE cohort, there was a decrease in pregnancy rate with increasing time, from 44% to 23%. In a limited number of cases, offspring health was evaluated in both semen sources and appeared reassuring.

CONCLUSION(S)

An extensive and at time exhaustive sperm quest yields kinetically and morphologically impaired spermatozoa without apparent impact on embryo developmental competence. Retrieval of spermatozoa from the seminiferous tubules provided more consistent fertilization and pregnancy outcomes than those retrieved from the ejaculate. A trend indicated that pregnancy rate decreased as search time increased in the TESE group. The utilization of the scarce and unselected spermatozoa did not obviously impair embryo development or cause post-implantation errors.

Copy number variation analysis implicates the cell polarity gene glypican 5 as a human spina bifida candidate gene

Neural tube defects (NTDs) are common birth defects of complex etiology. Family and population-based studies have confirmed a genetic component to NTDs. However, despite more than three decades of research, the genes involved in human NTDs remain largely unknown. We tested the hypothesis that rare copy number variants (CNVs), especially de novo germline CNVs, are a significant risk factor for NTDs. We used array-based comparative genomic hybridization (aCGH) to identify rare CNVs in 128 Caucasian and 61 Hispanic patients with non-syndromic lumbar-sacral myelomeningocele. We also performed aCGH analysis on the parents of affected individuals with rare CNVs where parental DNA was available (42 sets). Among the eight de novo CNVs that we identified, three generated copy number changes of entire genes. One large heterozygous deletion removed 27 genes, including PAX3, a known spina bifida-associated gene. A second CNV altered genes (PGPD8, ZC3H6) for which little is known regarding function or expression. A third heterozygous deletion removed GPC5 and part of GPC6, genes encoding glypicans. Glypicans are proteoglycans that modulate the activity of morphogens such as Sonic Hedgehog (SHH) and bone morphogenetic proteins (BMPs), both of which have been implicated in NTDs. Additionally, glypicans function in the planar cell polarity (PCP) pathway, and several PCP genes have been associated with NTDs. Here, we show that GPC5 orthologs are expressed in the neural tube, and that inhibiting their expression in frog and fish embryos results in NTDs. These results implicate GPC5 as a gene required for normal neural tube development.

Genetic and epigenetic characteristics of ICSI children

The outcome of pregnancy and the developmental wellbeing of children conceived from 12,866 consecutive intracytoplasmic sperm injection (ICSI) cycles was assessed. A total of 3277 couples delivered 5891 neonates. There was a higher than normal incidence of de-novo chromosomal abnormalities in a small sample of ICSI offspring. Controlling for maternal age showed that the incidence of low birth weight and gestational length were comparable with the naturally conceived counterpart. Rates of malformation in ICSI offspring ranged from 3.5 to 6.2%. At 3 years of age (n = 811), the proportion of children at risk for developmental delays was 10.4% in ICSI and 10.7% in IVF singletons. However, high order gestations were characterized by 19.4% of the children having compromised development. Epigenetic analysis of assisted reproductive technique conceptuses found minor imprinted gene expression imbalances. ICSI offspring presented with genetic defects that were inherited or arose de novo. Obstetric and neonatal outcomes of singleton pregnancies appeared to be dependent upon maternal age. ICSI and IVF appeared to exert a negative effect on the wellbeing of offspring mainly because of the association with multiple gestations. All assisted reproduction procedures should be monitored for the eventual effect of environmental aggressors on offspring epigenesis.

Major congenital anomalies place extremely low birth weight infants at higher risk for poor growth and developmental outcomes

BACKGROUND

Studies of growth and neurodevelopmental impairment in extremely low birth weight infants often exclude infants with major congenital anomalies; thus, there are few outcome data available on these infants.

OBJECTIVES

The purpose of this work was to compare growth and neurodevelopmental outcomes of extremely low birth weight infants with major anomalies to extremely low birth weight infants without these findings. It was hypothesized that infants with severe anomalies would have worse growth, neurodevelopmental, and survival outcomes.

METHODS

A retrospective cohort analysis was performed on 5920 extremely low birth weight infants surviving beyond 12 hours of life at 19 neonatal network centers between 1998 and 2001. Infants with significant anomalies were more likely to die before 18 to 22 months' corrected age. A total of 3705 children underwent neurodevelopmental and anthropometric evaluation at 18 to 22 months' corrected age. Statistical significance for unadjusted comparisons was determined by Wilcoxon tests for continuous variables and chi2 or Fisher's exact tests for categorical variables. Regression models were used to compare the outcomes after adjusting for potential confounders.

RESULTS

Children with major congenital anomalies were more likely to have Bayley Mental Development Index scores of < or = 70, Psychomotor Development Index scores of < or = 70, neurodevelopmental impairment, moderate-to-severe cerebral palsy, length in the < or = 10th percentile, head circumference in the < or = 10th percentile, more rehospitalizations, and higher rates of early intervention use at 18 to 22 months' corrected age.

CONCLUSIONS

At 18 to 22 months' corrected age, extremely low birth weight infants born with major anomalies have nearly twice the risk for neurodevelopmental impairment, increased risk of poor growth, and > 3 times greater risk of rehospitalization when compared with extremely low birth weight infants without major anomalies. This information may be valuable for counseling parents regarding the outcomes of these infants and for the facilitation of appropriate support and intervention services.

Growth and development of children conceived by in-vitro maturation of human oocytes

AIMS

The objective of this study is to evaluate the physical and mental development of infants born on in-vitro maturation (IVM) programs.

STUDY DESIGN

We compare 21 IVM children as study group and 21 non-IVM children as control group. We performed a general physical examination for malformations, neurological examination, developmental examination (Bayley Scales) on the IVM group and the non-IVM group.

RESULTS

We found all the children with normal karyotype and without major malformation in both IVM and non-IVM groups. The mean Mental Development Index scores for IVM subjects and the comparison group were 92.71+/-10.47 and 97.19+/-8.88, respectively (p=0.074). The mean Psychomotor Development Index scores were 96.67+/-8.91 and 96.19+/-7.05, respectively (p=0.817).

CONCLUSIONS

This is the first study designed to evaluate the physical growth and developmental indices of IVM children with combinational priming protocol of FSH and hCG. Our results suggest that IVM children didn't show developmental delay during infancy and early childhood.

Cerebellar involvement in midline facial defects with ocular hypertelorism

OBJECTIVE

Twenty-four patients were evaluated to better characterize neurological and neuroradiological aspects of midline facial defects with ocular hypertelorism.

METHODS

After a clinical genetics evaluation, the individuals were divided into two groups: 12 isolated cases (group 1) and 12 associated with multiple congenital anomalies (group 2). The investigation protocol included medical and family history, as well as dysmorphological, neurological, and neuroradiological evaluations by magnetic resonance imaging or computed tomography scan.

RESULTS

Because there was no significant difference concerning the neurological aspects of groups 1 and 2, they were analyzed together. Mild hypotonia (24 of 24), abnormalities in cranial shape (24 of 24), cranial nerves (19 of 24), motor coordination (18 of 24), dynamic equilibrium (14 of 24), and language problems (8 of 24) were noted. Measurements of the posterior fossa showed hypoplastic cerebellar vermis (8 of 17), the cerebellum at lower normality limits (5 of 17), and signs of cerebellar hypoplasia (3 of 7).

CONCLUSION

This study clearly demonstrates the presence of structural and functional neurological abnormalities related to midline facial defects with ocular hypertelorism, as well as involvement of the cerebellum. It provides a basis for future investigation of midline facial defects with ocular hypertelorism and should be considered during planning of rehabilitation treatment.

Neonatal data on a cohort of 2889 infants born after ICSI (1991-1999) and of 2995 infants born after IVF (1983-1999)

BACKGROUND

To evaluate the safety of ICSI, this study compared data of IVF and ICSI children by collecting data on neonatal outcome and congenital malformations during pregnancy and at birth.

METHODS

The follow-up study included agreement to genetic counselling and eventual prenatal diagnosis, followed by a physical examination of the children after 2 months, after 1 year and after 2 years. 2840 ICSI children (1991-1999) and 2955 IVF children (1983-1999) were liveborn after replacement of fresh embryos. ICSI was carried out using ejaculated, epididymal or testicular sperm.

RESULTS

In the two cohorts, similar rates of multiple pregnancies were observed. ICSI and IVF maternal characteristics were comparable for medication taken during pregnancy, pregnancy duration and maternal educational level, whereas maternal age was higher in ICSI and a higher percentage of first pregnancies and first children born was observed in the ICSI mothers. Birthweight, number of neonatal complications, low birthweight, stillbirth rate and perinatal death rate were compared between the ICSI and the IVF groups and were similar for ICSI and IVF. Prematurity was slightly higher in the ICSI children (31.8%) than in the IVF children (29.3%). Very low birthweight was higher in the IVF pregnancies (5.7%) compared with ICSI pregnancies (4.4%). Major malformations (defined as those causing functional impairment or requiring surgical correction), were observed at birth in 3.4% of the ICSI liveborn children and in 3.8% of the IVF children (P = 0.538). Malformation rate in ICSI was not related to sperm origin or sperm quality. The number of stillbirths (born > or =20 weeks of pregnancy) was 1.69% in the ICSI group and 1.31% in the IVF group. Total malformation rate taking into account major malformations in stillborns, in terminations and in liveborns was 4.2% in ICSI and 4.6% in IVF (P = 0.482).

CONCLUSIONS

The comparison of ICSI and IVF children taking part in an identical follow-up study did not show any increased risk of major malformations and neonatal complications in the ICSI group.

Intramedullary spinal tumors of disordered embryogenesis

Abnormal spinal embryogenesis is quite commonplace. While greater than 90 percent of these errors of embryogenesis leads to occult spinal dysraphism with minimal neurologic or orthopedic sequelae, there is a significant minority of these anomalies which leads to the formation of the so-called 'congenital tumors of disordered embryogenesis'. The purpose of this article is to discuss the embryology, presentation, diagnosis and management of the spinal dysraphic states with particular emphasis on those errors which lead to mass lesions in the spinal canal such as dermoids, epidermoids, lipoma/lipomyelomeningocoele and neurenteric cysts. We also include lesions such as dermal sinus tracts and thickened filum terminale in our discussion with particular emphasis on their relationship to the tethered cord syndrome. Proper surgical management of these various conditions necessitates a thorough understanding of their embryologic etiology and the anatomic/physiologic ramifications that such lesions have on the developing spinal cord.

Long-term follow-up of children born after inadvertent administration of a gonadotrophin-releasing hormone agonist in early pregnancy

Our objective was to evaluate long-term outcome of children born after inadvertent administration of a gonadotrophin-releasing hormone agonist (GnRHa) in early pregnancy, compared to a control group of children born to matched women undergoing in-vitro fertilization and children born after spontaneous pregnancies. Six children from six pregnancies, exposed to a long-acting gonadotrophin agonist, comprised the study group and 20 children were included in the control groups. Pre-, peri- and postnatal data were collected and the children were followed and examined at a mean age of 7.8 +/- 2.0 years. All children underwent physical and neurological examination, and psychological tests. In the study group, one child was born with a major congenital malformation (cleft palate), and four children subsequently demonstrated neurodevelopmental abnormalities, including epileptic disorder (n = 1), attention deficit hyperactivity disorder (n = 3), motor difficulties (n = 3) and speech difficulties (n = 1). In the control groups, one child had attention deficit hyperactivity disorder. This observation of neurodevelopmental abnormalities in four of six children in the study group justifies the need for long-term follow-up of more children previously exposed to gonadotrophin-releasing hormone agonist.

Pregnancies, growth and development of children conceived by subzonal injection of spermatozoa

Subzonal injection of spermatozoa (SUZI) was one of the first micromanipulation techniques efficient in treating male factor infertility and unexplained in-vitro fertilization failures. The aim of this retrospective study was to evaluate the in-vitro development of embryos conceived by SUZI, the obstetric outcome, the rate of congenital malformations and subsequent follow-up in children. Fifty-five pregnancies were obtained between 1991 and 1994 (54 after fresh embryos were transferred and one after cryopreserved embryos were transferred). Among the 50 clinical pregnancies, there were seven miscarriages (14%) and two ectopic pregnancies (4%). Among the 41 resulting evolutive pregnancies, the discovery of one anencephaly led to a medical abortion. Forty deliveries including six twin pregnancies occurred, leading to the births of 45 live neonates and one stillbirth. The gender distribution of the offspring included 17 males and 29 females (ratio 0.59:1). Birth weight, length and head circumference were within the expected ranges. Two children presented a malformation: the first one had one thumb with congenital shelf and the second a polymalformative neurological syndrome. Growth curves were normal for all these children except one (weight above the 2 SD curve). Medical follow-up detected no pathological features in these children apart from a physical disability in one girl. In this small series a 4.2% rate of malformation was observed, particularly affecting the neural tube, in SUZI offspring. However, no firm conclusions can be drawn since the study was carried out on a small cohort. SUZI is no longer performed but these observations suggest that it is necessary to collect extensive data about children conceived by microfertilization.

Congenital unilateral fusion of the maxilla and mandible

We present an uncommon severe first branchial arch congenital malformation, in which complete unilateral bony fusion between the maxillary and mandibular processes was found in a newborn exposed to carbamazepine medication all through pregnancy. This condition interferes with oral feeding, intubation, growth and development. In a review of previously reported cases it was found that this anomaly was commonly associated with other abnormalities. The etiology of this malformation was uncertain in our case, as carbamazepine was not proven to be the definite cause.

Children conceived by in vitro fertilisation after fresh embryo transfer

AIMS

To compare the outcome in in vitro fertilisation (IVF) children (after fresh embryo transfer) from multiple and singleton births with one another, and with normally conceived control children.

METHODS

A cohort of 278 children (150 singletons, 100 twins, 24 triplets and four quadruplets), conceived by IVF after three fresh embryos had been transferred, born between October 1984 and December 1991, and 278 normally conceived control children (all singletons), were followed up for four years after birth. They were assessed for neonatal conditions, minor congenital anomalies, major congenital malformations, cerebral palsy and other disabilities. Control children, all born at term, were matched for age, sex and social class.

RESULTS

The ratio of male:female births was 1.03. Forty six per cent of IVF children were from multiple births; 34.9% were from preterm deliveries; and 43.2% weighed less than 2500 g at birth. The IVF singletons were on average born one week earlier than the controls, weighed 400 g less, and had a threefold greater chance of being born by caesarean section. The higher percentage of preterm deliveries was largely due to multiple births and they contributed to neonatal conditions in 45.0% of all IVF children. The types of congenital abnormalities varied: 3.6% of IVF children and 2.5% of controls had minor congenital anomalies, and 2.5% of IVF children and none of the controls had major congenital malformations. The numbers of each specific type of congenital abnormality were small and were not significantly related to multiple births. IVF children (2.1%) and 0.4% of the controls had mild/moderate disabilities. They were all from multiple births, including two children with cerebral palsy who were triplets.

CONCLUSIONS

The outcome of IVF treatment leading to multiple births is less satisfactory than that in singletons because of neonatal conditions associated with preterm delivery and disabilities in later childhood. A reduction of multiple pregnancies by limiting the transfer of embryos to two instead of three remains a high priority.

Causes and associations of severe and persistent specific speech and language disorders in children

Eighty-two school-age children with severe and persistent specific speech and language disorders were studied. 71 had specific developmental language disorders, three had structural malformations (cleft palate) and eight had disorders acquired after a period of normal language development, including five with Landau-Kleffner syndrome. The sex ratio was 3.8 boys to one girl. Nearly half had a family history of speech-language disorder, with one in 5.2 affected siblings. Aetiological factors were found in 26 per cent: 11 per cent prenatal, 3 per cent perinatal and 12 per cent postnatal. 21 per cent had had a seizure and 7 per cent had had seizures after the age of eight. 29 per cent were left-handed, 90 per cent were clumsy and 22 per cent first walked after 18 months. The complex origins of specific speech and language disorders are discussed.

Ultrasonographic diagnosis of congenital anomalies in twins

To determine whether serial ultrasonographic examinations with basic anatomic surveys provide an adequate screen for congenital abnormalities that are more common in twins, we compared the results of prenatal sonograms and neonatal examinations for 314 twins (157 pairs) delivered during a recent 42-month period. An anomaly was defined as major if it potentially required surgical repair or precluded normal life expectancy; otherwise it was defined as minor. Thirty-three twins (9.5%) had 40 anomalies; 28 (9%) were major and 12 (4%) were minor. Prenatal ultrasonography with cardiac screening limited to the four-chamber view provided detection of 39% of all major anomalies, 55% of noncardiac major anomalies but none of the cardiac lesions, and 69% of the major anomalies for which routine prenatal management should be altered. No false-positive diagnoses incorrectly altered management. We conclude that serial prenatal ultrasonographic examinations are useful in detecting noncardiac anomalies for which twins are at increased risk, but the four-chamber view is not an adequate screen for the cardiac malformations of twins.

Congenital malformations and psychosocial development in children conceived by in vitro fertilization

To determine whether in vitro fertilization (IVF) as a method of conception is associated with an increased risk for congenital malformations or developmental dysfunction, we performed a general physical examination for malformations, neurologic examination, developmental examination (Bayley Scales), echocardiography, electrocardiography, abdominal ultrasound study, and, when possible, cranial ultrasound examination on a cohort of 83 IVF children and 93 matched non-IVF children. Major malformations were found in two IVF and one non-IVF subject; the rates were not significantly different. The mean Mental Development Index scores for IVF subjects and the comparison group were 115 +/- 13 and 111 +/- 13, respectively (p = 0.12). The mean Psychomotor Development Index scores were 114 +/- 14 and 108 +/- 15 (p = 0.04). Based on these small numbers but extensive evaluation, we found no association between conception by IVF and an increased risk for congenital malformations. Likewise, children conceived by IVF showed no evidence of developmental delay. Their high average achievement on the Bayley tests probably resulted from the exceptional motivation of their parents ("wantedness") and their generally high socioeconomic status.

Congenital malformations detected in 731 autopsies of children aged 0 to 14 years

A retrospective study of 731 autopsies of children aged 0 to 14 years, performed in the Pathological Anatomy Service of the University Hospital of Porto Alegre from 1977 to 1982, was carried out to determine the frequency, type, and seriousness of congenital malformations. The subjects were divided into five age ranges: stillborn (6), 0 to 24 hours (42), 1 to 30 days (50), 1 to 12 months (24), and 1 to 14 years (9). The malformations were classified as single or multiple (presence of two or more independent defects), and their contribution to death was evaluated. Congenital malformations were detected in 131 autopsies (18%). In most cases the defects were single (91), and the most common ones involved the cardiovascular system (37) and the genitourinary system (21). In the patients with multiple malformations (40), the cardiovascular system (24) and the genitourinary system (19) were also most frequently involved. Defects of the osteoarticular system were also frequently encountered in patients with multiple defects (25), although most of them were deformations caused by mechanical factors. Proportionally, congenital malformations were most frequently detected in the 0 to 24 hours range, which also included the highest proportion of multiple defects in relation to single ones (1:1). Congenital malformations were considered responsible for death in 76% of the 131 cases (87% of the multiple defects patients and 60% of the single defect patients). We believe that the data collected in the present study may contribute to a better understanding of the role played by congenital malformations in child mortality.

Congenital malformations in 10,000 consecutive births in a university hospital: need for genetic counseling and prenatal diagnosis

Ten thousand children born consecutively in a university hospital were surveyed for the presence of major congenital malformations. About 2% (174) had a major congenital defect. Seventy-eight percent (135 of 174) of these malformations are associated with increased recurrence risk (greater than 1%), and 9% carry a high recurrence risk (greater than or equal to 10%). On the basis of the recurrence risk of 1% or higher and the feasibility of prenatal diagnosis, such a procedure should be considered in future pregnancies in 45% (79 of 174) of the mothers, especially inasmuch as 40% were primiparae younger than 36 years.

Principles of genetics as related to the chromosome disorders and congenital malformations with reference to prenatal diagnosis and genetic counseling

A basic discussion of the chromosome disorders and congenital malformations with specific reference to syndromes of interest to the dermatologist is presented. Although the chromosome disorders are uncommon, an introduction to the most prevalent clinical findings should enable the clinician to increase his/her index of suspicion as to the presence of one of these disorders. The latest chromosome banding technics and their application to clinical diagnosis are discussed. Congenital malformations are also uncommonly seen in the practice of dermatology. However, approximately 7% of all newborns have a cutaneous lesion at birth; some of these are of serious medical significance or the manifestation of a systemic disease. These include café au lait marks, congenital nevocellular nevi, and sebaceous nevi. A basic understanding of the mechanics and theory of prenatal diagnosis is becoming increasingly necessary for the dermatologist. Recently, epidermolytic hyperkeratosis has ben diagnosed antenatally, with the promise of other primary dermatologic disorders also being amenable to detection before birth. As the ability to detect and diagnose genetic disease becomes more refined, patients who are at risk themselves or whose offspring are at risk for these disorders will require more detailed information than ever before. Appropriate advice regarding recurrence risk, full spectrum of disease, availability of prenatal diagnosis, and any potential therapy will have to be proffered via genetic counseling.

Familial occurrence of papillary thyroid carcinoma

We report two kindreds from northern Norway with 7 and 4 cases of papillary thyroid carcinoma in otherwise healthy, nonirradiated subjects. While histologic features were comparable the patient's age at the time of diagnosis was lower and lymph node metastases were more frequent in familial than in nonfamilial cases of papillary thyroid carcinoma from the same region. We conclude that genetic factors can predispose the patient for development of papillary thyroid carcinoma. The high local incidence may be due to interaction between susceptibility gene(s) and environmental factors.

Requesting the autopsy: a pediatric perspective. Psychosocial and professional aspects of the autopsy in caring for the dying child and his family

Many physicians find the request for autopsy to be one of the most difficult and unpleasant aspects of pediatrics. Lack of preparation, their own emotional reactions, and ambivalence about the necessity of autopsies contribute to this. This article offers an approach to the autopsy that emphasizes its importance to families and to pediatrics, and suggests a role for the physician at the time of the child's death that is both professionally and personally gratifying.

Endoscopy and tracheotomy in the neonatal period: a 10-year review, 1967-1976

The charts of 124 patients who underwent endoscopy as neonates during the period from 1967 to 1976 were reviewed. Twenty-nine of these patients (23.4%) had tracheotomies performed during the first month of life; analysis of this group also is included. Three hundred and ninety-two otolaryngological procedures were performed and included direct laryngoscopy (175), bronchoscopy (91), esophagoscopy (37), tracheotomy (29), bronchial lavage (14), change of tracheotomy tube (14), esophageal dilatation (13), incision and drainage of cyst (14), removal of tracheal granuloma (3), laryngeal dilatation (1), and bronchial dilatation (1). Two hundred and forty-nine lesions were found of which 146 were laryngeal, 44 tracheobronchial, 33 esophageal, 16 craniofacial, and 10 were orohypopharyngeal. Procedures were performed under general anesthesia and no anesthetic complications occurred. Surgical complications in the neonatal period were few and never life-threatening. In the nontracheotomized group two complications were found; 38% of this group was discharged within one day of endoscopy. In the tracheotomized group eight complications occurred; none were fatal. In many cases endoscopy proved to be essential in making the specific diagnosis.