Genetic Profiling of Idiopathic Antenatal Intracranial Haemorrhage: What We Know?

High Prevalence of Collagenopathies in Preterm- and Term-Born Children With Periventricular Venous Hemorrhagic Infarction

INTRODUCTION

The aim of this study was to evaluate genetic risk factors in term-born children with antenatal periventricular hemorrhagic infarction (PVHI), presumed antenatal periventricular venous infarction and periventricular hemorrhagic infarction in preterm neonates.

METHODS

Genetic analysis and magnetic resonance imaging were performed in 85 children: term-born children (≥36 gestational weeks) with antenatal periventricular hemorrhagic infarction (n = 6) or presumed antenatal (n = 40) periventricular venous infarction and preterm children (<36 gestational weeks) with periventricular hemorrhagic infarction (n = 39). Genetic testing was performed using exome or large gene panel (n = 6700 genes) sequencing.

RESULTS

Pathogenic variants associated with stroke were found in 11 of 85 (12.9%) children with periventricular hemorrhagic infarction/periventricular venous infarction. Among the pathogenic variants, COL4A1/A2 and COL5A1 variants were found in 7 of 11 (63%) children. Additionally, 2 children had pathogenic variants associated with coagulopathy, whereas 2 other children had other variants associated with stroke. Children with collagenopathies had significantly more often bilateral multifocal stroke with severe white matter loss and diffuse hyperintensities in the white matter, moderate to severe hydrocephalus, moderate to severe decrease in size of the ipsilesional basal ganglia and thalamus compared to children with periventricular hemorrhagic infarction/periventricular venous infarction without genetic changes in the studied genes (P ≤ .01). Severe motor deficit and epilepsy developed more often in children with collagenopathies compared to children without genetic variants (P = .0013, odds ratio [OR] = 233, 95% confidence interval [CI]: 2.8-531; and P = .025, OR = 7.3, 95% CI: 1.3-41, respectively).

CONCLUSIONS

Children with periventricular hemorrhagic infarction/periventricular venous infarction have high prevalence of pathogenic variants in collagene genes (COL4A1/A2 and COL5A1). Genetic testing should be considered for all children with periventricular hemorrhagic infarction/periventricular venous infarction; COL4A1/A2 and COL5A1/A2 genes should be investigated first.

Resolution of preeclampsia after selective termination in discordant twins: A case report and literature review

RATIONALE

Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. Growth discordance is associated with an increased risk of preeclampsia in twin pregnancies. The management of preeclampsia combined with discordant twins is difficult and controversial because of severe maternal conditions and severe growth restriction in 1 twin.

PATIENT CONCERNS

A 34-year-old woman with dichorionic diamniotic twin pregnancy complicated by preeclampsia at 29 weeks of gestation, and 1 twin with severe growth restriction and fetal intracranial hemorrhage.

DIAGNOSIS

The patient developed severe preeclampsia with high blood pressure (>160/100 mm Hg) and proteinuria, hydrothorax and leg edema. Ultrasound examination confirmed growth restriction (weight estimation: 915 g, <1st percentile) and abnormal umbilical flow in 1 twin (twin B), with a normal co-twin (estimated weight: 1693 g) (twin A). Magnetic resonance imaging revealed intracranial hemorrhage in the germinal matrix of twin B.

INTERVENTIONS

Selective termination of twin B by intracardiac injection of potassium chloride was performed at 31 weeks and 2 days' gestation.

OUTCOMES

Symptoms of preeclampsia resolved after selective termination, allowing the pregnancy to be prolonged for nearly 4 weeks. A healthy female infant was delivered at 35 weeks of gestation.

CONCLUSION

Delivery of both fetus is not the only choice for the management for twin pregnancy with severe preeclampsia and discordant twins. Selective termination of the fetus with poor prognosis could be a reasonable treatment choice in carefully selected cases.

Case report: Prenatal diagnosis of fetal intracranial hemorrhage due to compound mutations in the JAM3 gene

Intracranial hemorrhage is a common complication in preterm infants but occasionally occurs in fetuses. Disruptions of the genes, such as the COL4A1 and COL4A2 genes, are common genetic causes identified in fetal intracranial hemorrhage; however, the disruptions of the JAM3 gene are rarely reported. In the current investigation, fetal intracranial hemorrhage and dilated lateral ventricles were observed in three consecutive siblings in a pedigree. The pregnancies were terminated, and whole-exome sequencing, followed by Sanger sequencing, was performed on the affected fetuses. Pre-implantation genetic testing for monogenic diseases was performed to avoid the recurrence. The compound heterozygous variants of c.712 + 2T > A and c.813C > G p.Tyr271* in the JAM3 gene (NM_032801.4) were identified in the proband and its affected brother, which were predicted to be pathogenic. The variant of c.813C > G p.Tyr271* but not c.712 + 2T > A was identified in the fourth fetus, implying a good prognosis. Our findings expanded the spectrum of the pathogenic mutations in the JAM3 gene and revealed an important application of fetal whole-exome sequencing in idiopathic fetal intracranial hemorrhage.

An unexplained fetal intracranial hemorrhage with extensive and multifocal hemorrhagic lesions: A case report

RATIONALE

Fetal intracranial hemorrhage (ICH) is an extremely rare complication of pregnancy, with subsequent neurological sequelae or fetal death. The diagnosis of fetal ICH is primarily based on ultrasound or magnetic resonance imaging.

PATIENT CONCERNS

An asymptomatic woman at 31 weeks of gestation was referred for a detailed anomaly scan because routine fetal ultrasonography showed suspected fetal ICH.

DIAGNOSES

Fetal ICH with extensive and multifocal hemorrhagic lesions was diagnosed by ultrasound and magnetic resonance imaging imaging and finally confirmed by postmortem examination.

INTERVENTIONS

The woman opted for pregnancy termination after medical consultation. Labor was induced by mifepristone and rivanol infusion.

OUTCOMES

The patient delivered a stillborn male infant weighing 1522 g. We tried our best to screen the possible etiology contributing to fetal ICH; unfortunately, no evidence of obvious causes or predisposing factors was identified.

LESSONS

Medically unexplained massive fetal ICH may cause an unfavorable prognosis, and prompt termination of pregnancy is appropriate, although there is no consensus on the optimal mode of delivery.

COL4A1/COL4A2 and inherited platelet disorder gene variants in fetuses showing intracranial hemorrhage

BACKGROUND

Variants of COL4A1/COL4A2 genes have been reported in fetal intracranial hemorrhage (ICH) cases but their prevalence and characteristics have not been established in a large series of fetuses. Fetal neonatal alloimmune thrombocytopenia is a major acquired ICH factor but the prevalence and characteristics of inherited platelet disorder (IPD) gene variants leading to thrombocytopenia are unknown. Herein, we screened COL4A1/COL4A2 and IPD genes in a large series of ICH fetuses.

METHODS

A cohort of 194 consecutive ICH fetuses were first screened for COL4A1/COL4A2 variants. We manually curated a list of 64 genes involved in IPD and investigated them in COL4A1/COL4A2 negative fetuses, using exome sequencing data from 101 of these fetuses.

RESULT

Pathogenic variants of COL4A1/COL4A2 genes were identified in 36 fetuses (19%). They occurred de novo in 70% of the 32 fetuses for whom parental DNA was available. Pathogenic variants in two megakaryopoiesis genes (MPL and MECOM genes) were identified in two families with recurrent and severe fetal ICH, with variable extraneurological pathological features.

CONCLUSION

Our study emphasizes the genetic heterogeneity of fetal ICH and the need to screen both COL4A1/COL4A2 and IPD genes in the etiological investigation of fetal ICH to allow proper genetic counseling.

Fetal intracranial hemorrhage in a case of 16p microdeletion

Objectives

Intracranial hemorrhages are common events in premature infants but in fetal life those incidents are often of ominous prognosis and unknown etiology.

Case presentation

We present the diagnosis, evolution and management of a fetal hemorrhagic accident associated with an inherited maternal microdeletion of the chromosome 16 short arm. Abnormal neurosonography in routine second trimester ultrasound led to follow up. Fetal germinal matrix hemorrhage along with severe asymmetric ventriculomegaly and a secondary periventricular cyst developed in the early third trimester. Array CGH showed microdeletion 16p11.2.

Conclusions

This microdeletion had not been previously associated with fetal intracranial hemorrhage.

Magnetic resonance imaging evaluation of foetal intracranial haemorrhage and the correlation with ultrasound findings and postnatal outcomes

OBJECTIVES

The aim of the study was to compare the magnetic resonance imaging (MRI) findings of intracranial haemorrhage (ICH) in the middle- and late trimesters and to explore the relationship between the MRI features of foetal ICH and postnatal outcomes.

METHODS

This was a retrospective study which recruited foetal ICH diagnosed by MRI in one tertiary centre from 2015 to 2019. The prenatal and postnatal medical records were reviewed.

RESULTS

Of 39 ICH cases, 82.1% (32) had germinal matrix intraventricular haemorrhage (GM-IVH), and 18.9% (7) were diagnosed with non-GM-IVH. The cerebellum, corpus callosum and subdural space were affected in 5, 1 and 1 non-GM-IVH cases, respectively. MRI confirmed possible ICH on sonogram in 10 cases (35.7%) and the remaining 19 added ICH diagnoses that were not obtained on initial ultrasound imaging. Pregnancy outcome data were available in 82.1% of (32) cases, of which 21 were terminated pregnancies, 1 was foetal demise and 10 were delivered. One neonate died after birth and one infant suffered from hearing loss. The remaining eight patients had favourable outcome.

CONCLUSION

In our study, evaluation of the relationship between MRI findings and outcomes remains challenging, depending on the timing of examination and the hematoma itself. MRI was an adjunct to US in diagnosing ICH in utero which helps to assess postnatal development.