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    Prenatal PDF

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    Renuka Shastri

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    REVIEW ARTICLE MEDICINE The Prenatal Diagnosis of Genetic Diseases Peter Wiest ‘er, Johannes Steinhard SUMMARY Background: Prenatal diagnosis is a subfield of clinical genetic and gynecology that exemplifies the etfective integration of theoretical and clnial medicine. Milestones ints history include the development of cytogenetic, ‘molecular genetic, and molecular cytogenetic methods as ‘oll as advances in ultrasonography, Te later technique not only improves the safety of invasive procedures, but also enables earlier and more reliable diagnosis of ‘congenital malformations, Methods: This article provides an overview ofthe subject in the light of seloctivelyreviwed iterature, guidelines, and recommendation. Resuits and conclusion: Invasive prenatal diagnosis is most commonly performed to assess the embryonaVetal ‘chromosome set. An increasing number of monogenic diseases can be diagnosed prenatally by ether genetic or biochemical testing depending onthe particular disease being sought, Plygenic and mutifactorial diseases ‘cannot be reliably dagnosed by genetic testing at present, although a numberof malformations can be ascertained prenatally by utrasonography. We discuss the applications and imitations of Invasive and noninvasive techniques for Pronatal diagnosis. > cite this as ‘WieackerP,Steinhard J: The prenatal diagnosis of genetic diseases, Dtsch Arteb Int 2010; 10748): 857-62, DOL 10,3288/arzeb 2010.0857 ‘a tr tomangath Gaiannon Miao Pet eed Winker eke ake Ferbane ne abt, ran Pata Noda tnessesia hanson Demat Seen Deutsches cet remnant n 2010; a 85-82 he term prenatal diagnosis strictly comprises all diagnostic modalities aimed at gaining in- formation about the embry or fetus. However in its narrower usage it refers to the prenatal identification of genetically determined diseases and their disposition, In recognition of progress in this area the German ‘Medical Association (Bundesirztckammer, BAK) pub- lished guidelines on prenatal diagnosis of iliness and its disposition in 1998 (1), A disease of wholly or party genetic in origin is present in around 4% ofall neonates. Genetically deter- ‘mined or co-determined diseases can be divided into three groups: © Chromosomal aberrations © Monogenetic diseases which are caused by single gene mutation © Polygeneticimultifactorial diseases, which are caused by mutations in several genetic areas as ell as exogenous factors. ‘The following article will focus on the applications and Timitations of the prenatal diagnosis of chrome- somal abnormalities and monogenetic diseases, bu will, rot focus on ultrasonographic diagnosis of fetal anomalies, whether occurring in isolation or as part of syndromes including monogeneticaly inherited diseases ‘The prenatal diagnosis of chromosomal abnormalities ‘Common reasons for karyotype analysis are: (© Maternal age: the probability of chromosomal ‘anomalies increases with maternal age (Figure 1). ‘Around balf of chromosomal anomalies are ac counted for by trisomy 21 (Down syndrome) 2) © Following an abnormal result from non-invasive soreening © Following an ultrasound finding which raises the possibility fa chromosomal problem © In the presence of a known translocation, inver sion or insertion in one parent; in these eases, the probability of an unbalanced aberration is in- creased, over and above the maternal age-related risk © A chromosomal anomaly in an existing child of the couple's. For example, alter the binth of a child with free tisomy, the risk of a numerical chromosomal abnormality is inereased by 1% for 857, MEDICINE ° 20 2% 24 26 2% 30 32 34 36 98 40 a2 44 45 4B Age of mothe years) Probab fa hrrostralabaoally in te naoate dependent on atral age (rom Hooke, 188 ‘each subsequent child compared to other parents ‘of the same age (3). As chromosome analysis requires cellular material, ‘an appropriate intervention is needed, of which several ‘are available, depending on gestation, clinial question, ‘and interventional risk (Table/, eBax 1) Amniocentesis Amniocentesis is typically carried out under ultrasono- raphe contol, between 15 and 17 weeks of pregnan- cy. The procedure specifi risk is 0.5% to 1% (3) ‘Around 15 ml. of amniotic fuid would normally be aspirated. Chromosomal analysis requires prior cell culture, which takes on average two weeks. After this, metaphase chromosomes are analyzed numerieally and structurally (Figure 2). Uncultured amniotic fuid can ‘be used to determine levels of alpha fetoprotein (AFP), Which is present in inereased concentrations in open neural tube defects and other disorders such as absomi nal wall defects (e-., gastoschsis). In the presence of raised AFP level, acetylcholinestrase is measured as a marker of neural tube defects (eBax 2) Amniocentesis can also be used in conjunetion with a rapid soreening test for numerical aberrations of spe- cific chromosomes, which can be used on uncultured amniotic fluid, in conjunction with conventional eyto- ‘genetic analysis, Using FISH analysis (Auotescent in situ hybridization) with chromosome-specific probes at imerphase nuclei ot via molecular genetic analysis of highly polymorphic markers on a DNA probe isolated from uncultured amniotic fluid cells, information can be obtained regarding numerical abnormalities of chromosomes 13, 18 and 21, and the X and Y chromo= somes (Figure 3. This est allows detection of the come ‘monest chromosomal anomalies within one t© three ays. This testis of particular importance where phological abnormalities potentially associated with the above conditions have been detected, and where a rapid diagnosis is required a a late stage of pregnancy. ‘A prenatal rapid test can serve to reassure the pregnant ‘woman if normal, but cannot replace formal karyotyp- ing (http:/Avorw gihev defen/documentsfindex him), Chorionic villus sampling Chorionic villus sampling (CVS) is typically per formed inthe 11* to 12" weeks of pregnancy. It should not be earied out before the 11® week in view ofthe ine creased rsk of limb abnormalities associated with CVS prior to this date, which some commentators have linked to placental trauma and vascular infarction at a critical stage of development. Depending on placental site, CVS can be carried out either transcervically or transabdominally. Chromosome analysis is carried out cither as a direct preparation or following brief culture (1 day) as well as after fll culture (7 to 10 days). In experienced hands the procedure-specifi risk of mis carriage is up t0 1% (eBox 3) Placental biopsy Pacental biopsy isin elfect late transabdominal cho rionie villus sampling. It can be used to obtain a rapid result at late stage of pregnancy. Cordocentesis. Cordocentesis isa technically challenging intervention ‘in Which the umbilial vein is entered where possible at the site of placental insertion. The comm cations are suspected fetal anemia in association with rhesus disease, parvovirus BI9 infection, or fetal hydrops. Cordocentesis can also be used for rapid aryolyping or molecular genetic diagnosis from 16 10 20 weeks, depending on indication. Cordocentesis is Jmportaat where a rapid result is needed late in pregnancy, for example in the presence of tultrasonographically detected anomalies or severe growth restriction, which may point to 2 chromosomal abnormality. The result of chromosome analysis of Iymphoeytes from cord blood can be available in three to five days. ‘The limitations of cytogenetic diagnosis Prenatal karyotyping isa reliable procedure, bu like all tests, limited by factors which can be technical or bio- logical, The probability of obtaining no fetal celular material is ess than 1% in experienced hands, Culture failure can occasionally occu: ‘One limitation ofeyiogenctie diagnosis arises vi the ‘optical resolution ofthe chromosomes Structural chro :mosomal abnormalities smaller than the achievable op- tical resolution cannot be detected A further limitation relates 10 the detection of possible chromosomal mses cet emstnall Die Arce int 2010; 0785-82 ‘mosaic, where two oF more cell Ines can be present. A mosaic ean oly be detected if chromosomally aberrant cells are present inthe examined specimen. ‘The demonstration of certain structural abnormal- ities such as translocation of inversion often req further investigation (eBax 4), Noninvasive Investigations Invasive prenatal diagnosis on the grounds of maternal age is increasingly being replaced by combined assess- sent of Fisk factors, of which maternal age is just one. ‘The miscarriage risk in particular drives a need for non invasive allematives to the above interventions. In ad- ition to maternal age, certain biochemical parameters ‘in maternal blood and first trimester ultrasonographic appearances allow individualized assessment of the risk of aneuploidy. Counselling should make it clear hat these noninvasive methods modify the maternal ‘age-related risk of certain chromosomal abnormalities, but cannot rule out chromosomal abnormality. They can however aid decision making for or against an invasive method. Nuchal translucency screenk Increased nuchal transiveeney inthe fetus i associated with increased risk of chromosomal abnormality and cater diseases (4), Sonographic measurement of the thickness of the nuchal fold between 11-0 and 13-6 weeks of pregnancy, together with matemal age and biochemical markers allows an individualized risk of ancuplodies such as trisomy 21, 13, and 18to be calor lated. This allows, fora sereempositve rate of 5 %, 80 (nuchal translucency ony) to 90% (auchal transl cency plus biochemical parameters) of eases of isomy 21 wo be detected (Table 2) However, nuchal tans ceney measurement is not comparable with targeted anomaly diagnosis cartied out in a specialist setting as part of a so-called extended fist uimester screening ‘Tae sim ofthis ype of early anomaly sean isto identity fetal avomalies, with nuchal thickness as an integrated pat. The German Society for Uleasound in Meine (Deusche Geselschaf fr Ultraschall in der Mediin, DEGUM) (5) advises uyaecologisis in possession of a sucha translucency measurement certificate but who donot havea specialist qualification ia anomaly sean- ning to refer women with abnormal nuchal thickness measurements (greater than the 98° conile for ges tational age) and multiple pregnancy 10 a specialist center (DEGUM level I or Il). This patient group tray conceal numerous additional dineases such as anomalies, in addition to” chromosomal anomalies (4) Prerequisites for an interpretable nuchal thickness ‘measurement include operator qualification, choice of appropriate duration of investigation, and technical considerations. Inclusion of aditional parameters such as measurement ofthe nasal hone, Doppler assesment of the tricuspid valve, and the dacus venosus, and the facial angle allows individualised detection rates for trisomy 21 tobe inereased to up 10 95% (Table 2). Deutsches cet remnant n 2010; a 85-82 EOTs MEDICINE vasve prenatal diagnostic methods rs a rs ak Cherie ‘sits tieviweets | =13% | ~etvomowame anaiis (kaye) roar gerabe dagnoss ache! gross 1517 wots ~etramesome analysis dag of ope eal lube detects, roca gerabe Siagnoss ~boehemaldagrois ~craresone analysis “hoe gerbe ‘iagnoss biecemaldprois fom 1820, ~etramosme ana hartge and Dechenizal diagnosis ~siagnoss of specte ure dematses “yeaa “The mzanap kab utd ys eng ras tng Biochemical parameters In recent years, the measurement of human chorionie gonadotrophin (HCG) and pregnaney-assoctated plasma protein A (PAPP-A) in maternal serum between the 11® and 14” weeks of pregnancy have become increasingly established in combination with nuchal translucency measurement and maternal age (combined first trimester tes) (5). Prior to this, the so-called triple lest was offered (6), measuring’ alpha fetoprotein (AEP), HCG and free estriol between 15 and 20 weeks. ‘A further biochemical parameter, Inbibin A, when added to the triple test, yields the so-called quadruple lest (7). Accurate assessment of gestational age is essential for interpreting the biochemical parameters ‘As PAPP-A and HCG measurement in association with nuchal translucency measurement are always carried ‘out in conjunction with fetal biometry, For example using the crown ramp length, this allows concurrent assessment of gestational age. This isnot the ease with the triple test. Laboratories calculate individual risks for trisomy 21, 13 and 18 and for neural tube defects using the gestation as reported by the gynecologist. ‘This often involves using the last menstrual period, which leads to a relatively high level of error. In our experience, couples are often worried unnecessarily by a wrongly calculated triple test, This, together withthe Possibility of earlier and more precise risk assessment inthe frst trimester, is an argument against the triple test MEDICINE Cob wot pk a eh 8 ak aR i Figure 2: Karate ot tus win iso 18 Three conies chrome 18 canbe ogy of eemesome 11 sho a break (ge ro content Whe Figure 3: Domorsatn of Donn syome (sony 21) na prenatal rend diagnose test using FSH anajsi th probes specie or chromosomes 13 (ee) ané 21 fed) The tee signals confem rzomy 21 Prenatal diagnosis of monogenetically determined diseases Av the present time around 5000 known disorders are inherited in a monogenetic mendelian fashion, Fore- most among them are autosomal dominant, autosomal recessive and X-linked disorders, which carry a higher risk of illness than that conveyed by age-related risk. ‘An autosomal dominant condition carries an a prioti 50% inheritance risk where one parent is affected. An autosomal recessive disease carries a 25% inheritance risk for children of a healthy carrier couple. An X-linked recessive disorder caries 2 50% risk forthe son of cartier mother: Specific, albeit non-sereening genet tests are cur rently available for mote than 1000 of these diseases, Unlike cytogenetic prenatal diagnosis based on ma temal age, prenatal gene testing is nota sereening tet Given the individuality of each ease, prior planning is essential, Two differing strategies are possible: indirect and direct genetic testing Direct genetic testing involves the identification or exclusion of the relevant mutation(s), and assumes knowledge of existing mutations in the index patient. Indirect genetic testing involves the demonstration for exclusion ofthe so-called high risk haplotype in the fetus. Indireet geneife testing uses the principle of ‘genetic linkage, and requires examination of the Fail Tor polymorphic markers whose alleles are closely associated with disease inthis family. In theory, all tha is required in an informative family is the locus of the relevant gene. Diagnostic uncertainty arises where there is heterogeneity in the gene Ioeus, Le. when ‘mutations in different genes lead to the same disease. ‘An additional, albeit quantifiable uncertainty arises Where a gene recombines with a linked marker. It is obvious that the reliable interpretation of indirect ge- netic testing presupposes thatthe stated relationships within the pedigree are correct, In a positive prenatal diagnostic test, especially for ‘an autosomal dominant condition, the possibility of variable expression and reduced penetrance must be ome in mind. Variable expressivity of @ mutation ‘occurs when the resulting phenotype is more of less strongly expressed in different members of the same family Reduced penetrance implies missing expression of the mutation. In this situation the phenotype ean be normal despite the mutation, Variable expression and reduced penetrance can be explained by as yet largely ‘unknown modifving factors. For this reason it is important to discuss these issues during genetic coun- selling. For reasons dietated by time and technical consider» ations, a molecular genetic testis usually catied out in the context of CVS following polymerase chain reace tion (PCR) for amplification of DNA isolated from cho- rionie vill, before eventual DNA sequencing can be carried out (eBax 5), Inherited metabolic disorders can in some cases be iagnosed ftom chorionic villi of amaotic cells (10). “The prerequisite for this is that the relevant gene is expressed in these cells and the metabolic defect has been detected in fibroblasts (via skin biopsy) in an index patient within the family. Some penetie disorders are sought directly in the amniotic Nuid (eBax 6) Genetic counselling in prenatal diagnosis Te German genetic testing act (Gendiagnostikgesetz) of February I, 2010 stipulates that pregnant women must be offered genetic counselling before and after prenatal diagnostic testing (11). The following areas should be covered: {© Presentation ofthe background risk of congenital disease and anomaly, and individual increased risks (for example increased matemal age) mses cet emstnall Die Arce int 2010; 0785-82 © The options and limitations for prenatal genetic diagnosis 1 Possible diseases which can be detected 1 Risks associated with the relevant tests © Confictual areas in relation to prenatal diagnosis © Akternatives. Even the possibilty of prenatal diagnosis can plunge «couple into conflictual areas. In many’ eases prenatal diagnosis can provide reassurance. However, only in a small number of cases can pathology be effectively treated by early intrauterine or neonatal treatment. The detection of significant disease or impairment can be grounds for termination of pregnancy, According to faicle 218 a paragraph 2 SiGB (Stufgesetzbuch, the German Criminal Law), termination of pregnancy by a ‘medical practioner with the consent of the pregnant ‘woman is legal when: ... afler consideration of the present and future terms of living of the pregnant ‘woman it is medically established thal, in order to prevent danger to the life or danger of severe impai ‘ment of the physical or mental health of the mother, and this danger cannot be prevented by any other means acceptable to her". In this conflict between the parents’ wish for a healthy child and the basic recognition of protection forthe unborn child, termination of pregna cy following the detection of severe fetal illness oF ‘impairment represents an incomplete attempt to end a fundamentally insoluble confit” (1). ‘The principle of non-directiveness must be applied {in all genet counselling including prenatal diagnosis, In this coatext it should be made clear that a pathologi- cal result in no way automatically implies termination ‘of pregnaney. n addition to genetic counselling as part of prenatal diagnosis, psychosocial counselling can be offered. This may help the couple face and resolve the confits diseused, vis exploration ofthe possible cone sequences of diagnosis, and offer support in dealing with serious fetal anomaly. This is particularly advise able in the ease of serious anomaly. The new pregnancy canict act which took force on January 1, 2010 stipu- Jates that’ women considering legal termination of pregnancy must receive advice about psychosocial implications. Likewise, the woman must be informed ‘fer right to appropriate psychosocial counselling and ‘other specialist medical advice such as that of a special= ‘ned pediatrician, The responsibility for communication of this information Kies with the doctor who eonfims ‘the indication for termination of pregnancy. In addition, a three day “cooling off period” is required following communication of a diagnosis before the formal indi- cation for termination of pregnancy can be confirmed (ebox 7. seknoneegonet ews mae rt 8 Benn rere dca Taft tira atmo Trenre serie peel of ese her guns! Inert ene Wesel onal ar ariel sie oo 7 Noenber 208, ese vor seid 0 ‘ebay 20 Deutsches cet remnant n 2010; a 85-82 MEDICINE Detection rates for tiem 21 ploted against the type ‘of eerecing paramstere and tests used (moe rom, ianetsp Matera PAPP-A HCG, UA, NT measurement nd Tea ae20% oe ‘Combined test NT, PAPP-A, HOG, 8) ‘Contin est ps nasal bans, csp fow, uae eres and al are Motel age 2edtimestr out ost AFP HOG, MA) “Tile test AFP HCG, E, MA) ‘Gadpl ts (AP, HCG, £3, in, MA) ‘Uesound (1-28 week) wi arorly sening Ceri ie samgiog ‘oso ‘os ‘bse ‘os 30.50% os Annoceress ‘eaten Sara 207) aa Nas 28 A ranean APPA poylny esos mapean HCG, human hte: gmncorogn Wrath eshzenoy AP ec, ere REFERENCES |. Bsarater dr Hause Buntesiaskarne Reiee ar Hiab Dagon aren und arketsdsostoren Dish Aitl 7086, e560 8 3238 2, Hooke Est earasane abnor tent tera ges Ose Gel 1981 38: 282-5, 5. Maen rina Dag rn J ein Hal er fe Hurangerth, th oden, Saat TeV 2006; sae 4 Wal Mis. Wala & npn. Pratl srerig st 43 congenial ea cts stg ance amalznalsb Pen Ding 208, 78 109-08 8. Neaies Ki, za ye Mars, Maks Ft much vans ‘ary aso seeng er hercsoma tects r= resol progr SM 182, 304: 867-29. 6, Wa, Cull HS Dose etal: ata san sree Dos yar ney rear. BN) Te; 27: 8837. 7.aliN, Dense J Gage, Mss ih: Peal seven Dors crane sri asa ser mht, Pre: ign 1996; 18 143-52 8. Behan Liar revi ant sugested pa or managing asc sof mars One serene nal a, fetegenc bre stereedemut sharaned hums, pleas tne aber erp asl tere ust adel 7007, 5171875. 8. Neakies Some ous neue ae usr Ure ‘our Stet pel 2007: 30-671, 10.The ri Hal an lec ass red deoses (rslitaemmaecam} MEDICINE 1 Gast genesct rteschangen bl enschon (ereagnes: thgese~ Gn Buesgeeta 2008, 50, ‘arespoding aber Prema he Moser sis nrMumogerth alone 12-14 £8148 ser Goran nso For eeterences lease eet ‘users neal Fig and eBoes alae at ‘arta d!10n0857 Cg (© Thersk of cvomasoma anarmaliy inte fetus inreases wih increasing ‘maloma ge. Tsomy 21 anounts or around hao cases © Invasive agnosis of chromosomal bnarmabts canbe cared out using 2 varity of echriques, such as chor vil sampling and anniocentes. ‘© Sonographic measurement of nuchal ucency between 11+0 and 1346 wooks of pregnancy combined wih maternal age and biochemical parameters lows nda risk caeltion fr some aneupleides such a5 k'somy 21,13, nd 18 (© Inthe presence of ulvasoundatrormaltis inthe 18 trimester and ahigh sk ‘sl vimester screening rest, chorionic vilus sapling shoul be fered as ‘he most rapid invasive diagnose method, (© Monogerstiallynhated diseases can o some extent be diagnosed prenatally via molecular genet ets, «© Prior to prenatal diagnostic esting wih he an of detecting genetic disease, genetic counseling mustbe cated cu, in aosordance with the Geman ‘Genet Diagnosis ct which came into force on February 1, 2010 This must be norsectve, 28 must any genet counseling Dwscbes Ace er al on beet 2010; 0785-82 MEDICINE REVIEW ARTICLE The Prenatal Diagnosis of Genetic Diseases Wieacker, Johannes Steinhard Retorences of Jakson LS, Zachay JM, Foner SEA randomized ‘omparsen tvaseoncal and varsbioinal chorus ‘amin. Te US. atonal tae of rls eal ane Henan Levan: Chran-busSamotng an sects Say (Group. ME Jed 982; 327-594-1 2, Water rnaosed lic aot cote vis sama aed anneral Fleet, Canaan elaborate CFS Avice Crical Wl ou. ancel 1986; 8878. 1-8 8, Rhoats GG, Jackson. Sclessenan SE, eT eaely ns ttiacy hari sarin a ea rental agra of ‘ager aromas. rg J Med 1989, 320 608-17 Wai Reserh Cul urope af chron vue samaing MRC wor paren he vation fran les sampling, ance’ 1891 357" 1281-8 5, Caughey 8 Hepes LM, Nancn ME Chon vik samtng omparea wit aeocesei athe aerene nthe ot bregancy bs. Ostet ra 7006, 108: 612-8 8, War, Marl K, Bab Rt: DEOU-SuzelkEngfelng zr word sonogratichen Uresuchang f= DLSUM Ste ip ir zetrau 11-14 Schwangerschatsioaher Uasalin Wed 2004; 95 218-70 oF, Wlaes Ki, an Kasra OSD Uasctaltsuching von 11-1346 Sawangeshaawocren. enn: Fell Weds Foundation 2008 wereatredtne com 8 Gather J Subeand GR: Choosore aarti and eet counseling Car Los Press 208, ©, WaturnD:Oe nov balances crmoaure erangama'e ara ea voosoesoniied a prenatal agoss Cla Sncatce ad aston of realgoes, ro Hu Gene 81 48: 885-1013. £0, Buel T You. U, Ceret-Sergewal:Pokrptaagrskn Deuschand— Erarungn nd rev Enicaunen. J Ret ‘inset Endkng 2008 4.2" (71 Ase, Np Mares adn (UROEAT working gro: eatin artisan Evgatan eons in trina ase fal abnormal tye 20? Medgen 1888 1-776 172, DADA Stuy eu compris Ween, Nope Ie Cores of regrancies dagrosed win Kirt drone the posse nunc thas rotssionas, Pens: Dagh oe: 2: 882-6 Dts Aerial Ds Ati 2010; 10748 | Wes Siar: eeteeces De MEDICINE REVIEW ARTICLE The Prenatal Diagnosis of Genetic Diseases Peter Wieacker, Johannes Steinhard oo Fetal biopsy The embrjlogieal avelprent af asus which can bused er prenatal agnosis (mee For [0 onda (quarter of sos cals form te ner el mas. CS, corn vis sampling De DnschesAcelatrenatnall Discreet 200; 078 | ese Steharé: Fue MEDICINE REVIEW ARTICLE The Prenatal Diagnosis of Genetic Diseases Wieacker, Johannes Steinhard Source of cells used for prenatal diagnostic tests Cas of eg cure te, depending on the inerventon This inpotantn neretng he prognosis posle mosis, Around tea quarters of lasocyt as del vopabit cel, ‘Which for the ute layer fh chan il Acund a quarter become neal ms, ich ‘errs ino hypo ad pla. The tn and ameion mesasem develo om tha hypo ble, whe the past gues oth tee gor layer cade, mesodem and ender) and the amnion ecoda (oF). The cytogenetic analysis of amnion cells Cylogenai analysis uses a cule of amnion cells enced inthe sediment folowing centifogton, he amnion cls ae detvd from tre fetal ectoderm (n pattcular rom the skn and lower unary tra), Using the culture flask method, teal wo cates a grown in order to reduce the rik of fare and improve interpretation of chromasomal mosaics At eat 15 metaphases ar analyzed numeral and al fas structurally, Wit the inst method, a fast 1 metaphases tom 8 dones are analyze, ‘Atand esoluon of teat 400 bands in eaten to the hapkid chromosome seis requied for chromosome anal rom ICSN) (Guideline on Cytogenetic Laboratory Diagnosis: waw.ghev.de), Detches cet remaenall Dio Ate 2010; 0785 | MEDICINE The cytogenetic analysis of chorionic villi and the risk of miscarriage in chorionic villus sampling The yfogenatc analysis of chorionic wll ogra analysis both ater det propraon (1 day as ater longterm cute (7-10 days) bocausein tis \wayoalls faring emtryonal agin canbe exaringd. Th minmum requrement for chromosome analysis of chronic vl arasluon of 300 bands (n roan fo the haploid chromosome sol ‘The reported miscaiage rs folowing chorionic vilus sapling varies by study A larg scale randomized tal) of 3999 prognancis ound no «ference in miscarriage rlebetwoon vanscarvcal and vansabdominal chao vilus sampling (CVS). Canadian multcanar study of 2787 ‘women 22) and large Amaican study 3) bah showed no signcant difarnce in miscarage rate between CVS and amniocentsis, However, a European muticente study found higher ale of comical for CVS than for amiocaross 4). recenly published single contre study 8) campared 5243 chatonc vil biopsies wih 4817 casos where no invasive tetng was cared ut, and found no dference in miscaiage rk. (vera he data sugges that operator experience and taining are cnr o th complication ao. With appropitaexpariance the miscarriage rate shoud bein the region af up to ‘The Garman Soceyfr Utrasound in Medcin (Deutsche Geselschaf fr Ulvaschal nde Modzn, DEGUM) andthe London based Fetal dione Foundaton (FMF) recommend thal CVS shold be offered 2s te most rep invasive kagnostc testo were n whom an ultasound abnormally or an inceased risk of comosomalanotraty a rs! timeser scening have ben found (e867). I's not acceptable or woman ‘wha has chosen invasive testing inthe face of an increased rik to have lo wal weeks for amniocentesis. lhe vty least she shoul be lead the aerate option of ear kaetysing Diagnostic problems in cytogenetic prenatal diagnosis, Convetional tvomasame analysis is nate to dee structural changes below te mis ofthe achievable opal rescluon, More recent anew ethos, Aray-CGH (Comparative Genomic Hybridization) has been developed to overcome tis barr, Tis ena competitive hybridisation ofrefe- rence DNA and patient DNA which are marked, especvey wih diferent cloured fluorescent marke (fd and green) in a micro aay A genomic aay ofthis ype allows deed genome fragments to be fxed in amtctke formation for example on 2 glass sis, Cohybridizato of reference and test DNA alows ne dtectonoflosses and gains such as deletions or dupkcatons, va thert-gen aio, This allows the detection of mired laions and mirodupications which cannot be detected by coventonal chromosomal rays However, changes wih pathological mpliations rmustbe distinguished irom copy nuber variants of no inca significance isto be antipaed thats technology wil fm an important par of Prenatal agnosis in futur, if appropriate microarrays forthe relevant clinical question are validated in advance ‘The observation of ndidval a small numbers of calls wih a chromosomal aeration can presen a agnstic problem. Aditnton is made be- ‘ween ‘true masa, n whom aberrant cela presenti te fetus othe placenta aloe (conned placental mossicsm), and pseudoriosis, in whom the aberrant cols have arson dung culture or as a preparaton atfact. An intemaional classficaton has beoome established for interpreting findings such as hese, and ofring guidance on how to procood, taking the afoctd cromosore ilo account ().For example, some cass, cardoontei canbe undertaken to obtain further earflcation of uneaan mosaics fllwing chorionic lls samplng (CVS) or reiocetes, ‘ther diagnaste challenge can arta when aranslocaton or rversion i found. thi caso tis important fst to delarmine whather the cro- rmosomal aneraly arses fom one ofthe parents, or has arisen de novo. nthe case ofits being inherited, the Ikelnoed ca detectable increased fskof congenital abnormal sma. Where an anomaly such asa translocaton or inversion, has arson de novo, the possi of gona damage asing fom a breakin a gone canet be rule ou. Empcallydervod rik estates ae avalabloo aid assossment oti sk. Tho probabil congenital disease or anomaly round 6% folowing ade novo reciprocal ranslocaton and around 94% folowing ade novo inverson. tis ao posse hat ytogenetic prenatal dagnoss may reveal a marker cxomosome. Amarer eemosome isa stuctualy alered chvomesome whose omposion canal be determined using conventional banding echiques. A newly ain marker cromosome i associated wih a probability of congenital disease or anomaly fen average 15% (o8). Special Flurescetin-tu hybridzaton techniques (FISH) may mod tis robaity. In any ase deal anomaly scanning sould be cared oun a specialist cener wth view to detecting possible abnarmalies. Te mis of ultrasound to detect aboarmakios should be bore in mind De Dates ret leans 200; 078 | Wescha Sear eones Contamination of chorionic villi with maternal cells as a source of error in the prenatal diagnosis of monogenetically inherited defects chan are contaminated wih mataral cals the post of isiagnoss as. Fortis roason his poof diagnos proces sold aay be accompanied by acotaninaon chor, Thisinvlethecharacerzabon of aloes using shortand repeats inmtanal DNA and DNA fom fe chron Biopsy spacnen. te chro ips specimen conta wo maternal alles fo ase lous, contrat wih mata cass cbvius, Tis a ation fa repet procedure Preimplantation diagnosis In const prenatal gross, princantation cages PID) s cari cut on ember cls pro he establishment of pregnancy. This requres n vir fertlization (VF or irraytplasmic sperm rjcton (ICSI). fer culvation ofthe embryo to the Boel stage, one oa (blastomer), pial, is removed fer molecular cogent or molecular genetic analyss he aplication of PID are (© The detection or exclusion of speci unbalance chrrnosoms translocation, where one paren cares Robertsonian or ‘ecprocal translocation (© The detection or excuson of a partclar mutton inthe presence of an increased risk of armonogen seas, ‘As PID isnol cared out in Germany ds tothe Garman Embryo Protection At the ks and benefits of this method are not discussed in his article, The legal sats of PID is curently under nw dscusson in Germany following a recent cout judoment. Polar body diagnosis is @ method of peconosptual examination of the cocte which afer a posible temas to PD. ‘This requires IVF or ICSI Theft polar body arises ae he st meat dson and contains haploid genotype of normally 23 ctromasomes, wih each cromosome comprising two chromatids The sacond plar body arses allowing the second meio cision, wih each chromosome comprising a nae chromatid, The fist polar body develops shorty before onuaton, The second polar body savalabl So & hours air penetration ofthe coyls by he sperm, and therefore folowing ICSI, for example In erdaro cory wi he raquirament fhe Garman Emryo Proton Act. polar body dagnoss mus b com- leo by 20 hous follwing ICS, a by this sage the famale and male pronucls hav fused and an emiby has boon rated. Polar body diagnos canbe usod whon the woran caries abalancod translocation othe predisposition toa monoganet cally inherited d3oaso, Polar toay diagnos’ s curently fred alin afew cares in Gnmany (10), Prorto IVF ICSI t rust be decided foreach case whthar pla body agnosis is feasible. In rproducive mode, tishoped tha polar body

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