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Chromosomal Disorders

Definitions
• Gene: smallest unit of a single
characteristic
• Chromosome: structural elements in the
cell nucleus that carry the genes and
convey genetic information
• Each cell (except RBO) contain all of the
chromosomes from both parents in the
nucleus
• 23 pairs of chromosomes come from each
parent
• Autosome: one of the 22 pairs of
chromosomes that is not responsible for
determining the sex of the child
• Sex Chromosome: X and Y chromosomes
responsible for sex determination
Chromosomal Defects
• Abnormal Number
• Monosomy: one less than the diploid number
(45)
• Trisomy: one more than the diploid number
(47)
• Mosaicism: some cells have the correct
number of chromosomes and some have
more or less than the correct number of
chromosomes
• Abnormal Structure
• Deletion: loss of a chromosomal segment
• Translocation: the occurrence of a
chromosomal segment at an abnormal site
either on another chromosome or in the wrong
position on the same chromosome
Prenatal Diagnosis
• Maternal Serum Alpha-fetoprotein
(MSAFP)
• Done at 16 – 18 wks gestation
• High MSAFP: incorrect dates; multiple
gestation; neural tube defects,
abdominal wall defects; renal
anomalies; esophageal or intestinal
obstructions
• Low MSAFP: incorrect dates;
chromosomal defect (esp. Trisomy 21)
• Ultrasound
• Amniocentesis
• Usually done at 16 – 18 wks gestation
• Fluid analysis may require up to 2-3 wks
• Can usually determine: fetal sex,
metabolic disorders, chromosomal
abnormalities
• Chorionic Villus Sampling (CVS)
• Usually done at 8 – 10 wks gestation
• Fetal cell analysis usually takes 24 – 48
hours
Newborn Care
• History
• Family History: any similar relatives,
frequency of spontaneous abortions
• Prenatal History: fetal activity, maternal
exposures, uterine malformations
Newborn Assessment
• Face: configuration, spacing of feature,
location of features
• Head: size and shape of skull, fontanel
• Eyes: structure, location, color of iris
• Ears: low set or correct location, skin
tags
• Nose: number of nares, location, flattened
bridge
• Oral: size and shape of tongue, mouth,
jaw
• Neck: webbing, extra folds
• Hands & Feet: broad, square, polydactyly,
abnormal creasures, contractures,
overriding fingers or toes
Family Support
• Crisis
• Grief – loss of “perfect child”
• Genetic counseling
• Identify the normal
Trisomy 21
• a.k.a. Down’s Syndrome
• Caused by an extra chromosome 21

Normal Karyotype Trisomy 21 ( 47,XY,+21)


Trisomy 21
• Incidence
• 1 : 650 – 1000 live births, parental age related
• 75 % abort spontaneously
• Sex ratio: 3 males / 2 females
• Most common autosomal chromosomal
disorder causing mental retardation
• Risk Factors
• maternal age
• Parental carrier of translocation
• Prenatal Testing
• Triple screen (alpha-fetal protein decreased,
estriol decreased, beta-HCG increased)
• If positive, amnio or CVS may be indicated
Clinical Presentation
•Size: small, 20% are •Tongue: protrudes,
premature tongue thrusting
•Skull: short and round •Skin loose around
with a flat occiput, lateral and dorsal
separated sutures aspects of neck
•Eyes: slant upward and •Hands: fingers are
outward short, hands are square,
•Prominent epicanthal thumbs are low set,
fold separated more than
•Moon-shaped face usual from second
finger, 5th finger is short
•Brushfield’s spots and curves inward,
•Cheeks: red single/bilateral simean
•Palate: narrow and crease
short •Ears: low-set,
•Nose: short with flat posteriorly rotated ears
bridge
Clinical Presentation
•Umbilicus: herniated •Velvety, loose
•Feet: wide space adhering mottled
between great toe and skin in infancy,
2nd toe, deep crease
coarse skin in
between great toe and
the 2nd toe, flat feet adolescence
•Heart: VSD •Mouth frequently
•Duodenal atresia open/frequently open
•Muscular hypotonia mouth
•Retarded psychomotor •Visual and/or
development hearing impairment
•Hyperlaxity of ligaments
Prognosis
• Congestive heart failure d/t CHD
• Upper respiratory tract infections
• Developmentally delayed
• Mildly to severely mentally retarded:
IQ ranges from 25 – 70
• Increased risk for thyroid problems
and leukemia
Trisomy 18
• a.k.a. Edward’s Syndrome, Trisomy
E, Trisomy 16 – 18
• Caused by an extra chromosome 18

Normal Karyotype Edward’s Syndrome (47,XY, +18)


Trisomy 18
• Incidence
• 1 : 6000 – 8000 live births
• F > M (4 : 1)
• Most die in embryonic or fetal life
• Risk factors
• Increased paternal and maternal age
• Prenatal screening
• Good indicator is if in maternal serum during
mid trimester have low human chorionic
gonadotrophin and low unconjugated estriol
• Ultrasound
• If anomalies seen, amnio or CVS may be
indicated
3 Types of Trisomy 18
• Full Form
• Every cell in the body has 3
chromosome 18 instead of 2
• Severe form
• Mosaic Form
• Some cells have 3 chromosome 18 and
others have 2
• Less severe form
• Partial Form
• In some cells there may be an extra
copy of part of chromosome 18
• Severity dependent on anomalies
Clinical Presentation
•Prenatal hx: feeble fetal •Mouth: micrognathia,
activity, microstomia, cleft lip,
polyhydramnios, small cleft palate
placenta, single •Mental retardation
umbilical artery •Heart: VSD, PDA, ASD
•Post-dates •Feet: rocker bottom, big
toe shortened and
•SGA
dorsiflexed, clubfeet
•Weight: low birth •Crossed legs
weight in term infant •Diastasis recti
•Weak cry •Pectus carinatum
•Response to sound •GU defects: horseshoe
decreased kidneys,
•Ears: low set and/or hydronephrosis,
abnormal shape polycystic kidneys
Clinical Presentation
•Hands: clenched and •Head: abnormally
with flexed fingers
(usually where index prominent occiput,
finger overlaps 3rd and microcephaly
4th fingers),flexion •Hernias: umbilical,
contraction of the two
middle digits, inguinal
underdeveloped or •Redundant skin
absent thumb, simian
crease, arches on seven folds esp. over the
or more fingers, nails back of the neck
underdeveloped •Males:
•Syndactyly
cryptorchidism
•Eyes: ptosis of one or
both eyelids, epicanthal
folds
Prognosis
• 20 – 30% die during the first month
• 90% die by age one
• 1% chance of surviving to 10 yrs
• High mortality rate is caused by congenital heart
malformations, gastrointestinal and genitourinary
anomalies, feeding difficulties, and associated
central nervous system defects that produce
central apnea.
• Although they function with severe handicaps, all
older children with Trisomy 18 smile, laugh,
interact, relate to their families, and achieve some
psychomotor maturation.
• Mosaic cases may show milder phenotypic
expression and prolonged survival.
Care Management
• No treatment beyond supportive care
• NG or GT feedings
• Orthopedic management
• Cardiac management
• Genetic counseling
• Parental support
• Apnea monitoring / O2 if needed
Trisomy 13
• a.k.a. Patau’s Syndrome, 13+
Syndrome, 13 – 15 D Syndrome,
Trisomy Syndrome
• Caused by an extra chromosome 13

Normal Karyotype Trisomy 13 (47,XX,+13)


Trisomy 13
• Incidence
• 1 : 5000 live births
• Male = Female
• Risk Factors
• Increases with maternal and paternal age
• Increases with increased parity
• Parental carrier of balanced translocation
• Prenatal Screening
• Ultrasound
• If anomalies seen, amnio or CVS may be
indicated
Clinical Presentation
•Severe mental and •Nose: broad and
psychomotor retardation flattened
•Ears: malformed, low- •Mouth: cleft lip and
set palate
•Hands: flexion •Hernias: umbilical
deformities; polydactyly, hernia, inguinal hernia
simian crease, clenched •Kidneys: polycystic
hands •Skin: cutaneous
•Heart: VSD, PDA, ASD, hemangiomas
rotational anomalies •Head: dermal sinus on
(dextrocardia) scalp, microcephaly
•Eyes: microphthalmos, •Brain: gross defects,
colobomas of iris, grand mal seizures,
cataracts, retinal myoclonic jerks,
dysplasia, close set seizures,
(may fuse into one) holoprosencephaly
Clinical Presentation
•Skin loose around •Mouth: cleft lip, cleft
lateral and dorsal palate
aspects of neck •Spine:
•Single umbilical meningomyelocele
artery •Feet: rocker bottom
•Apnea •Low-birth weight
•Genitalia •Omphalocele
•Female: •GI XR or US may
bicornate/septate
uterus
reveal abnormal
•Male: rotation of internal
cryptorchidism organs
Prognosis
• 82% die within the first month
• 5 - 10% survive the first year
• Survival to adulthood rare
• Common disorders if survive beyond 1
month of age
• Severe mental retardation
• Feeding disabilities
• GE reflux
• Slow post natal growth
• Apnea
• Kidney defects
• Seizures
• Developmental disabilities
• Scoliosis
Care Management
• No treatment beyond supportive care
• Parental support
Turner’s Syndrome
• a.k.a. TS, Monosomy X, Gonadal
Dysgenesis, Bonnevie-Ullrich Syndrome,
XO Syndrome
• Is the absence of one set of genes from
the short arm of one X chromosome

Normal Karyotype Turner’s Syndrome (45,X)


Turner’s Syndrome
• Incidence
• 1 : 2000-3000 live-born females
• Females only affected
• 98% of pregnancies with TS spontaneously
abort
• 10% of pregnancies that spontaneously abort
have TS
• Risk Factors
• Increased paternal age
• Mother with mosaic or deletional Turner’s
Syndrome
• SHOX gene association
• SHOX gene provides instructions for making a
protein that regulates activity of other genes
Clinical Presentation
•Short stature; mean •Heart: coarctation of
birth weight 2.9 kg; the aorta, aortic vavular
average height: 4’7” stenosis, bicuspid aortic
valve, aortic dissection
•Webbed neck
•Eye: ptosis, strabismus,
•Low posterior hairline amblyopia, cataracts,
•Micrognathia epicanthal folds, dry
•Ears: low-set, eyes, red-green color
blindness
sometimes malformed,
•Congenital hip
prone to otitis media
dislocation
•Widely spaced •Abnormal growth
hypoplastic nipples on a patterns
shield-shaped chest •Congenital lymphedema
•Increased carrying of hands and feet
angle at the elbow
Clinical Presentation
•Absent or retarded •Gonadal dysplasia
development of •Horseshoe kidney
secondary sexual •Unilateral renal
characteristics that agenesis
normally appear at
•Intelligence: not at
puberty
risk for mental
•Absent
retardation, better
menstruation verbal then
•Absence of normal visuospatial abilities
vaginal moisture •Broad nasal bridge
•infertility
Prognosis
• Females are basically normal despite
failure of sexual development
• At risk for
• Middle ear infections
• Scoliosis
• Arthritis
• Cataracts
• Hashimoto’s thyroiditis
• Kidney abnormalities
• High blood pressure
• Obesity
• Diabetes mellitus
• Osteoporosis
• Keloid formation
Care Management
• Early
• Supportive care
• Surgery to correct treatable defects
• Late
• Growth hormone therapy
• Estrogen replacement therapy
• Counseling and psychiatric support
• 2 – 5% have some ovarian function and
can menstruate and become pregnant
• Others can have children using donor
eggs and in-vitro fertilization
VATER Association
• VATER = Vertebral anomalies
Anal atresia
Tracheo-Esophageal fistula,

Radial and renal dysplasia


• Incidence
• Unknown
• Etiology
• Unknown
Clinical Presentation
• Three or more of the following
defects must be present:
• Vertebral anomalies
• Anal atresia with or without fistula
• TEF with EA
• Radial dysplasia, including thumb or
radial hypoplasia, polydactyly, and
syndactyly
• Renal anomaly
• Single umbilical artery
• Prognosis
• FTT
• Possibility of normal life after slow
mental development during infancy
• Care Management
• Supportive care
• Surgery: surgical correction of
anomalies