Bi-allelic Mutations in NADSYN1 Cause Multiple Organ Defects and Expand the Genotypic Spectrum of Congenital NAD Deficiency Disorders.

Birth defects occur in up to 3% of all live births and are the leading cause of infant death. Here we present five individuals from four unrelated families, individuals who share similar phenotypes with disease-causal bi-allelic variants in NADSYN1, encoding NAD synthetase 1, the final enzyme of the nicotinamide adenine dinucleotide (NAD) de novo synthesis pathway. Defects range from the isolated absence of both kidneys to multiple malformations of the vertebrae, heart, limbs, and kidney, and no affected individual survived for more than three months postnatally. NAD is an essential coenzyme for numerous cellular processes. Bi-allelic loss-of-function mutations in genes required for the de novo synthesis of NAD were previously identified in individuals with multiple congenital abnormalities affecting the heart, kidney, vertebrae, and limbs. Functional assessments of NADSYN1 missense variants, through a combination of yeast complementation and enzymatic assays, show impaired enzymatic activity and severely reduced NAD levels. Thus, NADSYN1 represents an additional gene required for NAD synthesis during embryogenesis, and NADSYN1 has bi-allelic missense variants that cause NAD deficiency-dependent malformations. Our findings expand the genotypic spectrum of congenital NAD deficiency disorders and further implicate mutation of additional genes involved in de novo NAD synthesis as potential causes of complex birth defects.

Plasma DNA tissue mapping by genome-wide methylation sequencing for noninvasive prenatal, cancer, and transplantation assessments.

Plasma consists of DNA released from multiple tissues within the body. Using genome-wide bisulfite sequencing of plasma DNA and deconvolution of the sequencing data with reference to methylation profiles of different tissues, we developed a general approach for studying the major tissue contributors to the circulating DNA pool. We tested this method in pregnant women, patients with hepatocellular carcinoma, and subjects following bone marrow and liver transplantation. In most subjects, white blood cells were the predominant contributors to the circulating DNA pool. The placental contributions in the plasma of pregnant women correlated with the proportional contributions as revealed by fetal-specific genetic markers. The graft-derived contributions to the plasma in the transplant recipients correlated with those determined using donor-specific genetic markers. Patients with hepatocellular carcinoma showed elevated plasma DNA contributions from the liver, which correlated with measurements made using tumor-associated copy number aberrations. In hepatocellular carcinoma patients and in pregnant women exhibiting copy number aberrations in plasma, comparison of methylation deconvolution results using genomic regions with different copy number status pinpointed the tissue type responsible for the aberrations. In a pregnant woman diagnosed as having follicular lymphoma during pregnancy, methylation deconvolution indicated a grossly elevated contribution from B cells into the plasma DNA pool and localized B cells as the origin of the copy number aberrations observed in plasma. This method may serve as a powerful tool for assessing a wide range of physiological and pathological conditions based on the identification of perturbed proportional contributions of different tissues into plasma.

Impact of first childbirth on changes in women's preference for mode of delivery: follow-up of a longitudinal observational study.

BACKGROUND: A woman's childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. METHODS: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. RESULTS: Twenty-four percent (23.8%, 95% CI 18.4-29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7-767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1-353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4-20.6), higher family income (OR 3.2, 95% CI 1.1-8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0-6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0-1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). CONCLUSIONS: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women's wish to change to elective cesarean section.

Fetal parvovirus B19 infection in a twin pregnancy with 1 twin presenting with hydrops fetalis and the other asymptomatic: a case report.

BACKGROUND: Parvovirus B19 infection during pregnancy is a known cause of nonimmune hydrops, while about one third of maternal infection is asymptomatic. Spontaneous abortion, hydrops fetalis, intrauterine growth retardation and meconium peritonitis are possible manifestations of fetal infection, but the infection can also be asymptomatic. CASE: Both fetuses in a dichorionic, diamniotic twin pregnancy were infected with parvovirus B19 infection, but only 1 fetus presented with hydrops fetalis. That fetus died, while the other remained asymptomatic throughout the pregnancy. The mother had a normal delivery at 39 weeks of gestation, and the neonatal outcome of the surviving twin was normal apart from early-onset neonatal jaundice due to ABO incompatibility. CONCLUSION: This case, together with others, illustrates that parvovirus B19 infection in twin fetuses can present differently despite the fact that the fetuses are nurtured in rather similar intrauterine environments. A severe complication in 1 twin does not preclude a normal outcome in the other. The possibility of different manifestations should be borne in mind so that parvovirus B19 infection remains high on the list of differential diagnoses of nonimmune hydrops affecting only 1 fetus in a twin pregnancy.

When to induce labor for post-term? A study of induction at 41 weeks versus 42 weeks.

OBJECTIVE: To evaluate the pregnancy outcomes of two policies of timing of induction of labor for post-term pregnancies. STUDY DESIGN: It is a retrospective study in a University obstetric unit from 1997 to 2002. Five thousand eight hundred and ninety-two singleton, cephalic pregnancies with gestational age at delivery at or more than 41 completed weeks were studied. They were divided into two groups. Group A included women who delivered from January 1997 to February 1999 when the policy of the department was to induce labor for post-maturity at 42 weeks of gestation. Group B included those delivered between March 1999 and December 2002 when the timing of induction for post-term was advanced to 41 weeks. The intrapartum characteristics, delivery and perinatal outcomes were analyzed by Student's t-test and Chi-square test for continuous and categorical variables, respectively. RESULTS: Two thousand one hundred and seventy-six women were studied in Group A and 3716 in Group B. Twenty-nine percent of these pregnancies in Group A required induction of labor whereas 20.3% were for post-term. In Group B, 58% of pregnancies had labor induction and 55% for post-maturity. For the pregnancies undergoing induction of labor for post-term, both the duration of labor (P<0.001) and the need of intrapartum epidural analgesia were increased (OR 1.3, 95% CI: 1.0-1.6) in Group B. However, there was no significant difference in the mode of delivery, apgar scores and stillbirths between the two study periods. CONCLUSION: Compared to routine induction at 42 weeks, induction at 41 weeks is associated with a significantly higher risk of use of medical interventions and associated complications, with no observable benefits.

Dextrocardia in pregnancy: 20 years' experience.

OBJECTIVE: To identify all pregnancies complicated by maternal dextrocardia and report the obstetric performance in these patients. STUDY DESIGN: A retrospective review of all deliveries between May 1984 and December 2004 at Prince of Wales Hospital, Chinese University of Hong Kong. Maternal demographic data as well as information on the antenatal course and delivery outcome were abstracted from the maternal records. Neonatal record review yielded information on the gestational age at delivery, birth weight, Apgar scores, sex and neonatal conditions after delivery. RESULTS: Fifteen singleton pregnancies in 9 patients with dextrocardia were identified. There were 6 pregnancies in 3 patients with situs inversus and 9 pregnancies in 6 patients with isolated dextrocardia. There were no apparent antenatal complications. None of the patients developed any cardiac symptoms antenatally. All the infants had a 5-minute Apgar score > 7. Four small-for-gestational-age (SGA) infants, defined after correcting for parity, gestational age, maternal height and maternal entry weight, occurred in patients with situs inversus. This is significantly different from the 10% expected (p < 0.002). No SGA infants were born to patients with isolated dextrocardia. CONCLUSION: Pregnancies complicated by maternal isolated dextrocardia did not have any detrimental effect on the disease or vice versa. However, SGA infants should be watched in patients with situs inversus.

Reference charts of gestation-specific tissue Doppler imaging indices of systolic and diastolic functions in the normal fetal heart.

BACKGROUND: Assessment of fetal cardiac function is difficult because of limited accessibility. Tissue Doppler imaging (TDI) is a promising technique in assessing diastolic function in adults. There has been sparseness concerning the use of TDI in assessing fetal cardiac function. The aim of this study was to construct reference charts of TDI indices of systolic and diastolic functions of the normal fetal heart. METHODS: Ventricular myocardial velocities at the left ventricular (LV) wall, right ventricular (RV) wall, and interventricular septum (IVS) were assessed by TDI in 302 subjects. RESULTS: From 19 to 37 weeks of gestation, peak myocardial velocities during early diastole (Em) increased from 3.3 to 7.2, 3.9 to 8.3, and 3.2 to 5.0 m/s at the LV wall, RV wall, and IVS, respectively. Peak myocardial velocities during atrial contraction (Am) also increased throughout gestation, but the magnitude of increase was smaller (6.3 to 7.9, 7.7 to 10.6, and 5.5 to 5.9 m/s for the LV wall, RV wall, and IVS, respectively). As a consequence, the Em/Am ratio increased from 0.51 to 0.61 at midtrimester to 0.76 to 0.91 at term. Similar to Em, peak myocardial velocities during systole (Sm) also increased by almost 2 times from 18 to 37 weeks of gestation (3.8 to 6.0, 4.2 to 7.6, and 3.3 to 5.6 for the LV wall, RV wall, and IVS, respectively). Reference charts of gestation-specific Em, Am, Em/Am ratio, Sm, and E/Em were constructed accordingly. CONCLUSIONS: In midtrimester, fetal diastolic function is predominantly contributed by atrial contraction. As gestation advances, ventricular relaxation becomes increasingly mature. Reference charts for TDI indices were constructed, these will allow identification of fetuses with an abnormal diastolic function.

Effect of prostaglandin E2 for cervical priming on fetal hemodynamics.

OBJECTIVE: To assess the effect of the prostaglandin E2 (PGE2) on fetal vascular blood flow during cervical priming. STUDY DESIGN: In a prospective, observational study, 32 pregnant women > or =37 weeks of gestation requiring PGE2 for induction of labor were recruited. The resistance indices (RIs) of umbilical artery, middle cerebral artery, renal artery and ductus venosum were measured before, 2 and 4 hours after insertion of a PGE2 vaginal pessary. RESULTS: There were no significant changes in RIs of various fetal vessels during cervical priming with PGE2. CONCLUSION: There was no significant change in fetal hemodynamics after vaginal prostaglandin administration. This finding provides further evidence to support the safety of prostaglandin for normal fetuses.

Human decidual production of hepatocyte-growth factor is not influenced by trophoblastic invasion in vivo.

OBJECTIVE: To evaluate and compare production of hepatocyte growth factor (HGF) from human first-trimester implantation-site decidua (decidua basalis) and nonimplantation site decidua (decidua parietalis), and hence to determine whether human trophoblast invasion in vivo is associated with increased decidual HGF production. DESIGN: Controlled prospective study. SETTING: University hospital-based study. PATIENT(S): Ten women undergoing first-trimester termination of singleton pregnancy for psychosocial reasons without preexisting medical or gynecologic diseases. INTERVENTION(S): Decidual samples surgically excised and processed for paraffin-embedded immunohistochemistry and for reverse transcription-polymerase chain reaction (RT-PCR) studies. MAIN OUTCOME MEASURE(S): Protein and mRNA production in decidua basalis and decidua parietalis by immunohistochemistry and RT-PCR, respectively. RESULT(S): No statistically significant difference was found between decidua basalis and decidua parietalis in HGF protein or mRNA production. Immunohistochemical analysis (n = 9) showed a mean score of 3.28 +/- 2.37 for decidua basalis and 3.61 +/- 2.66 for decidua parietalis. Semiquantitative analysis of HGF mRNA expression between the two sites showed no statistically significant difference (n = 10) CONCLUSION(S): Human decidual production of HGF is not influenced by trophoblastic invasion in vivo.

Climacteric symptoms and knowledge about hormone replacement therapy among Hong Kong Chinese women aged 40-60 years.

OBJECTIVES: To evaluate the use of hormone replacement therapy (HRT), the prevalence of climacteric symptoms, and the knowledge about HRT. METHODS: A prospective study was conducted by telephone interview among a randomly selected population-based sample of 978 Hong Kong Chinese women aged 40-60 years. RESULTS: Of 414 women with a history of either natural or surgical menopause, 22 (5.3%) and 17 (4.1%), respectively, were either past or current users of HRT. The climacteric symptom scores of premenopausal women were significantly lower than those of perimenopausal women, but were comparable with those of postmenopausal women. The commonest climacteric symptom was 'muscle and joint pains' which was reported in 553 (56.6%) women, while only 228 (23.3%) and 151 (15.4%) women reported hot flushes and night sweating, respectively. Moreover, only 230 (23.5%) women realized that HRT could relieve menopausal symptoms and only 33 (3.4%) women were aware that HRT was protective against osteoporosis. In general, women with more climacteric symptoms, who had ever used HRT, and those with higher education level and higher family income, had better knowledge about HRT. CONCLUSIONS: Postmenopausal Hong Kong Chinese women have a low HRT usage rate and the majority of them are lacking of the knowledge about HRT.

Corticotropin-releasing hormone peptide and human first-trimester placental growth.

The aim of this study was to determine whether corticotropin-releasing hormone (CRH) regulates human trophoblast cell growth. The results showed that exogenous CRH significantly stimulated human trophoblast proliferation in first-trimester primary cultures. In vivo, CRH was strongly immunolocalised to cytotrophoblastic cells in proliferative cell columns and in chorionic villi. We postulate that CRH may have an important role in early placental development and successful pregnancy.

Successful pregnancy in a woman with congenital "Swiss-cheese" platelets. A case report.

BACKGROUND: Congenital "Swiss-cheese" platelets are a rare disorder of platelet function due to impaired calcium mobilization. Management of pregnancy in patients with this disorder had not been reported previously. CASE: Successful pregnancy occurred in a woman with congenital Swiss-cheese platelets. Neither the mother nor neonate experienced any hemorrhagic complications. CONCLUSION: Successful pregnancy is possible in women with congenital Swiss-cheese platelets. The lack of hemorrhagic complications may be due to the increase in platelet intracellular free calcium concentration during pregnancy.

Entrapment of viable trophoblastic tissue in a uterine hematoma after surgical evacuation. A case report.

BACKGROUND: Postevacuation uterine perforation is a common event. Early diagnosis and management are important to minimize the associated morbidity and mortality. CASE: A woman presented with persistent vaginal bleeding for two weeks following surgical uterine evacuation for missed abortion at 7 weeks' gestation. She had a persistently elevated serum human chorionic gonadotropin level. Ultrasonography revealed a 3-cm, heterogeneous mass with high vascularity at the left anterior uterine fundal region; the endometrial echo was normal. Cornual pregnancy was suspected, and surgical resection was planned. Intraoperatively, a uterine hematoma with evidence of previous uterine perforation was diagnosed. Hysterotomy, removal of the hematoma and repair of the uterus were performed. Histologic examination revealed entrapment of trophoblastic tissue in the specimen. The patient had an uneventful recovery. CONCLUSION: Entrapment of trophoblastic tissue in a uterine hematoma is a rare sequel of uterine perforation after evacuation and might be confused with cornual pregnancy.

Large choledochal cyst present through 2 pregnancies. A case report.

BACKGROUND: Choledochal cyst is rarely diagnosed during pregnancy, and it is very difficult to make a diagnosis of it clinically or radiologically. CASE: A woman was diagnosed as having an ovarian cyst and gallbladder mucocele on ultrasonography in both her first and second pregnancies. She was asymptomatic, and conservative management was adopted. Three days after delivery of her second child, the patient had a sudden onset of right upper quadrant pain associated with deranged liver function. Emergency laparotomy revealed a type I choledochal cyst with evidence of infection. Excision of the cyst, cholecystectomy and bilateral hepatojejunostomy in the Roux-en-Y fashion were performed. CONCLUSION: A choledochal cyst in pregnancy is difficult to diagnose and poses a threat to mother and fetus.

First trimester combined screening for Trisomy 21 in Hong Kong: outcome of the first 10,000 cases.

OBJECTIVE: To examine the effectiveness of first trimester fetal Trisomy 21 (T21) screening using a combination of maternal age, nuchal translucency, maternal serum levels of free beta-hCG and PAPP-A in a predominantly Chinese population in Hong Kong. METHODS: Consecutive women who underwent the combined screening for T21 between 11 and 13 + 6 weeks of gestation between 2003 and 2007 were recruited. Risk of T21 was calculated using Fetal Medicine Foundation algorithm and karyotyping was advised when the risk was 1:300 or above. All women were followed up for pregnancy and fetal outcome. RESULTS: 10,363 fetuses underwent screening. 99% of the women were Chinese and 27.4% were at or above 35 years old. 618 fetuses were screened positive (5.9%), which included 31 cases of T21, 14 cases of T18, 7 cases of T13, 10 cases of 45XO and 7 cases of other chromosomal abnormalities. Among the 9745 screened negative fetuses all but 50 (0.5%) had a known outcome, which included three T21 and four other chromosomal abnormalities. All were subsequently identified at the morphology scan except for one case of T21. The detection rate and false positive rates for T21 were 91.2% and 5.4%, respectively and the positive predictive value for all chromosomal abnormalities was 1 in 9. CONCLUSIONS: Combined screening for T21 is highly effective among Chinese women. Training, quality control, regular auditing and follow up are essential to maintain screening standards.

Innate immune response by ficolin binding in apoptotic placenta is associated with the clinical syndrome of preeclampsia.

BACKGROUND: Unidentified circulating factors derived from placenta are thought to be responsible for the exaggerated systemic inflammation leading to preeclampsia. Our aim was to identify the circulating factors present in preeclampsia and to investigate their relationship to the underlying systemic immune response responsible for the associated clinical manifestations. METHODS: We obtained blood samples from pregnant women with and without preeclampsia and performed comparative proteomic analyses to identify the abnormal circulating factors by 2-dimensional polyacrylamide gel electrophoresis and matrix-assisted laser desorption ionization time of flight for protein separation and identification. In placentas from preeclamptic pregnancies, we evaluated the potential role of the candidate proteins identified by Western and immunohistochemical analysis. We also used proinflammatory cytokine antibody arrays to investigate local and systemic immune responses. RESULTS: We found that ficolins, the pattern-recognition proteins involved in the lectin-complement pathway, were differentially expressed in plasma from preeclamptic pregnancies. Ficolins were present in low concentrations in plasma but at high concentrations in the placenta, particularly in syncytiotrophoblasts undergoing apoptosis. The binding of ficolins in apoptotic trophoblasts induced innate immunity through local and systemic cytokine activation and correlated with the clinical manifestation of preeclampsia. CONCLUSIONS: We identified specific in vivo circulating factors derived from the placenta that are responsible for the local immune recognition and systemic inflammatory response in the development of clinical manifestations of preeclampsia. These findings may have predictive value and also therapeutic applications to lessen adverse clinical outcomes of preeclampsia.

Higher median levels of free beta-hCG and PAPP-A in the first trimester of pregnancy in a Chinese ethnic group. Implication for first trimester combined screening for Down's syndrome in the Chinese population.

OBJECTIVE: To study the effect of ethnic Chinese on the medians of free beta-hCG and PAPP-A in the first trimester of pregnancy. METHODS: The data of 943 women undergoing first trimester combined screening for fetal Down syndrome were analysed to derive the Chinese-specific medians. The calculated risk of Down syndrome based on these Chinese-specific medians was compared with that based on the original algorithm of the Fetal Medicine Foundation (FMF). RESULTS: The maternal serum levels of multiples of median of free beta-hCG and PAPP-A were significantly higher among the Chinese than among the Caucasians. The weight-adjusted gestation-specific medians were developed. Without adjustment for ethnicity, the original FMF algorithm underestimated the risk of Down syndrome by a median of 1%. Adjustment by ethnicity increased the false-positive rate by 10% (from 5.3 to 5.9%). CONCLUSION: Ethnic Chinese have a significantly higher maternal serum level of free beta-hCG and PAPP-A in the first trimester, which could not be explained by differences in maternal weight. Adjustment for ethnicity may be necessary for these biochemical markers in a first trimester screening program.

Lack of site-specific production of decidual alpha-2 macroglobulin in human pregnancy.

BACKGROUND: Alpha-2 Macroglobulin (A2M) is a protease inhibitor that is present in both human and rat decidual tissue. In mice, decidual A2M prevents excessive trophoblastic invasion; however, its role in human decidual tissue is unknown. It is possible that A2M may also influence trophoblast invasion in human pregnancy, which would be reflected in increased A2M production in decidua basalis. The aim of the current study was to determine and compare A2M production from first trimester human decidua basalis and decidua parietalis. METHODS: Human decidual tissues were obtained from patients undergoing surgical termination at 9 to 12 gestational weeks. Strips of decidua basalis and decidua parietalis were obtained by uterine curettage under real-time ultrasound guidance. Tissue samples were fixed in 10% formalin or snap-frozen for immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, respectively. Protein and mRNA production between the two sites were compared using the Mann-Whitney U test. RESULTS: Paired basal and parietal decidua were analyzed by immunohistochemistry (n = 9) and by RT-PCR (n = 10). There was no significant difference in A2M mRNA expression between decidua basalis and decidua parietalis (P = .5). Immunohistochemical staining intensity for A2M protein was significantly higher in basalis than in parietalis (P = .004), but the extent of positively stained cells were not significantly different (P = .051). Strong A2M staining in decidua basalis was mainly localized in the intracellular storage vesicles, which may suggest a role of A2M in this site. CONCLUSIONS: We conclude that the expression pattern of A2M in human decidua basalis and decidua parietalis is not consistent with an important role of this gene during the observed gestational period. Contrary to its role in rodent implantation, A2M is probably not involved in regulating human implantation and trophoblastic invasion during this gestational window frame.

The utility assessment of Chinese pregnant women towards the birth of a baby with Down syndrome compared to a procedure-related miscarriage.

OBJECTIVE: This study was performed to investigate the preferences of Chinese pregnant women for Down syndrome-affected birth compared to invasive test-related miscarriage, using the standard gamble approach, and to investigate whether there is a difference in Utility Score between general obstetric patients and those who request prenatal screening. METHODS: An interviewer-administered survey was conducted on 67 women who presented to the General Obstetric Clinic for booking visits and 69 women who presented to the first-trimester Combined Screening Clinic for fetal Down syndrome in a University Obstetric Unit. Preferences for Down syndrome-affected birth compared to invasive test-related miscarriage were assessed using the standard gamble approach. The differences in Utility Scores for the two outcomes and difference in scores between the two study groups were compared. RESULTS: There was no significant difference in any of the Utility Scores studied between the two study groups. Therefore the summary statistics were performed using the whole study population. The median Utility Score for a Down syndrome-birth was 0.20 (IQR: 0.10-0.40), which was significantly lower than that of 0.55 (IQR: 0.40-0.80) for a procedure-related miscarriage (p < 0.001). Also, the Utility Scores were neither found to be associated with any particular patient demographic characteristics nor their perception of the functional disability of individuals with Down syndrome. CONCLUSION: The Chinese pregnant women in Hong Kong consider a Down syndrome-affected birth as a much worse health state and life event than a miscarriage. Whether or not to have a screening test appeared to be a result of accessibility and affordability rather than fundamental differences in attitude towards Down syndrome. The findings of the study provide important information on how prenatal screening and diagnosis of fetal chromosomal abnormalities should be offered.