Monochorionic Twin Discordance for Horseshoe Lung and Tricuspid Atresia.

Background: The horseshoe lung is a congenital malformation in which the bases of the right and the left lung are fused. Case report: We describe a monochorionic twin gestation with malformation discordance. The abnormal twin had a horseshoe lung with hypoplasia of the right lung, tricuspid atresia, cleft lip, and a pelvic right kidney. Conclusion: The discordance of anomalies in this monochorionic twin suggests that a postzygotic mutation, epigenetic change, or environmental factors may be responsible for these malformations.

Renal Dysplasia and Progressive Renal Failure in a Newborn with Interstitial Chromosome 4 Deletion 4q25-28.3: A New Phenotype?

The deletion of the long arm of chromosome 4 is rare, presenting with a variable phenotype depending on the chromosomic area affected. A term newborn with prenatal diagnosis of anhydramnios, dysplastic cystic kidneys, and cardiomegaly was born with generalized subcutaneous edema, several dysmorphic features, and progressive renal failure requiring dialysis. The infant continued to deteriorate and died at 52 days of age. Autopsy confirmed bilateral renal dysplasia with cysts. Array-comparative genomic hybridization (CGH) identified a large deletion on 4q25-q28.3, which is not yet described in association with renal disease. The clinical progression could be expected due to the severity of the perinatal clinical presentation.

Molecular and Clinical Investigations on Portuguese Patients with Multiple acyl-CoA Dehydrogenase Deficiency.

BACKGROUND: Multiple Acyl-CoA Dehydrogenase Deficiency (MADD) is a congenital rare metabolic disease with broad clinical phenotypes and variable evolution. This inborn error of metabolism is caused by mutations in the ETFA, ETFB or ETFDH genes, which encode for the mitochondrial ETF and ETF:QO proteins. A considerable group of patients has been described to respond positively to riboflavin oral supplementation, which constitutes the prototypic treatment for the pathology. OBJECTIVES: To report mutations in ETFA, ETFB and ETFDH genes identified in Portuguese patients, correlating, whenever possible, biochemical and clinical outcomes with the effects of mutations on the structure and stability of the affected proteins, to better understand MADD pathogenesis at the molecular level. METHODS: MADD patients were identified based on the characteristic urinary profile of organic acids and/or acylcarnitine profiles in blood spots during newborn screening. Genotypic, clinical and biochemical data were collected for all patients. In silico structural analysis was employed using bioinformatic tools carried out in an ETF:QO molecular model for the identified missense mutations. RESULTS: A survey describing clinical and biochemical features of eight Portuguese MADD patients was made. Genotype analysis identified five ETFDH mutations, including one extension (p.X618QextX*14), two splice mutations (c.34+5G>C and c.405+3A>T) and two missense mutations (ETF:QO-p.Arg155Gly and ETF:QO-p.Pro534Leu), and one ETFB mutation (ETFß- p.Arg191Cys). Homozygous patients containing the ETFDH mutations p.X618QextX*14, c.34+5G>C and ETF:QO-p.Arg155Gly, all presented severe (lethal) MADD phenotypes. However, when any of these mutations are in heterozygosity with the known ETF:QO-p.Pro534Leu mild variant, the severe clinical effects are partly and temporarily attenuated. Indeed, the latter destabilizes an ETF-interacting loop, with no major functional consequences. However, the position 155 in ETF:QO is localized at the ubiquinone binding and membrane interacting domain, and is thus expected to perturb protein structure and membrane insertion, with severe functional effects. Structural analysis of molecular models is therefore demonstrated to be a valuable tool to rationalize the effects of mutations in the context of the clinical phenotype severity. CONCLUSION: Advanced molecular diagnosis, structural analysis and clinical correlations reveal that MADD patients harboring a severe prognosis mutation in one allele can actually revert to a milder phenotype by complementation with a milder mutation in the other allele. However, such patients are nevertheless in a precarious metabolic balance which can revert to severe fatal outcomes during catabolic stress or secondary pathology, thus requiring strict clinical follow-up.

Fetal autopsy parameters standards: biometry, organ weights, and long bone lengths.

Fetal and perinatal growth charts and tables are essential for proper interpretation of autopsy anthropometric parameters. These parameters depend on factors that may vary between populations; thus, it is recommended that standards be developed from local target populations to ensure that they are truly representative. In this study, we established standards for a complete set of autopsy fetal parameters, including biometrical measurements, organ weights and long bone lengths, based on autopsy data collected retrospectively from a sample of Portuguese fetuses and neonates. Using a robust statistical regression methodology, to fit mean and standard deviation models, we constructed growth curves for gestational ages between 12 and 42 weeks, which aim to be useful for autopsy examination, particularly in the Portuguese population.

Ductus venosus agenesis and fetal malformations: what can we expect? - a systematic review of the literature.

Background The ductus venosus agenesis (DVA) is a rare condition with a variable prognosis that relies partly on the presence of associated conditions. The purpose of our study was to analyze the literature regarding the post-natal outcome of fetuses with DVA associated with fetal malformations, in order to discuss the best management options for couples. Methods We performed a systematic review of the literature of MEDLINE and SCOPUS electronic databases in a 25-year period from 1992 to September 2017. Methods We found 340 cases of DVA associated with fetal abnormalities. The most common chromosomal abnormalities were: monosomy X (12/48, 25%), trisomy 21 (11/48, 22.9%) and trisomy 18 (6/48, 12.5%). From the 340 cases with DVA, in 31 cases the umbilical venous shunt type was not reported. Of the fetuses, 60.8% (188/309) had an extrahepatic umbilical venous drainage while 39.2% (121/309) presented an intrahepatic connection. The DVA was associated in 71 cases (23.0%) with cardiac abnormalities, in 82 cases (26.5%) with extracardiac abnormalities and in 85 cases (27.5%) with both cardiac and extracardiac abnormalities. Conclusion DVA associated with both cardiac and extracardiac malformations may confer a poorer fetal outcome, a clinically relevant fact that should clarify what can be expected from this entity and help prenatal counseling.

Clinical impact of systematically performing autopsies following selective termination of pregnancies: comparison between multiples and singletons.

INTRODUCTION: The aim of this study was to evaluate the clinical impact of systematically performing autopsies following selective termination of pregnancy. MATERIAL AND METHODS: A retrospective study of necropsies following medical termination of pregnancy performed in a tertiary referral hospital. A correlation between prenatal diagnosis and postmortem findings was performed. The cases were classified as having complete agreement, complete disagreement or major agreement with additional information. A comparison between multiples (n = 29) and singletons (n = 374) was undertaken. RESULTS: The median gestational age at the time of termination/selective feticide was 19 (11-34) weeks in multiples and 18 (6-36) weeks in singletons (p = 0.190). In 5 cases (17.2%) of multiples (50.0% submitted to selective feticide) fetal autopsy was not possible, while in singletons autopsy was not feasible in only 1.3% (p < 0.005). DISCUSSION: Contrarily to singleton pregnancies, in twin pregnancies with termination of 1 fetus it should not be possible to undertake an autopsy. When a selective termination is performed away from delivery, the time of retention may hinder the feasibility of the necropsy study. In those cases, it is crucial to make an exhaustive investigation previously to selective feticide.

A novel mutation in FOXF1 gene associated with alveolar capillary dysplasia with misalignment of pulmonary veins, intestinal malrotation and annular pancreas.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, fatal, neonatal developmental lung disorder, which usually presents as persistent pulmonary hypertension unresponsive to treatment. The authors report the case of a neonate with persistent pulmonary hypertension, associated with duodenal stenosis secondary to annular pancreas and intestinal malrotation. Support treatment, inhaled nitric oxide, oral sildenafil and nebulized iloprost were used with no clinical improvement. The neonate presented an overwhelming course, with hypoxemia refractory to treatment. At autopsy lung histology showed the characteristic features of ACD/MPV. DNA sequence analysis revealed a heterozygous nonsense mutation c.539C>A;p.S180X, in the first exon of FOXF1. FOXF1 has been identified as one of the genes responsible for ACD/MPV associated with multiple congenital malformations. This clinical case is the first report of a heterozygous nonsense mutation c.539C>A;p.S180X in the first exon of FOXF1, in a patient with ACD/MPV associated with annular pancreas and intestinal malrotation.

Complete mole in a dichorionic twin pregnancy after intracytoplasmic sperm injection.

A dichorionic twin pregnancy with complete hydatidiform mole and coexistent fetus is a rare and challenging situation, whose pathogenesis has not been yet fully understood. We present a case of a 39-year-old woman who underwent intracytoplasmic sperm injection with two embryos transfer. The 12-week gestation ultrasound examination revealed normal fetus and placenta with features of hydatidiform mole, leading to pregnancy termination. Autopsy and histological examinations diagnosed a complete mole coexisting with a normal fetus, and the genetic analysis showed a diploid fetus with biparental genome and molar tissue with paternal diploidy. This case highlighted that complete molar pregnancies may still occur even though pregnancy is achieved after intracytoplasmic sperm injection. A review of the literature was performed by collecting data from the few similar reported cases and by commenting on the pathogenesis of this rare condition.

Complete mole in a dichorionic twin pregnancy after intracytoplasmic sperm injection / Mola hidatiforme completa em gravidez bicoriônica após injecção intracitoplasmática de espermatozoides

A dichorionic twin pregnancy with complete hydatidiform mole and coexistent fetus is a rare and challenging situation, whose pathogenesis has not been yet fully understood. We present a case of a 39-year-old woman who underwent intracytoplasmic sperm injection with two embryos transfer. The 12-week gestation ultrasound examination revealed normal fetus and placenta with features of hydatidiform mole, leading to pregnancy termination. Autopsy and histological examinations diagnosed a complete mole coexisting with a normal fetus, and the genetic analysis showed a diploid fetus with biparental genome and molar tissue with paternal diploidy. This case highlighted that complete molar pregnancies may still occur even though pregnancy is achieved after intracytoplasmic sperm injection. A review of the literature was performed by collecting data from the few similar reported cases and by commenting on the pathogenesis of this rare condition.

Uma gravidez bicoriônica com mola hidatiforme completa e feto normal é uma situação rara e desafiadora, cuja patogênese não foi ainda totalmente compreendida. Apresenta-se o caso de uma mulher de 39 anos submetida à injeção intracitoplasmática de espermatozoides com transferência de dois embriões. Na ecografia pré-natal realizada na 12ª semana de gestação, foi identificado um embrião morfologicamente normal e uma placenta com características molares. Esta situação resultou na terminação eletiva da gravidez. A autópsia e o estudo histológico permitiram o diagnóstico definitivo de uma mola hidatiforme completa coexistindo com feto normal. A análise genética mostrou feto diploide com genoma biparental e tecido molar com diploidia paterna. Este caso ressaltou que as gestações com mola hidatiforme completa poderão ainda ocorrer, mesmo que a gravidez seja realizada após uma injeção intracitoplasmática de espermatozoides. Foram realizadas uma revisão dos raros casos descritos na literatura e uma explicação da patogenia desta condição rara.

Alveolar Capillary Dysplasia with Misalignment of Pulmonary Veins (ACD/MPV): A Case Series.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, fatal, developmental lung disorder, which usually presents as persistent pulmonary hypertension of the newborn (PPHN) unresponsive to treatment. The authors present their own experience with three cases admitted during the last 15 years.

Cardiac findings in routine fetal autopsies: more than meets the eye?

OBJECTIVE: The main objective of this study was to evaluate the spectrum of cardiac anomalies found in routinely performed fetal autopsies and to establish the correlation between prenatal and postmortem diagnosis. STUDY DESIGN: A retrospective study of fetal autopsies was performed. Cases with cardiac anomalies were analyzed. Seven main categories were established and each case was assigned to a single group. Cardiac defects were also classified as isolated or with associated anomalies. In the cases with prenatal diagnosis, we performed a correlation between prenatal and postmortem findings. RESULTS: Abnormal cardiac findings were identified in 99 fetuses (13.6%). The two most common categories were septal defects and complex anomalies, each occurring in 21 fetuses (21.2%). Sixty-seven (67.7%) had associated anomalies. Septal anomalies were more frequent in cases with associated anomalies (p=0.012). Prenatal diagnosis had been performed in 50 cases. There was complete agreement between prenatal and postmortem diagnosis in 36 cases (72%), and major agreement with additional information in ten (20%). When the echocardiogram was not performed by a specialist, the number of cases classified with complete disagreement was higher (33.3% vs 2.4%) (p=0.002). CONCLUSION: The high prevalence of cardiac defects in lost pregnancies, some of them lacking prenatal diagnosis, highlights the importance of examining the heart in all cases.

A novel type of familial proximal axonal dystrophy: three cases and a review of the axonal dystrophies.

Three related infants of Roma ancestry, two of them siblings, showed hypotonia, predominantly axial, from birth, difficulty swallowing, myoclonic seizures, and respiratory difficulty. Dysmorphic features, principally micrognathia were present. EEGs showed focal epileptiform abnormalities. All three died in their 5th month from respiratory insufficiency complicated by pneumonia. Autopsy showed small brains without malformation. Microscopy revealed numerous axonal spheroids involving particularly the brain stem and spinal cord, with especial prominence in the middle cerebellar peduncle, the anterior part of the thalamic reticular nuclei, and the anterior horns and columns of the spinal cord. Spheroids that appeared to be on axons of lower motor neurons were especially large. No spheroids were seen in peripheral nerves; electron microscopy did not show spheroids in skin. By electron microscopy spheroids contained neurofilaments, sparse mitochondria, and electron dense granules. The material did not allow identification of microtubules. Closely packed vesicles excluded neurofilamanets from the center of many spheroids, especially in the middle cerebellar peduncle. Sprouting of axons from the surface of many spheroids was seen. This disease is distinct from the well described type of infantile neuroaxonal dystrophy (Seitelberger's disease) in view of the distribution of spheroids, presence of spheroids on proximal rather than distal parts of axons, sparing of the peripheral nerves, lack of staining for synuclein, presence of sprouting, and lack of membranous profiles in the spheroids. A review of reported types of axonal dystrophy has not shown identical cases.

Cervical ectopic pregnancy: hysterectomy specimen examination clarifies the cause of first trimester pregnancy bleeding.

A report on a difficult case of first trimester pregnancy bleeding in a 39-year-old woman solved by hysterectomy. The diagnosis was clarified by pathological examination that showed a cervical ectopic pregnancy with perforation.

Early signs of cardiac failure: a clue for parvovirus infection screening in the first trimester?

Parvovirus B19 is a small single-stranded DNA virus and a potent inhibitor of erythropoiesis due to its cytotoxicity to erythroid progenitor cells. Although adult disease is generally mild, fetal parvovirus B19 infection can cause spontaneous abortion in early pregnancy and aplastic anemia, nonimmune hydrops fetalis and in utero fetal demise. The prevalence of parvovirus B19 maternal infection during pregnancy is about 1-2%. The vertical transmission occurs in 10-35%, being highest in the first and second trimesters. The risk of adverse fetal outcome is 10%. In contrast to the second or third trimester, in pregnancies affected by increased nuchal translucency (NT) in the late first trimester, the prevalence of maternal infection was not higher than in the general population. We report a case of first-trimester parvovirus B19 infection with increased NT and reversed a-wave in the ductus venosus (DV) at 11 weeks, with fetal demise 2 weeks later.

Diagnosis and cause of death in a neonatal intensive care unit--how important is autopsy?

OBJECTIVES: To characterize mortality in a tertiary referral Neonatal Intensive Care Unit (NICU) in Portugal and evaluate the concordance between ante-mortem and post-mortem diagnoses. METHODS: Retrospective review of the clinical and pathological records of infants who died in five consecutive years was done. Pathological findings and clinical diagnoses were compared and classified according to general concordance and to modified Goldman classification. RESULTS: During the referred period, 1938 patients were admitted to the NICU, with a mortality rate of 5.7% (110 patients). The median of age at death was 10.5 days and the most frequent causes of death were congenital malformations and prematurity with its complications. Autopsy was performed in 53 patients resulting in a 48.2% overall autopsy rate. There was complete agreement between pathological and clinical diagnoses in 18 cases (34%) and additional findings were identified in 22 cases; in 13 cases (24.5%), the diagnosis was revised or established by pathology. Five autopsies revealed information relevant for genetic counseling. CONCLUSION: Despite the high agreement rate between clinical and pathological diagnoses, autopsy frequently added important data, including several cases in which it established the diagnosis or provided information relevant for parental counseling regarding future pregnancies.

Revisiting acrania: same phenotype, different aetiologies.

OBJECTIVE: To evaluate the contribution of prenatal and postmortem examinations in establishing the aetiology of acrania. METHODS: Retrospective evaluation of 14 cases of acrania managed through elective termination of pregnancy. RESULTS: The median maternal age was 30 years (range 18-40) and median gestational age at diagnosis was 13 weeks (range 12-15). One mother had epilepsy and was taking anticonvulsants and another had uncontrolled type II diabetes mellitus. Only 3 women were using folic acid at conception. Chromosomal abnormalities were detected in 3 of 8 cases analyzed. Unilateral anopthalmia, cervical rachischisis, midline facial and limb defects coexisted with acrania in 4 cases. Acrania with craniofacial dysmorphism and asymmetrical finger amputation were observed in a case of amniotic band syndrome. A previous history of anencephaly was documented in 1 case. CONCLUSION: Acrania is a characteristic phenotypic expression of a variety of different aetiologies. Investigation with cytogenetic studies and postmortem are essential to provide a definitive answer. This will provide a better understanding of the underlying aetiology and help establish the recurrence risk for future pregnancies.

Aneuploidies detection in miscarriages and fetal deaths using multiplex ligation-dependent probe amplification: an alternative for speeding up results?

OBJECTIVE: The aim of this prospective study was to apply the MLPA technique to products of miscarriages and fetal deaths in order to detect the more frequent chromosome aneuploidies and compare the results to conventional karyotyping. STUDY DESIGN: Multiplex ligation-dependent probe amplification (MLPA) is a relatively new molecular technique for targeted detection of common chromosomal aneuploidies, namely trisomy 13, 18, 21 and sex chromosomal abnormalities. The reliability and high accuracy of this technique constitute an alternative for rapid results in large scale testing. In this study, a total of 489 DNA samples from fetal tissue were used for aneuploidy detection of chromosomes 13, 18, 21, X and Y using a commercial MLPA kit (SALSA P095) and were simultaneously subjected to conventional karyotyping. RESULTS: MLPA was the only result available in 33% of the cases. A cytogenetic result was obtained in only 328/489 samples. MLPA detected 7.8% of chromosome aneuploidies. Among the total samples karyotyped, MLPA failed to detect some aneuploidies and the false-negative rate was 0.82%. As expected, ploidy changes and reciprocal translocations were not detected by this technique, but MLPA gave a conclusive result even in cases of mosaicism. CONCLUSION: The present data confirm that MLPA is a rapid, simple and reliable method for detection of chromosome 13, 18, 21, X and Y abnormalities in fetal tissue.

Gene expression pattern of IGF2, PHLDA2, PEG10 and CDKN1C imprinted genes in spontaneous miscarriages or fetal deaths.

Genomic imprinting is defined as an epigenetic modification that leads to parent-of-origin specific monoallelic expression. Some current research on the fetal control growth has been focused on the study of genes that display imprinted expression in utero. Four imprinted genes, two paternally expressed (IGF2 and PEG10) and two maternally expressed (PHLDA2 and CDKN1C), are well known to play a role in fetal growth and placental development. Pregnancy loss in the general reproductive population is a very common occurrence and other genetic causes beyond chromosomal abnormalities could be involved in spontaneous miscarriages or fetal deaths, such as alteration of expression in imprinted genes particularly those related to fetal or placental growth. Quantitative Real Time PCR was performed to evaluate gene expressions patterns of the four mentioned genes in spontaneous miscarriages or fetal deaths from 38 women. Expression levels of PHLDA2 gene were upregulated in the first trimester pregnancy cases and all four imprinted genes studied were upregulated in the second trimester of pregnancy cases comparing with controls. In third trimester PEG10 was downregulated in fetal samples group. This is the first study presenting data from human imprinted genes expression in spontaneous miscarriages or fetal deaths cases from the three trimesters of pregnancy.