Clinical Genetics Renata Gaillyová Clinical Genetics •Lecture hall - Clinic of pediatric infectious diseases, University Hospital Brno, Children's Hospital •Brno, Černopolní 22 • •Monday •8:00 – 12:00 Clinical Genetics •Tuesday •8:00 – 9:30 Clinical Cytogenetics •10:00 – 11.00 DNA diagnostics •11,00-12.30 Visit on the Department of Medical •Genetics (Children's Hospital, Černopolní 9, Building G, •3th floor) •(Bring a medical mantle and shoes in the laboratory, •please use the changing rooms for students Clinical Genetics •Wednesday •Cytogenetics •7,30-10.00DNA diagnost • • •Written test •Dates will be in May and June 2013 (IS) • Clinical genetics •Dept. of medical genetics •Genetic prevention •Genetic diseases •Patients on the departement of clinical genetics •Genetic counselling •Chromosome abnormalities •AD,AR,XR inheritance, disorders •Multifactorial inheritance •Teratogenes, Environmental hazards •Prenatal diagnosis •Reproductive genetics •Hereditary cancer Dept. of Medical genetics •Genetic ambulance •genetic counselling •Laboratory part •Cytogenetic laboratories •Prenatal cytogenetics •Postnatal cytogenetics •Oncocytogenetics •Molecular – cytogenetics •Lab. for DNA and RNA analysis (clinical genetics and oncogenetics) • • Characteristic of Medical Genetics •Preventive Medicine •Interdisciplinary cooperation •Information from genetics (disease, testing, posibilities) •Voluntary choice for patients •Informed agreement • Primary genetic prevention •Before pregnancy •Folic acid (cca 0,8 mg/day, 3+3 months) •Vaccination (rubella) •Genetic counselling •Contraception, family can opt for adoption or donor of gamets (oocytes, sperm) •Pregnancy planning •Rediction of environmental hazards (drugs, radiation, chemicals…) Reproduction of the optimal age •In women increases the risk of accidental congenital chromosomal aberrations in the offspring • •In men may increase the risk of de novo mutations in monogenic diseases (Neurofibromatosis, Achondroplasia..) Prevention of spontaneous and induced mutations • • •Healthy Lifestyle • • •The restriction of harmful substances - drugs, environmental hazards Vacctination, infection prevention •Prevention of rubella embryopathie Prevention of congenital toxoplasmosis •Testing for infectious disease risk in mothers (CMV, varicella-zoster virus, ...) Vitamin prevention of neural tube defects, anterior abdominal wall defects, clefts •Folic acid at a dose of 0.8 mg daily (twice the dose in non-pregnant) for 3-6 months prior to conception and till the end of 12. week of pregnancy Pre-conception consultation with the physician •Family history • •Long term therapy • •Chronic diseases Examination of acquired chromosomal aberrations •Preventive examinations of persons exposed to environmetal risks at work or persons with risk of long-term therapy (immunosuppressants, cytostatics, ....) •The possibility of vitamin therapy to improve repair of DNA (3-6 months) TIC,DIC,DF Z Contraception, sterilization •Contraception - temporarily prevents conception in the limited impact of risk (treatment) • •Sterilization - the long-term inhibition of pregnancy in a high risk of disease in the offspring (Hereditary disease) Adoption •Alternative family care as an option at high genetic risk families Donation •of sperm, oocytes and embryos • •reduction in high genetic risk • •reproductive problems Secondary genetic prevention •Prenatal diagnosis •Prenatal screening •Prenatal tests •Genetic counselling •Termination of pregnancy (the law in Czech Republic- end of 24. week of gestation) •Postnatal screening •Newborn screening • Genetics diseases •Chromosome abnormalities •about 0,6 - 0,7% • •Monogen diseases •about 0,36% •(study in 1 000 000 newborns) •most then 90% of monogen diseases occur in childhood • •Multifactorial (polygenic or complex) disorders •Occur in about 80% in the population Patients on genetic departements •Dead person •Adults •Pregnant women •Fetuses •Children • • Patients on genetic departements •Positive family history (chromosome abnormality, congenital malformations, mental retardation, diseases…) •Pregnant women with encrease risk for the fetus •Infertility – sterility, repeated fetal loss •Donors (gamets) •Patients with tumours • Children •Congenital malformations Children •Suspition of mongenic hereditary diseases or inherited metabolic disorders and their families • Children •Suspition on congenital chromosom aberations (children with congenital malformations, abnormal face, atipical visage, pre- or postnatal growth retardation, premature birth) • Children •early or delayed puberty •Malformations of the external or internal genitalia •Low or high figure Children •Preventiv genetic examinatioun before adoption Children or adults •Mental retardation •Psychomotor retardation •Developmental delay • Children and adults • •Gender identity disorder Children and adults • •people with long-term exposure to environmental pollutants •(alcohol, cigarettes, drugs, radiation) Children and adulds •patients with suspected hereditary cancer •patients with cancer (sporadic occurrence) Adults • •Donors of gametes •(preventive tests) • Adults •Related partners •(increased risk for hereditary disease with AR inheritance) • • adults •Infertility •Repeated spontaneous abortions Pregnant women •With unfavorable family history Pregnant women •with adverse pregnancy history (chronic diseases with established therapies, acute disease in early pregnancy - temperature, drugs, X-rays, CT, vaccinations, toxoplasmosis, rubella, ...) • Pregnant women •Prenatal biochemical screening •(Pathological results) Pregnant women •Ultrasound prenatal screening – pathological results •Congenital malformations in the fetus •Risk of chromosomal abnormality in the fetus Genetic counselling •Anamnesis •Family history •Pedigree analysis •Examination of the patient •Laboratory analysis •Other examinations - neurology, psychology, hematology, CT, MRI … • Mother •Name, surname, date of birth, maiden name •Place of birth •Place of birth of mothers parents •Relationship •Jobs - employment risks •Addictive substances • alcohol, cigarettes, • medication .. • Mother •Health problems from birth until today •Long-term medication •Long-term monitoring of a doctor •Gynecological anamnesis •The number of births, children, pregnancy, birth weight children, the health status of the children •The number of abortions, unsuccessful pregnancies •Unsuccessful attempt to pregnancy • Mother •In the case of health problems, if possible, to provide medical records from the attending physician •Long-term used drugs, how long • Father •Name, surname, date of birth •Place of birth •Place of birth ot hte fathers parents •Relationship •Jobs - employment risks •Addictive substances • alcohol, cigarettes, • drugs .. • • Father •Health problems from birth until today •Long-term medication •Long-term monitoring of a doctor •Number of children from any previous partners, their health status •The number of abortions, failed pregnancy (if any previous partner) •Unsuccessful attempt to become pregnant in previous partner • Father •In the case of health problems, if possible, to provide medical records from the attending physician •Long-term used drugs, how long • Child - Patient •Pregnancy •Swelling, nausea, protein in urine, sugar in urine, high blood pressure •Diseases in Pregnancy •Drugs in Pregnancy •Prenatal tests results Ultrasound, blood tests • Child •Birth - in time, early, after the deadline? •Complications, neonatal icterus, birth weight and length, nutrition •The mental and motor development •Diseases •Monitoring of specialists •Drugs •Test results • • Child •Clinical-genetic examination •Weight, height •Atypical visage •Malformations •Psychological state •Behavior • • Three-generation pedigree •Patient •Siblings •Children siblings •Parents •Parents siblings •Children of parents siblings •Parents parents Pedigree- our patient III/3 Neonatal death Syndaktilie Epilepsy Congenital heart disease Cleft lip I II III 1 2 3 marriage divorce konsanguinity monozyg. twins dizygot. twins childless miscarriage man woman diseased Unknown gender carrier proband dead person Genetic testing before family planning •? Know we well our health status ? • •? Know we healt status our partners? • •? Know we health status our relatives? Clinical examination Next steps •Recommend the laboratory genetic testing •Recommend other specialists if needed •Require medical records •Make photodocumentation The result of genetic counselling •Specify exact diagnosis (if possible) • •Determine genetic prognosis •Is the disease hereditary? •Type of inheritance •Genetic risks for other family members •Posibilities of treatment, prenatal analysis Chromosome abnormalities chromosome1 0,6-0,7% live born Congenital chromosome abnormalities •Autosomes •Gonosomes • •Numerous •Structural • •Balanced •Unbalanced • Populations frequency VZOR2mit G-pruhy VZOR2karkon Chromosome abnormalities in spont. abortions Maternal age and chromosome abnormalities in AMC (per 1000) Risk of Down syndrom (live births) Down syndrome • • karyotyp +21 Down syndrome •47,XX,+21 or 47,XY,+21 •About 1/800-1000 newborns, 1/75 SA •Hypotonia, joint laxicity, soft skin, flat face, prominent intercanthal folds, slanted palpebral fissurs, Brushfield´s spots of the irides, small, down set ears, small nose, protruding tongue, simian crease in the hands (about 45%), short statue, mental retardation, congenital heart disease in about 50% of patients with DS, (atrioventricular canal) Happy nature Vision and hearing disorders Hypothyroidism Correlation between positive stimulation and height IQ Male sterility Alzheimer-like symptoms in 40 Výsky T 21 1 na 800. Je dobre známa závislosť výskytu trizómie 21 na veku matky , emiprické riziká stúpaju s vekom matky. U muža táto závisloslosť nebola popísaná. Down syndrome- prenatal diagnosis •I. trimester screening – combined screening •10.-14. week of gestation •Ultrasound •Nuchal translucency - NT ( ) •(Absence of nose bone) •Blood •PAPP-A ( ) •free-beta hCG ( ) •Fals positive results less then 5% •Reveals about 95% of fetuses with Down syndrome •1/100 – positiv – genetic counselling and karyotiping •1/100-1/1000 – US and genetic counselling •1/1000 – negativ - US Down syndrome- prenatal diagnosis •II. trimester screening – biochemical screening •16. -18. week of gestation •AFP – alpha-fetoprotein ( ) •total hCG - chorionic gonadotropin ( ) •uE3 - unconjugated estriol ( ) • •Fals positive results about 5% • •Reveals about 70-80% of fetuses with Down syndrome • •1/250 – positiv •1/250-1/350 – border •1/350 - negativ Down syndrome- prenatal diagnosis •Ultrasound • •10.-14. week •NT •NB • •20. week •US- congenital heart disease and other malformations • Edwards syndrome •47,XX(XY),+18 •1/5000-10 000 in newborns, 1/45 SA •gynekotropie 4:1 •SA - 95%, death before 1 year mostly • •hypotrophy, atypical hands and foots, profil, prominent nose, small chin, congenital defects • Edwards syndrome •1:5000 •IUGR, hyopotrophie •microcephalie •dolichocephalie •Cleft palate •Down set ears •micromandibula •Hands, feets •Other cong. malformations Patau syndrome •47,XX(XY),+13 •1/5000-10 000 in newborns, 1/90 SA •95% SA •death before 1 year mostly • •cleft lip and palate bilateral, congenital defects (CNS, eyes, postaxial hexadactily…) Patau syndrome, + 13 •Microcephalie •Trigonocephalie •skin defects in the hairy part calva •congenital defects of the brain (holoprosencephalie, arinencephalie) •micro-anophthalmia •Cleft lip, palate hexadactilie •heart defects • Turner syndrome •45,X ( in about 55% ), mosaicism, structural abnormalitites of X chromosome •1/2500 newborn girls, min. 95% SA •prenat.- hydrops foetus, hygroma coli • •postanatal lymphedema on foots, pterygium coli, congenital heart defect coarctation of aorta, small stature, other congenital defects, hypogenitalismus, hypergonadotropins, sterility-infertility Turner syndrom 45,X •1:2000 •hygroma colli •hydrops •Low weight in newborns •Lymfoedema •Pterygia •Cubiti valgi •Aortal stenosis •Small statue •Sterility • Klinefelter syndrome •47,XXY •relatively frequent 1/600-1000 liveborn males •tall stature •hypogonadism, gynekomastia •sterility, infertility Others gonoseme abnormalities •47,XXX •47,XYY •48,XXXX •48,XXYY…. Structural chromosomal aberrations •deletion or a duplication of the genetic material of any chromosome, atypical structure - side by side to get the genetic material, which there normally is not - the effect of positional •partial-partial deletions •partial trisomy •inversions, insertions, duplications .... mutation2 Syndrom Wolf-Hirshorn 46,XX(XY),4p- •severe mental retardation •typical craniofacial dysmorphia - hypertelorism, pear nose, carp mouth, •pre-and postnatal growth retardation, •failure to thrive •other associated developmental defects - heart, urogenital tract ... Wolf-Hirschhorn syndrom (46,XX,4p-) Incidence? IUGR Hypotonia Charakteristic face Heart defects Hypotonie Hypotrophie Severe mental retardation Kardiovaskulárne anomálie okolo 40% -Atrioventrikulárny kanál Tracheoesofageálna fistula, pylorická stenóza , duodenálna atrézia 8% Hematologické-polycytemia, akútna lymfoblastická leukémia má zvýšený výskyt Syndrom Cri du chat 46,XX(XY),5p- •anomalies of the larynx causes the characteristic cry of a similar feline meow (only in infancy) •low birth weight and length •mental retardation, short stature, failure to thrive, small moon shaped face, the position antimongoloid eye slits, mikrocephalie •Other malformations and birth defects Cri du chat 46,XX(XY),5p- •1:50 000 •Typicaly cri in newborns •laryngomalacie •antimongoloid •epicanthi •hypotonie •hypotrofie FISH M-FISH (multicolor) Spektral karyotyping (SKY) Array CGH •DNA mikroarray • •Chip technology • Mikrocytogenetic Molekular cytogenetic •FISH (fluorescenc in situ hybridisation), M-FISH, SKY (spektral karyoptyping), CGH (komparativ genom hybridisation), MLPA •mikrodeletions or mikroduplications, marker chromosoms, complex rearegements, oncology – oncocytogenetics,fast prenatal diagnostics …) •fast methods (possible for prenatal dg) •metafase and intesfase examination FISH Comparativ genom hybridisation MLPA Multiplex Ligation-Dependent Probe Amplification Microdeletions •Di George syndrome (del 22q11) • •Prader-Willi / Angelman syndrome (del15q11-13) • •Williams Beuren syndrome (del7q11.23) • Syndrom Di George •Velo - Kardio- Facial syndrome •CATCH 22 •Congenital heart desease - conotruncal, craniofacial dysmorfism, thymus aplasie, imunodefitient¨cy, hypoparathyreoidismus Williams - Beuren syndrom •del 7q11.23 • •Facial dysmorfie - Elfin face, congenital heart disease, aortal or pulmonal stenosis, hypokalcemie, small statue, MR, hernie,... Prader-Willi syndrom •Hypotonie, hypotrofie in small children • •PMR, small statue, obesity, hyperfagie, akromikrie, hypogonadismus • •mikrodeletion15q11-12 paternal • Angelman syndrom •Severe mental retardation •Epilepsie •Laughter •severely delayed speech development •mikrodeletion 15q11-12 mat The telomere Rearangement of subtelomeric region in about 6-8% children with mental retardation with or without congenital defect (FISH, HR-CGH, MLPA) 1070-04 Čech Mendelian inheritance Monogenic diseases chromosome1 DNA analysis C >T DNA NF1 pacienta, mt C5839T ( Arg > STOP) Standardní DNA 5’ 3’ 5’ 3’ Autosomal Dominant •The sexes are involved equaly •Heterozygotes are mostly affected clinically •risk 50% for sibs and children •new mutations •penetrance, expresivity Pedigree AD inheritance • the risk 50% healthy ill AD - diseases •Neurofibromatosis 1 and 2 •Achondroplasia •Huntington disease •Marfan syndrome •Myotonic dystrophy • • Autosomal Recesive •Heterozygotes are generally unaffected clinicaly •The sexes are involved equaly •An individual manifesting a recesive disorder usually has heterozygous parents •Once a homozygote is identified, the recurence risk for other child of some parents is 25% • Pedegree - AR inheritance •The risk for next child 25% carrier carrier healthy ill carrier healthy AR - diseases •Cystic fibrosis •(frequency of heterozygotes CR- 1/30) • •Phenylketounria (1/40) • •Congenital adrenal hyperplasia (1/40) • •Spinal muscular atrophy (1/60-80) • Cystic fibrosis •Localized on chromosome 7q • •Frequency of Cystic Fibrosis in the Czech Republic: about 1/6000 • •Frequency of heterozygots in the Czech Republic about 1/30 • •About 1600 mutations in CFTR gene were identified • The reason for CFTR gene analysis •Newborn screening in CR from 10/2009 (analysis of 50 mutations in CFTR gene) •Suspition on Cystic fibrosis in a patient •Cystic fibrosis in the family •Partners of hyterozygots for Cystic fibrosis •Repeated fetal loss •Sterility •Relationship of the partners • • Most frequent CFTR mutations in Czech population Mutation Frequency in CR (%) F508del 70,7 CFTRdele2,3(21kb) 6,4 G551D 3,7 N1303K 2,8 G542X 2,1 1898+1 GtoA 2,0 2143delT 1,1 R347P 0,74 W1282X 0,6 X-linked Recesive •Females are not affected as severaly as males or are not affected •An affected male cannot transmit the train to his sons, becose the trait is on X-chromosome, and the father must necessarily transmit his Y-chromosome to a son •All of the daughters of an affected male must be carriers, because the only X-chromosome that the father can give to a daughter contains the mutation • • X-linked Recesive •Risk for daughters of a carrier - mother •50% for carrier • •Risk for sons of carrier - mother •50% for diseas X- recesive inheritance X XY XX X XY XR - diseases •Hemophilia A and B • •Duchenne and Becker muscular dystrophy • •Fragile X chromosome - X-linked disease Multifaktorial –polygenic inheritance Dieseases with complex heritability Teratogens Charakteristic •disease with multifactorial inheritance include not mendelian types of inheritance •diseases exhibit familial aggregation, because the relatives of affected individuals more likely than unrelated people to carry diseases predisposing predisposition Charakteristic •in the pathogenesis of the disease play a basic role non-genetic factors •disease is more common among close relatives and in distant relatives is becoming less frequent Examples •Congenital heart defects (VCC) 4-8/1000 •Cleft lip and palate (CL/P) 1/1000 •Neural tube defects (NTD, anencefalie, spina bifida,..) 0,2-1/1000 •Pylorostenosis •Congenital hip dislocation •Diabetes mellitus – most types •Ischemic heart desoease •Esential epilepsy Common congenital defects Congenital heart diseases •0,5 - 1% in liveborn infantsn - population incidence •etiology not known mostly •about 3% combine with chromosomal syndromes (+21,+13,+18, 45,X, 18q-, 4p-, del 22q11 Di George sy) •some mendelian syndromes associated with congenital heart disease (Holt-Oram, Williams, Noonan, Ivemark... Congenital heart diseases prenatal diagnosis •For most serious congenital heart diseases •Ultrasonography in 21. week of gestation - by specialists for prenatal kardiology Congenital heart disease - genetic risks Congenital heart disease genetic risks Cleft lip and palate •Incidence of CL in the population 1/500-1/1000 •Inheritence - multifactorial mostly •Chromosomal trisomies (+13,+18) •Syndromes associated with CL/CP/CLP •(van der Woude sy, EEC sy, Pierre Robin sequence…) •Prenatal diagnosis by ultrasonography not sure Cleft lip and palate- genetic risks Patau syndrome, 47,XX,+13 EEC syndrome Van der Woude syndrome Sequence Pierre Robin Neural tube defects •Multifactorial inheritance (risk for I. degree relatives about 2 - 4%) •Maternal serum screening – elevated level of AFP •Prenatal diagnosis by ultrasonography •Raised AFP levels in amniotic fluid •Primary prevention in pregnancies -folic acid •Risk in the population - probably related to nutritional status Teratogens •teratogen is a substance whose effect on embryo or fetus may cause abnormal development action may be direct or through the maternal organism Human Teratogens •Physical (radiation, heat (fever), mechanical impact) •Chemical (chemicals, drugs) • •Biological (infection, fungus ...) •Metabolic imbalance (disease mother) • The effect of teratogens depends on : •dose • •length of the action •contact time •genetic equipment of the fetus and the mother Critical period •14.-18. days after conception – the rule „all od nothing “ • •18.-90. day – organogenesis •The most sensitive period for the emergence of developmental defects Drugs •Distribution of medicines practice into categories • A • B • C • D • X •Food and Drug Administarion, 1980 A •in controlled studies have shown no evidence of risk to the fetus in the first trimester of fetal development or influence in the next period of pregnancy product appears to be safe B •Animal reproduction studies demonstrate a risk to the fetus, but there's no controlled studies in women Animal reproduction studies have shown adverse effects, but in controlled studies in women have not been confirmed C •Animal studies confirm the teratogenic embryotoxic or other adverse effects on the fetus, •non-controlled studies in women •lack of studies in animals and humans product should be administered with caution and only in cases where the benefit for the woman of his administration exceeds the potential risk to the fetus D •risk to the human fetus is known •medicine may be administered in a situation where its use for a woman needed (lifesaving) •no other safer drug is available • X •studies in animals and in humans clearly demonstrate a teratogenic effect •drugs absolutely contraindicated in pregnancy • Drugs with teratogenic effect •Thalidomid •Hydantoin •Valproic acid •Anti coagulans - Warfarin •Trimetadion •Aminopterin •Methotrexat •Cyklophosphamid • • • Drugs with teratogenic effect •Retinoids •Lithium •Thyxreostatic drugs •Androgens •Penicilamin •Enelapril, Captopril •Antituberkulotics-Streptomycin Thalaidomid •congenital heart defects •limb reduction anomalies •Other congenital defects (gastrointestinal, urogenital tract orofacial – ears anomalies, CNS defects..) Hydantoin •Atypicaly face, growth retardation, mild mental retardation, behavioral problems, hypoplastic nails and fingers • Aminopterin a Methotrexat •folic acid antagonist facial dysmorfism, cleft lip and/or palate, small mandible, ears anomalies, hydrocephaly, growth and mental retardation, miscarriage • Warfarin •coumarin antikoagulans •facial dysmorfism – nasal cartilage hypoplasia, CNS - defects • Retinoids •Cleft lip and palate, mikrognatia, eyes anomalies, ears dysplasia •Defects of CNS •Thymus hypoplasia •Limb defects Infection •Toxoplasmosis •Rubella •Cytomegalovirus •Herpesvirus •Others (parvovirus, antropozoonosy, chlamydia..) • • TORCH Toxoplasmosis •chorioretinitis •hydrocephaly or microcephaly •intracranial calcification, mental retardation •icterus, hepatosplenomegalia, carditis •prematurity • •positiv IgM in the mother – treatment with Rovamycin •Prenatal dg.: serology, DNA-PCR) Rubella •hearing and vision impairment (cataract, glaucoma, mikroftalmia, blidness) •mental retardation •Cong. heart defects •icterus, hepatosplenomegalia • •prevention- vaccination Cytomegalovirus •Intrauterin growth retardation •mikrocephaly, cacification in the brain, mental retardation, •hepatosplenomegaly • •Repeated maternal infection is possible •Prenatal dg.: serology,DNA-PCR Varicella zoster •Skin lesions and defects •Brain domage, mental retardation •Eye defects • •Prenatal dg. - serology, DNA-PCR Metabolic dysbalance •Fetal alcohol syndrom (FAS) •Maternal Phenylketonuria •Maternal Diabetes mellitus •Maternal Hypothyreosis Fetal alcohol syndrom •Hypotrophy, growth retardation, mental retardation •facial dysmorphism •Congenital heart defects •Limb defekts • •Abuse of 60g pure alcohol / day (longterm) •Combine with malnutrition, folic acid deficit... Maternal Phenylketonuria •Low birth weith •hypertonia •mikrocefaly, mental retardation •Cong. heart defects •hyperaktivity • •newborn screening •(frequency 1/10 000 newborns •inheritance - AR) •initiation of treatment within three weeks to prevent mental retardation in the child Reproductive Genetics Preconceptional testing Genetic counselling and analysis in couples with reproductive disorders Prenatal diagnosis Preimplantation genetic diagnosis Examination of potential donor gametes Secondary prevention of genetic •The procedures in pregnancy - prenatal diagnosis and early postnatal diagnosis bříško těhotenství.bmp Prenatal diagnosis •Non invasive methods- screening • •Invasive methods •CVS – after the 10. week of gestation •AMC – 15.-18. week of gestation •Cordocentesis – after the 20. week of gestation Prenatal diagnosis results •CVS – karyotype – about 5 days •AMC – karyotype – about 14-21 days • •DNA analysis (monogen diseases) •About 5-15 days •DNA from amniocytes after cultivation - exclusion contamination by maternal tissues Prenatal analysis of most frewquent aneuploidias QF PCR •Examination of the most common numerical changes in chromosomes 13, 18, 21, X and Y •The result for 24-48 hours • Prenatal screening (CR) •Ultrasound (12. - 2 0. - 33. week) •Ultrasound 20.week – cong. defect •Ultrasound 20-22. week – cong. heart defect •10-14. week of gestation •Free beta hCG, PAPP-A, US-NT,NB.. •16.-18.week of gestation •AFP, hCG, uE3 • Indications for prenatal examination / genetic counselling •US screening – congenital defects •Family history of known conditions for which diagnosis is possible (DNA analysis) •Known chromosomal abnormality (de novo finding in previous child, structural change in parents) •Positive prenatal screening for chromosomal abnormalities •Advanced maternal age (38-40 years) ??? • • Preimplatation Genetic Diagnostics •IVF – assisted reproduction • •Preimplantation genetic screening •aneuploidias - array- CGH, chip technology •FISH (13,18,21,X,Y, 15,16,22) • •Preimplantation Genetic Diagnostics •Structural chromososmal aberations •(parents are carries of balanced rearangement) •Monogenic diseases (known in family history) PG Diagnostic X PG Screening •PGD high genetic risk • • • •PGS (most common) aneuploidies Genetic counselling in infertility Infertility •Is the infertility one aspect of a genetic disorder that might be transmitted? •Will correction if infertility give an increased risk of malformations in the offspring? • •Genetic testing before use of metods of asisted reproduction. Infertility •Patological examination of the abortus where possible, this may identify major structural malformations. •Cytogenetic study of parents, this is especialy important where a structural abnormality is present. •In general the finding of a chromosome abnormality in the abortus but not in parent is not likely to be relevant or affect the genetic risks. Ukončena gravidita, VVV a VCA u plodu Potvrzena balancovaná translokace 46,XY,t(2;7) Infertility •A search for possible lethal mendelian causes (consanguinity- risk for AR diseases, X-linked dominant disorders lethal in male, myotonic dystrophy which gives heavy fetal loss in the offspring of mildly affected women) •Inherited trombophilias in women with recurrent abortions ( factor V Leiden, factor II - G20210A, hyperhomocystinaemia ? (MTHFR - C677T) Factor V - Leiden •frequency in the white European population of about 5 - 9% •AD inheritance •increased risk of thromboembolism in homozygots for FVL 50-100x, in heterozygots 5-10x • •increased risk of fetal loss after the 10. week of gestation Sterility in male •AZF (azoospermia factor) deletions of the DAZ gene Yq (deleted in azoospermia) • •Infertile man – 4-5% •Men with azoospermia – about 15% • •CFTR mutations and polymorphisms Genetic risk in cancer Genetic testing in oncologic patients •Specification of the: •Diagnosis •Therapy •Prognosis •Monitoring of minimal residual disease Genetic risks in cancer •Tumours following mendelian inheritance (most AD, about 5%) • •Genetic syndromes predisposing to malignancy Hereditary cancer syndromes •AD inheritance • •Preventive, pre-symptomatic testing • •Prevention • •Assotiated problems • Hereditary cancer syndromes following AD inheritance •Brest cancer – BRCA 1 and BRCA 2 •Familial Adenomatous Polyposis coli - FAP •Von Hippel – Lindau syndrome- VHL •Retinoblastoma •Neurofibromatosis- NF1, NF2 •Li-Fraumeni syndrome •Lynch syndrome – hereditary non polypous colon cancer - HNPCC Genetic testing in Hereditary cancer syndromes •Tests are voluntary •Mostly in adults only • •In children only when prevention in childhood is present and when the risk of tumours is in childhood • • Postnatal care and neonatal screening •Early diagnosis Dispensary Specialized Care Prenatal and perinatal managment of prenagncies with malformation or genetic disease in the fetus •Consultation with experts, who will continue to take care of the pregnant woman - ultrasound specialist, gynecologist, obstetrician, psychological support .. Consultions with specialists, who will care after the birth of newborns with disabilities The planned delivery of specialized care workplace - kardiocentrum, pediatric surgery, cardiology… Screened diseases in CR from 10/2009 •Kongenital hypothyreosis •Kongenital adrenal hyperplasia – CAH • •(cumulative risk 1/2900) • Screened diseases in CR from 10/2009 •Inborn errors of metabolism •Fenylketonuria (PKU, HPA) •Leucinosis •MCAD •LCHAD •VLCAD •Def.karnitinpalmitoyltransferasis I a II •Def.karnitinacylkarnitintranslocasis •Glutaric aciduria •Izovaleric acidurie •(cumulative risk 1/4000) • Screened diseases •Cystic fibrosis • •(1/4000) • • •cumulative risk of all 13 screened diseases in CR - 1/1200 •