Dr muhammad rafique assist prof paediatrics college of medicine k k u abha k s a
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Dr . Muhammad Rafique Assist. Prof. Paediatrics College of Medicine K K U Abha K S A. PRENATAL DIAGNOSIS. It introduces option for management. From interruption of abnormal pregnancies to prepare for specialized peri-natal care. PRENATAL Dx.------CONT. Methods of prenatal diagnosis :

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Dr . Muhammad Rafique Assist. Prof. Paediatrics College of Medicine K K U Abha K S A

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Dr muhammad rafique assist prof paediatrics college of medicine k k u abha k s a

Dr . Muhammad RafiqueAssist. Prof. PaediatricsCollege of MedicineK K U Abha K S A


Prenatal diagnosis

PRENATAL DIAGNOSIS

It introduces option for management. From interruption of abnormal pregnancies to prepare for specialized peri-natal care.


Prenatal dx cont

PRENATAL Dx.------CONT.

Methods of prenatal diagnosis:

.Maternal blood sampling.

.Fetal ultrasonography.

.Fetal X-ray

.Fetal MRI

.Amniocentesis

.Chorionic villus sampling


Maternal blood sampling

MATERNAL BLOOD SAMPLING

  • Elevated alpha fetoproteins:

    • Twins ,

    • intestinal obstruction ,

    • neural tube defects.

  • Decreased alpha fetoproteins:

    • Trisomy 21/ Down synd.

  • Elevated chorionic-gonadotropins:

    • Trisomy 21


  • Maternal blood sampling cont

    MATERNAL BLOOD SAMPLING—CONT.

    • Deceased chorionogonadotropin:

      .Trisomy 13,

      .Trisomy18

    • Decreased unconjugated estriol:

      .Trisomy 21


    Fetal ultrasonography

    FETAL ULTRASONOGRAPHY

    Maternal trans-abdominal USG can visualize all major fetal organs at 16-18 weeks of gestation and can diagnose disorders like;

    Hydrops fetalis , hydronephrosis , neural

    tube defects , intestinal obstruction , CHD ,

    diaphragmatic hernia , limb reduction

    anomalies and growth assessment etc.


    Cordocentesis

    CORDOCENTESIS

    Fetal blood can be directly sampled in late gestation through USG guided per-cutaneous umbilical cord blood sampling & can detect;

    .fetal anemia . Thrombocytopenia

    .thalassemia. Fetal oxygenation

    .acid base disorders .cells for DNA

    .fetal hypo-albuminemia


    Chorionic villus sampling

    CHORIONIC VILLUS SAMPLING

    CVS at 10-12 weeks provides good cyto- trophoblast (dividing cells) DNA for molecular analysis that can be rapidly karyotyped.

    Detection possible for:

    Thalassemia, hemophilia A, PKU, CAH.,

    alpa-1 antitrypsin deficiency, SCD etc.

    Trisomy21,18,13,turner&klinefelter synd.


    Amniocentesis

    AMNIOCENTESIS

    Amniotic fluid can be sampled at 10-14 weeks

    gestation for fetal cells -can be cultured For

    • Cyto-genetics

    • Molecular analysis

    • Metabolic analysis.

    • Alpha-fetoproteins measurement.

      Note –complication of miscarriage <1%.


    Amniocentesis1

    Amniocentesis


    Indications for cvs amniocentesis

    INDICATIONS FOR CVS/AMNIOCENTESIS

    • Maternal age above 35 years.

    • Previous child with chromosomal abnormality.

    • Either parent a translocation carrier.

    • F/Hx. of genetic disease, Dx. by biochemical or DNA analysis.

    • Parental request for sex determination because of F/Hx. of X-linked disorder.

    • Maternal blood sample show chromosomal abn.

    • As a part of work up for fetal anomalies by USG.


    Genetic testing

    GENETIC TESTING

    Analysis of genetic material to obtain information related to individual’s health status using either chr. analysis or DNA

    based testing.

    Two types.

    1-Linkage analysis

    2-Direct mutation analysis


    Linkage analysis

    LINKAGE ANALYSIS

    It is used if

    • Responsible gene is mapped but not yet

      identified.

    • Impractical to find specific mutation due to large size & No. of different mutation in a gene e.g. CF.


    Direct mutation testing

    DIRECT MUTATION TESTING

    • It is preferred to detect gene mutation because genome sequence is elucidated and

      technologies improved.

    • It avoids pitfalls of linkage testing by detection of gene mutation.

    • In some disorders all individual have same mutation. e.g. SCD.

    • In some, people have different mutation e.g. CF.


    Predictive genetic testing

    PREDICTIVE GENETIC TESTING

    • Testing in individuals who are at risk to develop a genetic disorder e.g. due to F/Hx. before developing s/symptoms , especially which disorders are age dependent and s/s increase with increasing age , e.g. Huntington disease, cancer.

    • Note-development of disease is not necessary in every mutation containing person.


    Genetic counsellinig

    GENETIC COUNSELLINIG

    • Process by which a person is informed about possibility of developing a disorder or transmitting it to his offspring and chances of his offspring having similar disorder.

    • Important steps are ;

      .History .pedigree construction .physical examination . diagnosis,

      .counseling .follow up


    Genetic ounselling steps

    GENETIC OUNSELLING STEPS

    • Offer possible help to manage disorder.

    • Sex detection & pre-natal Dx.by amniocentesis to decide parents to have/not the baby.

    • Explain outcome statistically for each pregnancy.

    • Provide good knowledge about disorder’s etiology, Dx. and Mx.in discussion.

    • Provide new information whenever available.


    Genetic counselling steps

    GENETIC COUNSELLING STEPS

    Timing of counseling;

    • Not too early (because family still concerned

      about welfare of affected individual &

      emotionally upset).

    • Not too late (because an other at risk fetus

      is conceived ).


    Genetic ounselling steps1

    GENETIC OUNSELLING STEPS

    • Careful F/Hx. and pedigree construction

    • Document pre-natal, pregnancy & delivery Hx.

    • Review available informationsabout disorder.

    • Careful physical exam. of affected individual and apparently unaffected family individuals.

    • Establish accurate Dx. by available tests.

    • Mode of inheritance establish and explain.


    Genetic ounselling steps2

    GENETIC OUNSELLING STEPS

    • Therapy and referral;

      Some pt. need specialist care e.g . Turner synd. need endocrinologist evaluation.

    • Prevention of complications should be priority

    • Support groups;

      Provide information about support group that provide funds for research on specific disorder

    • Nondirective counseling;


    Indications of genetic counselling

    INDICATIONS OF GENETIC COUNSELLING

    • Advanced parental age;

      .Maternal >35 years

      .Paternal >50years

    • Previous child with F/Hx. of

      .congenital abnormality

      .Dysmorphology

      .Isolated birth defects

      .metabolic disorder

      .Chromosomal abnormality

      .single gene defect


    Indications of genetic ounselling

    INDICATIONS OF GENETIC OUNSELLING

    • Adult onset disease/pre-symptomatic testing ;

      .cancer

      .Huntington disease

    • Consanguinity

    • Teratogenic exposure

    • Repeated miscarriage or infertility


    Indications of genetic counselling1

    INDICATIONS OF GENETIC COUNSELLING

    • Pregnancy screening abnormality

      .maternal high alpha fetoproteins

      .fetal USG

      .fetal karyotyping

    • Heterozygote screening based on ethnic risk;

      .sickle cell anemia

      .thalassemia

    • Follow up to abnormal genetic testing


    Management treatment of genetic disorders

    MANAGEMENT &TREATMENT OF GENETIC DISORDERS

    • GD mostly chronic.

    • Few are amenable to curative therapies.

    • Provide information about GD, G.counseling , anticipatory guidance and appropriate medical surveillance.

    • Surgical Mx. is available for many congenital anomalies that are predisposition to tumours.


    Management treatment of genetic disorders1

    MANAGEMENT &TREATMENT OF GENETIC DISORDERS

    • PHYSIOLOGICAL THERAPIES;

    • Attempts to ameliorate phenotype of a GD.

    • Underlying GD not altered by treatment.

    • Used in inborn error of metabolism e.g.

    • dietary manipulation in PKU, avoiding

      phenylalanine diet.

      .Enzyme supplement for

      methyl-malonic-acidemia.

      .Bisphosphonate for osteogenesis imperfecta.


    Management treatment of genetic disorders2

    MANAGEMENT & TREATMENT OF GENETIC DISORDERS

    PHARMALOGICAL THERAPIES;

    • Use of pharmaceuticals to remove ammonia in urea cycle defect.

    • It directly target defective cellular pathway that is altered by abnormal /missing gene.

      Replacement therapy ; e.g.

      .cystic fibrosis

      .Gauscher disease


    Management treatment of genetic disorders3

    MANAGEMENT & TREATMENT OF GENETIC DISORDERS

    Organ transplant;

    • E.g. transplant of liver in inborn error of metabolism.

    • Transplant of bone marrow in many haemotological disorders.

      Gene therapy;

    • Less invasive mean of achieving cure of a GD.


    Prevention of genetic disorders

    PREVENTION OF GENETIC DISORDERS

    • Some GD has gene defect + environmental factors impact e.g. multifactorial disorders.

    • Prevention possible by

      .avoiding inciting environmental factor e.g.avoid

      maternal phenytoin use to avoid fetal CHD.

      .By instituting treatment that reduce risk e.g.

      maternal use of folic acid to avoid fetal neural-

      tube defect.


    Newborn screening tests

    NEWBORN SCREENING TESTS

    1-Chromosomal analysis;

    Body cells are cultured ,arrested in mitosis in metaphase .Chromosome first evaluated microscopically then images are captured by video camera and stored on a computer . Homologous chr. are paired , arranged into Karyotype. Chromosomes are exposed to a hypotonic solution, fixed and stained with

    “ trypsinGiemsa”which produces dark and light bands for detail study.


    Newborn screening tests1

    NEWBORN SCREENING TESTS

    2-FISH (fluorescence in situ hybridization);

    - Used to identify , presence, absence, or rearrangement of specific DNA segment.

    - It involve unique DNA sequence labeled with a fluorescent dye , which is exposed to single stranded DNA on a microscopic slide.


    Newborn screening tests2

    NEWBORN SCREENING TESTS

    FISH---cont.

    -Probe, pairs with its complementary DNA sequence and can be visualized by fluorescence microscopy.

    - It is particularly useful for detecting very

    small deletion which not detectable by band

    analysis.


    Newborn screening tests3

    NEWBORN SCREENING TESTS

    3-Spectral karyotyping (SKY) & multicolour FISH;

    • 24 different chr. Painting probes are used for chr. and labeled with different combination of 5 fluorescent dyes(which omit at different wavelength).

    • 23 pair of chr. have unique spectra of wavelength fluorescence.

    • Especially used to identify complex chr.

      Re-arrangement found in tumours.


    Newborn screening tests4

    NEWBORN SCREENING TESTS

    4-COMPARITIVE GENOMIC HYBRIDIZATION(CGH)

    -FISH based method to measure differences in

    a particular DNA sequence / chr. segment

    between two different DNA samples.

    -Pt’s DNA labeled with green fuorescent dye & normal reference DNA with red .

    -Equal amount of two mixed &used for FISH.


    Newborn screening tests5

    NEWBORN SCREENING TESTS

    4-COMPARITIVE GENOMIC HYBRIDIZATION(CGH)

    -Ratio of green to red fluorescence measured along each chr.

    -Region of amplification of pt’s DNA shows excess green fluorescence & region of loss of pt’s DNA shows excess of red fluorescence.

    -If green and red same 1:1,chromosome would appear yellow.


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