GENETIC CAUSES IN RECURRENT PREGNANY LOSS

DR POONAM VARMA SHIVKUMAR PROF & HEAD OBGY MGIMS SEVAGRAM, WARDHA, MS

 Despite major advances in the field of genetics,

biology and immunology , RPL still poses a challenge to a treating obstetrician The cause of RPL is mostly unexplained in many patients and every therapeutic intervention remains controversial Polygenic mode of inheritance in RPL Advanced maternal age and partner specificity are important factors More the numbers of abortions in past poorer is the prognosis

INTRODUCTION

 Recurrent miscarriage (RM) is a heterogeneous condition that has many possible causes; more than one contributory factor may underlie the recurrent pregnancy losses. Each may have had a different cause Three or more consecutive miscarriages before 20 weeks from LMP Primary No full term delivery previously Secondary At least one successful pregnancy

INCIDENCE
May affect as many as 1-3% of childbearing women, 1women, 0.6 to 2.3%. First trimester losses -75% Second trimester losses -25% According to Los Angeles fertility experts ( Bayrak 2010) 10 TO 15 % miscarriages occur between 20 30 yrs, 15 to30 % between 30 40 yrs & 30 to 60 % if age between 40 - 45 yrs

Recurent Miscarriage Etiology

Explained

Anatomic (Sporadic) Endocrine

12%-16% 12%17%-20% 17%-

Un-explained 50%

Luteal phase deficiency Uncontrolled DM PCOS

Immunological

10%-16% 10%-

Anti phospholipid syndrome

Environmental

Alcohol, Smoking

Genetic factors 3.53.5-5%

LET US FIRST UNDERSTAND GENETICS

Genetic Abnormality includes
1. CHROMOSOMAL ABNORMALITIES Normal 22 pairs of autosomes & 1 pair of sex chromosomes

Abnormal chromosome number

Abnormal Autosomal chromosome no. Aneuploidy Inheritance of extra chromosome Eg - Autosomal trisomy 21,18,13 Loss of a chromosome Eg Monosomy Polyploidy Abnormal no of entire haploid set Eg Triploidy, tetraploidy (69xxy or Triploidy, 92xxyy)

Abnormal Sex Chromosome no. Eg 45,XO: Turner; 47,XXX: Super female; 47,XXY: Klinefelter Abnormality in Chromosomal Structure Deletions portion of chromosome missing Eg Cri du chat syndrome, Large or Microdeletions Duplication portion of chromosome included twice Translocation Segment of DNA breaks from one chromosome & attaches to other causing rearrangement Reciprocal & Robertsonian translocations Isochromosomes centromere breaks transversely InversionsInversions-two breaks with inversion of genetic material - peri or paracentric Mosaicism two or more cytogenetic lines in one zygote

2. PARENTAL BALANCED TRANSLOCATION 3. SINGLE GENE DISORDERS Hemoglobinopathies, Hemoglobinopathies, Thrombophilias 4. X- LINKED DISORDERS X5. CONFINED PLACENTAL MOSAICISM

GENETIC ETIOLOGY IN RPL

3.5%3.5%-5% Chromosomal - Global view 50 90 % Fetal chromosomal numerical abnormalities - 70 90 % Parental balanced chromosomal rearrangement - 3 8 % Single gene disorders 10 15 % Alpha thalassemia major Thrombophilia X linked dominant disorders 5 10%

5050-70% due to chromosomal numerical anomalies Autosomal trisomy - 50-60% - 13,16,18,21,others 5013,16,18,21,others Monosomy X - 20% Triploidy 15% Tetraploidy - 5% Fetal chromosomal abnormality in positive only in 25-32% of 25product of conception (POC)
y

This may be due to abnormalities in the egg, sperm or both.

Sperm aneuploidy (13,18,21,X,Y ) directly influences the rate of aneuploidy in the conceptus (Carrell et al 2003)

Unbalanced translocation-3-5% translocationParental Karyotypes normal Minimal recurrence risk

50% to 80% of first trimester abortions are due to abnormal chromosomal or other distinct genetic causes ThromboThrombo-embolic diseases (FVL Factor V Leiden) and alloimmune pregnancy loss (Shared HLA) could be because of perturbation of gene products Recurrent aneuploidy exists, usually associated with advanced maternal age According to CARP et al. finding of abnormal karyotype is 29 % in RPL.

Parental Chromosomal Abnormalities

Translocation (commonest) (1in 500) Reciprocal [50%] Robertsonian [24%] Mosaicism for a numeric aberration [12%] Inversion Balanced structural rearrangements (Translocation carriers) - No net gain or loss of genetic information - Phenotypically normal - Have high risk of producing unbalanced gametes - Unbalanced gametes produce abnormal offspring, embryonic deaths

Translocations
Two major types Reciprocal translocation- two nonhomologous chromosomes exchange information Robertsonian translocation -two non-homologous acrocentric chromosomes break at the centromere and the long arms fuse. The short arms are often lost.
Source- Emery s book of principles of Medical Genetics

Reciprocal Translocation
 Two non-homologous chromosomes exchange information if no genes are broken, individuals appears normal (no phenotype) - No gain or loss of genetic information - Individuals are translocation carriers t(11,22)  If one of the breaks occurs in a gene - gene can be disrupted - can have a phenotype
Source-Internet

Consequences of Reciprocal Translocations

Robertsonian translocation
 Incidence-1:1000  Occurs most frequently with acrocentric chromosomes  Produce one new large chromosome made from the two long arms of two different chromosomes.  Two short arms of each chromosome are lost  Example Down syndrome  Commonest Rob Trans(13,14)  Risk of phenotypically abnormal offspring- 1%  Risk of RM- Upto 30%

Source-Internet

Segregation of chromosomes at meiosis in a 14-21 translocation carrier

Balanced carrier
Source-Internet

Down syndrome
Source-Internet

A 2 breakpoint event involving one chr, chr, segment between the break gets inverted, and reinserted Two typestypesPericentric (0.12-0.7%)(0.12-0.7%)Paracentric(0.1-0.5%)Paracentric(0.1-0.5%)Common normal variantsvariantsInv 1,9,16,Y
Source- Emery s book of principles of Medical Genetics

Pericentric Inversion

Source-Internet

Rearrangement

Carrier

Risk of Abnormal live born Upto 10% 10-15% 5% 100% 5-10% 0.1-0.5%

RM

Reciprocal Robertsonian (D;G & G;G) t(2;21) Inversion (Pericentric) Paracentric

Either parent Mother Father Either Either parent -do-

30-50% Upto 30%

50%

Single Gene Disorders in RM

Second and 3rd trimester losses Alpha Thalassemia Myotonic dystrophy X linked Dominant disorder Incontinentia Pigmenti Chondrodysplasia punctata Focal dermal hypoplasia of Goltz Rett Syndrome Aicardi Syndrome

Single Gene Disorders in RM

Hereditary thrombophilia First and later trimester losses Microthrombosis in placenta ;Impaired uteroplacental circulation Factor V Leiden gene mutation Evidence based Prothrombin G 20210A mutation inc. risk Protein C,S deficiency Antithrombin III No significant association MTHFR C677T mutation Combination of any of above-Increased risk

Risk Factors for Karyotypic abnormalities Gestational age

Higher in early gestation
90% in anembryonic preg/Blighted ova preg/Blighted 50% at 8-11wk 830% at 16-19 wk 166-12% >20wk

Risk Factors for RM

y

Advanced maternal age

y

Affects ovarian function, giving rise to a decline in the number of good quality oocytes, resulting in chromosomally abnormal oocytes, conceptions that rarely develop further. RM risk -75% in women >45years

Previous number of miscarriages

Pr i t r

t ti t r r r i

r l

(PGS) i f tr l

i t r

f f i t

il

l i r r i r : . G . r t it f hCG ( G . l ha t r t i . ( j at tri l) l) . I hi i . PAPP ( Pr nancy associat ancy rot in)

lasma

USG Markers of Aneuploidy: Aneuploidy: NT (Nuchal Translucency 11 weeks) (Nuchal NF ( Nuchalfold Thickness) Nasal bone TR (Tricuspid regurgitation) Ductus Venosus. Venosus. Anomaly scans or genetic sonograms are commonly used to rule out the anomalies now a days

FISH (Fluorescent in situ hybridization), CGH (Comparative Genome hybridisation) hybridisation) and Iso- thermal genomic amplifications are the methods Isoavailable. These can help detection of aneuploidy and enable the transfer of only euploid embryos Chorion Villous sampling and amniocentesis are advised in high risk cases of known family history of chromosomal abnormalities and advanced maternal age beyond 35 years. It is advised to defer invasive techniques since other non invasive markers are available presently.

Karyotype of the abortus (fetal/placental tissue) Peripheral blood Karyotyping of the parents in all couples with RM

Spontaneous abortion Recurrent Miscarriage 10-15% 50-70% abortuses chromosomally abnormal Couple karyotype usually normal Recurrence risk negligible 1-3% 25-30%abortuses chromosomally abnormal Couple karyotype may be rearrangement carrier Recurrence risk upto 50%

Successful culture requires healthy cells derived from the fetus Unsuccessful in upto 50% of cases Overgrowth of fetal cells Poor growth of abortus tissue esp. if there is a long time interval from the demise until the culture is performed Poor chromosome morphology

Whether we should do POC karyotype????

No definite recommendations for routinely obtaining abortus karyotype (ACOG 2001) Karyotype analysis of abortus tissue for couples with a subsequent second or third pregnancy loss al 2003) (Hogge, (Hogge, et

If abortus is aneuploid, maternal cause is excluded aneuploid, (ACOG, 2001)

If POC karyotype not possible, do parental karyotype

Normal Abnormal (trisomy or chromosomal (trisomy rearrangement)

Both requires parental karyotype

Direct parental karyotype is more cost effective No need for first abortion

Individuals with Balanced Chromosomal Rearrangement usually phenotypically normal Are at risk of having conceptus with normal balanced unbalanced
spontaneously aborted phenotypically malformed

phenotypically normal

Genetic Evaluation and Testing Recommendation

History of Recurrent miscarriage Clotting disorder Still birth/neonatal death Babies with dysmorphic features Infertility Mental retardation /developmental delay Inherited disorder

(J Gen Counsel ;14(3)2005)

Karyotypic abnormalities in couples with Recurrent abortions

Total Couples n=742(1484 cases) Duration -12 years Chromosomal rearrangements = 52 (7% ) Structural aberrations 22 (2.9%) Reciprocal (6,8,11,18)=15 (68.2%) Robertsonian (21,22,13,14)=4 (18.1%) Inversion(4)=1 (9%) Deletion=2 Numerical anomalies (mosaics with XO,XXX, XXY)= 9 (1.2%) Chromosomal variants (para centromeric (para heterochromatin/fragile sites) = 21 (3.2%)
Dubey et al. Ind J Hum Genet 2005

Special thanks to Neerja Gupta & Madhulika Kabra

Division of Genetics Department Of Pediatrics All India Institute of Medical Sciences New Delhi

I VF

Donor egg or sperm

Treatment Options

Skewed Chromosome Inactivation Human leukocyte antigen-G antigenpolymorphisms Assisted reproductive technologies (specifically, preimplantation

Future

Thank You