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Management of a triplet gestation complicated by uterus didelphys.

BACKGROUND: Assisted reproductive technologies are making it possible for women to conceive when it was otherwise impossible. One of the side effects is multiple gestations. This may be especially disadvantageous when it occurs within an anomalous uterus. PATIENT AND METHODS: A 36-year-old women with the help of gamete intrafallopean transfer conceived triplets in a uterus didelphys. This pregnancy was further complicated by anencephaly of one of the triplets. The patient was managed by a combination of chorionic villi sampling and selective reduction that ended with the successful delivery of a term infant. CONCLUSION: Pregnancy reduction can be safely performed in a twin pregnancy on one side of a uterus didelphys. More reports will be required to determine whether this is the most optimal choice.

Adult

[Prenatal fetal blood group determination using chorionic villi biopsy].

The presence or absence of Rhesus D, c and Kell antigens on foetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling. Pregnancies in 15 severely sensitized women (9 Rh D, 5 Kell and I Rh c) with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in 13 of the 15 cases studied.

Blood Group Antigens

First-trimester prenatal diagnosis of Roberts syndrome.

We present a case of prenatal detection of premature centromere separation on chorionic villi sampled at 8 weeks' gestation from a woman at risk of recurrence of Roberts syndrome. The same cytogenetic characteristic was confirmed on amniocytes at 14 weeks when ultrasound examination showed morphological anomalies of the fetus. To our knowledge, this is the first report of early prenatal diagnosis of Roberts syndrome.

Abnormalities, Multiple

Prenatal diagnosis of 30 fetuses at risk for fragile X syndrome.

The results of 30 prenatal diagnoses for fragile X syndrome are reported. Amniotic fluid cells were examined in 1 case, fetal blood in 4, and chorionic villi samples in the others. Of the 5 fetuses analyzed by cytogenetic methods, 1 had showed 4% of fraXq27.3 expression sites and the pregnancy was terminated. For 1 diagnosis, linkage analysis was used: the female fetus turned out to be normal. In 24 fetuses, the direct analysis of the mutation by StB12.3 probe was performed: 6 female and 3 male fetuses were found to carry a full mutation and 1 female fetus was found to carry a premutation. In 3 cases, the diagnoses were verified on fetal blood samples. Several tissues of 2 aborted male fetuses were analyzed for the fragile X mutation. The results are reported and discussed.

Chorionic Villi Sampling

[Alpha-mannosidosis].

Alpha-mannosidosis is a rare autosomal recessively inherited lysosomal storage disorder. We describe three patients with alpha-mannosidosis who were born in Tromsø between 1983 and 1987, in order to increase awareness of the disease. It is characterized by a typical facial look, with a prominent forehead, hypertelorism, small nose, flat nasal bridge and hypoplastic teeth. The patients are mentally retarded, often have dysostosis multiplex, recurrent infections and typically severe loss of hearing and delayed speech development. The disease is slowly progressive in the first decade, but shows considerable clinical variability. In most cases, the lymphocytes are vacuolized, but diagnosis depends on measurement of alpha-mannosidase activity in the lymphocytes. Prenatal diagnosis is available, based on chorionic villi sampling in the 9th to 11th week of pregnancy. No causal therapy is known, but establishment of the diagnosis is important to avoid complications, recognize hearing loss and provide speech therapy and special education. The specific diagnosis is critical for genetic counselling and prenatal diagnosis. The authors therefore outline the diagnostic strategy.

Abnormalities, Multiple

Prenatal diagnosis of infantile hypophosphatasia.

Prenatal diagnosis was attempted in a pregnant Japanese woman whose son had died of infantile hypophosphatasia, using chorionic villi sampled at 10 weeks of gestation. Southern blot analysis of restriction fragment length polymorphism was used as a guide, with cDNA for the human liver-type alkaline phosphatase as a probe, and BclI as a restriction enzyme. The fetus was found to be a heterozygote; the pregnancy was allowed to continue; and the baby born was phenotypically normal.

Alkaline Phosphatase

Validity of cytogenetic analyses from trophoblast tissue throughout gestation.

Cytogenetic findings in the Münster Chorionic Villi Sampling (CVS) program are presented after 1,184 first trimester transcervical samplings and 131 second and third trimester placentacenteses. In the first trimester series the abnormality rate is low (2.4%) in patients with only an age-dependent aneuploidy risk. In this group terminations were performed in only 1.6% because of aneuploidy. True mosaicism was found more frequently after CVS, and the risk of maternal cell contamination seems higher as compared to amniocentesis. There are no obvious differences in the overall rate of diagnostic errors after both procedures, when metaphases after direct preparation and chorionic cell cultures are analysed and doubtful findings such as mosaicism are adequately followed up by amniocentesis. The cytogenetic techniques also offer a very rapid approach to karyotyping in the second and third trimester. We found a high rate of aneuploidy (15%) when placentacentesis was performed after sonographic diagnosis of fetal abnormalities. We conclude that cytogenetic analysis from trophoblast tissue is an accurate diagnostic tool applicable from first to third trimester of pregnancy.

Amniocentesis

A simple, modified technique for direct chromosome preparation from chorionic villi.

Chorionic villus sampling (CVS) has proved to be an elegant and safe technique for prenatal diagnosis of genetic diseases during the first trimester of pregnancy. Despite a number of obvious advantages, the wide application of direct cytogenetic analysis of CVS has been hampered by serious technical problems involving large numbers of incomplete metaphases and poor chromosome morphology. A chromosome preparation technique direct from CVS has been devised which involves modifications in the hypotonic and dissociation stages. It yielded satisfactory results in fifteen samples within 24 h of sampling. It is suggested that this simple, modified technique can provide complete chromosomal analysis within a short time for prenatal diagnosis of genetic diseases, and may be used as a routine method in cytogenetic laboratories.

Adult

[Opinion of primiparae on the possibility of sex selection].

Recent medical-technological developments such as chorionic villi sampling and in vitro fertilization make sex selection in principle possible. The literature and our own experiences suggest an increasing demand for it. We interviewed a selected group of 180 women regarding sex selection, of whom 127 responded. More than 80% of these rejected a selection based on sex. The legitimacy of withholding information about the sex of the foetus is questionable. The existence of a demand, however small, should prompt professionals to take a stand about its acceptability.

Abortion, Induced

Recent experience in prenatal diagnosis of fragile X.

Our experience with 48 prenatal fragile X cases (35 amniocenteses; 13 chorionic villi samplings) is summarized. Of these 48 cases, 18 consultands were known to be carriers of fragile X. No cytogenetic false negatives or positives were identified but 2 cases were uninterpretable. Cytogenetic recommendations include: 1) Ten or more days recovery time after growth in Chang medium, and 2) use of 3-4 media/inducer systems with duplicate harvests. Direct DNA probe testing will likely be the method of choice for prenatal diagnosis after sufficient data are collected to verify interpretation. Until then, both cytogenetic and direct DNA techniques should be utilized.

Amniocentesis

[In-situ hybridization on chorionic villi chromosomes].

Novel techniques for the prenatal diagnosis of inherited defects are currently being developed. The long-range aim is to be able to predict precisely, at an early stage of fetal development, the tendency of the fetus to develop multiple genetic, congenital or acquired diseases. We adapted the technique of gene mapping by in-situ hybridization for use with chromosomes from fetal chorionic villi sampling (CVS). Refined mapping of the genes coding for cholinesterase (CHE) in comparison with the haptoglobin and the transferrin receptor genes on CVS chromosomes Nos. 3 and 16 revealed 3 CHE genes in positions 3q21, 3q26, and 16q12. In view of genetic linkage data, at least 2 of these appear to be potentially active. These findings demonstrate that genes, for which molecularly cloned DNA probes are available, may be localized on CVS chromosomes by comparing their localization with that of known genes after in-situ hybridization. The implications for prenatal diagnosis are promising.

Cholinesterases

Prenatal diagnosis of the Pallister-Killian mosaic aneuploidy syndrome by CVS.

Prenatal cytogenetic analysis at 11 weeks of gestation revealed an abnormal karyotype 47,XX,+mar in all metaphases obtained from a chorionic villi sample after 24 h culture. Karyotyping of amniotic fluid cells in the second trimester showed mosaicism 47,XX,+i(12p)/46,XX with 10% aneuploid cells. The pregnancy was terminated at 20 weeks of gestation on the patient's request. The aborted fetus showed typical manifestations of the Pallister-Killian mosaic aneuploidy syndrome. The identity of the supernumerary isochromosome 12p was proven by LDH isozyme electrophoresis using cultured fibroblasts and by nonradioactive in situ hybridization using a biotinylated set of chromosome 12-specific DNA probes.

Abnormalities, Multiple

Prenatal and molecular diagnosis of hemophilia B.

Prenatal diagnosis was carried out on a woman who had previously given birth to a son with a spontaneous mutation of C-->T transition at nt 31133 of the factor IX (F.IX) gene. The diagnosis was performed on chorionic villi sampling by the method of amplification-created restriction site (ACRS). It revealed a female fetus with a normal F.IX gene, as confirmed by DNA sequencing after delivery. Meanwhile, a survey using the ACRS method to evaluate the inheritance of 63 individuals from 8 hemophilia B families was done. A different single-point mutation in each family was proved by DNA sequencing. One individual had a mutation with a naturally-created restriction site. In each of the remaining patients, we were able to show an enzyme-cutting site in their DNA amplification product for ACRS with the designed mutagenesis primers. All patients and carriers could be diagnosed accurately by comparing ACRS results with clinical and laboratory findings. There were new novel mutations among the patients.

Base Sequence

First trimester live pregnancy and subsequent fetal loss. Impact of transcervical CVS and colonization of the cervix.

A consecutive series of 224 women undergoing transcervical chorionic villi sampling (CVS) were analyzed for the presence of cervical microbes. The outcome of pregnancy was related to age, number of aspirations and to the presence or not of microbes. The CVS group was compared to a group of 200 women with live fetuses at 8-11 weeks of gestation not undergoing CVS (ultrasound, US group). In the US group the miscarriage rate was 8.5% with 5.9% occurring after the 16th week of gestation. In the CVS group 20.3% ended as a miscarriage, 28.9% of these after the 16th week. There was no correlation between miscarriage rate and maternal age in the US group. In the CVS group younger women had a prominent rate of fetal loss. In the present study the risk of fetal loss after CVS was associated with a previous history of spontaneous abortions, with several aspirations performed, and with bacterial colonization of the cervix--candida and gardnerella excluded.

Abortion, Spontaneous

[Prenatal diagnosis using chorionic villi].

Chorionic villus sampling (CVS) has a promising future about early detection of fetal abnormalities. It has the potential to become a major tool in the prenatal diagnosis and therapy of genetic disorders. Villus samples can be analyzed by means of cytogenetic, biochemical or molecular technics. Information available at present indicates fetal loss rate should be in the same proportion than amniocentesis. CVS appears to be a reasonably safe and reliable method of prenatal diagnosis in the first trimester of pregnancy. This procedure is setting as fast as it is possible like an excellent alternative to amniocentesis.

Chorionic Villi Sampling

Pallister-Killian syndrome: normal karyotype in prenatal chorionic villi, in postnatal lymphocytes, and in slowly growing epidermal cells, but mosaic tetrasomy 12p in skin fibroblasts.

We report on two patients with Pallister-Killian syndrome: an 18 month old male infant followed since the neonatal period and a 4 year old boy. Prenatal diagnosis by chorionic villi sampling (CVS) in the first case showed a normal karyotype without mosaicism. Chromosome analysis on peripheral lymphocytes of the newborn also showed a normal karyotype. The clinical diagnosis of Pallister-Killian syndrome was made after the first year of life because of the typical facial dysmorphism and other characteristic clinical features, such as frontotemporal alopecia, depigmented area of the skin, sensorineural hearing loss, and severe psychomotor retardation. Chromosome analysis from skin fibroblasts now showed an isochromosome 12p mosaicism. The origin of the extra chromosome was confirmed by in situ hybridisation using a chromosome 12 specific library. In the second case chromosomal analysis from peripheral lymphocytes at the age of 19 months showed a normal karyotype 46,XY. Following the clinical diagnosis of Pallister-Killian syndrome a superficial skin biopsy was performed which showed very poor and slow growth of cells and a normal karyotype. Because of the typical symptoms a larger and deeper skin biopsy was performed from which there was rapid growth of fibroblasts. Now the diagnosis was established on the basis of the presence of an i(12p) extra chromosome in 69% of the metaphases.

Abnormalities, Multiple

Confined placental chimerism: prenatal and postnatal cytogenetic and molecular analysis, and pregnancy outcome.

The presence of two cell lines in chorionic villi sampling (CVS) represents a significant complication in CVS analysis, interpretation, and counseling. We report on the cytogenetic and molecular analysis of a pregnancy that was conceived on clomiphene citrate. Two cell lines (46,XX and 47,XY,+9) were discovered in CVS analysis done for maternal age; 94% of the cells in the culture were 46,XX and 6% were 47,XY, +9 (the direct preparation was 46,XX). As neither line could have derived from the other, chimerism and not mosaicism was suspected, with the 47,XY,+9 cells deriving from a co-twin whose demise was the result of the autosomal trisomy. At a subsequent amniocentesis, only normal female cells were observed and a normal female infant was delivered at term. Cytogenetic analysis done on the infant's peripheral blood and on a sample of an umbilical vessel showed only 46,XX cells, while amnion and a fibrotic area of the placenta contained 2 cell lines, 46,XX and 47,XY,+9. Molecular analysis of 3 different tissues was done by the polymerase chain reaction (PCR) and Southern blotting, using Y specific primers and probes, respectively. The presence of Y specific DNA was detected in the placenta and amnion, but not in the umbilical blood vessel. These data excluded true chimerism in the fetal tissues at the level of about 1 in 10(5) cells and have defined for the first time probable confined placental chimerism (CPC), the result most likely of a "vanishing twin." Whenever two cell lines are found in CVS, especially in the setting of pharmacologically stimulated ovulation, the possibility of CPC should be considered. The effects of CPC on placental function and fetal outcome merit further study.

Adult

[Sampling, culturing and karyotyping of chorionic villi].

The authors report on 69 samples of chorionic villi taken from patients who were undergoing therapeutic termination of pregnancy. These samples were taken using small forceps which were guided by ultrasound. The reliability and the chances of culturing these villi in order to work out the caryotype of the fetus and to study the enzymes is discussed.

Chorionic Villi