1. Genetic Patterns in Adverse Pregnancy Outcomes: Miscarriage and Preterm Birth September 13, 2007 Seventh Annual Primary Care and Prevention Conference Atlanta, Georgia Siobhan Dolan, MD, MPH Associate Professor of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine, Bronx, NY

3. Conception Birth 1 Year Fetal Infancy 20 wks28 wks4 wks Spontaneous Abortion Early Fetal Late Fetal Neonatal Postneonatal Infant Feto-Infant Perinatal I II III Age at Loss Ectopic Spectrum in Timing of Adverse Pregnancy Outcomes

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7. Genetic Patterns in Adverse Pregnancy Outcomes: Miscarriage and Preterm Birth

8. Objectives Discuss genetic findings in miscarriage Discuss genetic findings and gene-environment interactions demonstrated in preterm birth Introduce preterm birth as a common complex disorder Outline genomics principles including family history Propose a framework for a genomic approach in research to improve perinatal outcomes

9. Genetics: The study of the patterns of inheritance of specific traits.

10. Pedigree

11. Karyotype

12. Clinical indications for karyotype in pediatric and obstetric care Multiple congenital anomalies Mental retardation, mild to profound, of unknown origin or associated with minor or major malformations Multiple unexplained spontaneous abortions Family history of Down syndrome or other chromosome abnormality Ambiguous genitalia Primary amenorrhea Advanced maternal age Ultrasound abnormalities

13. Frequency of Chromosome Abnormalities Livebirths 0.6% –Congenital anomaly with MR 23.0% –Congenital heart disease 13.0% –Institutionalized individual with MR 12.0% Couples with multiple spontaneous abortions 5.0% Stillbirths and perinatal deaths 6.0% Spontaneous abortions (first trimester) 60.0%

14. First Trimester Spontaneous Miscarriage ~15% of all first trimester pregnancies end as spontaneous miscarriage Of those: –40% have normal chromosomes –60% have abnormal chromosomes

15. First Trimester Spontaneous Miscarriage The abnormal chromosomal findings include: –Autosomal trisomy in 50% Most common is trisomy 16 (~16%) Trisomy 16 is never observed in liveborns –Turner Syndrome (45, X) in 25% ~99% abort spontaneously –Triploidy and tetraploidy in 20% –Structural abnormalities in < 5%

16. Chromosomal Abnormalities in Newborns Abnormality Balanced translocation Unbalanced translocation Pericentric inversion Trisomy 21 Trisomy 18 Trisomy 13 47, XXY 47, XYY 47, XXX 45, X Frequency at birth 1 in 500 1 in 2000 1 in 100 1 in 700 1 in 6000 1 in 10000 1 in 1000 males 1 in 1000 females 1 in 5000 females

17. Most Chromosome Abnormalities are Prenatal Lethals (Outcome of 10,000 Conceptions) Spontaneous Abortions OutcomeConceptions# SAbs% SAbsLive Births Total10,000150015 8,500 Normal Chromosomes 9,200 750 88,450 Abnormal Chromosomes Total8007509450 Triploid/tetraploid170170100 45, X140139991 Trisomy 16112112100 Trisomy 182019951 Trisomy 2145357810 Trisomy, other20920899.51 47, XXY, 47, XXX, 47, XYY1942115 Unbalanced rearrangements2723854 Balanced rearrangements1931616 Other3937952

18. Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2005 Percent HP 2010 Objective Preterm Birth Rates United States, 1983, 1993, 2003, 2004 Percent 30 Percent Increase

20. Major Categories of Risk for Preterm Birth Extremes of maternal age Unintended pregnancy 34, 35, 36 weeks Maternal race Multiple gestation Cesarean section

21. Types of Preterm Birth Spontaneous Preterm Labor Spontaneous Premature Rupture of the Membranes Medical Intervention Preterm Birth While this suggests distinct pathways, many of the risk factors for all 3 are similar.

22. Risk Factors for Preterm Labor/Delivery The best predictor of having a preterm birth is multifetal gestation or history of preterm labor/delivery Other risk factors: –multifetal pregnancy –maternal age ( 35 years) –black race –low SES –unmarried –previous fetal or neonatal death –3+ spontaneous losses –uterine abnormalities –incompetent cervix –genetic predisposition –low pre-pregnant weight –obesity –infections –bleeding –anemia –major stress –lack of social supports –tobacco use –illicit drug use –alcohol abuse –folic acid deficiency

23. Preterm Birth is a Common Complex Disorder

24. Complex “Complex genetic traits refer to those phenotypes not fitting patterns of Mendelian segregation and/or assortment but exhibiting a preferential familial clustering that cannot be explained by cultural or environmental causes.” Muenke et al. Genet Med 2004:6(1):1-15.

25. Complex Disorders 1. Genetic contribution 2. Environmental influences 3. Gene-environment interactions

26. Complex Disorders Genetic contribution –Familial aggregation –Recurrence of preterm birth –Racial disparity

27. The Risk of Preterm Birth Across Generations Porter et al. Obstetrics & Gynecology. 1997;90:63-67. Objective: To examine the risk of preterm birth for mothers who themselves were born before term. 1405 preterm mothers 2781 term mothers Conclusions: An increased risk of preterm delivery exists for women who themselves were born before 37 weeks gestation. This risk is inversely correlated with the maternal gestational age at birth and is influenced by maternal age and parity.

28. Genetic influence on birthweight and gestational length determined by studies in offspring of twins Clausson et al. BJOG. 107:375-381. 2000. Objective: To determine the relative importance of genetic effects on birthweight, gestational length and small for gestational age. 868 monozygotic female twin pairs 1141 dizygotic female twin pairs Conclusions: Concordance rates and intra-class correlations for birthweight, gestational length and small for gestational age were consistently higher in monozygotic compared with dizygotic twins. Model fitting suggested heritability estimates in the range from 25% to 40%. ** PRETERM BIRTH = 36% (0.03 – 0.51) **

29. Maternal and Paternal Influences on Length of Pregnancy Lie et al. Obstet Gynecol 2006;107:880-5. Methods: 77,452 boys and girls in the Medical Birth Registry of Norway who later became parents themselves. Records were linked between parents and children. Results: Gestational age of the child at birth increased on average 0.58 days for each additional week in the father’s gestational age (0.48-0.67) and 1.22 days for each additional week in the mother’s gestational age (1.21-1.32).

30. Complex Disorders Genetic contribution Environmental influences Gene-environment interactions

31. Complex Disorders Environmental influences –Smoking –Infection –Stress

32. Complex Disorders Genetic contribution Environmental influences Gene-environment interactions

33. Maternal Cigarette Smoking, Metabolic Gene Polymorphism, and Infant Birth Weight Wang et al. JAMA. 2002;287:195-202. Objective: To investigate whether the association between maternal cigarette smoking and infant birth weight differs by polymorphisms of 2 maternal metabolic genes: CYP1A1 and GSTT1. 741 mothers with singleton livebirths 174 ever smokers 567 never smokers 207 cases low-birth-weight or preterm 534 controls

34. Maternal Cigarette Smoking, Metabolic Gene Polymorphism, and Infant Birth Weight Wang et al. JAMA. 2002;287:195-202. Conclusions: Maternal CYP1A1 and GSTT1 genotypes modified the association between maternal cigarette smoking and infant birth weight, suggesting an interaction between metabolic genes and cigarette smoking.

35. A polymorphism in the promoter region of TNF and bacterial vaginosis: Preliminary evidence of gene-environment interaction in the etiology of spontaneous preterm birth Macones et al. AJOG. 2004;190:1504-8. Objective: To assess if the presence of symptomatic bacterial vaginosis amplifies the risk of spontaneous preterm birth in those with a “susceptible” TNF genotype (TNF-2). 125 cases: delivered before 37 weeks as a result of ruptured membranes or preterm labor 250 controls: delivered after 37 weeks

36. A polymorphism in the promoter region of TNF and bacterial vaginosis: Preliminary evidence of gene-environment interaction in the etiology of spontaneous preterm birth Macones et al. AJOG. 2004;190:1504-8. Conclusion: This study provides preliminary evidence that an interaction between genetic susceptibilities (TNF-2 carriers) and environmental factors (BV) is associated with an increased risk of spontaneous preterm birth. Group% TNF-2 carriers %TNF-2 carriersOR (95% CI) in cases in controls Overall45%23%2.1 (1.7-4.5) BV Positive69%27% 6.1 (1.9-21.0) BV Negative34%22%1.7 (1.0-3.1)

37. Genomics: All of the structure and function of an entire genome (e.g., the human genome), including its sequences, structures, regulation, interactions, and products.

38. “HuGE”: Human Genome Epidemiology

39. Framework for a Genomic Approach to Preterm Birth

40. Pathways to Preterm Birth Inflammation / Infection (ascending), 40% Stress (maternal/fetal), 25% Bleeding / Clotting Abnormality (thrombophilia, decidual hemorrhage, abruption), 25% Abnormal Uterine Distension (stretching), 10%

41. proteases Uterine Contractions Cervical Change Infection: - Chorion-Decidual - Systemic Decidual Hemorrhage Abruption CRH E1- E3 Prothrombin G20210A Factor V Leiden Protein C, S, Z Type 1 Plasminogen MTHFR Pathological Uterine Distention Multifetal Preg Polyhydramnios Uterine abnormalities Inflammation Maternal-Fetal Stress Premature Onset of Physiologic Initiators Activation of Maternal/Fetal HPA Axis CRH + + Chorion Decidua Chorion Decidua uterotonins Mechanical stretch Gap jct IL-8 PGE2 Oxytocin recep pPROM Interleukins IL-1, IL-5, IL-8 TNF-  Fas L Adapted from: Lockwood CJ, Paediatr Perinat Epidemiol 2001;15:78 and Wang X, et al. Paediatr Perinat Epidemiol 2001; 15: 63 Susceptibility to Environmental toxins CYP1A1 GSTT1 MMP s PTB

42. Common Complex Disorders “From a public health perspective, genes with mutations that are less highly penetrant but much more prevalent have a greater effect on the population than genes that are highly penetrant but uncommon.” Guttmacher AE, Collins FS. Genomic Medicine – A Primer. N Engl J Med 2002:347(19):1512-1520.

44. Genomics... Allows us to consider genetic variation as the background for environmental influences Encourages research to examine gene- environment interactions

45. Genomics... May enhance our understanding of the mechanisms of disease and allow us to target or expand clinical interventions and public health strategies

46. Prevalence of spina bifida and anencephaly among all 24 surveillance programs 19951996199719819992000 Pre-fortificationOptional Fortification Mandatory Fortification 2001 Teratology 2002; 66:33-39. Updated 6/2004.

47. Source: Cummings AM, Kavlock RJ. Crit Rev Toxicol 2004;34:461-85. Folate Metabolism

48. Genomics... Highlights the role of family history

49. Protocol for Folic Acid Average Risk High Risk Routine components of preconception & prenatal care Targeted 4 mg folic acid supplement + Assess Personal and Family History

50. Hypothetical Protocol for Preterm Average Risk High Risk Extremely High Risk Routine components of preconception & prenatal care Targeted smoking cessation and weight management Consider progesterone + + + Assess Family History

51. Genetic and Genomic approaches do not replace but can add to: Community based interventions Patient / Consumer education Provider education Equity in health outcomes and health care

52. Common Complex Disorders “The study of genomics will most likely make its greatest contribution to health by revealing mechanisms of common, complex diseases, such as hypertension, diabetes, and asthma.” Guttmacher AE, Collins FS. Genomic Medicine – A Primer. N Engl J Med 2002:347(19):1512-1520.

53. Common Complex Disorders “The study of genomics will most likely make its greatest contribution to health by revealing mechanisms of common, complex diseases, such as hypertension, diabetes, and asthma.” … miscarriage and preterm birth. Guttmacher AE, Collins FS. Genomic Medicine – A Primer. N Engl J Med 2002:347(19):1512-1520.

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