Associated malformations among infants with neural tube defects

Infants with neural tube defects (NTDs) often have associated congenital anomalies. The reported frequency and types of associated malformations vary between different studies. The purpose of this investigation was to assess the frequency and types of associated malformations among infants with NTDs in a geographically well-defined population from 1979 to 2008 of 402,532 consecutive births. Of the 441 infants with NTDs born during this period, 20.4% had associated malformations. Infants with associated malformations were divided into those with recognizable conditions [11 (2.5%) infants with chromosomal and 23 (5.2%) with non-chromosomal conditions], and those without recognizable conditions [56 (12.7%) infants with multiple malformations]. Associated malformations were more frequent among infants with encephalocele (36.8%) than those with anencephaly (11.5%) or spina bifida (23.8%). Oral clefts and malformations in the musculoskeletal, renal and cardiovascular systems were the most commonly observed associated anomalies. The frequency of associated malformations in infants with NTDs emphasizes the need for a thorough investigation of these infants. Routine screening for other malformations, especially facial clefts and musculoskeletal, renal and cardiac anomalies, may need to be considered in infants with NTDs, and referral of these infants for genetics evaluation and counseling seems warranted.     

Recurrence risk after neural tube defects in a genetic counselling clinic.

The recurrence of isolated neural tube defects in a population of women from a genetic counselling clinic was found to be 3.4%. After one baby with a neural tube defect the recurrence was 2.3%. Of the 15 pregnancies of women who had two previous babies with neural tube defects, there were three further recurrences. These findings show that the Hungarian recurrence risk of isolated neural tube defects has not changed with a declining birth prevalence, and that the rate in genetic counselling clinic patients is the same as in a previous population based epidemiological study.     

Toward understanding the genetic basis of neural tube defects

Neural tube defects (NTDs) represent a common group of severe congenital malformations that result from failure of neural tube closure during early development. Their etiology is quite complex involving environmental and genetic factors and their underlying molecular and cellular pathogenic mechanisms remain poorly understood. Animal studies have recently demonstrated an essential role for the planar cell polarity pathway (PCP) in mediating a morphogenetic process called convergent extension during neural tube formation. Alterations in members of this pathway lead to NTDs in vertebrate models, representing novel and exciting candidates for human NTDs. Genetic studies in NTDs have focused mainly on folate-related genes based on the finding that perinatal folic acid supplementation reduces the risk of NTDs by 60-70%. A few variants in these genes have been found to be significantly associated with an increased risk for NTDs. The candidate gene approach investigating genes involved in neurulation has failed to identify major causative genes in the etiology of NTDs. Despite this history of generally negative findings, we are achieving a rapid and impressive progress in understanding the genetic basis of NTDs, based mainly on the powerful tool of animal models.     

Use of genetic counselling services for neural tube defects

Genetic counselling is recommended for parents of children with neural tube defects (NTDs) to inform them of the recurrence risks and the option of prenatal diagnosis. British Columbia provides an excellent site to examine the use by parents of genetic counselling services for NTDs. Genetic services for the entire province are centralized, and there is virtually complete ascertainment of all NTD births. The results from this study indicate that use of genetic counselling services is influenced by the type of NTD present and whether the index case was live or stillborn. Genetic counselling is most often sought after the birth of a liveborn infant with spina bifida.     

Recurrence risks for neural tube defects in a genetic counseling clinic population.

The recurrence of neural tube defects (NTD) in the sib following the index case of all patients who consulted the South-East Thames Regional Health Authority Genetics Centre in the period 1972 to mid-1979 was calculated. A total of 1037 consecutive patients was studied, of whom 958 (93%) were traced. The overall recurrence was 3.44% (1 in 29). However, if the index case was the first affected child in the family, the recurrence in the next sib was 3.15% (1 in 32), and if it was the second affected child, the recurrence was 11.76% (1 in 9). These figures give an indication of the actual recurrence among the 'selected' population who consult a genetic advice centre, and are somewhat, but not significantly, different from figures for the general NTD population, which have been derived from studies of whole families.     

Anterior neural tube malformations induced after all-trans retinoic acid administration in white rat embryos. I. Macroscopical observations

For this study all-trans-retinoic acid was administered in pregnant white rats in their "prima gravida" pregnancy. Rats were divided in five groups. The first three groups were treated with 20 mg R.A./kg b.w. at several gestational days. The fourth group was treated with corn oil, while the fifth group remained untreated. All the animals were sacrificed during the first hours of the 21st gestational day. In the first group, three embryos, five absorptions and six compact embryonic masses were counted in litters. All the embryos presented exencephaly, combined with external anopthalmia. They also presented severe craniofacial malformations. In the second group, nine embryos and five compact embryonic masses were counted in litters. Three of the embryos presented exencephaly combined with external anopthalmia, while the six remaining presented complex craniofacial anomalies. In the third group, exencephaly was present in two embryos combined with anopthalmia, seven embryos had complex anomalies and four compact embryonic masses were counted in litters. Our results indicate the teratogenic involvement of all-trans-retinoic acid in anterior neural tube differentiation.     

A genetic risk factor for mouse neural tube defects: defining the embryonic basis

Genetic polymorphisms are thought to play an important role in determining susceptibility to neural tube defects (NTDs), for example between different ethnic groups, but the embryonic manifestation of these polymorphic genetic influences is unclear. We have used a mouse model to test experimentally whether polymorphic variations in the pattern of cranial neural tube closure can influence susceptibility to NTDs. The site at which cranial neural tube closure begins (so-called closure 2) is polymorphic between inbred mice. Strains with a caudal location of closure 2 (e.g. DBA/2) are relatively resistant to NTDs, whereas strains with a rostrally positioned closure 2 (e.g. NZW) exhibit increased susceptibility to NTDs. We tested experimentally whether altering the position of closure 2 can affect susceptibility to cranial NTDs, by back- crossing the splotch ( Sp (2H) ) mutant gene onto the DBA/2 background. As a control, Sp (2H) was transferred onto the NZW background, which resembles splotch mice in its closure pattern. Approximately 80% of Sp (2H) homozygotes develop NTDs, both cranial (exencephaly) and spinal (spina bifida). After transfer to the DBA/2 background, the frequency of cranial NTDs was reduced significantly in Sp (2H) homozygotes, confirming a protective effect of caudal closure 2. In contrast, Sp (2H) homozygotes on the NZW background had a persistently high frequency of cranial NTDs. The frequency of spina bifida was not altered in either backcross, emphasizing the specificity of this genetic effect for cranial neurulation. These findings demonstrate that variation in the pattern of cranial neural tube closure is a genetically determined factor influencing susceptibility to cranial NTDs.     

Molecular genetic analysis of human folate receptors in neural tube defects

Neural tube defects (NTDs) are the most common congenital malformations and are considered to have a multifactorial origin, having both genetic and environmental components. Periconceptional folate administration reduces the recurrence and occurrence risk by 70-100%. Recently we discovered the first genetic risk factors for NTDs: the 677 C-->T and the 1298 A-->C mutations in the methylenetetrahydrofolate reductase gene explaining at the most 35-50% of the protective effect of folate. In this study we further explored the genetic component of NTDs by analysing the coding region, including the intron-exon boundaries and signal sequences of the folate receptor genes by SSCP analysis. Among 39 patients with spina bifida (SB), 47 mothers with a child with SB, and 10 controls, no polymorphism was present in the folate receptor alpha (FR-alpha) gene or in the folate receptor beta (FR-beta) gene.     

Is disordered folate metabolism the basis for the genetic predisposition to neural tube defects?

Vitamin levels were measured in twenty women under 35 years of age with a history of two or more neural tube defect pregnancies. Each index case was compared with a female control matched for age, obstetric history and social class. The mean concentration of red cell folate in the subjects was 178 ng/ml, significantly lower than the mean of 268 ng/ml for the control group (P = 0.005). Red cell folate levels showed a linear relationship with the number of neural tube defect pregnancies, the levels being lowest in women who had had three or four affected offspring. There was no significant difference in serum folate; plasma or white cell vitamin C; plasma vitamin A; thiamine, riboflavine or pyridoxine status; serum vitamin B12; plasma vitamin E; total protein, albumin, transferrin, magnesium, copper or zinc. Diet was assessed by a questionnaire. The dietary intakes of total folate and other vitamins except vitamin A were lower in the subjects than the controls but none of the differences were statistically significant. Regression analysis showed a difference between subjects and controls in the relationship of red cell folate to dietary folate. This study demonstrates an association between susceptibility to offspring with neural tube defects and depressed red cell folate levels which cannot be entirely attributed to a lower dietary intake of folate. It is postulated that one factor predisposing to the occurrence of neural tube defects may be an inherited disorder of folate metabolism.     

Neural tube malformations: complex segregation analysis and calculation of recurrence risks.

Familial data on neural tube malformations in Great Britain were submitted to segregation analysis under the mixed model. Maternal and fetal factors cannot be discriminated in the absence of substantial bodies of data on spina bifida survivors who reproduce or on half-sibs. Early abortion studies would allow differential mortality in utero to be taken into account. After fitting the mixed and generalised single locus models, it is concluded that the multifactorial model can provisionally be used for calculation of recurrence risks. Pathogenic hypotheses implicating twinning seem to rest on little evidence.     

Spondylocostal dysplasia and neural tube defects.

Spondylocostal dysplasia (Jarcho-Levin syndrome) comprises multiple malformations of the vertebrae and ribs coupled with a characteristic clinical picture of short neck, scoliosis, short trunk, and deformity of the rib cage. We describe a patient with the syndrome who also had spina bifida and diastematomyelia. We surmise that this association is not coincidental. Additional evidence is needed to support the hypothesis that spondylocostal dysplasia and neural tube defects are aetiologically related.     

5,10 Methylenetetrahydrofolate reductase genetic polymorphism as a risk factor for neural tube defects

Persons with a thermolabile form of the enzyme 5,10 methylenetetrahydrofolate reductase (MTHFR) have reduced enzyme activity and increased plasma homocysteine which can be lowered by supplemental folic acid. Thermolability of the enzyme has recently been shown to be caused by a common mutation (677C^→T) in the MTHFR gene. We studied 41 fibroblast cultures from NTD-affected fetuses and compared their genotypes with those of 109 blood specimens from individuals in the general population. 677C^→T homozygosity was associated with a 7.2 fold increased risk for NTDs (95% confidence interval: 1.8–30.3; p value: 0.001). These preliminary data suggest that the 677C^→T polymorphism of the MTHFR gene is a risk factor for spina bifida and anencephaly that may provide a partial biologic explanation for why folic acid prevents these types of NTD.