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ecurrent spontaneous abortion (RSA) is a common condition in 1-5% of pregnant women. The structural chromosomal abnormaliti-es and thrombophilia are well-documented etiologic factors in
RSA.1,2 X autosome translocations are rare and are estimated as
1/30 000 in live births.3Females with balanced X; autosome translocations constitute a clinically heterogeneous group of patients ranging from he-althy individuals to severely disabled patients depending on the X
break-De Novo Balanced (X;14) Translocation
in a Patient with Recurrent Miscarriages:
Case Report
AABBSS TTRRAACCTT We report a 23-year-old phenotypically normal female patient who had previously suffered from recurrent spontaneous abortion (RSA) who found to have an X;14 trans location and a Methylene- Tetrahdrofolate-Reductase (MTHFR) C677T heterozygote mutation. G-banding cy-togenetic analysis was cultured from the peripheral blood lymphocy tes. MTHFR, factor V Leiden and prothrombin gene mutations were studied from DNA obtained from peripheral blood lym-phocytes with stripassay. DNA for X inactivation pattern study was also obtained with the method described above. G-banding cytogentic analysis from cultured peripheral blood lymphocytes of the patient revealed 46,XderX,t(X;14)(q13;q32) and found to be heterozygous for C677T MTHFR mutation. An X inactivation pattern study revealed a complete inactivated nor mal X chromosome, asexpected. The possible causes of recurrent miscarriages in our patient were unbalanced gametes, skewed X inactivation and MTHFR C677T heterozygote mutation.
KKeeyy WWoorrddss:: Abor ti on, ha bi tu al; he te rozy go te de tec ti on; X chro mo so me inac ti va ti on; trans lo ca ti on, ge ne tic
Ö
ÖZZEETT Bu çalışmada, 23 yaşında, fenotipik olarak normal ancak daha önceki tekrarlayan düşükleri nedeniyle X;14 translokasyonu ve Metilen-Tetrahidrofolat Reduktaz (MTHFR) C677T heterozigot mutasyonu taşıyıcılığı saptanan bir olgunun sunulması amaçlandı. Periferik kan lenfosit kültüründen Standart G bantlama ile sitogenetik analiz, yine periferik kan lenfositlerinden izole edilen DNA'dan strip yöntemi ile MTHFR, faktör V, protrombin gen mutasyonu ve X inaktivasyon paterni çalışıldı. Olguda dengeli X-otozom translokasyonu 46,XderX, t(X;14)(q13;q32), MTHFR C677T heterozigot mutasyonu ve X inaktivasyon paterninde tamamen normal X'in inaktif olduğu saptandı.Olgunun anne-babası, eşi ve son gebeliği sonucu doğan kızının ise sitogenetik analiz sonucunda karyotipleri normaldi. Olgumuzda tekrarlayan düşüklerin muhtemel nedenlerinin dengesiz gametler, sapmış X inaktivasyonu ve MTHFR C677T heterozigot mutasyonu olabileceği düşünüldü.
AAnnaahh ttaarr KKee llii mmee lleerr:: Dü şük, tek rar la yan; he te ro zi got sap ta mak; X kro mo zo mu inak ti vas yo nu; trans lo kas yon, ge ne tik
TTuurrkkiiyyee KKlliinniikklleerrii JJ MMeedd SSccii 22001111;;3311((33))::771122--55
Ferda ALPASLAN PINARLI, MD,a Gülsen ÖKTEN, MD,a Tayfun ÖZÇELİK,b Nurten KARA, MD,a Sezgin GÜNEŞ,a İdris KOÇAK, MDc Departments of aMedical Biology,
Section of Medical Genetics,
cObstetric & Gynecology,
Ondokuz Mayıs University Faculty of Medicine, Samsun
bMolecular Biology and Genetics,
Bilkent University Art & Science Faculty, Ankara
Ge liş Ta ri hi/Re ce i ved: 11.05.2009 Ka bul Ta ri hi/Ac cep ted: 26.01.2010 Ya zış ma Ad re si/Cor res pon den ce: Ferda ALPASLAN PINARLI, MD Ondokuz Mayıs University Faculty of Medicine, Department of Medical Biology, Section of Medical Genetics, Samsun, TÜRKİYE/TURKEY
ferdapinarli@yahoo.com
doi:10.5336/medsci.2009-13428 Cop yright © 2011 by Tür ki ye Kli nik le ri
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po int po si ti on and rep li ca ti on be ha vi or.4In this pa per, we re port a he althy wo men with X;14 trans lo ca ti on who pre vi o usly had re cur rent mis-car ri a ges and ga ve birth to a he althy girl.
CA SE RE PORT
A phe noty pi cally nor mal 23 ye ars old fe ma le pa ti ent had suf fe red from two mis car ri a ges in pre vi o -us thre e ye ars (at 7thand 14thwe eks of preg nancy) but no cyto ge ne tic analy ses we re per for med for the se fe tu ses. Obs tet ri cal workup inc lu ded ul tra -so nog raphy (USG) and hyste ro sal pin gog raphy (HSG) which we re fo und to be nor mal. In ad di ti on, the re we re no syste mic, en doc ri ne, ana to mic and en vi ron men tal risk fac tors.. Cyto ge ne tic analy sis of the pa ti ent was per for med and she re ce i ved ge ne -tic co un se ling. G-ban ding cyto ge ne -tic analy sis was per for med on cells cul tu red from pe rip he ral blo od lymphocy tes. The MTHFR, fac tor V Le i den and prot hrom bin ge ne mu ta ti ons work-up was do ne from DNA ob ta i ned from pe rip he ral blo od lym-phocy tes with strip as say (Vi en na Labs).5DNA was ex trac ted from 10 ml ve no us blo od samp les with Nuc le oS pin Blo od kit (Mac he rey-Na gel, Dü ren, Ger many) ac cor ding to the ma nu fac tu rer’s pro to -col. DNA for X inac ti va ti on pat tern study as well as PCR and elec trop ho re tic analy ses we re per for -med with the met hod des cri bed by Al len et al.6 Then, gel pro ducts we re vi su a li zed by et hi di um bro mi de sta i ning, and den si to met ric analy sis of the al le les was per for med at le ast twi ce using the Mul-ti A nalyst ver si on 1.1 soft wa re. A cor rec ted ra Mul-ti o (CrR) was cal cu la ted by di vi ding the ra ti o of the pre di ges ted samp le (up per/ lo wer al le le) by the ra ti o of the nonpre di ges ted samp le for nor ma li za ti -on of the ra ti os that we re ob ta i ned from the den si to met ric analy ses. The use of CrR com pen sa -tes for pre fe ren ti al amp li fi ca ti on of the shor ter al-le al-le when the num ber of PCR cycal-les in cre a ses. Af ter con sul ta ti on, she de ci ded for a third preg-nancy but did not ac cept am ni o cen te sis. The kar y-oty ping of her mot her, fat her and hus band we re allnor mal. A cli ni cal risk of mis car ri a ge was evi -dent at the 6th we ek of the preg nancy and low mo-le cu lar we ight he pa rin was used un til the 20thwe ek of preg nancy be ca u se of the high fe tal loss risk. All
over, she had a he althy baby girl at the 40thwe ek of her preg nancy.
RE SULTS
G-ban ding cyto ge ne tic analy sis from cul tu red perip he ral blo od lymphocy tes of the mot her re ve a -led 46,XderX,t(X;14)(q13;q32) (Fi gu re 1a, b, c). The kar yoty pe of the baby was nor mal (46,XX). The mot her was al so fo und he te rozy go te for C677T MTHFR mu ta ti on. The fac tor V Le i den (G1691A) and the G20210A mu ta ti ons in the prot hrom bin ge ne we re fo und to be ne ga ti ve.
X inac ti va ti on pat tern study re ve a led a comp -le te inac ti va ted nor mal X chro mo so me as ex pec ted (Fi gu re 2). A ske wed po pu la ti on is de fi ned as a cell po pu la ti on with gre a ter than 80% ex pres si on of one of the AR al le les. This cor res ponds to CrR va l-u es of <0.33 or >3. As a re sl-ult of this analy sis, we
FI GU RE 1a, b, c: G-ban ding cyto ge ne tic analy sis from cul tu red pe rip he ral blo od lymphocy tes of the mot her.
a) der (14) (14pter→14q32::Xq13→Xqter) chro mo so me, chro mo so me 14, and chro mo so me 14 ide og ram.
b) der (X) (Xpter→Xq13::14q32→14qter) chro mo so me, chro mo so me X, and chro mo so me X ide og ram.
c)Me tap ha se ima ge of the pa ti ent: Up per ar row: der (14) chro mo so me. Lo wer ar row: der (X) chro mo so me.
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Alpaslan Pınarlı ve ark. Tıbbi Genetik
ob ser ved comp le te ske wing of the X-chro mo so me inac ti va ti on in our pa ti ent.
DIS CUS SI ON
In fe ma les with ba lan ced X; au to so me trans lo ca ti ons, X bre ak po int po si ti on and rep li ca ti on be ha vi -o ur can inf lu en ce phe n-oty pic -out c-o me. Fe ma le car ri ers of ba lan ced X; au to so me trans lo ca ti ons are ge ne rally phe noty pi cally nor mal but may suf fer from mul tip le con ge ni tal ab nor ma li ti es and/or de-ve lop men tal de lay, pre ma tu re ova ri an fa i lu re, re-cur rent mis car ri a ges and X-lin ked syndro me. Mo re o ver, offs pring of the pa ti ents with ba lan ced trans lo ca ti on may carry an un ba lan ced trans lo ca -ti on and may ha ve va ri o us ab nor ma li -ti es.4The re -fo re, we sug gest that one of the pos si bi li ti es which ca u sed re cur rent mis car ri a ges in our pa ti ent might be the un ba lan ced ga me tes.
Furt her mo re, X inac ti va ti on is a do sa ge com-pen sa ti on mec ha nism in wo men who se both X chro mo so mes are ac ti ve in the early emb ryo ge ne -sis. Me anw hi le, a ran dom trans crip ti o nal si len cing of a sing le X chro mo so me oc curs in eit her pa ter -nally or ma ter -nally de ri ved X chro mo so me.7,8 Inac ti va ti on of the nor mal X chro mo so me in un ba -lan ced trans lo ca ti on is a ra re but pos sib le event, to con fer a sur vi val ad van ta ge to the emb ryo.3,9 In ba lan ced fe ma le car ri ers of X chro mo so me; au to so me trans lo ca ti ons, the nor mal X chro mo so me is usu ally inac ti va ted for al lo wing full ex pres -si on of ge nes on the trans lo ca ted seg ments.10 Si mi larly, our pa ti ent’s X inac ti va ti on pat tern study sho wed a comp le te inac ti va ti on of the nor-mal X chro mo so me, as ex pec ted. Sin ce she has not de mons tra ted any Xlin ked di sor der or phe noty -pe al te ra ti on, the ba lan ced trans lo ca ti on on the
ac-ti ve X chro mo so me do es not se em to har bor any ge nes. Con tra dic tory re ports exist abo ut the as so -ci a ti on of re cur rent spon ta ne o us abor ti ons and ske wed Xchro mo so me inac ti va ti on pat tern. Hog -ge et al. sug -ges ted that ske wed X-inac ti va ti on was not as so ci a ted with re cur rent spon ta ne o us abor ti -ons but it was as so ci a ted with in cre a sing ma ter nal age.1Ho we ver, Ba gis lar et al. re por ted that 17.7% of 62 pa ti ents with re cur rent spon ta ne o us abor ti -ons we re ex tre mely ske wed with X-chro mo so me inac ti va ti on.11
In he ri ted and ac qu i red throm bop hi li a are res pon sib le for re cur rent preg nancyloss of unk -nown ca u se in mo re than 50% of wo men. Throm-bop hi lic risk fac tors are al so fre qu ent in wo men with ot her vas cu lar pla cen tal pat ho lo gi es such as pla cen tal ab rup ti on, pre ec lamp si a, in tra u te ri ne growth re tar da ti on and la te fe tal loss. The gre a test risk was do cu men ted in wo men with ho mozy go us mu ta ti ons for the fac tor V Le i den or prot hrom bin ge ne or com bi na ti ons of the se risk fac tors.5Ho we -ver, the re is li mi ted da ta in the li te ra tu e abo ut the as so ci a ti on of MTHFR C677T mu ta ti on and re cur -rent mis car ri a ges. Bak su et al. re por ted two ca ses with de ep ve no us throm bo sis and fe tal loss as so ci a ted with FV Le i den and MTHFR C677T he te -rozy go te mu ta ti ons.12 Re cently, Xu et al. de -mons tra ted that the ge ne tic poly morp hisms of MTHFR C677T we re as so ci a ted with unexp la i ned re cur rent early spon ta ne o us abor ti on.13Alt ho ugh the evi den ce in the li te ra tu re is li mi ted, we think that the he te rozy go us MTHFR C677T mu ta ti on of our pa ti ent might be an ad di ti o nal risk fac tor for fe tal loss. Thus, pos sib le ca u ses of re cur rent mis carri a ges in our pa ti ent we re un ba lan ced ga me tes, ske -wed X inac ti va ti on and MTHFR C677T he te-rozy go us mu ta ti on.
Pre ma tu re ova ri an fa i lu re may be ca u sed by so me ge ne tic di sor ders, which may in du ce ske wed X-chro mo so me inac ti va ti on.14In ad di ti on, the im-por tan ce of X-bre ak po int po si ti on has be en de mon-s tra ted in cyto ge ne tic mon-stu di emon-s of fe ma lemon-s with go na dal dysfunc ti on.4Sin ce it has be en shown that X inac ti va ti on cen ter is lo ca li zed at Xq13, and pre-ma tu re ova ri an fa i lu re which has be en usu ally con-fi ned to pa ti ents with bre aks wit hin a cri ti cal FI GU RE 2: X-chro mo so me inac ti va ti on pat tern of the pa ti ent. A sing le al le le
in the Hpa II di ges ted samp le in di ca ting nonran dom Xchro mo so me inac ti -va ti on was ob ser ved. M rep re sents the mar ker.
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re gi on bet we en Xq13 and Xq26,3,15,16 we spe cu la te that our pa ti ent might ha ve a bre ak po int at Xq13 along with ske wed X-chro mo so me inac ti va ti on ma king her a pos sib le can di da te for early ova ri an fa i lu re in the fu tu re.
CONC LU SI ON
As a re sult of 3:1 mal seg re ga ti on, the offs pring of fe ma le car ri ers of ba lan ced X; au to so me trans lo ca -ti on may ha ve nor mal kar yoty pe as in our pa -ti ent, or may ha ve ba lan ced X; au to so me trans lo ca ti on
with nor mal phe noty pe, but may al so ha ve un ba -lan ced trans lo ca ti ons re sul ting with re cur rent mis-car ri a ges or mul tip le con ge ni tal ab nor ma li ti es. Mo re o ver, the ske wed Xchro mo so me inac ti va ti on and MTHFR C677T mu ta ti ons might be ad di ti -o nal risk fac t-ors f-or re cur rent mis car ri a ges. Fe ma le car ri ers of ba lan ced X; au to so me trans lo ca ti on sho uld re ce i ve ge ne tic co un se ling for the se pos si bi li -ti es as well as for pre ma tu re ova ri an fa i lu re. The new born sho uld be fol lo wed for the pos si bi lity of be ha vi or ab nor ma li ti es and chec ked for mo sa i cism.
1. Hog ge WA, Pro sen TL, La na sa MC, Hu ber HA, Re e ves MF. Re cur rent spon ta ne o us abor ti on and ske wed X-inac ti va ti on: is the re an as so ci a ti on? Am J Obs tet Gyne col 2007; 196(4):384.e1-6.
2. Ku o PL, Gu o HR. Mec ha nism of re cur rent spon ta ne o us abor ti ons in wo men with mo sa i -cism of X-chro mo so me ane up lo i di es. Fer til Ste ril 2004;82(6):1594-601.
3. Gup ta N, Go el H, Phad ke SR. Un ba lan ced X; au to so me trans lo ca ti on. In di an J Pe di atr 2006; 73(9):840-2.
4. Wa ters JJ, Camp bell PL, Croc ker AJ, Campbell CM. Phe noty pic ef fects of ba lan ced Xau -to so me trans lo ca ti ons in fe ma les: a ret ros pec ti ve sur vey of 104 ca ses re por ted from UK la bo ra to ri es. Hum Ge net 2001; 108(4):318-27.
5. Kot ze MJ, La Gran ge C, Mans velt EPG. Ra pid throm bop hi li a ge ne tic test fa ci li ta tes im pro ved pre na tal ca re for mot her and child. SA Fam Pract 2005;47(7):50-1.
6. Al len RC, Zogh bi HY, Mo se ley AB, Ro senb latt HM, Bel mont JW. Meth yla ti on of Hpa I
-I and Hha-I si tes ne ar the poly morp hic CAG re-pe at in the hu man an dro gen-re cep tor ge ne cor re la tes with X chro mo so me inac ti va ti on. Am J Hum Ge net 1992;51(6):1229-39. 7. Po po va BC, Ta da T, Ta ka gi N, Brock dorff N,
Nes te ro va TB. At te nu a ted spre ad of Xinac ti -va ti on in an X;au to so me trans lo ca ti on. Proc Natl Acad Sci U S A 2006;103(20):7706-11. 8. He ard E, Clerc P, Av ner P. X-chro mo so me
in-ac ti va ti on in mam mals. An nu Rev Ge net 1997;31:571-610.
9. Ab rams L, Cot ter PD. Pre na tal di ag no sis of de no vo X;au to so me trans lo ca ti ons. Clin Ge net 2004;65(5):423-8.
10. Kalz-Fül ler B, Sle e gers E, Schwa nitz G, Schubert R. Cha rac te ri sa ti on, phe noty pic ma ni fes -ta ti ons and X-inac ti va ti on pat tern in 14 pa ti ents with X-au to so me trans lo ca ti ons. Clin Ge net 1999;55(5):362-6.
11. Ba gis lar S, Us tu ner I, Cen giz B, Soy le mez F, Ak yer li CB, Cey la ner S, et al. Ex tre mely ske -wed X-chro mo so me inac ti va ti on pat terns in wo men with re cur rent spon ta ne o us abor ti on. Aust N Z J Obs tet Gyna e col 2006;46(5):384-7.
12. Bak su B, Da vas İ, Eroğ lu B, Dö lek B, Ak yol A, Çı nar S. [Fac tor V le i den and meth yle ne -tet rah yro fo la te re duc ta se c677t mu ta ti ons in de ep ve no us throm bo sis and re current preg nancy loss: two ca se re ports]. Tur -kish Jo ur nal of Pe ri na to logy 2004;12(1):43-6.
13. Xu L, Li u XM, Zhang HY, Zha o J, Qi QW, Chang YF. [Re la ti ons hip bet we en thre e throm-bop hi lic ge ne mu ta ti ons and unexp la i ned re-cur rent early spon ta ne o us abor ti on]. Zhong hu a Fu Chan Ke Za Zhi 2007;42(3):180-3.
14. Sa to K, Ue ha ra S, Has hi ya da M, Na bes hi ma H, Su ga wa ra J, Te ra da Y, et al. Ge ne tic sig ni f-i can ce of ske wed X-chro mo so me f-inac tf-i va tf-i on in pre ma tu re ova ri an fa i lu re. Am J Med Ge net A 2004;130A(3):240-4.
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