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Immediate chromosome diagnosis on bone marrow cells: An aid to management of the malformed newborn infant
Volume 94 Number 2
Brief clinical and laboratory observations
289
Immediate chromosome diagnosis on bone marrow cells: An aid to management of the malformed newborn infant Uta Francke, M.D.,* Michael G. Brown, M.S., and Kenneth Lyons Jones, M.D., San Diego, Calif.
WHEN FACED with a severely malformed but viable newborn infant who requires immediate therapeutic measures to sustain life, a decision about the extent of treatment has to be made by parents and physicians. In most instances, the crucial question concerns the prospect for normal mental development, and vigorous treatment will most likely be initiated if there is no indication of a defective brain. Chromosomal imbalance is one cause of congenital anomalies associated with impaired central nervous system development. If karyotype results were available during the first day of life for those malformed infants in whom a chromosomal syndrome is suspected, a more rational decision could be made about providing or withholding life-sustaining treatment. The bone marrow provides an accessible source of metaphase cells for immediate chromosome analysis. Although this approach using standard chromosome staining was suggested several years ago, 1-3 it has not been routinely applied and no serial studies have been reported. We have employed trypsin-Giemsa (G-) and quinacrine mustard (Q-) banding methods to chromosome preparations from bone marrow. The use made by physicians and parents of the karyotype information establishes the value of the bone marrow karyotyping approach. PATIENTS AND METHODS Thirteen of the 15 patients were born in community hospitals and were transferred to an intensive care nursery because of severe malformations or respiratory distress or both; two were delivered at University Hospital. When an autosomal trisomy syndrome was suspected, written consent for a bone marrow aspiration was obtained from the parents. Bone marrow was aspirated from the iliac crest or tibia into a plastic syringe containing 0.1 ml of heparin. Using this technique, sufficient cells have been From the Department of Pediatrics, University of California, San Diego, and San Diego Children's Hospital and Health Center. Supported in part by The National Foundation-March of Dimes and the San Diego Regional Center for the Developmentally Disabled *Reprint address: Department of Human Genetics, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510.
0022-3476/79/200289+04500.40/0 9 1979 The C. V. Mosby Co.
obtained to permit karyotyping in all instances in which the procedure has been attempted. The sample was inoculated into three sterile 15 ml plastic tubes and incubated using the following conditions: (1) 15 minutes at 37~ in 5 ml 0.075 M KC1 containing colchicine (0.2 gg/ml); (2) 60 minutes at 37~ in 5 ml minimum essential medium containing 15% fetal calf serum and colchicine (0.2 gg/ml); (3) 2 to 3 hours at 37~ in mininum essential medium with fetal calf serum and colchicine. Tubes 2 and 3 were centrifuged at 1,000 rpm after the respective incubations and the pellets were resuspended in hypotonic (0.075M) KC1 for 10 minutes. Additional cultures were set up for longer periods of incubation if there was enough bone marrow available. For fixation, standard 3:1 methanol:glacial acetic acid was used with no change of fixative, and air-dried slides were prepared immediately with one drop of cell suspension per slide. Fresh slides were heated in a 95~ oven for 10 minutes. After cooling to room temperature they were dipped into 0.05% trypsin in isotonic saline for 12 to 20 seconds, and rinsed quickly in two changes of saline. The optimal time in trypsin has to be established individually for each batch of slides, and depends on relative humidity and temperature of the environment. Treated slides were stained with Wright or Giemsa stain diluted 1:4 with phosphate buffer at pH 7.0 for 2 min, rinsed twice in water, blown dry, and coverslipped. For Q-banding, heated or fresh slides were stained in quinacrine mustard (50 gg/ml) in Mcllvaine buffer, pH 7.0, for 20 minutes, rinsed in water, mounted in 60% sucrose, and examined with a Zeiss photomicroscope III with incident fluorescent illumination. Slides treated for G- or Q-banding were screened systematically for metaphase spreads suitable for karyotyping. Depending on which incubation time yielded the most useful material, the time periods between aspiration of bone marrow and the karyotype report ranged between two and 12 hours; with increasing experience the average time period was two to four hours. Blood samples obtained at the same time were cultured for 48 hours and karyotyped according to standard methods. Blood karyotype results served to confirm the bone marrow results, and to better define structural rearrangements.
290
Brief clinical and laboratory observations
The Journal of Pediatrics February 1979
Table Suspected diagnoses, indications for immediate chromosome analysis, bone marrow karyotypes, and outcome in 15 patients
Patient No. Suspected 1 2 3 4 5
Clinical conditions trisomy 18 Omphalocele, hydrocephalus, RD Omphalocele, cardiomegaly, RD Diaphragmatic hernia, CHD, ventilator/assistance required Esophageal atresia with TE fistula, CHD, RD CHD, RD
Bone marrow karyotype
Outcome
47,XY, + 18 47,XY, + 18 47,XX, + 18
Died day 1 Died day 1 Died day 1
47,XY, + 18 47,XX, + 18
Died day 3 Improved spontaneously, died 3 rno, pneumonia Improved spontaneously, died 12 months Died day 3, respiratory failure Died day 32, respiratory failure after surgical treatment of obstruction and omphalocele
6
CHD, apnea, ventilatory assistance required
46,XX,-21 + t(18q21q)
7 8
Imperforate anus, CHD, congestive heart failure Omphalocele, partial gastrointestinal obstruction due to volvulus, ventilator/assistance required
46,XX,13q+ 46,XY
Suspected trisomy 13 9 Omphalocele 10 CHD, RD 11 CHD, possible TE fistula Suspected trisomy 21 12 Duodenal atresia 13 Persistent fetal circulation, congestive heart failure Multiple malformations without specific diagnosis 14 Apnea, esophageal atresia, TE fistula, hypoplastic left heart Ambiguous genitalia 15 Parental distress due to conflicting information regarding child's sex
I
47,XY, + 13 47,XY, + 13 46,XY
Died day 2, aspiration Died day 1, respiratory failure Alive, seizures, retardation
47,XX, + 21 47,XX, + 21
Died at surgery Died day 14, gastric perforation
46,XX
Died day 5, CHD
46,XY
Reared as male
RD = Respiratorydistress;CHD = congenitalheart defect; TE = tracheoesophageal.
RESULTS Of the 15 patients studied, seven were boys, seven girls, and one had ambiguous external genitalia. They are classified into five groups according to their suspected diagnosis (Table). The manifestations calling for an immediate bone marrow chromosome analysis are also listed. With one exception, a 43-year-old mother of a patient with trisomy 13, the maternal ages of our patients were between 16 and 32 years, a range for which prenatal chromosome testing is not recommended. None of the families had previous children with aneuploidy. Of eight children suspected of having trisomy 18, six had typical dysmorphic features. Trisomy 18 was confirmed by bone marrow karyotype in five; the sixth had a normal chromosome number of 46 with a chromosome 21 replaced by a medium size submetacentric chromosome consisting of the long arm of a chromosome 18 and the long arm of a chromosome 21 fused at the centromere: t(18q21 q) (Figure, a). The reciprocal translocation product consisting of short arms of 18 and 21 was not present. Thus, this patient had trisomy for only the
long arm of 18, which results in the clinical syndrome characteristic of full trisomy 18.'. ~ Both parents had normal karyotypes, which implies a low recurrence risk. Although the clinical phenotype of two patients was suggestive of trisomy 18, both had 46 chromosomes in the bone marrow preparations. One of these had an abnormal chromosome 13, with the distal third of the long arm replaced by a larger piece of lightly staining chromosomal material (46,XX, 13q +). This was subsequently characterized as a duplication 15q/deletion 13q unbalanced derivative of the mother's balanced reciprocal translocation t(13; 15) (q32;q22) (Figure, b). No structural chromosome abnormality was detected in the other patient. Trisomy 13 was confirmed by bone marrow karyotype in two patients with characteristic clinical presentations; the third infant, who was clinically less affected, had a normal karyotype. One infant with multiple malformations not suggestive of an aneuploidy syndrome had a normal karyotype, and the one infant with ambiguous genitalia was a chromosomal male.
Volume 94 Number 2
Brief clinical and laboratory observations
a
29 1
b
16
17
18
I
21
t118q21ql
13
14
t (13;15) r
15
;q 22)
Figure. Structural chromosome rearrangements identified in bone marrow karyotypes from newborn infants: a, Partial karyotypes of Patient 6 with de novo trisomy for the long arm of chromosome 18 due to a t(18q21q) centric fusion translocation (indicated by arrow). Chromosome 21 has been placed upside down to facilitate comparison, b, Partial karyotypes of mother of Patient 7 with reciprocal t(13; 15) (q32;q22) translocation. Arrows pointing to the rearranged chromosomes indicate the points of breakage and rejoining. Patient 7, having inherited the derivative chromosome 13 together with the normal chromosome 15, had deficiency of region 13q22----~qter and duplication of region 15q22--.qter. When the abnormal karyotype results were presented to the parents the following decisions were made: Surgical repair of an omphalocele was not performed in three patients. In an infant with trisomy 18, repair of a diaphragmatic hernia had been performed immediately after admission, before the diagnostic possibility of trisomy 18 had been raised. Five patients who required ventilatory assistance were extubated and died shortly thereafter; in another, respirator therapy was not initiated. In one infant with Down syndrome the parents decided against surgery, but a court order was obtained and surgery was carried out; the infant died secondary to operative complications. The other infant with trisomy 21 was discharged without requiring therapeutic intervention to sustain life, but developed a surgical complication at 14 days for which the parents decided to withhold treatment. Despite the abnormal chromosomal results, the parents of one infant requested that respirator therapy be continued; the child improved but subsequently died within the first year of life. DISCUSSION Prenatal detection by amniocentesis of a chromosomal imbalance known to cause mental retardation and malformations is a widely practiced approach which enables prospective parents choose a selective abortion over having a defective child. When a child is born with a defect requiring immediate life-sustaining measures, the decisions involving treatment are complicated by high parental expectations after a full-length pregnancy, the pressure of time, the momentum inherent in life-sustainhag technology, and ethical and legal considerations. The
parents' decisions will depend on the prognosis for survival, quality of life, economics, effect on other family members, and future childbearing. An informed decision requires accurate information, and, if aneuploidy is suspected, a bone marrow karyotype can provide immediate confirmation. In the present series this was accomplished in nine instances, whereas two had different chromosome abnormalities from those suspected and two had normal karyotypes. Experience with the 15 patients herein described has led us to the strong conviction that the indications for immediate chromosome diagnosis on bone marrow cells should be strictly limited. Clinical diagnosis of trisomy without requirement of respirator or surgical treatment is not an indication for a bone marrow karyotype, since the diagnosis can be confirmed within three days by a routine blood culture analysis. Furthermore, we do not recommend a bone marrow karyotype in patients with an unknown malformation syndrome, since a much greater output of time and effort than for a standard lymphocyte karyotype is required, and the quality and reliability of the results are significantly lower. Using chromosome banding we were able to recognize structural chromosome rearrangements in two patients with normal chromosome counts. However, a normal bone marrow chromosome report does not necessarily rule out the presence of a small structural abnormality which is more easily detected in a lymphocyte culture, especially with cell synchronization methods. 6 Sex determination is easily carried out by bone marrow studies. In addition to complete karyotyping, interphase cells can be analyzed for Y bodies or Barr bodies.
29 2
Brief ctim'cal a~xl laboratory observations
However, not every child with ambiguous genitalia needs a bone marrow karyotype. Determination of the chromosomal sex is only one factor in the evaluation of such an infant, and the sex of rearing may depend on the prospect for functional repair, rather than the genetic sex. Bone marrow karyotyping on the first day of life, before a complete evaluation of the external and internal genitalia and the metabolic status have been carried out, could lead the parents to over-value this one piece of information and might interfere with their ability to make a rational decision in choosing the most appropriate gender for their child. We recommend that bone marrow chromosome analysis in newborn infants should be utilized only when the following three criteria have been met: (1) There is a strong clinical suspicion of a chromosomal syndrome known to be associated with a severe defect in brain development. (2) Immediate surgical treatment or assisted ventilation or both are required to sustain life. (3) The parents and physicians are prepared to take action depending on the outcome of the procedure.
The Journal of Pediatrics February 1979
We are grateful to the staff of the Newborn Intensive Care Nurseries and of the Hematology Services at University Hospital and San Diego Children's Hospital for their support, to Ms. No,lynn Oliver for competent technical assistance, and to Ms. Kathie Johnson and Ms. Melanie Culver for secretarial assistance.
REFERENCES
1. Gong BT, Jones KL, and Smith DW: Rapid diagnosis of Down's syndrome, Lancet 2:346, 1974. 2. Smithies A, and Valman HB: Rapid diagnosis of Down's Syndrome, Lancet 1:1056, 1974. 3. Myers TL: Chromosomal emergencies in the neonate, Pediatrician 1:65, 1972/73. 4. Cohen MM, Finch AB, and Lubs HA: Trisomy 18 with an E/G translocation (46,XY,21-,t(21q18q)+), Ann Genet 15:45, 1972. 5. Dziekanowska D, Dziuba P, and Sobanski T: The trisomy 18 syndrome with an E/G translocation, Hum Genet 31:347, 1976. 6. Yunis JJ: High resolution of human chromosomes, Science 191:1268, 1976.
Perinatal problems (excluding neonatal withdrawal) in maternal drug addiction: A study of 830 cases Enrique M. Ostrea, Jr., M.D.,* and Cieofe J. Chavez, M.D., Detroit, Mich.
THE FETUS or infant of a drug-dependent woman is at risk to a number of problems during the perinatal period, besides the neonatal withdrawal syndrome. These problems should be recognized and, if possible, prevented, since they are principally responsible for the mortality in the infants during the neonatal period. MATERIALS
AND METHODS
A total of 830 drug-dependent mothers (90% black) and their infants, Who were born at Hutzel Hospital from i973 to 1976, were studied. All were staff patients (no private physician). Sixty-nine percent of the women were clinic patients who used methadone and heroin during pregnancy, whereas 31% were nonclinic patients who were on heroin. In both groups, the use of other drugs, such as barbiturates, amphetamines, benzodiazepines, was common. The obstetric history of the mother and the postnatal From the Department of Pediatrics, Hutzel Hospital, and Wayne State University School of Medicine. *Reprint address: Hutzel Hospital, 4707 St. Antoine Blvd., Detroit, MI 48201.
course of the infant were reviewed to determine the perinatal problems that had occurred. For comparison, a group of nondrug-dependent mothers (86% black) and their infants, who belonged to a low socioeconomic group, were used as controls (N = 400).* Abbreviation used IDDM: infants born to drug-dependent mothers
[
RESULTS In a decreasing order of frequency, the antenatal problems that were significantly increased (P < 0.01) in the pregnant drug addict are shown in Table I. By far, meconium-stained amniotic fluid, anemia, and premature rupture of the membranes were the most frequent compli*By the use of random numbers generated by a computer, 100 control mothersand theirinfantswereselectedfromeachyear (1973-1976),from a mother-infam population at Hutzel Hospital who met the following criteria: (1) nondrug dependent, (2) no health insurance or receiving Medicaid,O) staffpatient.
0022-3476/79/200292 +04500.40/0 9 1979 The C. V. Mosby Co.
Brief clinical and laboratory observations
289
Immediate chromosome diagnosis on bone marrow cells: An aid to management of the malformed newborn infant Uta Francke, M.D.,* Michael G. Brown, M.S., and Kenneth Lyons Jones, M.D., San Diego, Calif.
WHEN FACED with a severely malformed but viable newborn infant who requires immediate therapeutic measures to sustain life, a decision about the extent of treatment has to be made by parents and physicians. In most instances, the crucial question concerns the prospect for normal mental development, and vigorous treatment will most likely be initiated if there is no indication of a defective brain. Chromosomal imbalance is one cause of congenital anomalies associated with impaired central nervous system development. If karyotype results were available during the first day of life for those malformed infants in whom a chromosomal syndrome is suspected, a more rational decision could be made about providing or withholding life-sustaining treatment. The bone marrow provides an accessible source of metaphase cells for immediate chromosome analysis. Although this approach using standard chromosome staining was suggested several years ago, 1-3 it has not been routinely applied and no serial studies have been reported. We have employed trypsin-Giemsa (G-) and quinacrine mustard (Q-) banding methods to chromosome preparations from bone marrow. The use made by physicians and parents of the karyotype information establishes the value of the bone marrow karyotyping approach. PATIENTS AND METHODS Thirteen of the 15 patients were born in community hospitals and were transferred to an intensive care nursery because of severe malformations or respiratory distress or both; two were delivered at University Hospital. When an autosomal trisomy syndrome was suspected, written consent for a bone marrow aspiration was obtained from the parents. Bone marrow was aspirated from the iliac crest or tibia into a plastic syringe containing 0.1 ml of heparin. Using this technique, sufficient cells have been From the Department of Pediatrics, University of California, San Diego, and San Diego Children's Hospital and Health Center. Supported in part by The National Foundation-March of Dimes and the San Diego Regional Center for the Developmentally Disabled *Reprint address: Department of Human Genetics, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510.
0022-3476/79/200289+04500.40/0 9 1979 The C. V. Mosby Co.
obtained to permit karyotyping in all instances in which the procedure has been attempted. The sample was inoculated into three sterile 15 ml plastic tubes and incubated using the following conditions: (1) 15 minutes at 37~ in 5 ml 0.075 M KC1 containing colchicine (0.2 gg/ml); (2) 60 minutes at 37~ in 5 ml minimum essential medium containing 15% fetal calf serum and colchicine (0.2 gg/ml); (3) 2 to 3 hours at 37~ in mininum essential medium with fetal calf serum and colchicine. Tubes 2 and 3 were centrifuged at 1,000 rpm after the respective incubations and the pellets were resuspended in hypotonic (0.075M) KC1 for 10 minutes. Additional cultures were set up for longer periods of incubation if there was enough bone marrow available. For fixation, standard 3:1 methanol:glacial acetic acid was used with no change of fixative, and air-dried slides were prepared immediately with one drop of cell suspension per slide. Fresh slides were heated in a 95~ oven for 10 minutes. After cooling to room temperature they were dipped into 0.05% trypsin in isotonic saline for 12 to 20 seconds, and rinsed quickly in two changes of saline. The optimal time in trypsin has to be established individually for each batch of slides, and depends on relative humidity and temperature of the environment. Treated slides were stained with Wright or Giemsa stain diluted 1:4 with phosphate buffer at pH 7.0 for 2 min, rinsed twice in water, blown dry, and coverslipped. For Q-banding, heated or fresh slides were stained in quinacrine mustard (50 gg/ml) in Mcllvaine buffer, pH 7.0, for 20 minutes, rinsed in water, mounted in 60% sucrose, and examined with a Zeiss photomicroscope III with incident fluorescent illumination. Slides treated for G- or Q-banding were screened systematically for metaphase spreads suitable for karyotyping. Depending on which incubation time yielded the most useful material, the time periods between aspiration of bone marrow and the karyotype report ranged between two and 12 hours; with increasing experience the average time period was two to four hours. Blood samples obtained at the same time were cultured for 48 hours and karyotyped according to standard methods. Blood karyotype results served to confirm the bone marrow results, and to better define structural rearrangements.
290
Brief clinical and laboratory observations
The Journal of Pediatrics February 1979
Table Suspected diagnoses, indications for immediate chromosome analysis, bone marrow karyotypes, and outcome in 15 patients
Patient No. Suspected 1 2 3 4 5
Clinical conditions trisomy 18 Omphalocele, hydrocephalus, RD Omphalocele, cardiomegaly, RD Diaphragmatic hernia, CHD, ventilator/assistance required Esophageal atresia with TE fistula, CHD, RD CHD, RD
Bone marrow karyotype
Outcome
47,XY, + 18 47,XY, + 18 47,XX, + 18
Died day 1 Died day 1 Died day 1
47,XY, + 18 47,XX, + 18
Died day 3 Improved spontaneously, died 3 rno, pneumonia Improved spontaneously, died 12 months Died day 3, respiratory failure Died day 32, respiratory failure after surgical treatment of obstruction and omphalocele
6
CHD, apnea, ventilatory assistance required
46,XX,-21 + t(18q21q)
7 8
Imperforate anus, CHD, congestive heart failure Omphalocele, partial gastrointestinal obstruction due to volvulus, ventilator/assistance required
46,XX,13q+ 46,XY
Suspected trisomy 13 9 Omphalocele 10 CHD, RD 11 CHD, possible TE fistula Suspected trisomy 21 12 Duodenal atresia 13 Persistent fetal circulation, congestive heart failure Multiple malformations without specific diagnosis 14 Apnea, esophageal atresia, TE fistula, hypoplastic left heart Ambiguous genitalia 15 Parental distress due to conflicting information regarding child's sex
I
47,XY, + 13 47,XY, + 13 46,XY
Died day 2, aspiration Died day 1, respiratory failure Alive, seizures, retardation
47,XX, + 21 47,XX, + 21
Died at surgery Died day 14, gastric perforation
46,XX
Died day 5, CHD
46,XY
Reared as male
RD = Respiratorydistress;CHD = congenitalheart defect; TE = tracheoesophageal.
RESULTS Of the 15 patients studied, seven were boys, seven girls, and one had ambiguous external genitalia. They are classified into five groups according to their suspected diagnosis (Table). The manifestations calling for an immediate bone marrow chromosome analysis are also listed. With one exception, a 43-year-old mother of a patient with trisomy 13, the maternal ages of our patients were between 16 and 32 years, a range for which prenatal chromosome testing is not recommended. None of the families had previous children with aneuploidy. Of eight children suspected of having trisomy 18, six had typical dysmorphic features. Trisomy 18 was confirmed by bone marrow karyotype in five; the sixth had a normal chromosome number of 46 with a chromosome 21 replaced by a medium size submetacentric chromosome consisting of the long arm of a chromosome 18 and the long arm of a chromosome 21 fused at the centromere: t(18q21 q) (Figure, a). The reciprocal translocation product consisting of short arms of 18 and 21 was not present. Thus, this patient had trisomy for only the
long arm of 18, which results in the clinical syndrome characteristic of full trisomy 18.'. ~ Both parents had normal karyotypes, which implies a low recurrence risk. Although the clinical phenotype of two patients was suggestive of trisomy 18, both had 46 chromosomes in the bone marrow preparations. One of these had an abnormal chromosome 13, with the distal third of the long arm replaced by a larger piece of lightly staining chromosomal material (46,XX, 13q +). This was subsequently characterized as a duplication 15q/deletion 13q unbalanced derivative of the mother's balanced reciprocal translocation t(13; 15) (q32;q22) (Figure, b). No structural chromosome abnormality was detected in the other patient. Trisomy 13 was confirmed by bone marrow karyotype in two patients with characteristic clinical presentations; the third infant, who was clinically less affected, had a normal karyotype. One infant with multiple malformations not suggestive of an aneuploidy syndrome had a normal karyotype, and the one infant with ambiguous genitalia was a chromosomal male.
Volume 94 Number 2
Brief clinical and laboratory observations
a
29 1
b
16
17
18
I
21
t118q21ql
13
14
t (13;15) r
15
;q 22)
Figure. Structural chromosome rearrangements identified in bone marrow karyotypes from newborn infants: a, Partial karyotypes of Patient 6 with de novo trisomy for the long arm of chromosome 18 due to a t(18q21q) centric fusion translocation (indicated by arrow). Chromosome 21 has been placed upside down to facilitate comparison, b, Partial karyotypes of mother of Patient 7 with reciprocal t(13; 15) (q32;q22) translocation. Arrows pointing to the rearranged chromosomes indicate the points of breakage and rejoining. Patient 7, having inherited the derivative chromosome 13 together with the normal chromosome 15, had deficiency of region 13q22----~qter and duplication of region 15q22--.qter. When the abnormal karyotype results were presented to the parents the following decisions were made: Surgical repair of an omphalocele was not performed in three patients. In an infant with trisomy 18, repair of a diaphragmatic hernia had been performed immediately after admission, before the diagnostic possibility of trisomy 18 had been raised. Five patients who required ventilatory assistance were extubated and died shortly thereafter; in another, respirator therapy was not initiated. In one infant with Down syndrome the parents decided against surgery, but a court order was obtained and surgery was carried out; the infant died secondary to operative complications. The other infant with trisomy 21 was discharged without requiring therapeutic intervention to sustain life, but developed a surgical complication at 14 days for which the parents decided to withhold treatment. Despite the abnormal chromosomal results, the parents of one infant requested that respirator therapy be continued; the child improved but subsequently died within the first year of life. DISCUSSION Prenatal detection by amniocentesis of a chromosomal imbalance known to cause mental retardation and malformations is a widely practiced approach which enables prospective parents choose a selective abortion over having a defective child. When a child is born with a defect requiring immediate life-sustaining measures, the decisions involving treatment are complicated by high parental expectations after a full-length pregnancy, the pressure of time, the momentum inherent in life-sustainhag technology, and ethical and legal considerations. The
parents' decisions will depend on the prognosis for survival, quality of life, economics, effect on other family members, and future childbearing. An informed decision requires accurate information, and, if aneuploidy is suspected, a bone marrow karyotype can provide immediate confirmation. In the present series this was accomplished in nine instances, whereas two had different chromosome abnormalities from those suspected and two had normal karyotypes. Experience with the 15 patients herein described has led us to the strong conviction that the indications for immediate chromosome diagnosis on bone marrow cells should be strictly limited. Clinical diagnosis of trisomy without requirement of respirator or surgical treatment is not an indication for a bone marrow karyotype, since the diagnosis can be confirmed within three days by a routine blood culture analysis. Furthermore, we do not recommend a bone marrow karyotype in patients with an unknown malformation syndrome, since a much greater output of time and effort than for a standard lymphocyte karyotype is required, and the quality and reliability of the results are significantly lower. Using chromosome banding we were able to recognize structural chromosome rearrangements in two patients with normal chromosome counts. However, a normal bone marrow chromosome report does not necessarily rule out the presence of a small structural abnormality which is more easily detected in a lymphocyte culture, especially with cell synchronization methods. 6 Sex determination is easily carried out by bone marrow studies. In addition to complete karyotyping, interphase cells can be analyzed for Y bodies or Barr bodies.
29 2
Brief ctim'cal a~xl laboratory observations
However, not every child with ambiguous genitalia needs a bone marrow karyotype. Determination of the chromosomal sex is only one factor in the evaluation of such an infant, and the sex of rearing may depend on the prospect for functional repair, rather than the genetic sex. Bone marrow karyotyping on the first day of life, before a complete evaluation of the external and internal genitalia and the metabolic status have been carried out, could lead the parents to over-value this one piece of information and might interfere with their ability to make a rational decision in choosing the most appropriate gender for their child. We recommend that bone marrow chromosome analysis in newborn infants should be utilized only when the following three criteria have been met: (1) There is a strong clinical suspicion of a chromosomal syndrome known to be associated with a severe defect in brain development. (2) Immediate surgical treatment or assisted ventilation or both are required to sustain life. (3) The parents and physicians are prepared to take action depending on the outcome of the procedure.
The Journal of Pediatrics February 1979
We are grateful to the staff of the Newborn Intensive Care Nurseries and of the Hematology Services at University Hospital and San Diego Children's Hospital for their support, to Ms. No,lynn Oliver for competent technical assistance, and to Ms. Kathie Johnson and Ms. Melanie Culver for secretarial assistance.
REFERENCES
1. Gong BT, Jones KL, and Smith DW: Rapid diagnosis of Down's syndrome, Lancet 2:346, 1974. 2. Smithies A, and Valman HB: Rapid diagnosis of Down's Syndrome, Lancet 1:1056, 1974. 3. Myers TL: Chromosomal emergencies in the neonate, Pediatrician 1:65, 1972/73. 4. Cohen MM, Finch AB, and Lubs HA: Trisomy 18 with an E/G translocation (46,XY,21-,t(21q18q)+), Ann Genet 15:45, 1972. 5. Dziekanowska D, Dziuba P, and Sobanski T: The trisomy 18 syndrome with an E/G translocation, Hum Genet 31:347, 1976. 6. Yunis JJ: High resolution of human chromosomes, Science 191:1268, 1976.
Perinatal problems (excluding neonatal withdrawal) in maternal drug addiction: A study of 830 cases Enrique M. Ostrea, Jr., M.D.,* and Cieofe J. Chavez, M.D., Detroit, Mich.
THE FETUS or infant of a drug-dependent woman is at risk to a number of problems during the perinatal period, besides the neonatal withdrawal syndrome. These problems should be recognized and, if possible, prevented, since they are principally responsible for the mortality in the infants during the neonatal period. MATERIALS
AND METHODS
A total of 830 drug-dependent mothers (90% black) and their infants, Who were born at Hutzel Hospital from i973 to 1976, were studied. All were staff patients (no private physician). Sixty-nine percent of the women were clinic patients who used methadone and heroin during pregnancy, whereas 31% were nonclinic patients who were on heroin. In both groups, the use of other drugs, such as barbiturates, amphetamines, benzodiazepines, was common. The obstetric history of the mother and the postnatal From the Department of Pediatrics, Hutzel Hospital, and Wayne State University School of Medicine. *Reprint address: Hutzel Hospital, 4707 St. Antoine Blvd., Detroit, MI 48201.
course of the infant were reviewed to determine the perinatal problems that had occurred. For comparison, a group of nondrug-dependent mothers (86% black) and their infants, who belonged to a low socioeconomic group, were used as controls (N = 400).* Abbreviation used IDDM: infants born to drug-dependent mothers
[
RESULTS In a decreasing order of frequency, the antenatal problems that were significantly increased (P < 0.01) in the pregnant drug addict are shown in Table I. By far, meconium-stained amniotic fluid, anemia, and premature rupture of the membranes were the most frequent compli*By the use of random numbers generated by a computer, 100 control mothersand theirinfantswereselectedfromeachyear (1973-1976),from a mother-infam population at Hutzel Hospital who met the following criteria: (1) nondrug dependent, (2) no health insurance or receiving Medicaid,O) staffpatient.
0022-3476/79/200292 +04500.40/0 9 1979 The C. V. Mosby Co.