Phase 2 KPH - Week 1 (Foetal development, screening, Down syndrome) Flashcards
Describe the events of the first 4 weeks of gestation and when they occur
Day 0 = Zygote formed (fertilisation) Day 1 = Cleavage begins Week 1 = Morula formation, blastocyst formation, blastocyst hatching implantation (day 6) Week 2 = Bilaminar disc formation Week 3 = Gastrulation Week 3-8 = Organogenesis Week 4 = Heart begins to beat, limb buds form
Describe cleavage
- Mitotic divisions of fertilised oocyte
- Overall size remains the same - allows passage down isthmus (narrowest part of uterine tube)
- Surrounded by tough glycoprotein coat - zona pellucida - to prevent immature implantation
Describe morula formation
Around day 4, cells maximise contact with each other, forming cluster of cells held together by tight junctions = morula
Describe blastocyst formation
- First cellular differentiation
- Inner cell mass = forms embryo and extraembryonic tissues
- Trophoblast = formed from outer cells, contributes to the placenta
- As embryo enters uterine cavity, fluid enters via the zona pellucida into spaces of the inner cell mass - fluid filled blastocyst cavity (blastocoel) forms
Describe blastocyst hatching
- Blastocyst starts to run out of nutrients - needs to implant
- Inner cell mass (ICM) cells proliferate, fluid builds up in cavity
- Blastocyst hatches from zona pellucida to facilitate implantation
When does the blastocyst implant?
- Day 6
- Must occur to trigger secretion of human chorionic gonadotrophin (HCG) to maintain the corpus luteum
- Without HCG and the corpus luteum the pregnancy will not continue
Describe implantation of the blastocyst
- Interaction between embryo and endometrium
- Trophoblast differentiates into inner villus cytotrophoblast and non-dividing outer syncytiotrophoblast
- Blastocyst attaches to epithelial surface of uterus
- Trophoblast extensions penetrate between uterine epithelial cells invading the uterine stroma
- Embryo becomes completely embedded, uterine epithelial cells grow over implantation site
- Decidual reaction
Describe abnormal implantation of the blastocyst
- Common sites - external surface of uterus, ovary, bowel, Gi tract, mesentery, peritoneal wall
- Causes ectopic pregnancy
Describe the structure of the embryo following formation of the bilaminar disc
- Amnion, yolk sac + chorion form
- Bilaminar disc forms in centre - top is epiblast, bottom is hypoblast
Amnion
- Continuous with the epiblast
- Persists until birth
- Fills with amniotic fluid
- Protection for the developing embyo
Yolk sac
- Continuous with the hypoblast
- Important in nutrient transfer in weeks 2-3
- Disappears around week 20
Chorion
- Trophoblast and extra-embryonic mesoderm
- Forms the foetal component of the placenta - chorionic plate
- Chorionic cavity seen in early pregnancy, disappears when amnion expands
Define gastrulation
Process of cell division and migration resulting in formation of the 3 germ layers. Bilaminar disc -> trilaminar disc
List the germ layer
- Ectoderm
- Mesoderm
- Endoderm
Define the primitive streak
Region of migration from the epiblast layer forming the mesoderm and endoderm
Describe the process of gastrulation
- Cells from the epiblast move through the primitive streak
- Undergo an epithelial to mesenchymal transition in order to delaminate and migrate
- Once cells have invaginated, some displace hypoblast creating endoderm
- Others between epiblast and endoderm form mesoderm
- Remaining cells in epiblast form ectoderm
List the tissues derived from the ectoderm
- Epidermis of skin and its derivatives (sweat glands, hair follicles etc.)
- Epithelial lining of mouth and anus
- Cornea and lens of eye
- Nervous system
- Sensory receptors in epidermis
- Adrenal medulla
- Tooth enamel
- Epithelium of pineal and pituitary glands
List the tissues derived from the mesoderm
- Notochord
- Skeletal system
- Muscular system
- Muscular layer of stomach and intestine
- Excretory system
- Circulatory and lymphatic systems
- Reproductive system (except germ cells)
- Dermis of skin
- Lining of body cavity
- Adrenal cortex
List the tissues derived from the endoderm
- Epithelial lining of digestive tract
- Epithelial lining of respiratory system
- Lining of urethra, urinary bladder and reproductive system
- Liver
- Pancreas
- Thymus
- Thyroid and parathyroid glands
Describe the changes in body form which occur during week 4 of gestation
- Embryo ‘rolls up’ from flat disc -> closed cylinder along its long axis
- Growth of embryo makes embryo fold laterally
- Head and tail end curl under fast growth of neural tube
- Embryo now resembles human form
- Limb buds develop
Describe the formation of limb buds
- Limb buds made of undifferentiated mesoderm cells, covered by ectoderm
- Upper limb buds appear first as ridges from ventrolateral body wall
- Lower limb as small bulges
What is the normal chromosome number?
46 chromosomes, 23 homologous pairs
Describe the sex chromosomes
- XX in a normal female
- XY in a normal male
- Y is smaller than X, X has genes that Y does not have
How can the difference between the X and Y chromosomes be significant clinically?
- Sex-linked disorders
- X-linked recessive disorders will affect males more as they don’t have another allele to mask the effect of the harmful allele
- X-linked dominant disorders where the father is affected will affect females more, as they must get an X from their father, whereas males get the unaffected Y from their father
Give examples of sex-linked disorders
Haemophilia, duchenne muscular dystrophy, colour blindness (all X-linked recessive)
List the mutations to chromosomes which can cause genetic disorders
- Deletions
- Duplications
- Translocations
- Inversions
- Insertions
- Rings
- Isochromosome
Deletion
Portion of the chromosome is missing or deleted
Duplication
Portion of the chromosome is duplicated, resulting in extra genetic material
Translocation
- Portion of one chromosome is transferred to another chromosome
- Two types -
- Reciprocal - segments from to different chromosomes have been exchanged
- Robertsonian - entire chromosome has attached to another at the centromere
Inversion
Portion of the chromosome has broken off, turned upside down and reattached - genetic material is inverted
Insertions
Portion of one chromosome has been deleted from its normal position and inserted into another chromosome
Rings
- Portion of a chromosome has broken off and formed a circle/ring
- Can happen with/without loss of genetic material
Isochromsome
Formed by mirror image copy of a chromosome segment including the centromere
Give examples of genetic disorders cause by mutations to chromosomes
- Colour blindness
- Cri-du-chat
- Cystic fibrosis
- Down syndrome
- Duchenne muscular dystrophy
- Haemophilia
- Sickle cell disease
- Tay-sachs disease
- Turner syndrome
- X-linked severe combined immunodeficiency (X-SCID)
- Marfan syndrome
Describe the mutation which causes colour blindness
Point mutation on X chromosome (sex-linked)
Describe the mutation which causes cri-du-chat
Partial deletion on chromosome 5 - non-dysjunction
Describe the mutation which causes cystic fibrosis
Most common is partial deletion on chromosome 7
Describe the mutation which causes Down syndrome
Extra chromosome 21 - trisomy 21
Describe the mutation which causes duchenne muscular dystrophy
Partial deletion on X chromosome
Describe the mutation which causes haemophilia
Point mutation on X chromosome
Describe the mutation which causes sickle-cell disease
Point mutation on chromosome 11
Describe the mutation which causes Tay-Sachs disease
Point mutation on chromosome 15
Describe the mutation which causes Turner syndrome
Female missing an X chromosome
Describe the mutation which causes X-linked severe combined immunodeficiency
Point mutation on X chromosome
Describe the mutation which causes Marfan syndrome
Point mutation on chromosome 15
Describe the epidemiology of Down syndrome
- 1/700 live births
- Risk increases with maternal age
- 20 y/o = 1/2000
- 35 y/o = 1/365
- 40 y/o = 1/100
- 80% born to mothers <35
Describe the cause of Down syndrome
- Trisomy 21 (95%)
- 5% extra chromosome 21 translocated to another chromosome (most common is 14;21, next most common is 21;22) - Robertsonian translocation
- Can also be 21q21q translocation - extra chromosome 21 is attached to another chromosome 21
List the body systems which are affected by Down syndrome
- Cardiac
- CNS
- GI
- Endocrine
- EENT
- Growth
- Haematologic
- Musculoskeletal
Describe how the cardiac system can be affected by Down syndrome
- Increased risk of congenital heart disease - most often ventricular septal defects and AV canal
- Increased risk of mitral valve prolapse and aortic regurgitation later in life
Describe how the CNS can be affected by Down syndrome
- Cognitive impairment - mild (IQ 50-75) to severe (IQ 20-35)
- Motor language delay
- Autistic behaviour
- Alzheimer disease
Describe how the GI system can be affected by Down syndrome
- Duodenal atresia
or stenosis - Hirschsprung disease
- Celiac disease
Describe how the endocrine can be affected by Down syndrome
- Hypothyroidism
- Diabetes
Describe how the EENT system can be affected by Down syndrome
- Opthalmic disorders e.g. congenital cataracts, glaucoma, strabismus, refractive errors
- Hearing loss
- Increases incidence of otitis media
Describe how a person’s growth can be affected by Down syndrome
- Short stature
- Obesity
Describe the haematologic problems which can be caused by Down syndrome
- Thrombocytopenia
- Neonatal polycythemia
- Transient myelodysplastic disorder
- Acute megakaryotic disorder
- Acute lymphocytic leukaemia
Describe how the musculoskeletal can be affected by Down syndrome
- Atlanto-axial and atlanto-occipital instability
- Joint laxity
What is the average life expectancy of a person with Down syndrome?
- 55 y/o
- Less than average due to heart disease, susceptibility to infections and acute myelogenous leukaemia
Describe how reproduction can be affected by Down syndrome
- Affected women have 50% chance of having a foetus with Down syndrome
- Many affected foetuses abort spontaneously
- Men with Down syndrome are infertile - except those with mosaicism
List the signs/symptoms associated with Down syndrome
- Neonates - placid, rarely cry, hypotonia
- Flat facial profile - flattening of the bridge of the nose
- Unusual physical characteristics develop during infancy
- Flattened occiput
- Microcephaly
- Extra skin around back of neck
- Eyes slanted upwards
- Epicanthal folds at inner corners of eyes
- Brushfield spots (grey to white spots around iris)
- Mouth often held slightly open
- Protruding furrowed tongue, lacks central fissure
- Ears often small and rounded
- Hands are short and broad, often have simian crease
- Fingers often short - incurving (clinodactyly) of 5th digit - often only has 2 phalanges
- Feet may have wide gap between 1st and 2nd toes
When are ultrasound performed on pregnant women?
1st scan (dating scan) - 8-14 weeks
2nd scan (anomaly scan) - 18-21 weeks
How is diagnosis of Down syndrome often initially suspected?
- Physical anomalies detected by foetal ultrasound
- E.g. increased nuchal translucency seen during dating scan
Describe how nuchal translucency contributes to the diagnosis of Down syndrome
- Foetuses have collection of nuchal fluid at back of neck
- Can be measured between weeks 11-14
- Before week 11 foetus is too small
- After week 14 nuchal fluid is absorbed by lymphatic system
- Foetuses with Down syndrome show nuchal thickening - chromosome 21 has gene which codes for type VI collagen, gene is over-expressed, results in connective tissue with more elastic composition
- NT of less than 3.5mm is normal when foetus measures between 45mm-84mm
- As NT increases, chance of Down syndrome increases
List the chemical signs which contribute to the diagnosis of Down syndrome
Abnormal levels of: - Plasma protein A in late 1st trimester - Alpha-fetoprotein - Beta human chorionic gonadotrophin - Unconjugated estriol - Inhibin in early 2nd trimester On maternal serum screening
When are diagnostic tests for Down syndrome used?
If ultrasound or maternal screening suggests abnormality or case is high risk (maternal age >35) chorionic villus sampling and/or amniocentesis are offered
Chorionic villus sampling
- Samples chorionic villus of placenta
- Should contain same chromosome complement as foetus
- 10-14 weeks of gestation
- Miscarriage ate = 1-2%