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Arhip L, Agreda J, Serrano-Moreno C, Motilla de la Cámara M, Carrascal Fabián ML, Bielza A, Velasco Gimeno C, Camblor M, Bretón I, Cuerda C. Two pregnancies of an ornithine carbamoyltransferase deficiency disease carrier and review of the literature. NUTR HOSP 2024. [PMID: 38258666 DOI: 10.20960/nh.04867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND the underlying cause of the deficiency of ornithine carbamoyltransferase (OTCD) is a gene mutation on the X chromosome. In females, the phenotype is highly variable, ranging from asymptomatic to neurologic compromise secondary to hyperammonemia and it can be prompted by numerous triggers, including pregnancy. OBJECTIVE the objective of this article is to report a case of two pregnancies of an OTCD-carrier, and to review the literature describing OTCD and pregnancy, parturition and postpartum. METHODS an extensive search in PubMed in December 2021 was conducted using different search terms. After screening all abstracts, 23 papers that corresponded to our inclusion criteria were identified. RESULTS the article focuses on the management of OTCD during pregnancy, parturition, and the postpartum period in terms of clinical presentation, ammonia levels and treatment. CONCLUSIONS females with OTCD can certainly plan a pregnancy, but they need a careful management during delivery and particularly during the immediate postpartum period. If possible, a multidisciplinary team of physicians, dietitians, obstetrician-gynecologist, neonatologists, pharmacists, etc. with expertise in this field should participate in the care of women with OTCD and their children during this period and in their adult life.
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Affiliation(s)
- Loredana Arhip
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Javier Agreda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Clara Serrano-Moreno
- Nutrition Unit, Hospital General Universitario Gregorio Maranón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Marta Motilla de la Cámara
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - María Luisa Carrascal Fabián
- Nutrition Unit. Hospital General Universitario Gregorio Maranón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Atocha Bielza
- Nutrition Unit, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Cristina Velasco Gimeno
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Miguel Camblor
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Irene Bretón
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Maranón. Instituto de Investigación Sanitaria Gregorio Marañón
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Souter V, Prigmore B, Becraft E, Repass E, Smart T, Sanapareddy N, Schweitzer M, Ortiz JB, Wang Y, Benn P. Reproductive Carrier Screening Results With Maternal Health Implications During Pregnancy. Obstet Gynecol 2023; 142:1208-1216. [PMID: 37562044 DOI: 10.1097/aog.0000000000005318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/22/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To identify conditions on a reproductive carrier screening panel with the potential for carrier manifestations during pregnancy and review the implications for obstetric care. METHODS This was a retrospective cross-sectional study of consecutive samples from female patients aged 18-55 years submitted to a commercial laboratory for a 274-gene carrier screening panel (January 2020 to September 2022). A literature review was performed to identify genes on the panel with potential for pregnancy complications in carriers. Carrier expression and published recommendations for clinical management were reviewed. RESULTS We identified 12 genes with potential for carrier manifestations during pregnancy based on reports in the literature: nine with manifestations irrespective of the fetal genetic status ( ABCB11 , COL4A3 , COL4A4 , COL4A5 , DMD , F9 , F11 , GLA , and OTC ) and three ( CPT1A , CYP19A1 , and HADHA ) with manifestations only if the fetus is affected by the condition. Manifestations included cardiomyopathy, hemorrhage, gestational hypertensive disorders, cholestasis of pregnancy, acute fatty liver, hyperammonemic crisis, and maternal virilization. Published recommendations for carrier management were identified for 11 of the 12 genes. Of 91,637 tests performed during the study period, a pathogenic or likely pathogenic variant was identified in 2,139 (2.3%), giving a carrier frequency for any of the 12 genes of 1 in 43 (95% CI 1/41-45) 1,826 (2.0%) of the study population were identified as carriers for one of the nine genes with the potential for carrier manifestations irrespective of an affected or unaffected fetus. CONCLUSION Approximately 1 in 40 female patients were identified as carriers for a condition with potential for maternal manifestations in pregnancy, including some serious or even life-threatening complications. Obstetric care professionals should be aware of the possibility of pregnancy complications among carriers and the available recommendations for management. FUNDING SOURCE This study was funded by Natera, Inc.
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Affiliation(s)
- Vivienne Souter
- Natera, Inc., Austin, Texas; and the University of Connecticut Health Center, Farmington, Connecticut
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3
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Feigenbaum A, Lamale-Smith L, Weinstein L. Considerations for prenatal and postpartum management of a female patient with ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100894. [PMID: 36620386 PMCID: PMC9817480 DOI: 10.1016/j.ymgmr.2022.100894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 01/11/2023] Open
Abstract
We report on pregnancy management and outcomes in a 27-year-old female patient with ornithine transcarbamylase (OTC) deficiency, the most common inherited enzyme deficiency in the urea cycle. Our patient was diagnosed during childhood after hyperammonemia associated with surgery and steroid treatment and was well-controlled with nitrogen scavenger treatment, low-protein diet, and L-citrulline supplementation. OTC gene sequencing identified a variant of unknown significance that has more recently been classified as likely pathogenic. Women with OTC deficiency are at increased risk of hyperammonemia during pregnancy and the postpartum period, therefore monthly follow up and laboratory assessments are critical in management decision making. Our patient was maintained on glycerol phenylbutyrate, L-citrulline and essential amino acid supplements, along with restricted protein intake during pregnancy. A multidisciplinary approach with the obstetrics, prenatal genetics, high risk obstetric, and anesthesia teams was also necessary for optimal management during pregnancy, throughout labor and delivery, and during the postpartum period. After successful childbirth and discharge, our patient experienced a hyperammonemic crisis related to poor enteral nutrition, and acute management protocols were implemented to stabilize her. For her newborn son, acute hyperammonemia protocols were on standby, and newborn screening and laboratory testing were expedited to assess his risk. He was healthy and did not experience symptoms of concern. In this case report, we emphasize the importance of close collaboration with maternal-fetal medicine team members during and immediately after pregnancy to ensure successful management of a female patient with OTC deficiency and her newborn.
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Key Words
- BCAA, branched-chain amino acids
- BID, twice daily
- D10, 10% dextrose
- EAA, essential amino acids
- GPB, glycerol phenylbutyrate
- IV, intravenous
- NICU, neonatal intensive care unit
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PICC, peripherally inserted central catheter
- PO, per os/orally
- Peripartum management
- Pregnancy
- TID, three times daily
- UCD, urea cycle disorder
- Urea cycle disorder
- X-linked, hyperammonemia
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Affiliation(s)
- Annette Feigenbaum
- Department of Pediatrics and Biochemical Genetics, Rady Children's Hospital-San Diego, University of California San Diego, 3020 Children's Way #5031, San Diego, CA 92123, USA
- Corresponding author at: 3020 Children's Way #5031, San Diego, CA 92123, USA.
| | - Leah Lamale-Smith
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, 9300 Campus Point Drive, #7433, San Diego, CA 92037, USA
| | - Lawrence Weinstein
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
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4
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Seasely AR, Sinkey RG, Dean SJ, Descartes M, Duncan VE. Placental Pathology in Maternal Ornithine Transcarbamylase Deficiency. Pediatr Dev Pathol 2022; 25:278-284. [PMID: 34958254 DOI: 10.1177/10935266211055286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ornithine transcarbamylase (OTC) deficiency is the most common urea cycle disorder, inherited in an X-linked manner. Males are severely affected. Female phenotypes vary from asymptomatic to severe, and symptoms may be triggered by high metabolic states like childbirth. Literature on OTC deficiency in pregnancy and placental pathology is limited. METHODS Pathology records were searched at a single referral center from 2000-2020 and identified three placental cases from two mothers heterozygous for OTC deficiency. Placental pathology and maternal and neonatal history were reviewed in detail. RESULTS The placenta from one symptomatic mother carrying an affected male fetus showed widespread high-grade fetal vascular malperfusion (FVM) lesions of varying age. These lesions were not seen in the two placentas from the asymptomatic mother. DISCUSSION In cases of symptomatic maternal OTC deficiency, our findings highlight the need for placental examination. Since thrombotic events in the placenta have the potential to associate with fetal and neonatal endothelial damage, a high index of suspicion for neonatal thrombosis may be warranted.
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Affiliation(s)
- Angela R Seasely
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, 9968University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Genetics, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel G Sinkey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah Joy Dean
- Department of Genetics, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria Descartes
- Department of Genetics, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Virginia E Duncan
- Department of Pathology, Perinatal Section, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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5
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Sysák R, Brennerová K, Krlín R, Štencl P, Rusňák I, Vargová M. Effect of Ornithine Transcarbamylase (OTC) Deficiency on Pregnancy and Puerperium. Diagnostics (Basel) 2022; 12:diagnostics12020415. [PMID: 35204506 PMCID: PMC8871159 DOI: 10.3390/diagnostics12020415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/23/2022] [Accepted: 02/01/2022] [Indexed: 12/30/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is the most common inherited metabolic disorder in urea cycles with an incidence of 1:14,000 live births. Pregnancy, childbirth and the postpartum period are considered challenging for women with this hereditary metabolic disorder, with a risk of hyperammonemia, especially in the first week after delivery. In our article, we discuss severe hepatic failure, a pregnancy complication in an OTC deficient patient that has not previously been published. Firstly, our aim is to highlight the need for a strict adherence to the recommendation of the gradual increase of protein intake during pregnancy and the importance of multidisciplinary monitoring of pregnant patients with OTC deficiency. Secondly, we refer to critical postpartum hyperammonemia in patients with this hereditary metabolic disorder.
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Affiliation(s)
- Rastislav Sysák
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
- Correspondence:
| | - Katarína Brennerová
- Department of Pediatrics, National Institute of Children’s Diseases, 831 01 Bratislava, Slovakia;
| | - Romana Krlín
- 2nd Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 821 01 Bratislava, Slovakia;
| | - Peter Štencl
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
| | - Igor Rusňák
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Slovak Medical University, 831 01 Bratislava, Slovakia;
| | - Mária Vargová
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
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6
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Billingham MJ, Rizk R. Role of early management of hyperornithinaemia-hyperammonaemia-homocitrullinuria syndrome in pregnancy. BMJ Case Rep 2021; 14:14/7/e241424. [PMID: 34210698 PMCID: PMC8252674 DOI: 10.1136/bcr-2020-241424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hyperornithinaemia-hyperammonaemia-homocitrullinuria (HHH) syndrome is a rare inherited metabolic disorder of the urea cycle. Few reports exist to guide practices during pregnancy and fetal delivery. Yet, with affected patients often surviving into reproductive age, appropriate management of the peripartum phase is essential to ensure positive maternal and fetal outcomes. Reassuringly, the vast majority of offspring of parturients with HHH syndrome have normal developmental outcomes; yet as seen here, fetal growth restriction does appear more frequently. Furthermore, in addition to the absent fetal corpus callosum observed in this case, other fetal cerebral abnormalities, including speech delay and intellectual impairment, have been recognised. Unregulated dietary intake is one proposed factor for the observed disruption in fetal growth and early cerebral development. These stipulations not only reinforce the importance of extensive planning and teamwork, but also demonstrate the importance of timely intervention by a metabolic dietician and dietary compliance in the early organogenesis stage of pregnancy.
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Affiliation(s)
| | - Rania Rizk
- Department of Obstetrics and Gynaecology, Birmingham Heartlands Hospital, Birmingham, UK
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7
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Manta-Vogli PD, Schulpis KH, Dotsikas Y, Loukas YL. Nutrition and medical support during pregnancy and lactation in women with inborn errors of intermediary metabolism disorders (IEMDs). J Pediatr Endocrinol Metab 2020; 33:5-20. [PMID: 31804959 DOI: 10.1515/jpem-2019-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The establishment of expanded newborn screening (NBS) not only results in the early diagnosis and treatment of neonates with inborn errors of intermediary metabolism disorders (IEMDs) but also helps the affected females to reach the reproductive age under medical and dietetic support, as well as to give birth to normal infants. In this review, we aimed to focus on laboratory investigation tests, dietetic management and medical support for most known IEMD pregnant and lactating women, such as those suffering from aminoacidopathies, carbohydrate metabolic diseases and fatty acid (FAO) oxidation disorders.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition and Dietetics, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Yannis Dotsikas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274696, Fax: +30 210 7274039
| | - Yannis L Loukas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274224, Fax: +30 211 1826131
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8
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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9
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Torkzaban M, Haddad A, Baxter JK, Berghella V, Gahl WA, Al-Kouatly HB. Maternal ornithine transcarbamylase deficiency, a genetic condition associated with high maternal and neonatal mortality every clinician should know: A systematic review. Am J Med Genet A 2019; 179:2091-2100. [PMID: 31441224 DOI: 10.1002/ajmg.a.61329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/30/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is a rare X-linked urea cycle disorder. Maternal OTCD can lead to life-threatening hyperammonemia if untreated. We aimed to compare the outcomes of maternal OTCD when diagnosis is known prior to pregnancy to when diagnosis is made during pregnancy. We performed a systematic literature review on maternal OTCD using the databases Ovid MEDLINE and PubMed from 1982 through 2018. Studies were included if addressed maternal OTCD signs, symptoms, and detailed pregnancy outcomes. We calculated the median or the mean for continuous variables and percentages for categorical variables. Of 36 cases of maternal OTCD, 20 (55%) were diagnosed prior to pregnancy while 16 (45%) were not. In the 20 patients diagnosed prior to pregnancy, 7 (35%) had either a neurologic or psychiatric presentation during pregnancy or postpartum. Two hyperammonemic patients (11%) experienced ICU admission, dialysis, and coma with no maternal deaths. All had a favorable outcome. In the 16 patients not known to have maternal OTCD prior to pregnancy, 13 (81%) had neurologic or psychiatric presentation during pregnancy or postpartum. Four presented with hyperemesis gravidarum. Eleven (69%) hyperammonemic patients had ICU admission and coma and 7 (47%) of them had dialysis. There were 5 (31%) maternal deaths. Three patients (19%) had prolonged hospitalization course. Overall, three male neonatal deaths were reported. Three other male children had liver transplant. Maternal OTCD is associated with high maternal and neonatal morbidity and mortality when diagnosis is made during pregnancy compared to when diagnosis is known prior to pregnancy.
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Affiliation(s)
- Mehnoosh Torkzaban
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Haddad
- Department of Obstetrics & Gynecology, Medstar Washington Hospital Center, Washington, District of Columbia.,Medical Genetics Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, Maryland
| | - Jason K Baxter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William A Gahl
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, Maryland
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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10
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Lefrère B, Ulmann G, Chartier M, Patkaï J, Cynober L, Neveux N. Malnutrition with hypoaminoacidemia in a 22-year-old pregnant patient masking a likely ornithine transcarbamylase deficiency. Clin Nutr ESPEN 2019; 30:89-93. [PMID: 30904234 DOI: 10.1016/j.clnesp.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 01/03/2019] [Accepted: 02/01/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Symptoms and clinical presentations of OTC deficiency vary widely according to the remaining activity of the enzyme. Three factors determine the residual enzyme activity. First, as the OTC gene is carried on the X chromosome, a complete inactivation of this enzyme in a newborn boy results an acute ammonia intoxication. Second, the female mosaicism due to lyonization (differential randomized X-inactivation) leads to differential OTC expression in hepatocytes. Third, the degree of severity depends on the mutation and the level of remaining activity it leaves to the protein. Published cases of OTC deficiency during pregnancy are scant. Most often, diagnosis of the metabolic disease is made before pregnancy or during the post-partum period. METHODS We report the case of a 22-year-old woman's successful pregnancy with a moderate form of ornithine transcarbamylase (OTC) deficiency, unsuspected before pregnancy, biochemically consistent with plasma aminoacidogram and orotic acid analysis, and initially masked by malnutrition. RESULTS - CONCLUSION Although maternal ammonia was subnormal and the neonate was safe, an OTC deficiency was revealed by stress factors such as the pregnancy itself and infection, and associated with uncontrollable maternal vomiting and psychiatric syndrome. However, this metabolic disease, revealed by aminoacidogram and urine orotic acid analysis, fortunately did not prevent a successful pregnancy. Even if infrequent, this situation deserves to be highlighted.
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Affiliation(s)
- B Lefrère
- Clinical Chemistry Laboratory, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France.
| | - G Ulmann
- Clinical Chemistry Laboratory, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France; Laboratory of Biological Nutrition, Faculty of Pharmacy, Paris Descartes University, 4 Avenue de l'Observatoire, EA 4466, France
| | - M Chartier
- Department of Obstetrics, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France
| | - J Patkaï
- Department of Neonatology, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France
| | - L Cynober
- Clinical Chemistry Laboratory, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France; Laboratory of Biological Nutrition, Faculty of Pharmacy, Paris Descartes University, 4 Avenue de l'Observatoire, EA 4466, France
| | - N Neveux
- Clinical Chemistry Laboratory, Cochin Hospital, AP-HP, 27 Rue du Faubourg Saint-Jacques, Paris, France; Laboratory of Biological Nutrition, Faculty of Pharmacy, Paris Descartes University, 4 Avenue de l'Observatoire, EA 4466, France
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11
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Abstract
The life expectancy and quality of life of women with genetic disorders continues to improve, resulting in more women reaching reproductive age and desiring fertility. It is becoming increasingly important that obstetricians become familiar with common genetic disorders and their associated risks in pregnancy. The authors review pregnancy in women with various genetic disorders, including review of pregnancy outcomes, management recommendations, and genetic risk assessment. Most data on pregnancies in women with genetic conditions are based on case reports and literature reviews. Additional studies, including pregnancy registries, are needed to improve our understanding and care of this patient population.
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Affiliation(s)
- Sarah Harris
- University of North Carolina at Chapel Hill School of Medicine, 3010 Old Clinic Building, CB 7516, Chapel Hill, NC 27516, USA
| | - Neeta L Vora
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, 3010 Old Clinic Building, CB 7516, Chapel Hill, NC 27516, USA.
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12
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Abstract
Once based mainly in paediatrics, inborn errors of metabolism (IEM), or inherited metabolic disorders (IMD) represent a growing adult medicine specialty. Individually rare these conditions have currently, a collective estimated prevalence of >1:800. Diagnosis has improved through expanded newborn screening programs, identification of potentially affected family members and greater awareness of symptomatic presentations in adolescence and in adulthood. Better survival and reduced mortality from previously lethal and debilitating conditions means greater numbers transition to adulthood. Pregnancy, once contraindicated for many, may represent a challenging but successful outcome. Successful pregnancies are now reported in a wide range of IEM. Significant challenges remain, given the biological stresses of pregnancy, parturition and the puerperium. Known diagnoses allow preventive and pre-emptive management. Unrecognized metabolic disorders especially, remain a preventable cause of maternal and neonatal mortality and morbidity. Increased awareness of these conditions amongst all clinicians is essential to expedite diagnosis and manage appropriately. This review aims to describe normal adaptations to pregnancy and discuss how various types of IEM may be affected. Relevant translational research and clinical experience will be reviewed with practical management aspects cited. Based on current literature, the impact of maternal IEM on mother and/or foetus, as well as how foetal IEM may affect the mother, will be considered. Insights gained from these rare disorders to more common conditions will be explored. Gaps in the literature, unanswered questions and steps to enhance further knowledge and systematically capture experience, such as establishment of an IEM-pregnancy registry, will be summarized.
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Affiliation(s)
- Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, M6 8HD, UK.
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Kido J, Kawasaki T, Mitsubuchi H, Kamohara H, Ohba T, Matsumoto S, Endo F, Nakamura K. Hyperammonemia crisis following parturition in a female patient with ornithine transcarbamylase deficiency. World J Hepatol 2017; 9:343-348. [PMID: 28293384 PMCID: PMC5332424 DOI: 10.4254/wjh.v9.i6.343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/02/2017] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked disorder, with an estimated prevalence of 1 per 80000 live births. Female patients with OTCD develop metabolic crises that are easily provoked by non-predictable common disorders, such as genetic (private mutations and lyonization) and external factors; however, the outcomes of these conditions may differ. We resuscitated a female patient with OTCD from hyperammonemic crisis after she gave birth. Hyperammonemia after parturition in a female patient with OTCD can be fatal, and this type of hyperammonemia persists for an extended period of time. Here, we describe the cause and treatment of hyperammonemia in a female patient with OTCD after parturition. Once hyperammonemia crisis occurs after giving birth, it is difficult to improve the metabolic state. Therefore, it is important to perform an early intervention before hyperammonemia occurs in patients with OTCD or in carriers after parturition.
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Alfadhel M, Mutairi FA, Makhseed N, Jasmi FA, Al-Thihli K, Al-Jishi E, AlSayed M, Al-Hassnan ZN, Al-Murshedi F, Häberle J, Ben-Omran T. Guidelines for acute management of hyperammonemia in the Middle East region. Ther Clin Risk Manag 2016; 12:479-87. [PMID: 27099506 PMCID: PMC4820220 DOI: 10.2147/tcrm.s93144] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Hyperammonemia is a life-threatening event that can occur at any age. If treated, the early symptoms in all age groups could be reversible. If untreated, hyperammonemia could be toxic and cause irreversible brain damage to the developing brain. Objective There are major challenges that worsen the outcome of hyperammonemic individuals in the Middle East. These include: lack of awareness among emergency department physicians about proper management of hyperammonemia, strained communication between physicians at primary, secondary, and tertiary hospitals, and shortage of the medications used in the acute management of hyperammonemia. Therefore, the urge to develop regional guidelines is extremely obvious. Method We searched PubMed and Embase databases to include published materials from 2011 to 2014 that were not covered by the European guidelines, which was published in 2012. We followed the process of a Delphi conference and involved one preliminary meeting and two follow-up meetings with email exchanges between the Middle East Hyperammonemia and Urea Cycle Disorders Scientific Group regarding each draft of the manuscript. Results and discussion We have developed consensus guidelines based on the highest available level of evidence. The aim of these guidelines is to homogenize and harmonize the treatment protocols used for patients with acute hyperammonemia, and to provide a resource to not only metabolic physicians, but also physicians who may come in contact with individuals with acute hyperammonemia. Conclusion These suggested guidelines aim to ease the challenges faced by physicians dealing with acute hyperammonemia in the region. In addition, guidelines have demonstrated useful collaboration between experts in the region, and provides information that will hopefully improve the outcomes of patients with acute hyperammonemia.
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Affiliation(s)
- Majid Alfadhel
- Department of Pediatrics, Division of Genetics, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Fuad Al Mutairi
- Department of Pediatrics, Division of Genetics, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nawal Makhseed
- Department of Pediatrics, Jahra Hospital, Ministry of Health, Jahra City, Kuwait
| | - Fatma Al Jasmi
- Department of Pediatric, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Khalid Al-Thihli
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | | | - Moeenaldeen AlSayed
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Zuhair N Al-Hassnan
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; The National Newborn Screening Program, Ministry of Health, Riyadh, Saudi Arabia
| | - Fathiya Al-Murshedi
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Johannes Häberle
- Department of Pediatrics, Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Tawfeg Ben-Omran
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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Murphy E. Medical Problems in Obstetrics: Inherited Metabolic Disease. Best Pract Res Clin Obstet Gynaecol 2015; 29:707-20. [PMID: 26088792 DOI: 10.1016/j.bpobgyn.2015.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 04/06/2015] [Accepted: 04/07/2015] [Indexed: 11/26/2022]
Abstract
An increasing number of women with rare inherited disorders of metabolism are becoming pregnant. Although, in general, outcomes for women and their children are good, there are a number of issues that need to be considered. Currently, limited specific guidance on the management of these conditions in pregnancy is available. Prepregnancy counselling with information on inheritance, options for reproduction, teratogenicity risk, potential impact on maternal health and long-term health of children should be offered. With appropriate specialist management, the teratogenic risk of conditions such as maternal phenylketonuria (PKU) can be eliminated, and the risk of metabolic decompensation in disorders of energy metabolism or intoxication significantly reduced. Multidisciplinary management, and close liaison between obstetricians and other specialists, is required for those women in whom there is cardiac, renal, respiratory, joint or other organ involvement.
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Affiliation(s)
- Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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16
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Abstract
An increasing number of women with rare inherited disorders of metabolism are becoming pregnant. Whilst, in general, outcomes for women and their children are good, there are issues that need to be considered. Due to the rarity of many conditions, there is limited specific guidance available on best management. Prepregnancy counselling with information on inheritance, options for reproduction, teratogenicity risk, potential impact on maternal health and long-term health of children should be offered. With appropriate specialist management, the teratogenic risk of conditions such as maternal phenylketonuria (PKU) can be eliminated, and the risk of metabolic decompensation in other disorders of intoxication or energy metabolism significantly reduced. Newer therapies, such as enzyme replacement therapy, appear to be safe in pregnancy, but specific advice should be sought. Multidisciplinary management, and close liaison between obstetricians and other specialists is required for women in whom there is cardiac, renal, respiratory, joint or other organ involvement.
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Affiliation(s)
- Elaine Murphy
- Inherited Metabolic Disease, Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
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