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Beta thalassemia in Pakistan is a serious health concern with an estimated 5-8% carrier frequency and birth of 5000 major children every year in the country. The treatment of beta thalassemia major patients poses a great economic burden; hence, the ideal approach towards this disease should encompass effective prevention services. At present only one government funded project "Punjab Thalassemia Prevention Programme" existed in Punjab province, and providing free of cost services for beta thalassemia screening and prenatal diagnosis. Complete blood count and haemoglobin electrophoresis remains the preliminary test for screening, while chorionic villi sampling and amplification refractory mutation system method have been most widely used for molecular diagnosis of beta thalassemia. Modern molecular techniques, non-invasive prenatal diagnosis, and pre-implantation diagnosis are in trial phases. In this review we have discussed the available diagnostic facilities and status of prevention programmes for beta thalassemia in Pakistan as well as future perspectives.

This study aims to observe the spectrum of Prenatal Diagnosis of Rare Genetic conditions at a Tertiary care hospital in Karachi. This is a retrospective review conducted at the Aga Khan University Hospital, Karachi from January 2016 to July 2018. All cases undergoing invasive testing by Chorionic villus sampling for indications other than Thalassemia were included. Forty percent of patients in our cohort underwent invasive testing for muscular dystrophies particularly survival motor neuron (SMN) gene deletion and 32% for Cystic Fibrosis. Other rare disorders like JAM 3 mutation, PEX 1 gene, Barters Syndrome, Wardenberg, Bardet-Beidl Syndrome and Lissencephaly accounted for 28%. Sophistication in laboratory technology and DNA banking has improved the prenatal diagnosis of rare genetic disorders particularly SMN gene deletion. Integrated care involving foetal medicine specialist, Paediatric geneticist, and dedicated Laboratory personnel improves Counseling and Diagnosis of rare genetic conditions. Provision of dedicated nursing staff along with strengthening of welfare facility for non-affording patients would improve the uptake of invasive testing.

Objective: To assess the knowledge among parents of thalassemia major patients about prenatal diagnosis, premarital screening for carrier detection and impact of consanguineous marriage on disease transmission., Study Design: Descriptive study., Place and Duration of Study: The Thalassemia Centre, Sir Ganga Ram Hospital, Lahore, from July to September 2009., Methodology: One hundred and fifteen parents of β-thalassemia major patients were enrolled in this study. A questionnaire was developed and parents were interviewed to assess their knowledge about preventive measures against thalassemia major. Parents of patients with all other types of blood disorder were excluded from the study., Results: There were 74 male (64.3%) and 41 female (35.7) patients with mean age of 9.5 ± 5.1 years. Eighty-eight patients (76.5%) were accompanied by mothers and the rest by their fathers. Seventy-four parents (32.1%) were illiterate; among the literates only 7 were highly educated (3%). Ninety-four couples (81.7%) had consanguineous marriage. Fiftytwo parents (44.6%) knew that thalassemia is an inherited disorder. Thirty-eight (33%) had heard about the test for detecting thalassemia carrier. Premarital screening and prenatal diagnosis was known to 97 (84.3%) and 88 (76.5%) parents respectively. Ninety-nine parents (86.1%) knew about the termination of pregnancy on positive prenatal test but only 69 considered it acceptable religiously (60%). Major source of information to the parents were doctors., Conclusion: Parental knowledge about thalassemia and its preventive measures was inadequate; this requires intervention in the form of public health education programs concentrating on high risk/targeted population.

Objectives: We report two siblings with Roberts syndrome (RBS), and an attempt to delineate the underlying molecular mechanism leading to familial recurrence., Methods: Cytogenetic studies and direct sequencing of the ESCO2 gene were carried out in the second affected fetus and the parents. Fetal DNA was obtained from amniocytes after amniocentesis. Parental DNA was obtained from peripheral blood samples., Results: Cytogenetic analysis of amniocytes revealed a normal male karyotype in 20 analyzed metaphases and chromosomal aneuploidies in 10 metaphases. All metaphases displayed premature separation of centromeres and puffing of heterochromatic regions near the centromere. A homozygous mutation leading to a frameshift in ESCO2 was identified in the fetal DNA sample. Both parents are heterozygous carriers of the same mutation., Conclusion: The present case demonstrates the prenatal diagnosis of RBS associated with a frameshift mutation in ESCO2.

Objective: To evaluate the service for prenatal diagnosis of beta-thalassemia in Pakistan., Methods: All prenatal diagnoses (PNDs) for beta-thalassemia since the introduction of the service in 1994 were studied. PND was done by the Amplification Refractory Mutation System (ARMS), or linkage analysis, when required. The reported errors in PND were investigated for clerical mistakes, technical problems with PCR, maternal contamination and nonpaternity., Results: In the 12 years 2174 PNDs were done for beta-thalassemia at the country's main referral center. The use of PND has increased from 26 in 1994 to 381 in 2006. Over 97% of the couples who requested PND already had an affected child. In over 97% of the cases PND was done by direct mutation analysis. The reported rate of misdiagnosis was 0.37%. The causes of misdiagnoses included one clerical mistake, three false positive PCR results, and two maternal contaminations in the chorionic villus sampling (CVS)., Conclusion: PND for beta-thalassemia is technically feasible by direct mutation analysis in most cases in Pakistan. The procedure is quick and cost effective. Strict quality assurance can achieve an acceptably low error rate., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Objective: To establish intrauterine diagnosis of thalassaemia major in couples with thalassaemia trait by chorionic villous sampling., Methods: A total of 60 couples with children suffering from transfusion dependent beta-thalassaemia or couples who were known carriers of beta-thalassaemia were included in this study. The standard procedure was followed for the collection of samples which was finally transferred in appropriate medium to Armed Forces Institute of Pathology Rawalpindi for detection of thalassaemia mutation., Results: After DNA analysis of the submitted samples, no thalassaemia mutation was detected in the foetus in 24 cases. In 8 cases foetus were heterozygote for thalassaemia having a single mutation. In 28 cases, foetus were homozygous for beta-thalassaemia., Conclusion: Appropriate and extensive screening, accurate detection and counseling of at risk couples, along with antenatal diagnosis is a promising strategy for the reduction of mortality and morbidity from thalassaemia in countries where it is prevalent. Based on these results, it can be concluded that prenatal diagnosis of beta-thalassaemia for prevention can be done using chorionic villous sampling.

Objective: To determine the regional and ethnic distribution of beta thalassemia mutation and the effect of consanguinity in patients referred for prenatal diagnosis of beta b-thalassemia and to target the high risk population for screening., Design: Cross-sectional, analytical study., Place and Duration of Study: The study was conducted in Gentec Laboratory, Lahore, from January 2001 to December 2005., Patients and Methods: A total of 499 couples were referred to Gentec Lab., Lahore, from all over Pakistan for prenatal diagnosis of b-thalassemia. After counseling, chorionic villus sampling was done between 10-16 weeks of gestation. DNA analysis was done by Amplification Refractory Mutation System (ARMS) for type of mutation in the Armed Forces Institute of Pathology, Rawalpindi. Ethnicity, race and consanguineous relationship of parents was determined., Results: b-thalassemia was prevalent in Punjabis (60.7%) followed by Saraikees (25.5%). Castewise it was most frequent in Rajputs followed by Jatts, Arain, Sheikhs and Pathans. 56.7% of the couples were first cousins and 19.8% were relatives. The commonest mutations were Frameshift 8-9 (Fr8-9) 33.5%, Intervening Sequence 1-5 (IVS 1-5) 17.2%, Fr4142 - 8%, IVS 1-1 - 5.2%, Deletion 619 (Del 619) 4.2% and Codon 5 (Cd 5) - 4.2%. In samples sent for analysis, 53.1% turned out to be carriers (trait), 25.3% were diseased (thalassemia major) and 21.6% were normal. P-value of all results was less than 0.001., Conclusion: In this series, the highest frequency was found in Punjabi Rajputs. The commonest mutation was Fr 8-9. Most parents were first cousins. Premarital thalassemia carrier testing can effectively reduce the disease.

Pakistan has a large population of more than 150 million people with an overall carrier frequency of approximately 5.6% for beta-thalassemia. Punjab is the largest province of the country having more than 50% of the population. The state of beta-thalassemia is alarming as consanguinity is very high (>81%) and the literacy rate is low in South Punjab. A thalassemia prevention program is the need of the hour in this part of Pakistan. In this study, we initiated awareness, screening, and characterization of the mutations causing beta-thalassemia as well as a genetic counseling program mainly in the districts of Faisalabad and D.G. Khan to establish prenatal diagnosis, a facility previously unavailable in this region for disease prevention. A total of 248 unrelated transfusion-dependent children and the available members of their families were screened to characterize the mutations and identify the carriers. Genetic counseling was provided to these families and prenatal diagnosis offered. In the samples analyzed, 11 beta-thalassemia mutations and three hemoglobin variants were detected mainly by using the Monoplex and Multiplex ARMS-PCR. First-trimester prenatal diagnosis was carried out through chorionic villus sampling (CVS) in seven pregnancies at risk. As a result of our campaign, 145 carrier couples planning to have more children gave their consent to have retrospective prenatal diagnosis in every pregnancy in future. A cooperative trend and a positive attitude toward the prevention of beta-thalassemia were noticed in the families with affected children and in the general population.

Objective: To examine molecular genetics and prenatal diagnosis of beta-thalassaemia., Methods: The study was conducted at the COMSATS Institute of Information Technology, Sahiwal, Pakistan, from October 2012 to October 2013, and comprised families having children affected by thalassaemia and autosomal recessive b-thalassemia. Blood samples of thalassaemic children and their parents were collected from different areas of Pakistan. They were screened for reported mutations through amplification refractory mutation system-polymerase chain reaction. Once mutation was characterised, chorionicvilus sampling was carried out to provide the retrospective first trimester prenatal diagnosis., Results: A total of five families were included in this study. Electropherogram showed that both mother and father were heterozygous (carrier) for intervening sequence I-5 mutation whereas the affected child was homozygous for this mutation. Five chorionic villus samples were examined to analyse the molecular defects which were responsible for beta-thalassaemia in the families. Prenatal diagnosis was performed for these families. They had at least one affected child (thalassaemia major) who was transfusion-dependant. Amplification refractory mutation system-polymerase chain reaction was found to be a very sensitive method to find the known point mutations present in beta-globin gene. Point mutations identified included intervening sequence I-5 (G-C), frameshift codon8/9 (+G) and frameshift codon-41/42 (-TTCT)., Conclusions: It is the best preventive action to adopt the screening process to overcome the disease.

A service for prenatal diagnosis of beta-thalassaemia was introduced in Pakistan in May 1994. Two renowned Islamic scholars, consulted before the service was introduced, ruled that a pregnancy can be terminated if the fetus is affected by a serious genetic disorder, and if termination is before 120 days (17 weeks) of gestation. During the first 3(1/2) years of the service 300 couples requested the test. Almost all the couples had been informed by their treating doctors. Most diagnoses were made between 10 and 16 weeks of gestation, and only 15 (5%) were reached after the 16th week. DNA analysis was by the amplification refractory mutation system (ARMS). A multiplex ARMS was developed in which three primer combinations identified the mutations in 91.5% of the couples. In 13 couples (4. 3%) linkage analysis was required for the fetal diagnosis. In 47/53 (88.7%) women carrying an affected fetus the pregnancy was terminated. In six cases it was declined principally on religious grounds. Postnatal confirmation of the prenatal diagnosis was possible in 117 unaffected children. One year after the start of the service, interviews with 141 couples with an affected child showed that 72% knew of the availability of prenatal diagnosis. Thirty-two of the informed couples had had a pregnancy, but only 18 (56%) used prenatal diagnosis. The main reasons for non-utilization of prenatal diagnosis were the cost of the test and fear of undergoing the test, though some gave no clear explanation. This study demonstrates that prenatal diagnosis is feasible and acceptable in a Muslim country such as Pakistan., (Copyright 2000 John Wiley & Sons, Ltd.)

Cockayne syndrome (CS) is a rare neurodegenerative disorder characterized by impaired neurological functions, cachectic dwarfism, microcephaly and photosensitivity. Complementation assays identify two groups of this disorder, CS type I (CSA) and CS type II (CSB), caused by mutations in ERCC8 and ERCC6, respectively. This study aimed to investigate the genetic basis of a consanguineous Pakistani family with three affected individuals presenting with typical clinical symptoms of CS. We employed whole exome sequencing of the proband and then Sanger sequenced all the family members to confirm its segregation in the family. Different bioinformatics tools were used to predict pathogenicity of this variant. Variants were filtered according to the pedigree structure. We identified a novel homozygous variant (c.202A>T; p.Ile68Phe) in ERCC8 gene in the proband. The variant was found to segregate in the family. These findings add to the genetic heterogeneity of ERCC8 and expands the mutation spectrum. Also, identification of this variant can facilitate prenatal diagnosis/genetic counselling set ups in Pakistan where this disease largely remains undiagnosed. [ABSTRACT FROM AUTHOR]

The beta-thalassaemia mutations in 702 unrelated carriers originating from seven different regions of the Indian subcontinent have been characterized using allele specific priming of the polymerase chain reaction (PCR). It was possible to identify the mutations in 688 (98%) of the individuals studied. Eleven different mutations were identified, of which five common ones accounted for 93.6%; namely the ones at IVS-1 position 5 (G-C), codons 8/9 (+G), IVS-1 position 1 (G-T), codons 41/42 (-CTTT) and the 619 bp deletion at the 3' end of the gene. The mutations at IVS-2 position 1 (G-A) and codon 30 (G-C), previously undescribed in Asian Indians, were found in two and six individuals respectively. Some regional variation in the distribution of beta-thalassaemia alleles was noted. These findings should prove useful for the development of a first trimester prenatal diagnosis programme based on direct detection of mutations.

Objectives: To determine the effectiveness and feasibility of transabdominal chorionic villi sample (CVS) procedure for prenatal diagnosis of β-thalassaemia in a Muslim majority community. Methodology: Between January 2005 and December 2011, we analysed 798 high-risk mothers with 12-16 weeks of pregnancy for β-thalassaemia using CVS, performed with a transabdominal route under local anesthesia and ultrasound guidance. The chorionic villi extracted were investigated upon using genomic amplification of β-globin gene by polymerase chain reaction (PCR). Results: A total of 798 of which 224(28%) fetus were diagnosed as major, 400(50.1%) as minor, 173(21.6%) as healthy fetus and 1(0.12%) fetus had undetected mutation. Procedure related complications were seen in 20 cases (2.4%) and missed abortion occurred in 6/798. Seven (3%) couples had refused to abort β-thalassaemia major fetus where as 97% fetus was aborted as per recommendations. Conclusion: Ultrasound guided transabdominal CVS is an effective procedure for prenatal diagnosis of β- thalassaemia in a Muslim community. We found no cultural hurdles for fetal sampling and prenatal diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence and prognosis of proteinuria at enrolment in the 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia cluster randomized trials., Methods: We identified pregnant women eligible for inclusion in the trials in their communities in four countries (2013-2017). We included women who delivered by trial end and received an intervention antenatal care visit. The intervention was a community health worker providing supplementary hypertension-oriented care, including proteinuria assessment by visual assessment of urinary dipstick at the first visit and all subsequent visits when hypertension was detected. In a multilevel regression model, we compared baseline prevalence of proteinuria (≥ 1+ or ≥ 2+) across countries. We compared the incidence of subsequent complications by baseline proteinuria., Findings: Baseline proteinuria was detected in less than 5% of eligible pregnancies in each country (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004; Pakistan: 315/10 885), almost always with normotension (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). There was no consistent relationship between baseline proteinuria (either ≥ 1+ or ≥ 2+) and progression to hypertension, maternal mortality or morbidity, birth at < 37 weeks, caesarean section delivery or perinatal mortality or morbidity. If proteinuria testing were restricted to women with hypertension, we projected annual cost savings of 153 223 981 United States dollars (US$) in India, US$ 9 055 286 in Mozambique, US$ 53 181 933 in Nigeria and US$ 38 828 746 in Pakistan., Conclusion: Our findings question the recommendations to routinely evaluate proteinuria at first assessment in pregnancy. Restricting proteinuria testing to pregnant women with hypertension has the potential to save resources., ((c) 2020 The authors; licensee World Health Organization.)

Objective: To compare the response towards prenatal diagnosis (PND) of b-thalassaemia, in individuals who had not received genetic counselling and a genetically counselled population., Study Design: Cross-sectional survey., Place and Duration of Study: Department of Haematology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from March 2009 to December 2010., Methodology: Using non-probability consecutive sampling, a total of 176 individuals having thalassaemic children, were interviewed regarding PND of thalassaemia, by using a structured questionnaire. Forty two individuals were taken as controls as they had received genetic counselling for PND, whereas the remaining 134 were taken as cases. Responses towards PND were compared using chi-square test. Odds ratio was also calculated for subsequent PND utilization., Results: Seventy (52.2%) cases and 42 (100%) controls were aware of the availability of PND in Pakistan. This difference in awareness was statistically significant (p < 0.001). In the controls, 40 (95.3%) individuals were aware of the appropriate timing of the test, in contrast to 52 (39%) cases (p < 0.001). PND was used in subsequent pregnancies by 50 (37.3%) cases and 32 (80%) controls (p < 0.001). The calculated odds ratio for subsequent PND utilization was 5.37., Conclusion: The study reflects a very positive attitude of genetically counselled thalassaemia affected families towards PND. For better utilization of PND, genetic counselling services should be available at all health strata.

Prenatal diagnosis (PND) of β-thalassemia has been underutilized in Pakistan because of a number of social and economic factors. National Institute for Biotechnology and Genetic Engineering Faisalabad in collaboration with Multan Institute of Nuclear Medicine and Radiotherapy Multan introduced free PND service for carrier couples of Multan district. Multan has a population of about 4 million. More than 170 couples registered for retrospective PND and in 2 years 105 PND were carried out through first trimester chorionic villus sampling. Almost 90% of these couples were unable to afford the cost of PND and would not have undergone the test as free service was not available. Monoplex and Multiplex Amplification Refractory Mutation System-polymerase chain reaction and genomic DNA sequencing were used for detection of IVS (intervening sequence)-I-5 (G-C), FSC (frameshift codon)-8/9 (+G), FSC-41/42 (-TTCT), IVS-I-1 (G-T), 619 bp deletion, and CD-15 (G-A) β-globin mutations. Eighty-one percent (85/105) couples analyzed were in a consanguineous marriage. Twenty-three fetuses were found homozygous mutant and all couples opted for discontinuation of affected pregnancies. More families are registering for PND after establishment of this free and accessible PND service.

Objective: To assess the impact of fetal echocardiography in altering the course of action for neonatal cardiac expertise and services available in Pakistan following an antenatal diagnosis of congenital heart defect (CHD). Study Design: Cross-sectional study. Place and Duration of Study: Pediatric Cardiology Unit, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi Pakistan, from Feb 2020 to Sep 2021. Methodology: Fetuses aged 18 to 38 weeks of gestational age referred to the Pediatric Cardiac Unit due to risk of or suspicion of congenital heart disease underwent fetal cardiac echo. Data were collected and reviewed retrospectively to seek any impact of the antenatal diagnosis on post-natal planning. Results: The mean age of the mothers was 29.79±5.24 years (range, 17-47 years), and the mean gestational age at which the fetal echocardiography examination was performed was 27.29±4.47weeks (range: 12-38 years). Of the 609 pregnancies, fetal echocardiogram evaluation was performed, and sixty-three (10.3%) fetal echocardiograms were abnormal. Of the 63, only 06(9.5%) returned to the neonatal cardiac unit for follow-up and treatment in the first ten days of life. Conclusion: The real impact of fetal echocardiography is possible only with the availability of well-developed, readily accessible fetal and neonatal cardiac services. Poverty and a struggling healthcare infrastructure confound the benefits. [ABSTRACT FROM AUTHOR]

Objectives: Perception and attitude regarding prenatal screening and induced abortion vary across different populations. This study assesses the attitudes and perceptions regarding prenatal screening and induced abortion among Pakistani adults., Methods: We conducted a cross-sectional study among adults (18+) coming to the Aga Khan University Hospital, a private tertiary care hospital in Karachi, Pakistan., Results: Majority (65%) of the study population had knowledge about prenatal screening and it was acceptable to most (85.5%) of them. Significant proportion had high acceptance for induced abortion (23%) of a fetus that has serious congenital anomalies. On the other hand, 15% were unwilling to consider termination of pregnancy (TOP) in any circumstances. Women had more favorable attitude toward induced abortion. Most of the respondents (63%) were in favor of abortion if fetal death was imminent as a result of a congenital abnormality. Majority wanted mutual consultation of husband and wife for making decision regarding induced abortion (84%)., Conclusion: There was a considerable discord in opinion about abortion in the study population. Health care providers should involve both parents in making decisions about abortions and counsel them adequately about congenital disorders., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

We present here an analysis of 888 unrelated beta-thal chromosomes consisting of 444 transfusion dependent children from various regions of Punjab and Islamabad Pakistan. By using Multiplex ARMS- PCR, restriction endonuclease analysis, allele specific oligonucleotide (ASO) hybridization and sequencing, 17 beta-thal mutations and 3 Hb variants were detected in 99.5 % (884/888) of the chromosomes analyzed. First trimester prenatal diagnosis by chorionic villus sampling (CVS) was also carried out in seven pregnancies at risk of beta-thalassemia. Our results indicate that three most common mutations accounted for 86.8% of the beta-thal alleles in this region. These findings have important implications for prevention of beta-thalassemia through genetic counseling and prenatal diagnosis in this part of Pakistan.

Objectives: Most births of children affected with beta-thalassaemia major in the United Kingdom are to parents of Pakistani origin. A popular explanation for this is that Pakistanis decline termination of pregnancy on religious grounds. However, various factors influence people's attitudes towards prenatal diagnosis and termination of pregnancy, which have not been investigated in a UK Pakistani sample. This study is aimed at exploring the attitudes of pregnant Pakistani women towards prenatal diagnosis and termination of pregnancy for beta-thalassaemia major in the North of England., Methods: Forty-three pregnant women tested for thalassaemia carrier status were interviewed following receipt of their test results. Interviews were analysed using the grounded theory approach., Results: Findings showed: (1) women's awareness of and attitudes towards prenatal diagnosis; (2) the relationship between attitudes towards prenatal diagnosis and termination of an affected foetus; (3) the relationship between attitudes towards termination of pregnancy and religious beliefs, perceptions of severity of the condition, influence of significant others, and (4) the impact of gestational age at the time of the offer of termination of pregnancy., Conclusions: Pakistani women's attitudes towards prenatal diagnosis and termination of pregnancy are influenced by various factors, and therefore their religion should not be taken as a proxy for their attitudes either for or against termination of pregnancy., (2006 John Wiley & Sons, Ltd.)

Thalassemia awareness among the youth is vital for policy- making to reduce the disease burden in our country. A descriptive cross-sectional study was conducted via simple random sampling technique for which data was collected from May 2020 to May 2021 through Google forms. Results showed that out of a total of 394 non-medical university students, the majority, i.e. 265 (67.3%), were not aware of prenatal screening. Majority, i.e. 117 (29.7%), agreed that the couple should be screened before marriage, and 190 (48.2%) strongly agreed, while 46 (11.7%) had no knowledge. Students, however, believed premarital screening was either unavailable, not possible, or expensive. Other reasons included custom and culture of arranged marriages and religious reasons. The query that if both the parents are carriers and the foetus has thalassemia major should they have an abortion, showed mixed results. The key to controlling thalassemia is awareness of future parents.

Thalassaemia is the most common inherited disorder in Pakistan and there are very inadequate treatment facilities for over 4000 homozygotes born each year. Prevention of these disorders therefore forms an essential part of the management of this enormous health problem. We have characterized 1216 beta-thalassaemia alleles from the five major ethnic groups of Pakistan. The complete spectrum comprised 19 different mutations. There are important ethnic and regional differences in the prevalence of mutations. The five most common mutations, IVSI-5 (G-C) (37.3%), Fr 8-9 (+G) (25.9%), del 619 (7.0%), Fr 41-42 (-TTCT) (6.7%) and IVSI-1 (G-T) (5.4%), constitute 82.3% of the total. Fr 8-9 (+G) is the most common mutation in Northern Pakistan (41.3%), whereas IVSI-5 (G-C) is the most frequent mutation in Southern Pakistan (52.2%). Six subjects with transfusion-dependent thalassaemia major showed only a single mutant allele. One subject with transfusion-dependent thalassaemia major showed a novel 17 bp deletion involving Cd126-131. Our findings provide a comprehensive basis for carrying out prenatal diagnosis of thalassaemia in a geographical area where it is found in high frequency.

The concept of informed choice for antenatal screening consists of Western ideologies, encapsulating individualistic approaches, and may be valued differently by people from countries with more collectivist cultures. This study aimed to explore perceptions of informed choice in antenatal screening in women from China, Hong Kong and Pakistan. A Q-methodology study was conducted during June 2016 to February 2017, in China (Shanghai and Duyun), Hong Kong and Pakistan (Lahore). A total of 299 women rank ordered 41 statements. Following by-person factor analysis, five distinct viewpoints were identified: choice as a maternal responsibility entrusted to doctors; choice as a shared decision led by the mother; choice as a shared decision led by the partner; choice as a responsibility delegated to the partner and doctors; and choice within a religious discourse. The findings highlight ethical dilemmas for healthcare professionals in facilitating informed choice for antenatal screening where policy and practice guidelines adapt predominantly individualistic approaches. Women's preferences for decision-making with health professionals and/or their partner, with minimal emphasis on individual rights, suggest the need for clarification of the role of health professionals in supporting and facilitating decision-making to enhance women's autonomy. Policy and practice guidelines need to be (re)framed to facilitate decision-making processes for antenatal screening using relational approaches to autonomy.

Objectives: The objective of current genetic research was to verify the genetic basis of ß-thalassemia and its pattern of inheritance in families of Pashtun ethnicity in District Dera Ismail Khan, Pakistan., Methodology: Blood samples from clinically diagnosed five unrelated ß-thalassemia families were collected and target Sanger Sequencing of HBB gene was done. Moreover, in silico analysis including protein modeling and Protein-Protein docking was aslo performed., Results and Discussion: Clinical analysis of patients from family 1,2, 4, and 5 revealed Thalassemia Intermedia, while patient from family 3 was suffering from thalassemia major. The average Hb concentrations between the cases that were severe were found to be a little lower (6.3 mg/dl) than the patients with milder clinical manifestations (7.6 ± 1.4). Genetic analysis in family 1 identified compound heterozygous mutation of HBB (NM&#95;000518) i.e. c.20A>T +c.92 G>A, in family 2 and 4 compound heterozygous mutations c.20A>T + c.27&#95;28insG, in family 3 homozygous mutation c.27&#95;28insG, while in family 5 we identified homozygous mutation c.92 + 5 G>C (IVS-1 + 5 G>C)., Conclusion: This study offers an effective incentive to establish a mutation detection as well as prenatal diagnosis (PND) centers at a larger scale in the Pashtun ethnicity residing in District Dera Ismail Khan, Pakistan.

β-Thalassemia is the most common genetic disorder in Pakistan, where more than 6000 affected children are born annually, and the carrier population is around 10 million. The objective was to study β-globin gene mutations in chorionic villous biopsy samples. Prenatal screening of 383 pregnant women between 2003 and 2010 was carried out using a panel of 13 mutation primers and amplification refractory mutations system (ARMS)-PCR. In addition, DNA sequencing was used to confirm uncharacterized mutations and in some cases fetal disease status was confirmed by linkage analysis. Families enrolled in this study represented major ethnic groups in Pakistan. Of the 13 mutations tested, three mutations accounted 71% of the total, including IVS1-5(G-C)[HBB:c.92+5G>C], codon 8/9(+G) [HBB:c.27&#95;28insG] and del 619[NG&#95;000007.3:g71609-72227del619]. Mutations in four uncharacterized samples were later confirmed by DNA sequencing as -88(C-T)[HBB:c.-138C>G], -90(C-T)[HBB:c.-140C>T] and codon 59(+T)[HBB:c.178&#95;179insT]. To our knowledge, this is the first report of these mutations in Pakistan. Moreover, 19.2% fetal samples were normal and 52.3% heterozygous, whereas 26.4% were affected with thalassemia major. IVS1-5:IVS1-5 was the most common genotype in fetal samples. Prenatal diagnosis of β-thalassemia using ARMS PCR is an efficient approach for reducing the burden of this disease in Pakistan. In addition, rare mutations reported in this study should be incorporated in the diagnostic strategy.

Objectives: To assess the prevalence and associated risk factors of syphilis among antenatal clinic attendees by a multi-center cross-sectional study in Karachi, Pakistan., Methods: We administered a structured questionnaire and obtained a blood sample for syphilis serology (rapid plasma reagin test with Treponema pallidum hemagglutination assay confirmation) from all women giving informed consent over six weeks in 2007. Prevalence was calculated at 95% confidence intervals. Multivariate analysis was adapted to assess risk factors., Results: There were seven (0.9%) confirmed cases of syphilis (95% CI: 0.4, 1.8) in a sample size of 800 women recruited from three urban sites (-1% refusal rate). Women who lived in an area where male drug use is prevalent had 1.5% higher prevalence rates than women from the other two sites 0.5%., Conclusions: We documented higher-than-expected syphilis seroprevalence rates in a low risk population of antenatal clinic attendees in Pakistan. Bridge populations for syphilis may include drug users, who are usually married, and Hijras or their clients. In accordance with our results, the national policy for syphilis control in Pakistan should be modified to include universal syphilis screening in antenatal clinics with subsequent partner notification.

Introduction: Consanguineous unions occur when a couple are related outside marriage and is associated with adverse genetic and perinatal outcomes for affected offspring. The objectives of this study were to evaluate: (i) background characteristics, (ii) uptake of prenatal and postnatal investigation and (iii) diagnostic outcomes of UK consanguineous couples presenting with a fetal structural anomaly.Material and Methods: This was a retrospective and partly prospective cohort study comparing consanguineous (n = 62) and non-consanguineous (n = 218) pregnancies with current or previous fetal structural anomalies reviewed in a UK prenatal genetic clinic from 2008 to 2019. Outcomes were compared using odds ratios (OR).Results: Most consanguineous couples were of Pakistani ethnicity (odds ratio [OR] 29, 95% confidence interval [95% CI] 13-62) and required use of an interpreter [OR 9, 95% CI 4-20). In the consanguineous group, the uptake of prenatal invasive testing was lower (OR 0.4, 95% CI 0.2-0.7) and the number declining follow up was greater (OR 10, 95% CI 3-34) than in the non-consanguineous group. This likely explained the lower proportion of consanguineous couples where a final definitive unifying diagnosis to explain the fetal structural anomalies was reached (OR 0.3, 95% CI 0.2-0.6). When a diagnosis was obtained in this group, it was always postnatal and most often using genomic sequencing technologies (OR 6, 95% CI 1-27). The risk of perinatal death was greater (OR 3, 95% CI 1-6) in the consanguineous group, as was the risk of fetal structural anomaly recurrence in a subsequent pregnancy (OR 4, 95% CI 1-13). There was no difference in the uptake of perinatal autopsy or termination of pregnancy between groups.Conclusions: Consanguineous couples are a vulnerable group in the prenatal setting. Although adverse perinatal outcomes in this group are more common secondary to congenital anomalies, despite the evolution of genomic sequencing technologies, due to a lower uptake of prenatal testing it is less likely that a unifying diagnosis is obtained and recurrence can occur. There is a need for proactive genetic counseling and education from the multidisciplinary team, addressing language barriers as well as religious and cultural beliefs in an attempt to optimize reproductive options. [ABSTRACT FROM AUTHOR]

Due to the large number of children with disabilities in the local area, Calderdale and Kirklees Health Authority commissioned a research project. The aim was to explore the issues surrounding antenatal screening--the needs of parents and the risk of giving birth to a baby with a disability. Triangulation using both qualitative and quantitative methods was used and data was collected through questionnaires, interviews and focus groups. Findings led to the identification of themes: access of local services, parents knowledge of antenatal screening tests and local services, and professionals beliefs around antenatal screening issues. The project highlights professional's lack of knowledge and therefore the need for antenatal screening coordinators in all Trusts, in-service training, improved information for parents and education in the community, especially for 'at risk' groups such as ethnic minorities.

Objective: To determine the feasibility of a PCR based strategy for prenatal diagnosis of Haemophilia-A in Pakistani Families., Design: Prospective., Setting: Department of Haematology, Armed Forces Institute of Pathology, Rawalpindi., Subjects: Five families with at least one child affected with Haemophilia-A. Each family comprised of father, mother, affected child and fetus when present., Main Outcome Measures: Short Tandem Repeat (STR) analysis in the Intron 22 of factor VIII gene., Results: PCR based analysis of the STR in intron 22 of factor VIII gene showed that the marker was informative in 4/5 study families and could be used in these families for the prenatal diagnosis of Haemophilia-A. In two families prenatal diagnosis was carried out by Chorionic Villus Sampling at 10-13 weeks gestation and the results in both the cases showed a carrier female fetus., Conclusion: Linkage based prenatal diagnosis of Haemophilia-A by an intragenic STR marker is feasible in most of the Pakistani families. The long term response of the Haemophiliac families to the availability of prenatal diagnosis remains to be seen. The STR marker can also be used for carrier detection of female subjects in the affected families.

Objectives: To determine the frequency of various blood group antibodies responsible for haemolytic disease of the new born (HDN)., Design: A prospective study of all neonates and still born foetuses suspected to have haemolytic disease of the new born and their mothers., Subjects: Neonates suspected to have HDN as per study criteria along with their mothers and mothers of still born foetuses with hydrops foetalis., Methods: Pertinent serological tests, serum bilirubin estimation, haemoglobin estimation and reticulocyte count on neonate's blood samples and demonstration/titration of blood group specific antibodies in maternal blood samples., Results: Six cases of HDN due to blood group antibodies were detected so far. Four were due to anti-D and all were of mild severity as per study criteria. Two cases were of severe haemolytic disease (hydrops foetalis). Both were due to anti Kell. Both women had history of previous blood transfusion and abortions., Conclusion: Comprehensive antibody screening should be performed during antenatal period in women who have received blood transfusion and/or have history of un-explained abortions.

ABSTRACT Objective: To emphasize the importance of antenatal diagnosis of the morbidly adherent placenta, employ management options accordingly and their impact on the patient's outcome. Study Design: Cross-sectional study. Place and Duration of Study: Combined Military Hospital, Okara Pakistan, Jan 2018 to Aug 2020. Methodology: One hundred and twentyfour patients were enrolled in the study. Diagnosed morbidly adherent placenta was made through transabdominal ultrasound, and a Doppler study in selected cases of posterior placenta previa magnetic resonance imaging (MRI) was performed. The surgical approach was either a high transverse placenta sparing or a classical incision on the uterus. After delivery of baby, conservative management included resection of part of uterus with adherent placenta followed by reconstruction of the lower uterine segment, segmental resection of myometrial tissue and hemostatic sutures, and over sewing of placental bed. The requirement of blood transfusion, intensive care unit stay, post-operative recovery, and day of discharge, along with all demographic and surgical details, was noted. Results: In 87(70%) patients, high transverse or placental sparing incision was made to assess the baby. Over sewing of the placental bed was done in 37(29.8%) patients, and myometrial segment resection was done in 57(46%) patients. An obstetrical hysterectomy was carried out in 30 patients. Blood transfusion of > 4 units RCCs was required in 92(74%) patients. 16% the patients required intensive care management. Conclusion: Antenatal diagnosis of morbidly adherent placenta through useful imaging modality allowed for a planned surgical approach and minimized maternal morbidity. [ABSTRACT FROM AUTHOR]

Objectives: Inborn errors of metabolism (IEMs) are rare genetic disorders. Generally, IEMs are untreatable; however, some IEMs causing intellectual disability are potentially treatable if diagnosed earlier. In this study, levels of some clinically important biochemical parameters in intellectually disabled children suspected for IEMs were tested to see their association with intellectual disability, which could be helpful in preliminary screening. Methods: This comparative cross-sectional observational study was carried out from 2014 to 2017. Blood samples from 800 boys and girls (aged 4–24 years) were collected, of which 391 were healthy (IQ >90) and 409 were intellectually disabled (IQ <70) children with unknown cause. Clinically important (Liver and kidney enzymes etc.) biochemical parameters were analyzed in sera samples using commercial kits on semi-automated clinical chemistry analyzer. Results: Serum analysis showed the levels of ALP (p < 0.00001), ASAT (p = 0.001), ALAT (p = 0.016), albumin (p < 0.001), uric acid (p < 0.001), cholesterol (p < 0.001), triglycerides (p < 0.001), and hemoglobin (p = 0.005) were significantly different between healthy and intellectually disabled children. Conclusion: Changes in the liver function test and lipid profile parameters were significantly different in children with intellectual disability; however, it requires further detailed analysis for complete characterization of these diseases. [ABSTRACT FROM AUTHOR]

Abstract: Understanding the psychosocial impact of a congenital condition such as Down syndrome on affected individuals and their family requires an understanding of the cultural context in which they are situated. This study carried out in 2008 used Q-Methodology to characterize understandings of Down syndrome (DS) in Pakistan in a sample of health professionals, researchers and parents of children with the condition. Fifty statements originally developed for a UK study and translated into Urdu were Q-sorted by 60 participants. The use of factor analytic techniques identified three independent accounts and qualitative data collected during the Q-sorting exercise supported their interpretation. In two accounts, the ‘will of God’ was central to an understanding of the existence of people with DS although perceptions about the value and quality of life of the affected individual differed significantly between these accounts as did views about the impact on the family. The third account privileged a more ‘scientific worldview’ of DS as a genetic abnormality but also a belief that society can further contribute to disabling those affected. Attitudes towards prenatal testing and termination of pregnancy demonstrated that a belief in the will of Allah was not necessarily associated with a rejection of these technologies. Accounts reflect the religious, cultural and economic context of Pakistan and issues associated with raising a child with a learning disability in that country. [Copyright &y& Elsevier]

β-Thalassemia (β-thal) is a monogenic disease characterized by mutations on the HBB gene, affecting the production of globin that results in hypochromic and microcytic anemia. The aim of this study was to determine the prevalence of six common β-thal mutations, and their frequency and inheritance pattern in affected populations of North Waziristan Agency, Pakistan. In this study, 130 blood samples from 37 unrelated β-thalassemic families having a minimum of one transfusion-dependent child with β-thal major (β-TM), were retrieved either from the Thalassaemia Centre for Women and Children Hospital Bannu or their home towns situated in Noth Waziristan Agency. All samples were analyzed by the amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) using six allele-specific primers for the presence of the six β-thal mutations common in the Pakistani population. Of the six common mutations, our study demonstrated five HBB mutations comprising HBB: c.27&#95;28insG, HBB: c.92+5G>C, HBB: c.126&#95;129delCTTT, HBB: c.92+1G>T and HBB: c.17&#95;18delCT from the families studied, while mutation HBB: c.47G>A [codon 15 (G>A)] was not detected in any of the studied families. Furthermore, the HBB: c.27&#95;28insG and HBB: c.92+5G>C were noted to be the most common with frequencies of 42.85 and 31.42%, respectively. The findings of the present study may be useful in launching carrier screening and prenatal diagnosis (PND) programs by screening analyzed and other unanalyzed affected families for the possible presence of common mutations through the ARMS-PCR technique that will help to control the disease.

The present study was designed to assess the Knowledge, Attitude and Practices (KAP) of the parents of b-thalassaemia children (410) selected from public (73.2%) and private (26.8%) thalassaemia centers of Rawalpindi-Islamabad. Qualitative and quantitative approaches were used to collect the data, which was analyzed by using SPSS. Majority of the respondents (70%) were rural young parents with no knowledge of thalassaemia before marriage. However, now 81.2% were aware about this. Majority of the respondents (89%) had the knowledge about premarital screening, 86.1% were opposed to intermarriages of carrier and 57% believed that if carrier got married then prenatal diagnosis or Chorionic villus sampling test is necessary. About 76.8% of the couples were screened and 42.2% had an experience of Chorionic villus sampling among which 20% abortions were reported. Overall 82% parents had received genetic counselling. The present study suggests that parent's regular visits and genetic counseling at thalassaemia centers have played important role about awareness.

Background: In Pakistan, incidence of antenatal depression ranges from 18 to 80 %, which goes undiagnosed, resulting in maternal and neonatal implications. The current study aimed to examine the association of antenatal depression with maternal dietary intake and neonatal outcome.Methods: A hospital-based, prospective cohort study was conducted on 94 middle class antenatal attendees coming to a tertiary care hospital in Lahore, Pakistan at the beginning of second trimester. Participants fulfilling eligibility were enrolled consecutively after taking written informed consent. Exposure group was identified by Edinburgh Postnatal Depression Scale (EPDS) and cohort members were followed till after delivery. Maternal dietary intake was assessed by 24-h Recall and Food Frequency Checklist, while neonatal outcome was identified through patient files before discharge. Data on potential confounders was collected. Loss to follow up was 13 % (82/94). Data was collected from April-September 2013. Results for 82 participants were analyzed using SPSS version 21.Results: EPDS screened 35/82 (43 %) eligible antenatal attendees as depressed, out of which 16/35 (20 %) were severely depressed and 19/35 (23 %) were moderately depressed. Incidence of poor maternal dietary intake was more in females with antenatal depression. Antenatal depression increased the risk of poor Healthy Eating Index (RR = 2.58, C.I 1.60-5.23, AR = 62 %), carbohydrate <175 gm (RR = 1.188, CI 0.836-1.688, AR = 15 %), protein <71 gm (RR = 1.343, CI 1.059-1.703, AR = 26 %) and fat <55 gm (RR = 2.954, CI 1.612-5.416, AR = 67 %) Incidence of neonatal outcomes included, Fetal Growth Retardation (RR = 2.70, C.I 0.69-3.70, AR = 60 %), preterm birth (RR = 1.60, C.I 0.72-2.45, AR = 54 %), low Apgar score (RR = 2.70, C.I 0.69-3.70, AR = 60 %) and Low Birth Weight (RR = 0.56, C.I 0.93-1.39, AR = -44 %).Conclusion: Antenatal women with depression developed poor dietary intake and had increased incidence of Fetal Growth Retardation, preterm birth and low Apgar score, but not of Low Birth Weight. [ABSTRACT FROM AUTHOR]

Objective: The increased prevalence of adverse effects of altered thyroid functions in pregnancy inspired us to study the frequency of subclinical hypothyroidism (SCH) and the relationship with glycaemic control and foetal weight in pregnant females with and without gestational diabetes mellitus (GDM) in Pakistani population.Patients and Methods: Five hundred and eight pregnant females were enrolled and grouped as per the International Diabetes Association criteria into GDM (n = 208) and healthy control (n = 300). Random blood glucose (RBG), thyroid function tests, anthropometric analysis and foetal ultra sound scans were performed on all study subjects. Data were analysed using Mann-Whitney U test and Chi-square test wherever applicable. Spearman correlation and multiple regression analysis were performed. p values of <0.05 was considered significant.Results: A total of 61.5% GDM subjects depicted SCH with normal circulating T4 and T3 versus 6.0% healthy controls (p-value < 0.001). Moreover, TSH remained independently associated with RBG (r = 0.109; p < 0.05), poor glycaemic control (r = 0.227; p < 0.001) and negatively associated with foetal growth (r = -0.206; p < 0.001).Conclusion: The detection of high TSH with normal T3 and T4 in females with GDM strongly emphasises the need of thyroid screening as a routine in all antenatal clinics. [ABSTRACT FROM AUTHOR]

Objective: To assess the needs related to prenatal genetic counselling in a developing country., Methods: The prospective observational study was conducted at the Prenatal-Genetic Counselling Clinic of Aga Khan University Hospital, Karachi, from October 2007 to September 2010. In-depth interviews were conducted and the data was stored in the form of patient charts. Information was then extracted from the charts and entered into a structured questionnaire., Results: Of the 93 couples in the study, 49 (53%) were in the self-referral group and 44 (47%) were in the physician- referral group. Diagnosis was not given for previously affected children by the paediatrician or by obstetrician for recurrent miscarriages in 68 (73%)cases. Besides, 20 (22%) couples had voluntarily terminated a pregnancy without any tests because of the fear of having a diseased child. Eleven (12%) couples were looking for amniocentensis or chorionic villus sampling. Death in previous children was the main reason to seek genetic counselling and was seen in 57 (61%) couples. Consanguinity was seen in 77 (83%) couples., Conclusion: A clear deficiency of knowledge of genetics was seen among the non-genetic healthcare providers. Demand of antenatal genetic testing among the public was also seen, highlighting the need of diagnostic facility for genetic and metabolic disorders. However, this needs to be explored in the context of the existing healthcare infrastructure.

This molecular genetics study was conducted in Karachi, Pakistan from 2004 to 2006 to provide guidelines for prenatal diagnosis programmes in the country. Blood samples of patients with beta-thalassaemia minor (n=200) and beta-thalassaemia major (n=150) were collected from hospitals, transfusion centres and diagnostic laboratories from different districts of Karachi, representing 5 major ethnic groups. Molecular analysis revealed 11 genetic mutations of the beta-thalassaemia gene, among which 5 mutations accounted for 88% of the total beta-thalassaemia genes identified [IVS-1-5 (G-C), Fr 8/9 (+G), Fr 41/42 (-TTCT), IVS-1-1 (G-T) and Del 619]. Other mutations identified were: CAP+1 IVS-II-1 (G-A), Cd 5 (-CT), Cd 15 (G-A). Cd 16 and Cd 30.

An infant with a prenatal diagnosis of citrullinemia, who started standard treatment at birth (L-arginine; sodium benzoate and a personalized diet characterized by a low protein intake and supplementation of essential nutrients and amino acids), presented at 4 months of age with extended, progressive, and severe skin lesions consistent with acrodermatitis dysmetabolica. Guidelines for the diagnosis and management of urea cycle disorders underline that a low-protein diet places patients at risk of essential fatty acids, trace elements, and vitamin deficiency. At hospital admission, our patient had normal levels of zinc and alkaline phosphatases. The plasmatic amino acid profile revealed a severe and generalized deficiency. In particular, the serum levels of arginine, valine, and isoleucine were very low and the dermatitis did not improve until the blood levels of these amino acids increased. In our patient, skin lesions happened despite an early diagnosis of citrullinemia and timely treatment due to compliance issues as a consequence of linguistic barriers. [ABSTRACT FROM AUTHOR]

This paper presents ethical dilemmas concerning the termination of pregnancy, the management of childbirth, and the withdrawal of life-support from infants in special care, for a small sample of British Pakistani Muslim parents of babies diagnosed with fatal abnormalities. Case studies illustrating these dilemmas are taken from a qualitative study of 66 families of Pakistani origin referred to a genetics clinic in Southern England. The paper shows how parents negotiated between the authoritative knowledge of their doctors, religious experts, and senior family members in response to the ethical dilemmas they faced. There was little knowledge or open discussion of the view that Islam permits the termination of pregnancy for serious or fatal abnormality within 120 days and there was considerable disquiet over the idea of ending a pregnancy. For some parents, whether their newborn baby would draw breath was a main worry, with implications for the baby's Muslim identity and for the recognition of loss the parents would receive from family and community. This concern sometimes conflicted with doctors' concerns to minimize risk to future pregnancies by not performing a Caesarean delivery if a baby is sure to die. The paper also identifies parents' concerns and feelings of wrong-doing regarding the withdrawal of artificial life-support from infants with multiple abnormalities. The conclusion considers some of the implications of these observations for the counselling and support of Muslim parents following the pre- or neo-natal diagnosis of fatal abnormalities in their children., (© 2011 Blackwell Publishing Ltd.)

Hepatitis B virus (HBV) is a major cause of morbidity and mortality worldwide. Although the United Kingdom (UK) prevalence of HBV is low, it is increasing. There is some evidence that the rate of infection is much higher in some populations living in Britain of non-white ethnicity or who were not born in Britain, compared with the British-born white population. We examined the prevalence of HBV infection in pregnant women through hepatitis B surface antigen (HBsAg) or e-antigen (HBeAg) in Birmingham UK between May 2004 and December 2008 and the effect of ethnicity on the relative risk of infection. There was a significant increase in the number of antenatal HBV infections detected over the study period from 106 cases in 2005 to 161 cases in 2008 (p=0.037). Women who define themselves as of black African, non-British white and Pakistani ethnicity had a markedly elevated rate of HBV infection (relative risk (RR): 11.25, 5.87 and 2.33 respectively) compared to the England average. Health organisations that serve populations with a high or increasing proportion of women originating from intermediate and high HBV prevalence areas of the world such as Africa, some parts of Europe and Asia, should anticipate a need for perinatal and postnatal prophylaxis to children born to HBV infected mothers.