Turner Syndrome

Turner Syndrome is a condition that affects only girls or women. Most people are born with two chromosomes. While a boy inherits the X chromosome from his mother and Y chromosome from his father, a girl inherits one X chromosome from each parent. In case of Turner syndrome, one copy of the X chromosome is missing or partially missing or is significantly changed.

Named after Henry Turner, the first doctor who reported it in 1938, Turner Syndrome is one of the most common chromosomal disorders and likely the most common genetic disorder of females.

Genetic alterations that causes Turner Syndrome

Monosomy: Complete absence of X chromosome - caused due to an error of father's sperm or in the mother's egg.

Mosaicism: An error that occurs in cell division during early stages of fetal development.

Y chromosome: In a small percentage of Turner Syndrome patients, some cells have only one copy of X chromosome and other cells have one copy of the X chromosome and some Y chromosome material. Though these individuals develop biologically as girls, due to the presence of Y chromosome material increase, the risk of developing a type of cancer called gonadoblastoma is present.

Turner Syndrome can cause a variety of medical problems. Short height, puberty failure, infertility, heart defects and learning disabilities and social adjustment problems are some of the prominent signs of this syndrome. Family history is not a risk factor in this syndrome as it is quite unlikely that parents of one child with this syndrome will have another child with the same disorder.

Prenatal symptoms

Prenatal ultrasound of a baby with Turner Syndrome may reveal:

• Heart abnormalities,
  
• Large or abnormal fluid collection at the back of neck,
  
• Kidney abnormalities.

Physical features of Turner Syndrome at birth and during infancy

A wide neck, receding small lower jaw, high narrow roof of the mouth, low-set ears, low hairline behind neck, broad chest with widely spaced nipples, short fingers and toes, arms that turn outward at the elbows, narrow and upward turned fingernails and toes, swelling of hands and feet at birth, smaller than average height at birth and delayed growth.

Physical features noticeable in girls in teens/ young women

There could be occurrences when Turner Syndrome is not quite apparent. Some noticeable features are: No growth spurts, short stature – less than might be expected for a female member of the family, learning disabilities especially that involve spatial concepts or math, inability to understand other people's emotions and social situations, absence of sexual changes expected during puberty due to ovarian failure, early end to menstrual cycles but not due to pregnancy, lack of sexual development during teenage years, inability to conceive a child without fertility treatment.

Diagnosis

Sometimes even during fetal development, diagnosis of this syndrome can be made. While ultrasound screening may raise suspicion of Turner Syndrome in the baby; prenatal screening tests that evaluate the baby's DNA in the mother's blood could also indicate an increased risk of this syndrome. Other than the characteristic physical features described above, Turner Syndrome may be diagnosed prenatally, before birth, during infancy or in early childhood, although sometimes the diagnosis might be delayed. It is imperative that girls and women with this syndrome undergo ongoing medical care from a variety of specialists and regular checkups and appropriate care are taken.

Clinical testing

Karyotyping is a laboratory test that evaluates the chromosomes which is usually the determining factor for Turner Syndrome. In most cases a blood sample is taken to ascertain a person's karyotype. This syndrome is increasingly diagnosed before birth based on chromosomal analysis subsequent to amniocentesis or Chorionic Villus Sampling CVS. A sample of fluid that surrounds the developing fetus is removed and analyzed. In CVS, it involves the removal of tissue samples from a portion of the placenta. Accumulation of lymph fluid near the neck of a developing fetus can sometimes be seen on a routine fetal ultrasound.

MRI is performed in those affected for the presence of symptoms potentially associated with Turner Syndrome such as liver, kidney and heart abnormalities. Complete cardiac workup including echocardiogram is done to assess the structure and function of the heart. Thyroid and liver function tests, hypertension screening is done. Children and adults require periodic evaluation for hearing also.

Complications arising out of Turner syndrome

Some of the complications arising out of this syndrome include:

Heart defects or slight abnormality in the heart structure that could increase the risk of serious complications. This could be defects in the main blood vessel leading out of the heart or increased risk of a tear in the inner layer of the aorta.

Women with Turner Syndrome can have increased risk of diabetes and high blood pressure. Hearing loss is also common among girls and women with this syndrome. Gradual loss of nerve function could be the reason for hearing loss in some. Slight abnormalities in the shape of the skull could also increase the risk of frequent middle ear infections.

Kidney problems are seen in one-third of girls with Turner Syndrome who have malformation of kidneys. This could increase pressure and urinary tract infections, although they do not necessarily cause medical problems.

Increased risk of certain immune disorders such as hypothyroidism can be seen in some women with this syndrome. This disorder results in low production of hormones that is important for controlling heart rate, growth and metabolism.

Diabetes, inflammatory Bowel Disease and intolerance to wheat are conditions that can be caused by Turner Syndrome. Poor and abnormal tooth development and greater risk of tooth loss or crowded teeth and poorly aligned bite are complications of this syndrome.

Girls with Turner Syndrome pose risk of increased vision problems, due to weak muscle control of eye movements and farsightedness. Bones are bound to get affected by this syndrome, with increased risk of abnormal curvature of the spine and forward rounding of the upper back. Osteoporosis is another common risk of this syndrome.

Though most women with this syndrome are infertile, a small number do get pregnant spontaneously, and others become pregnant with fertility treatment. But, there are instances where women with this syndrome are likely to experience failure of the ovaries and subsequent infertility very early in adulthood. A cardiologist intervention is essential before pregnancy as they are at increased risk of aortic dissection during pregnancy. They are also at increased risk of high blood pressure and gestational diabetes during pregnancy.

Some girls and women do have psychological issues due to Turner Syndrome with disabilities in math and spatial concepts, difficulties in social situations and increased risk of attention-deficit/hyperactivity disorder.

Treatment and medication

Since chromosomal abnormality causes this syndrome, as such there is no specific cure. However, researchers have developed a number of treatments that can help with growth problems. Growth hormone therapy is recommended for most girls with this syndrome. This is done to increase height as much as possible at appropriate times during childhood and teen years. Growth hormone is given by way of injections several times a week and if the height is really short, doctors recommend androgens in addition to growth hormone.

Estrogen therapy is administered in order to begin puberty and achieve adult sexual development. Estrogen is also given along with growth hormone. Estrogen therapy usually continues throughout life until average age of menopause.

In case of some women with Turner Syndrome, they can become pregnant with donation of an egg or embryo. A specially designed hormone therapy is necessary to prepare the uterus for pregnancy. And pregnancy can be high-risk with Turner Syndrome.

Management of Turner syndrome

Those affected are advised regular checkups which can improve the quality and length of life. Periodic checkups for hearing loss, eye problems, high blood pressure and diabetes and osteoporosis are imperative. Follow-up with a heart specialist is essential as are regular ultrasounds of the heart. Healthy lifestyle habits such as maintaining proper weight and exercising regularly are important throughout life.

And, although girls with Turner syndrome exhibit learning disabilities, most can attend school regularly, write well, learn by hearing, can memorize and develop reasonably good language skills.

Tips for those with Turner syndrome

• Stay active in sports or hobbies.
  
• Consider some voluntary work. Helping others can boost your self-esteem.
  
• Talk to a professional therapist.
  
• Discuss your problems with your parents if you think they can help.
  
• Talk to your school counselor in case of any particular problem.
  
• Record your feelings in a journal or diary about the challenges you are coping with.

Valsalva Maneuver

Valsalva Maneuver is a technique that involves forced expiratory efforts wherein the person forcefully exhales while keeping the mouth and nose closed. The Valsalva Maneuver is performed sometimes by fighter pilots by grunting and tightening abdominal muscles to prevent blackouts during high performance flying. Valsalva Maneuver is used in medical and fitness fields for different purposes. However, it is normally adopted as a diagnostic tool to evaluate the heart condition of the patient. Valsalva Maneuver is often used in conjunction with echocardiography to assess heart abnormalities.

Valsalva Method

• Draw in air through nose or preferably through mouth to the maximum extent possible.
  
• Hold your chest/stomach muscles tight as if you are straining to initiate a bowl movement.
  
• Hold this position for a short while - about 10 seconds or as per your comfort level.
  
• Blow out the air sharply through the nostrils
  

Four different phases of hemodynamic changes occur while performing the Valsalva Maneuver.

1. At first phase of Valsalva Maneuver, pressure rises inside the chest cavity and pushes the blood out of the pulmonary circulation into the left atrium. This increases the blood pressure slightly.

2. During second phase, output of the heart is reduced and blood pressure falls, while the heart rate and peripheral vascular resistance are both increasing thereby raising aortic pressure.

3. The third phase involves releasing of breath which results in immediate drop in intrathoracic pressure. The compression of the heart chambers is eased out and the venous return is smooth, increasing the pre load.

4. During fourth phase, sudden increase in cardiac output and aortic pressure occurs due to rise in venous blood volume. As the intra-aortic pressure rises, heart rate reduces and also causes vagal (parasympathetic) stimulation.

Any deviation from these normal responses indicates abnormality of heart and autonomic nervous control of the heart. It is particularly useful in diagnosing left-sided heart failure and heart murmurs. If the patient is suffering from hypertrophic obstructive Cardiomyopathy, the murmur of the heart becomes louder with Valsalva Maneuver. In case of aortic valvular stenosis, the noise of the murmur decreases with Valsalva as less blood will be released through the aortic valve.

It also acts as a corrective measure, to treat abnormal heart rhythms or relieve chest pain. When Valsalva maneuver is carried out, the blood pressure of the patient spikes and thus allows the heart to respond by correcting its rhythm and beating more slowly.

This Maneuver is also used to treat particular ear disorders. It is in fact named after Italian physician-anatomist Antonio Maria Valsalva, who recommended it for clearing pus from an infected middle ear.

Valsalva maneuver is also useful to patients with multiple sclerosis as it helps them to empty the bladder completely. The Valsalva maneuver is also widely used in the field of fitness, particularly while performing lifts. The Valsalva Maneuver increases the intra-abdominal pressure, providing more support for the back during lifts.

Valsalva maneuver is also useful for correcting air pressure blocking your ears when climbing high altitude or scuba diving.

Cardiologist

Cardiologists are physicians who diagnose and treat ailments related to the cardiovascular system that comprises of the heart, arteries, and veins. Pediatric cardiologist is a physician who focuses on diagnosing and treating heart problems in infants, children and young adults. Cardiologists specialize in treatment of angina (chest pain), heart attack, heart failure, high blood pressure and irregular heart beats. A cardiologist has to complete medical school and undergo residency in internal medicine for a period of three years. Further three years of specialization in the field of cardiology is required. For pediatric cardiologists a specialization in pediatrics is required prior to cardiology specialization. Cardiologists are specialists who provide complete heart care; they can determine the working condition of a person's heart by means of different tests. The responsibilities of the cardiologist include:

• The primary function of a cardiologist is to check on how well a person's heart is working.
  
• They determine this by asking for various tests like the treadmill test (exercise electrocardiogram), and through procedures like angioplasty, cardiac catheterization etc.
  
• They offer treatments for the diagnosed heart diseases through interventional cardiology like angioplasty, where a mechanical device is used to set right the problem in the heart.
  
• They use electrophysiology that helps in treating the electrical functioning of the heart.
  
• They also have the additional responsibility of keeping control over the factors that determine the health of the heart such as blood pressure and cholesterol levels. These levels in the blood of a person are kept under control thus keeping the heart comfortably functioning.

Modern techniques used in the field of cardiology

With the advancement in the field of medicine, cardiologists have the access to the latest technologies like:

Auscultation: A stethoscope is used to identify and detect heart abnormalities and murmur in the heart.

Echocardiography: Ultrasonic waves are used to visualize the heart.

Electrocardiography: EKG instruments are used to monitor the electrical activity of the heart.

Holter monitor: Records the EKG for 24 hours and more non-stop.

Modern blood tests: Determining the levels of HDL, LDL, triglycerides, homocysteine, and C-reactive protein helps in easy identification of heart problems.

Stress testing: Determines the levels of stress and cardiac function of the heart.

Coronary catheterization: Functioning of the heart is determined by inserting a catheter into the heart.