title: Previous miscarriages and GLI2 are associated with anorectal malformations in offspring.
abstract: Are anorectal malformations (ARMs) associated with previous miscarriages or single nucleotide polymorphisms (SNPs) in the Bone Morphogenetic Protein 4 (BMP4) and GLI family zinc finger 2 (GLI2) genes?
  
  
  
  The SNP rs3738880 in GLI2 and miscarriages were associated with ARM, especially in patients with multiple congenital anomalies (MCA).
  
  
  
  ARM are one of the most common birth defects of the gastrointestinal tract. The etiology is likely to be multifactorial, involving both environmental and genetic factors. SNPs in BMP4 and GLI2 genes were associated with ARM in non-Caucasian populations. During a patient information day, several mothers of ARM patients reported their concerns about previous miscarriages.
  
  
  
  A case-control study was performed among 427 ARM patients and 663 population-based controls.
  
  
  
  We examined the associations of ARM with SNPs in GLI2 and BMP4 using DNA samples of the children and associations with previous miscarriages using parental questionnaires. In addition, gene-gene and gene-environment interaction analyses were performed.
  
  
  
  The SNP rs3738880 in GLI2 was associated with ARM, especially in patients with MCA (homozygous GG-genotype: odds ratio (OR): 2.1; 95% CI: 1.2, 3.7). We identified previous miscarriages as a new risk factor for ARM, especially when occurring in the pregnancy directly preceding the index pregnancy and in patients with MCA (OR: 2.1; 95% CI: 1.3, 3.5). No association with rs17563 in BMP4, nor gene-gene or gene-environment interactions were found.
  
  
  
  The possibility of recall errors for previous miscarriage, but we expect these errors to be limited, as a miscarriage is a major life event. In addition, potential misclassification regarding miscarriages and stillbirth, but sensitivity analyses showed that this did not influence our results.
  
  
  
  This study showed associations of ARM with rs3738880 in GLI2 and with previous miscarriages. Both associations were stronger in patients with MCA, showing the importance of stratifying the analyses by patients with isolated ARM or MCA.
  
  
  
  This study was funded by the Radboudumc. The authors have no conflict of interest to disclose.
authors.affiliation: Department for Health Evidence (133), Radboud Institute for Health Sciences, Radboud University Medical Center (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, the Netherlands Romy.vandePutte@radboudumc.nl.
authors.forename: Romy
authors.initials: R
authors.lastname: van de Putte
authors.affiliation: Department for Health Evidence (133), Radboud Institute for Health Sciences, Radboud University Medical Center (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Charlotte H W
authors.initials: CH
authors.lastname: Wijers
authors.affiliation: Department of Surgery-Pediatric Surgery, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands.
authors.forename: Ivo
authors.initials: I
authors.lastname: de Blaauw
authors.affiliation: Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands.
authors.forename: Carlo L M
authors.initials: CL
authors.lastname: Marcelis
authors.affiliation: Department of Pediatric Surgery, Sophia's Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Cornelius E J
authors.initials: CE
authors.lastname: Sloots
authors.affiliation: Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Alice S
authors.initials: AS
authors.lastname: Brooks
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
authors.forename: Paul M A
authors.initials: PM
authors.lastname: Broens
authors.affiliation: Department for Health Evidence (133), Radboud Institute for Health Sciences, Radboud University Medical Center (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.|Department of Paediatrics, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands.
authors.forename: Nel
authors.initials: N
authors.lastname: Roeleveld
authors.affiliation: Department for Health Evidence (133), Radboud Institute for Health Sciences, Radboud University Medical Center (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Loes F M
authors.initials: LF
authors.lastname: van der Zanden
authors.affiliation: Department for Health Evidence (133), Radboud Institute for Health Sciences, Radboud University Medical Center (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Iris A L M
authors.initials: IA
authors.lastname: van Rooij
mesh_terms: D000026:Abortion, Habitual / Q000235:genetics*; D000328:Adult; D000071056:Anorectal Malformations / Q000209:etiology* / Q000235:genetics; D055415:Bone Morphogenetic Protein 4 / Q000235:genetics; D016022:Case-Control Studies; D005260:Female; D005838:Genotype; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D009687:Nuclear Proteins / Q000235:genetics*; D020641:Polymorphism, Single Nucleotide; D011247:Pregnancy; D011795:Surveys and Questionnaires; D000075746:Zinc Finger Protein Gli2 / Q000235:genetics*
chemical_list: C525809:BMP4 protein, human; D055415:Bone Morphogenetic Protein 4; C082593:GLI2 protein, human; D009687:Nuclear Proteins; D000075746:Zinc Finger Protein Gli2
keywords: anal atresia; bmp4; etiology; gene–gene interaction; gli2; multiple congenital anomalies; spontaneous abortion