Invasive Procedures for Antenatal Diagnosis GEORGE ATTILAKOS and PETER W. SOOTHILL INTRODUCTION Obstetric ultrasound fostered the development of invasive techniques co assist 19 antenatal diagnosis, Methoals such as chorionic villus sampling (CVS), armmoce blood sampling (UBS), and fecal issue biopsy’ allow testing ob feta materials lor chromosomal, genetic, and biechenvical ab malities. The tvpe of procedure selecsed depends an rvany faciurs, including the indication, che gestational age, and Ihaw sion the resale is needed Posvdle applications are rapidly with advances in human genetics and the cevalation al molecular tools, but all invasive in utero diag nestic techniques carty a risk of fetal nqury or death, Thes risks must be properly explained to the parents dusing thy Informed consent process, Noninvasive approaches, such as ‘measuring free fetal DNA sn the mothers Blood, shaw great promise but, are at present, used clinically nly in specstic areas, such a6 fetal blond group or sex prediction. Although LDNWand the introduction of effective screening stratezies have led to fewer invasive procedures, being perfumed the latter are required for the delimuive agnosis of most fetal genetic prnbslems ‘This chapter summarizes the indications, methods, and complications of the methests the use of free ist common invasive diagnostic ISSUES COMMON TO ALL INVASIVE DIAGNOSTIC TECHNIQUES All af the techniques described in this chapver share certar features Guidelines for Training The Royal Calleze of Obstetricians and Gynaccologists ERCOG) published guidelines for amniocentesis and, CVS, including guidance en training sn antenatal snvasive agnostic methods! They are praised for sheir elferts to seek standards They suggest thac practitinners who petform invasive procedures must have a high level of sraim ing in obstetric ultrasound and chat waining with clinica skills madels be considered. Because training is nov abi oan a ono cxbstconsa cow competency-based, they di not specify a minimum number of supervised procedures before practitioners can act nds pendently. However, they suggest that trainers. perform 2, Jeast 30 ulrascund-guided invasive procedures annually After complesing Gaining, physicians should perform at least 10 invasive procedures per vear in onder to reain thei the subject. It is also recommended that amniocentesis for ‘multiple pestatinn be performed ina certiary fetal mehcine unit Training in CVS and FBS is not part of general obstetric training and is usually limited to erainees who specialize i fetal and maternal medicine Units that perform mor comple fetal procedures shold perform enough proceduces each year to maintain skills. They should perietcally aude resulis and amke these available to patents and cok tues reasonable minimuiny number of complex pr dluses is 12 per year skills, although i is emphasized that there is ne evidenc: Consent. The procedure, ts goals, and hkely ar significant complicae Lions must be explained in fanguaue that is understandable to the patient so that written informed consent can be obtained. The speci cunsierations for each procedure ar dliscussed [a Audit of Practice Ic is impontnt that the rate of complications for indivi ‘operators is monitored through tobust mechanisms, Because scence of complications is small, i is proposed that #5% confidence interval (Cl) be used asa monitoring tool For example, the mariage tate for amniocentesis should noc be more than Saito or teat Kid eonsect tive procedutes. IF these values are iggered, = change ray be necessary A method of prospective perorman, monitoring by: saisical process contend charts has been diescihed” The compheation suidied was muluple needle insertion fo ammiocentess, abe the authors used the Chas a warning: lne and the 95% Cl as an “action” ine An indivicual with poor performance would have triggered the action line alter $5 procedures, 143144 SECTION THO # Early Prenatal Sampling Site Ultrasound is used 10 determine the best site to obtain the sample, considering the target size, needle lengch, needle path, and potential njury co structures in he path ‘Phe ski sit lor needle insertion is planned, but the posi Ultrasound-Guided Needling Technique Then approaches 10 ultrasound-puited needling are used needle guide and freehand Needle Guide The needle guide technique uses a sector or cunvilinear ultrasound «ransdacer with a guide that has anv acachead eedle channel, Lines on the ultrasound sereen indicate path of the thon inserted dwn the guise. The tiansdacer is moved until hese lines cross the incendled target This approach allows the use of thinner needles ie, 22-26 gauge! than those needed for 2 freehand pri cedure gauge), Despite the use oF 3 shinner beedie and the fcc that the entire length of the needle byt usually secn, the tips visible a alright dot Some have suguested thatthe comp u and its movement confined te on his ave hited The gale Goss pot seem) 0 heseas the need ta remove and reinsert the needle, por w there 3 relationship bevween the number of insertions and. the complication rate may be lower than with ele is thir though data frechanel technique, perhaps because th ingle plar Freehand The Hrechard techniewe uses a curvilinear or linear ulsae seaind gansducer The ulrasound transducer s moved ant the imended sampling sie 1s alentied ard appears on one side of the ultrasound seen, with the skin insertion point don the other The intended ne dicular te che ultrasound bean, allowing th le path is neatly perpen length of the adequately imaged ‘Fig 9-1), The freehand xled FIGURE 9-1 rete F essesde(N) enter hnique allows the operator te adiust vo changes during etal movements! ancl he authors ca have an assistant control thy scanning wansduicer, but then che operator forfeits conti! 4 the ingended needle path. Others preter sing cle and the other Holes the ultrasound tansiucer An assistant is eauited (0 athdrawe the necle sit, fica syenge,aspuate atthe right time, and place the sample m appropriate caneainers without spillage, chntamination, ar mslabeling hique in which one hand hokis the Preparation Regardless of technique, the atmosphere should be infor andl any adiivional stail requited should be present for the procedure and introduced t the patient Anything: chat ives the patient an image of an operation” (eg., surgical masks, hats. drapes) should be minimized or replaced by 3 scrupulous “nuctouch® technique. The length of the need fequied! depends an abdominal wall thickness, amnintic Hud volume, and les] and placental pasttions, An $ te 1D-cm needle is usally: salticient, Buc ab in doubt, the dis lance shoul be measured on Che streen betore the pr dure Detailed) ulasoand examinatinn of the fetus is performed lure because the discovery af th. or other prablems may tients cheive New ultrasnand he procedure unnecessary, ar help sub= when there is an unusual chromosomal finding siructaral deh ater the physicians and findings may mak: sequent such as mosaicism Needle Path Selection Ii using the freehand technique, the target is visual screen, and the transducer i rotated through 180 degrees uunul a path that avoids fetal parts and maternal vessels is identiied. The uansducer is sdiusted until site and the skin insertion poing are on op the screen With the neehandl technique, the best skin inser linn poine is determined by obyerving sanographically hi sc of digital pressure on the maternal abdomen. When a calle guide is used, simply line up the needle track wit anget he sampling site sides af Antiseptic and Anesthetic Th skin insertion site i sr tic solution fe, chlorhexic iger than by Incal ance thetic, which is injected tt into the skin and then inte the alndominal and wicrine pesnoneam When using the fre hand ecianique, the anesthetic wee tion may help confirm the needle angle required to follow the intended path and may decrease the need t change the d ping needle during the procedure When a needle guide i set, simply line up the needle track with the (arget and inject the lees anesthetic with a shorier needle. Patents ths have undergone ammiocentesis with a 22-gnuge need ith and. without local anesthesia reported simlar pain inl lencer pain scoves than outpatient alvsly cleanest with antiser auige needle may be helpes ion af the samCeaeies 9 # Invasive Procedures for Antenatal Diagnosis 145) Viral Infections Consideration should he given ce the possibility of feta infection by macernal-tetal crangmission ding the proces lure It appears the risk of fecal infection by hepantis Bs low and the hepatitis P eantigen status can help guide counseling.” Similatly the risk of hepatitis C vansmission appears low, but such data are hinited "Vertical transmie sian of HIV irae, and the vinus is not detectable in amin ‘ove fluid even sf avis detectable in the maternal blood However, the risk af vertical transmission may’ be increased by amniocentesis, particulaly if the mother is not on ant retroviral therapy" and if a fecal “needle-stick’ accurs. It is recommended that all screening wptions are considered in the case of mothers with HIV before invasive procedures are cotered." The use of anciresrevinal therapy is likely to reduce the risk of infection.” Postprocedure Considerations The patient should be shown bath the fetus and the mosien of the lel hesrt on the ultrasound menitor alter the proce- use. The sample is cavetully labeled, and the details ccanfirmed by the woman before the sample is ken t Taboratony. The information submitted co the laboratory must be sufficient lor testing to be dane and diagnosis tbe made. [t should include information about consent, include ing permission 10 store DNA and maintain cells kines, i applicable Alloimmunization An invasive provedur has a risk of Rhesus sensitization intrauterine procedure, SCOILE rather than 2501U. anti-l> immunoglobulin can be given intramuscularly to an at-risk Rhesus negative woman, and indeed, the Society of Obstex Uricians and Gynaccologists of Canada recommends 3 dase fof BHOTLL (300 Le cordacentesis" asscciated with placental bleed HO Nter an invasive following somniocentesis, CVS, or Multiple Pregnancies Invasive procedures should be pesformed sn women with ‘multiple pregnancies only: in 2 fetal medicine unit! In the fins: rimester, the chonionicty «i each sac should be care= fully determined and the placental implantation mapped In monochorionic pregnancies, a single amninti Hud sample may he reasonable. unless ultraseund. shows dliscondance for fetal abnormalities when both fetuses should besampled. In dichorionic presnancies, both sacs souk be sampled separately, either with a single needle threngh thi intertwin septum!” *or with two separate maternal abcam= nal punctures” The aperscor should be able and w'lling te periorm a selective feticie if an abnormal result i discor- dlant or refer the patient 10 am aponupriav T loss rate after amniocentesis i Gwin pregnancies appears slightly higher than an singleton pregnancies The risk ol miscarriage in various studies has been calculated bhecween 139% and 1.89; Ultrasound. guidance eliminates che need for any dye lis harmful dves such as Injection, and if used, porter methylene blue should! not he used** Instead of using a dye some operacors inject 2 0 3 malo annnionic thud mised with airback in the amnintic sac aiter the frstamnincentesis This Creates intense echogenicity in the Hrst ammiutic sac tan 30 als, which allows adequate time tor the second formed. IH an injection af dye seems to 08) se anmiocentesis to be p pniders, indigo carmine is preferred. Fetal zyyoiey ean be determined frum DNA when clinically indicated or at risk for ineritable syndromes ” the Tewuses Complications ‘The loss ric after an a combination of the procedure related less tate and the backaround loss rate. The background loss rate is much Igher ib the fetus has an anomaly ‘eg, chromosomal abnormality intravterine growth restriction, fetal hydrps ‘The procedure relsed Inxs rate is the product of many factors including maternal age, operator experience, type of proceddare, technique used, and the eiliculies experienced luring the provedare’** The gestational age at the ume of the procedure i also relevant. Inne stds, the race of fet loss an older scomen alter transabdominal and transcersica CVS was 5.8% and 62%, respectively, if done before 12 weeks, but 21% thereafter Some portion athe excess loss carly in gestation destined to occur whether the procedure was done or pot, Farly CVS and agnosis of ancuplatdy may result in ermimation, with al of the physical and psychological implications tor the parents, whereas delayed CVS or amniocentesis may, by Virtue of the later gestation alles Une for sponsaneas loss to precede the planned procedure Several multicenter studies failed to show consistene proved ‘ences with regard tothe safety of CVS compa methinls. The pracedure-sclated huss race for CVS, amniocentesis, andl IBS is reported in many studies, including those listed in Table 9-12 "No standard entera ae used to deter mine background loss rates. Postptocedural loss rates gemnet- ally include all up co 28 weeks and up to term in sor studies Others suawest thae most procedure-related losses occur within 2 weeks ofthe procedure Table 97 Procedures should be caniined to centers with volumes larae enough to calculate their own Toss rates rather than to quiet the rates of other units rvasive diagnostic procedure is reflects. losses related differ: sd with other le SPECIFIC PROCEDURES Chorionic Villus Sampling Introduction CVS, or placental biopsy, ss performed tram IE weeks ‘onwand for the diagnosis of many chromosomal and genetic Conditions. Ampircentesis used t@ be the most common invasive diagnostic test, but over the fase few years, CVS has grow in some countries to more than 303% af the mene sive diagnostic procedure, and the procedure Is associated with more than S08 of diagnoses “of -chromosona abnormality” probably because af fusuimester screening CVS is usualy performed by ansabeominsl needle spire tion, although some praccitioness still use a Wanscerviea146 sccTIONTS * arly Prenatal [0G Reported Outcomes after Invasive Prenatal Diagnostic Procedures ‘SERIES PROCEDURE STUDY NPE REPORTING OF OUTCOMES Aario Repete eutsome until heed of he Baio Pages ‘Sh fet Bak 2901 G wk} ned abertor, SB (A wk and Ccenasan ia, 298° Aavnio.CVS CT aboron loss 140 days between 241. 186ay5 SmittJensenelal 1992 Arnin.G¥S ROT Repeted eutsome unt he rectal petoe casied 11 soolenceusloss bers tne prootcue laste abortenpostarosteue. and uiantioal loss Jensen et) 1996 aaris rer Repete cusone a pstpracedu tal tal lessate unt teen Nonadesetal,:926* Arnio CVS Ghsewstonal —Gutpanesssied 1 trallosssponanous 2 induce) andseentaneous oss (U3/M0) Sunibergetal £927 Arnin.C¥S bse a0 Hanson eval, 1967" ‘avnio,C¥S. obser Eber etal 1 Anis Onsen ew 2988 Anis aria CVS Pepeted ss unre nk and nk aerbity Anis Repates fetal oss 24 we, $B 36 6 pote later 36k Papartoncuetal.2001° ria eal oss 2 we <28 hand > 28k Bessed ela 2001 Anis < eal ess wthn 30day5 Anis 24 wknd HND Brunetal, 2002 os Obsenatonal Heported fea loss< 2B wk and >2Bwk Lavell, 2005 os ‘hentia Reperted SA<24 wk. SB 24k anc ND Mawel eal 1991 Fs Csenstona] Reporte ossesin premercies wth normal fal nstony feta abrone tes. ftal pysiocgs assessment norinmarehdhons 2wk cut fo prosedueelatedoss Snardaune’etal 1993" FS ‘eerasonal —Reparted less wr=7F3S was cone for fetal aber onsean neva fuses, rein hytos asic nternal age 2 wk cu fo prooecureracedons ‘hin esl, 199 1 Fas, ‘Obsenstonsl —Rperted culos kaw nsk ous total fealleses < 28 wk and>28 wk ae Fs ‘Onsenstonal _Repertedpececireelated os nasesyth normal eal goat arate ea abrarmal of US nk ‘Were and Ghar Fas ‘Obseatonal —Repartedeutomesuntl tery 2-wk cute fr pracesureelace lass 1986 Overview of Pregnancy Losses after Amniocentesis, Chorionic Villus Sampling, and Fetal Blood Sampling, as Classified crerene villus sami: FBS. fatal roth resistor TEST TOTAL (%) MINUS KNOWN LETHAL CONDITION MINUS 32/52 PROCEDURE RELATED (=) Anrioertess 2018) 3 3 ayo) Crorerevilussaming $8 (4.1) “ 3 1(923) Fata bloodserpling 18 (107) 16 ° 2{L.13) From Nana B42 Scot PA ‘stent cose rin Prenat apyoash allow of uns wih &Cuastes 9 # Invasive Procedures for Antenatal Diegnas’s 147 technique, with catheter aspiration er biopsy. Many con sider uranscervical CVS an alpsolete technique because of the higher procedure pregnancy [oss rates.” Indications Feel uophoblst cells, espectally from the mesenchymal cane of the vill, divide rapidly: The advantage of fiscine ester CVS ss rapid hagnows at an early gestation. I? an abnormality is detected, surgi! terminsuen, rather than imeicalinluction, ear be offered. Farly detection ob chro imesimal disondets the most common indication for CVS The introduction and growing availability of first trimester screening far Down syndrome ‘eat nuchal translucency B human charionke gonadetropin BUICG| an pregnaney associated plasma provein A [PAPP.A, measurement?” have increase the importance al CVS. Nomnwasive anpreaches such as measuring maternal plasma tree fetal DNA, have made invasive testing for sex-related disease unnscessay In 51% of the cases because if is requited only when the fetus Because ov the increasing number of disgnosable monogenic disorders, couples with 9 fanny is the acrisk sex” Inscory of a genetic disorder should be offered genetic counseling, either before conceptinn or early in pregnancy Rapid direct preparation of the feral Karvotype or thiores {cont in situ hybridization ‘FISH have langely been replaced, with quantitative sluorescent polymerase chain. reacsion (QE-PCR) of chramasomes 13, 18, 21, and Yat requested Fetal cells are also cultured for karyotype analysis, but ais very likely that this will be replaced by molecular whole genome approaches such as aray comparative genome hybridization (CGH) CVS can be used at any tine in aestation, and placental biopsy 18 a very successiul: way to cbiain 9 karyotype atter delivery when the fetus has died CHORIONIC VILLUS SAMPLING Consent The procedure should be described to the patient Counseling must include the aims of the CVS ti.c.. karyotype. DNA analysis), and the risk of @ serous complication {often desenbed as 1%), including misoar- er provecure-elated or background, snould be quoted. The possiole risk of limb defects Is mere tioned by some, but the Fisk is minimal after 10 weeks, The limitations of a karyotyoe and the risks of unve‘ated abnormalities that are not detected by a karyotype should be explained, Patients should also be informed of the small chance that testing will show confined placenta’ mosaic'sm or sex chromosome abnormality {and the small possibility ofa further imasive technique such 3s amniocentesis or fetal blog sampling to Confirm a ciagnosis. Altemative diagnostic techniques may be discussed. Only after the counseling process is complete is the patient asked to provide written consert ‘Sampling Site The ideal target is a thiok patt of t can be sampled at an angle that allows 2 long needle pat ciough te placerta and avoids # perpenc cular patn toward the chorionic plate. Very rarely, at approxi mately 11 weeks, transaddominal CVS is difficult if the Uterus is rettoverted, the placenta s posterior, and lateral approach is not possible. Some operators switch to a transcervical aporoach, but we would ask the patient to return in a week, when sampling may be ier Target Puncture Tansabdominal CVS can be done either freenand or with @ needle guide. With te “double-needle” technique (Fig. 9-2), afler a local anesthetic has been administered, the frst needle is acvanced through the matemal skin, though the uterine wall, and into the placenta, The stylet is removed, arc @ second needle is passed into the placenta and attached to a syringe that contains normal saline. The placental vill are then aspirated. By drawing the finer needie into the outer neecle during aspiration, the sharp bevel of the first needle seems to cut te villi, reducing the ‘need for needle movement and presumaoiy reducing placental trauma.” A placental bioosy feroeps may also be used through an guter guide needle. With the double-needle technique, ifthe tip is inserted correct'y into the placenta, maternal contamination cannot ‘cout IF single needle is used, the asprated tissue oan de examined with a dissection microscope to exclude maternal contamination, but the tisk of cone tamination should d€ considered. Whatever tecnnique is selected, the sample is placed in 2 sutable CVS medium before it is transferred to the cytogenetics laborstory, Maternal contamination of chorionic cell cutures may lead to @ false-negatve ciagnoss, particularly when polymerase chain reaction (PCR) amplification is, Used and in some biochemical examinations. Operator experience reduces the risk of maternal cell contamination Transcervical CVS This approach is less common now because of an apparent increasec ‘tal loss and an increased isk oF FIGURE 9-2 An 18 22 40 5 ke serpling OVS) the tiie 21 glee of evl148 SECTION TWO Early Prenatal likelihood of failure’? Only 2%, and now probably less. of fetal _mecicine consultants. in the Lnted Kingdom perform transeerveal CVS."° Some practitior ners consider this approach useful in high risk patents who require ear'y diagnosis or when the uterus is ret roverted and the placenta is posterior or when an ante- i an abdominal approach diffgult. A bendable polyethylene catheter with a metal ‘obturator is introduced through the gervix and advanced into the placenta under ultrasound guidance. A syringe that is parvaly filed with saline attached to the hub and a vacuum created to aspirate 10 10 50 me of tissue, which is then rinsed inta a Petr dish. Some Units prefer curvee biopsy forceps.” Complications CVS should be performed only under continucus ultrasvunad dausdance Canadian arnt Danish” gral found ne significant dlitterence in procedure related loss rates between the fist and the second timesters, Only she Danish study” allowed, a randomized comparison al uansabcominal CVS and see onal-trimester ammocemtesis anc! the fetal lass rates were similar A 1 excess fetal loss rate is usually quoted tor amniocentesis and CVS, Sime reports suggest that firstuimester CVS includiny those pesfoamed as early as 6-7 wh) may be associated with severe limb devecte "These defects were nat abserved in CVS performed after 11 weeks gestation. The World Fleslth Organization WHO} Inernational Registry. for Liev Detects found no difference in the prevalence nf limb defects, after CVS compared with the background population. ‘Theretore, during counseling, its standard practice to ind cate that ther e of lim de To weeks is no increased incideny ces alter Placental Mosaicism Confined placental mosaicism occurs in approximately 13 oi samples but this rate may be lower with experienced laboratones, Analyzing, several cultures makes il easier to detect in vitro changes because they are usually present in a single culture. (pseudomosaicism), Hawever, the sam finding in several or all of the cultures increases she likel hood of re mosaicism, either confined te the placenta or present in both placenta ancl fetus. In this case, anocher feta issue, such as blond or amniatic fu, should he tested depending in parc en the particular chromosome invulved The finding of structural abnormality on ultrasound 1s wery important ari makes it much fess likely that the results are caused by confined pla Late Placental Biopsy Several small series inicace chat fate placensal biopsy sath safe and rehable for dhagnosis The loss rate 1s sar to chat of tst-uimester CWS" Conclusion CVS proviesa rich source of fetal cells DNA foranabysis at karvorwpic and genetic disorders. Its usually peviormed ater 11 weeks, typically by a ansabdominal route One advantage of fst trimester CVS is that an abnormal res allows surpical termination, desired, Nosaicism is = rare Camplication i about 1% of samples, the race i lower with Indications Genetic QFPCR/‘luorescent in situ hybrid zation, karyotype, DNA Procedural Options ransabdominal is the route of choice Complications Fetal lo mnie Fear of limb reduction defects (gestation dependent) Placental mosaicism Alloimmunization Maternal contamination ss vale hes been reported to be sitmilat to ntesis, though this remains eontieversial FER amas fue nyc. et aya, er Iya er liv’. 75,16 hve: 79,80 mye: a7 hie. 86Chast Amniocentesis Introduction Ampiotic Hud contains amniecytes in addition ta fetal cell from the skin, genigourinary system, and gut, along with biochemical products that may be removed for analysis Amniccentesis should be performed only under continues ultrasnand guidance * Indications GENETIC Ammiocentesis is usually performed sr determine feta! karvowpe. Indications tor fetal karyowvping include an abnarmal screening. test result for tisomy 21, advanced maternal age, a sonographically detected statural abnor malty, previous ancuploidy, and Known chromosomal trans location in ether partner: With the advance of genetics and iclecular biniogy, more genetic diseases Can be diagnosed boy amniocentesis rather than other more “direct” methods for example, harlequin ichthyosis ean now be dingosed with DNA-based testing on amniotic thre rather than skin biopsy" The amniotic uid container is labeled and examined boy the patient lor accuracy, and the sample is sent promptly to the evtogenetics laboratory for analysis. The amniacytes are stilied during the metaphase stage of cell division Although standard culture cechniaues recuire 3 co 3 weeks newer methods with the cells grown an 3 cover slip, allow a-complete analysis in 7 t0 1 days." and itis likely harvo- typing will be replaced by molecular approaches an the next fee years, Approsimacely 1.5% of cultures are unsccvesse less olten, macermal contamination complicates the diagno sis Less than 6 49% of cultures show evidence of pseudo. mosaicism of true mosaicism?" FRS may’ be helpfal, but a nremal result does not guarantee that al is well Direct DNA probing of interphase chromosomes by HSHT can be used to detect Known deletions. sich as 224 in abrsk pregnancies, im ackliion to rapid diagnosis of trisomy 13, 15, and 21° ut the later has’ beer replaced by QEVCR. Although a positive test resale is reliable, detecting 96% or more of chromosomal abnor malities, some problems detectable by haryntyping. wl nat be found on sapid cesting Carrently, rapid aneuploid screening is usually periormed with QI-PCR whose tian rate for the common aneuplondies (chromosines. 13 18,21, X. and Y) 46 98 65°" QF-PCR as some advantages dover FISH which is why itis used! more wisely. It has beer argued that QERCR could be used ay a. ‘stand alone test ino karyotype performed), us this could result in a small proportion ob abnormalities not being. diagnosed PCR-based primers are now used ith DNA trom amniatic Hud samples to determine almost all potentially relevant fetal red blood cell and platelet genotypes. "Methods using fiee fetal DNA in maternal blood are likely to further reduce the need for amnincentesis fy some countries, i is already used to detect fetal D status, when indicated as part of routine prenatal care and high throughput testing is being intraduced cy reduce the administration of the blood product” anc in routine antenatal prophylasis!™ 9 # Invasive Procedures for Antenatal Disg 149 BIOCHEMISTRY ‘Molecular DNA analysis has largely replaced amniocentesis, to diagnose inborn errors of metabolism and cystic ibrosis bby: measuring fetal enzymes activity and their products a subssrates, Likewise, amniocentesis to measure fetoprotein and acetvicholinesterase to diagnose a neural wibe defect are rarely om ecause of the rehabiliy of ultrascnography"! FETAL INFECTION Although eytomegalovins is exereted in fetal urine ancl feta infection is sciably detected by culture of amniotic thu PCR te antenatal diagnosis of fetal viral infection because: many vinwes glow poorly in clinial hbaratories aw se Chapters 2731 PCR has replaced che aadhtinal meus inoculation test for toxoplasmosis because it can be used nlogy is the method ot choice for the cearlier in pregnancy and has greater sensitivity (also see Chapter 32°" As with traditional methous, a falve-neyat result may occur there has beer insutlicient time for rane placental passaze te Therelore, in cases ob suspected losoplasmosis, a negative amimoventesis result does not provide complete reassurance and ultrasound follow-up 1s Fecormmenced CHORIOAMNIONITIS Sucvessful amniocentesis is possible in 49% 10 98% of women with preterm premature rupture of the membranes {PROMI "The Ihgher in more recent publications "= The specimen can be assewed by ditect microscopy, Gram stain, cult, apd 3 series ot new protenmic sis eis uncear whether manage ment based nthe information gained in women with PPROM changes the chinkal outcome: No randamized a suoports the tse af coutine amniocentesis 0 Giagnose Chorioamnioniuis in womten with either preterm labor oF PROM, although 3 small sudy showed an increased hos pntol say for babies in the “ne amniacencesis’ group!” A recent Feast study concluded that a randemized stay of amaiacentess versus no aminiacentesis yn waren with PPROM would he Feasible“ Amniocentesis may’ be use when the woman is asymptomatic and let! infection 1 sas ikelihood of successial sempling. is pected Hetween 17% and 34% of asymptomatic women with PPRONT have postive culture findings" which may allow for earlier diagnosis and treatment” Hawever, most women with positive culture findings delwer within 48 Hours, and there 6 anadequate informasin to gue ani ‘ote selection ensure therapeutic concentrations che site cf infection FETAL LUNG MATURITY Improved gestational dating, appropriate u roids, and a growing understanding of the ‘genic premature delivery have nearly eliminated the need for amniotic Fund analysis te assess Fetal hung macurty" Early Amniocentesis ol corticostes ming of iatr arly amniccentesis 215k) would bbe an alternative to CWS" However, che risks of early ammivcentes’s. including spontanceus abortion, stillbirth and neonatal death, are greater than those ot CVS." The150 SECTION TWO* Early Prenatal Canadian Farly and. Mid wimester Anmincentesis. Tra (CLMAT) group concluded that carly amniocentess should be performed only in special circumstances because of the Inher Fetal loss rare and inciclence al talspes with early verse second timester_ammocentesis. The risk ol membrane rupture is particulatly high when pertormed betore 14 com pleted weeks, possibly Because, at this stage, the arvnion Is not adherent to the chorian and so is more hhke'y to ruplare and persistent ar nv chorion separacion may’ be a isk factor even fer in pregnancy. Several other stiies found 3n increased risk of oligohydiamnins and associated arthoneti abnoimalities, ncliding talipes equmovanis ™* Tenting of the amniooe membrane and the smaller amounc of uid in the amniotic sc belore 13 weeks increase the incslence ob a dry" tap” The sample volume is smallerand there ae fewer cells permite, although the percentage wt cells dvidin is Ingher. Dialah and colleagues” reported that longer culture times were required alter early amniocentesis AMNIOCENTESIS Amniogentesis is perfoomed under ultr@sourd guidance after 15 weeks’ gestation. A typical karyotypic study reauires the removal of 15 to 20 mL of amniotic fluc Removal of larger volumes sould be avoided ur necessary for specific tests. Consent The indication and risks of the procedure should be fully explaineo to the woman. Serious or frequently occurring risks of amniocentesis that shoule be quoted to patients“! These include miscamrage (<1% excess Tiski, failure to obtain the sample, fetal jury, maternal bowel injury, amniotic fud eakage, severe seosis (<1/1000}, and failure of cell culture. Preprecedure ing by 8 midwife practitioner nas been success ‘oduced in some hospitals. Antiseptic and Anesthetic The skin is scrupulously cleaned with antiseptic solue tion (e.g. chlorhexidine}. Local a © 1S not nor mally requires for diagnostic amniocentesis, because it does not decrease the pain perception.”® Target Puncture Under ultrasound guidance, into the targeted pool of an to avoid the fetus, olscerta, A 22-gauge needles usualy us feenand technique 's used. the ultrasound beam is directed so that tne length of the neecle is visualized, allowing the ‘operator to alter the course in response to fetal move ments and contractions. When the tip oF the needle reaches the targeted location, a very small volume of amniotic fluid iS aspirated and discarded to avoid maternal contamination. Aporoximately 15 ta 20 mL o fiuid is aspirated and sent for analysis. To prevent maternal contamination, the syringe 's removeo from the nub before the needle is withdiaun from tne patient the neegle is advanced jatic fui. with care taken Complications nclaing € fof 3.2% after amniocentesis, "These losses are believed to rellect, atleast in pare, the lange needles used 219 gauge as well as unsiccessiul attempts. The liriish Working Party fon Amniacentesis rep 4 total fetal lass rate before 28 weeks (sullbirth rate of 12%) v6 0.8%) am control sul& iets) andl neonatal death (65% control subjects), But cone cluded chat she loss rate attributed eirectly te amniocentesis, was 1.5%!" The only randomized taal of Inw-nisk women sted! a 18% risk of spomtanenus abortion after anuntor ccontesis Interestingly, a secondary analysis of the patients, cearolled in the FASTER ‘First and Second Trimester Fvahie ation of Risk) wal!" shoved no difference inthe fetal loss MAT, Varly stale, orted 2 sotal loss rate rates before 24 weeks between the amniocentesis and the cantol “Te would be premature to adopt this cane chision ent literature reviews suggest an eXces6 Fetal los afer amnacentesis of © 636 [es possible that the canttol gsoup had 2 higher oss rate because of undhag nase chromosomal abrarmalicy cases sill being anche ‘while not being present nthe amniocentesis group. Out Siudy of fetal Toss alter amnincentess (lined 36 the tua lis tate minus knoven lethal condi ion mus losses bess 2 weeks postprocedure) was 0.7%2" The RCOG advises that a 15 nsk should be auoted to patienss, and i lower risks are quoted, they should be supported By robust cal dita! Pertating the placenta sncreases the relive tsk of loss 2.6 umes anc increases the maternal serum de fetopritein level $3 times. The sransplacental route should, therefore be avoided unless no ather option is avails Although avy randemized concroled tals assessed th related loss rate from amniocentesis sn multi Hpenancies, case-control studies suggest that the loss rate is only shghtly higher than the background sat C1591, 895)257"" OLIGOHYDRAMNIOS Up co 25% af amnincenteses are associated with chronic leakage of amniotic uid Ic is plausible that the risk is smaller needles, Thote are variable reports of an increased prevalence of neonatal respiratory metbidity alter ammocentesis: the small risk uf ahgohy= dlramnis afer amiccentesis may contribute te this compl cation" “Sigvfarly, talipes enuinovanus is rarely attributable co amniacentests, and probably only secondary to uligehydrannios ssnalier with the use ¢ FETAL TRAUMA, Fnadvercen puncture of the fetus during anratocencesis has not been not reperted in a large series when the procedure ‘was performed under contingens ultrasound guidance by experienced operators, Several case reports. suggest. ar association between animocemtesis and skin dimpling, #stue las, cord hematoma, ane! corneal pertoration Because incendie! fetal puncture rately leaves a mark and sinnl fink ings occur in neonates sho did not undergo anmiocentesis, the association is dubious, Hinwever, this 1s obviously cu be avoided, partly because al possible risks of viral transmission such as HIVChavtes 9 # Invasive Proc Conclusion Amniocentesis after 15 weeks is the most widely performed antenatal diagnostic technique. Ie is relatively simple to pettorm, and aichongh a fetal karvewype is che most commen Indications Chromosome analysis: fluorescent in situ tybridization. PCR. karyotype DNA diagnosis: single gene disorders (e.g, Huntingdon’), Xlinked disorders Biochemistry: exetoprotein, acetyleholinesterase Fetal infection: toxoalasmosis, oytomegalovirus Choricamniontis Lung, atutity Procedural Options, Local anesthesia not necessary Continuous ultrasound control Complications Fetal Loss Related lo experience of operator Inoveased with early aniniocentesis Chorioamniantis Preterm premature rupture of the membranes, oligetydramnos Alloimmurization Maternal contamination (goed orstoe sit POR, sola Fetal Blood Sampling Introduction Veal blood was frst cbained daring bor from the capillary circulation of the presenting part’?! FBS in a continuing Drcgnanes was fitst undertaken transabdeminally by fetor- Copy to dingnse severe whericed ciseases, with fermination planned it the fetus was alfected Cordecentesis was first reported in the 19808!°° The development of medical approaches to fetal disease has made the role of fetal phle- botomy ‘typically by cordocentesis) comparable with chat in postnatal medicine Indications Indications for FBS may be grouped inte diagnostic anal therapeutic areas. Here we focus on the diagnostic inde cations FBS is indicaced when the potentia! benetit of a dures for Antenatal Disgrosis 181 indication, the pracedure has many uses. The application of PCR has steadily recuced the amount of amniovic Mic needed for testing and the gine required for at least an inva! result Evidence Quality and Recor mmencdation References mye. 89-92 —/apP - 1} 96 he 97-100 w/e. 101-403 hie. 106 bya 7 we. 4 a} 4 [bya 54,58,67 Wwe at Haye 441 Wwe a7 Wwe 5s. change in management cunweighs the procedure related risks Diagnostic Uses CHROMOSOMAL ABNORMALITIES The sapid rate at which white blond cell divide allows 2 Igh-nualiy Karyotype with good chromosame banking swithin 48 t0 79 hours. The mast commun indications for a rapid karyotype are fetal malformation or severe early nset fetal growth restrictinn detected by ultrasonngraphy Hovwever the value of the speed of the result is falling with the rousing use of amnioti Hid PCR or ISH Other preoks lens that can be investigated by letal blood cytngenetic analysis incluce possible mosaicism and culture failure after either amniacentes's or placencal biopsy. Tor many’ indicae tions, QF PCR has replaced 1S182. StCT SINGLE-GENE DEFECTS HIS can diagnose hemaglebinopathies, coagulapathies, severe combined immanexteticieney: Chronic granlomatcas disease. and some metabolic disiners!™” FBS ws perlormed 6 disorders less often for antenatal diagnosis of sin than previously because many can be diagnoxcd earlier seestation by applying DNA techniques to amnicytes, FBS temas an option fr aterisk patients wh seek cate ate and when DNA analysis is nat prassible ANEMIA Although various indirect methods are used 0 assess fet ancinia (also see Chapter 13), the delinitive after birch is measurement of the hemoglobin concentration. This may be required in maternal red cell allaimmanizae tion!” and some eases of nonimmune hydrops!” The reli ability Doppler peak velocity so ligarse snemin hes areatly reduced the role of FHS to detect anemia" THROMBOCYTOPENIA Severe fetal thrombocytopenia as 2 result af alleimmnn thrombacytopenia may lead to cerebral hemorrhage beter dduning, ar after birth and might cause mental harvdicap or The fecal pe nos and ereaument, but this is used because af the st belore andl # the use of middle cerebral arsery death salso see Chapter et cou measated to guide d much less than previa figctiveness of intravenous immunoglobulin, which is now often used wing HIS HYPOXIA AND ACIDOSIS Fecal acicemia may be excluded by Doppler sudies of th Chapters 16 and 1 dj an be caniimed or related Increasing evilence shows mia is associated with impaired fetal vasculature alse fetal hyposia or acidemia by feral blood gas analysis that chronic fetal aci Susp long term neurexlevelopment!* However, there is. ne convincing evidence that the benelits of fetal a status outiecigh the risks of FES, and therefore, ais rare indicated INFECTION Apprapnawe fetal bluod tests (ep, sifection-specitic fet immunoglobulin Mur detection of specie genmmic maceta by PCR can determine whether maternal infecsion has led to fetal imlection, However, she difference between being ‘nfected’ and “affected” (ie damaged) must not be forgot ten. Fetal blood tests. are almost never used because th nniotic thud PCR has become established and the importance of ulesound findings is len MONITORING OF TRANSPLACENTAL THERAPY reaved by dnags that are given wo the miother, cross the placenta, and achieve therapeutic concer atone in dhe fetus. Fsamples include anvarshythimi ‘eg. Mecainale or digoxin’ to correct fetal tachyarrhy thmias and garmaglobulin to improve law fetal placelet counts, FPS, can be used to measure fetal d hoe ents Procedure Options The opersior chy technique from several options, described ear ses the intended sampling site and guide ‘SAMPLING SITE Umbilical Cord Vessels (Cordocentesis) HAS) was tst_petformed under fetoscupic: guidance’ anal envailed smpliation I addition, che macemal sedation used clita the proce blood gas measurements." Uae asidered sater and the preterted dure affected the fe sournd-guided needling is techniauy The placental origin of the umbilical cor is often she casiesi site to puncture: Nany preter this site because of ts n, which prevents movement of the needl nt free lonp puncture, bat use pancure niu fixed Incat Others minimize subsequent fi puncture without fetal paralysis and suggest ne obvious increase i fetal less rate!” A relevant cons the Ineation, but the case of access. The fetal umbilical cord is problematic Because there is bulfer the effect of Feral mmosement alter puncture ard the potential for braiycaraia may be increase. Althosigh dlacencesis is usually dane after 18 weeks, saccessis reported gs early a6 12 weeks, ab the cos note” Fetal Intrahepatic Vessels Blood can also be obtain the umbilical vein ig MThis procedure is use sehen the umbilical cond insertion spot accesible Ica made casi by adminstratinnof vecurnmun or paneuroniam int the vein for feta paraivss. This # especial tion IS mo of th length te an increased fetal loss ul from the intrahepatic portion of sel when a lengthy wanstusion is anticipated, The complication FIGURE 9-2 a bondsarpingty uvasoune ques nese ng oftrelnvatepatsFIGURE 9-4 Feallondserpingbylvasounequced ness ngottreheat. FIGURE 9-5 iyo. nese guide uses to ptm creooentess Thesal Fespanta ons te nese oer te senogenicplae shor at Inpenceaes eskn rates of this approach are comparable with those of cords ccentesss, and Us seems apphieable tn intravascular transhin sion as well ® There possibly. a smaller hkehood of bleeding alter this procedure, which may onake it more suite able for use when severe fetal thrombocytopenia i suspected! Fetal Heart The heart is larger than the umbilical cord, and puncuare of the heart is relatively simple (Fig. 91) Despite fear of damage. cardiac puncture is telacwely safe ! The heart ean he used sm the unusual event that the umbilical card or hepatic vein cannot be punctured and fetal blood must be sblained. Iecan ako be usetul ian emergency block anshue sian is equited ‘eg, 10 creat procedure-related Bleeding) ot fr fetede. Because the fetal heart contains blued froat dit. ferent circulatory origins, it may not be suitable for blood Anteratal Disgnoss 153 FIGURE 9-6 NEEDLING TECHNIQUE A needle guile or freehand technique may be used (igs and 9-6) A combined technique, in which the need vide is used! For the approach to che cord and a freehand chnique far the vessel punctate, has aso been describe Pan FETAL BLOOD SAMPLING The whethe wing elements a 2S is 2 with 2 needle only by physicians have extensive experence with otter obstetic, ultiz sound gu ded needle procedures (e.g... amniocentesis, ‘onsat cvs fer this service must minal CVS}, Units that m enough cases to maintain expertise: 20 proce dhres pe easonable minimum. This i reauir with many referrals.! Preparation An utger oo equited # the pregnancy is a potential nd if the indication access to an operative delivery roam with an at ust immeciately avaiable in viable pregnances. 1 mother should be postticned to avoid supit sion; hyperventilation and sedation should be avoid: An 8 to 120m needle is usually suFicient depending g iuid volume and e distance should be mess tal aporoa lacental cord origin, unless the placenta ior. However, in women with red cell , Wansplacental puneture boosts the154 SECTION TO Lary Prenatal FIGURE 9-7 Tarspaceal (and fy fra loos sap rom te lacenialinsertonoflhe unbaiealoed cedocetess. PL place (a) ) tibody titer as a result of fetalmate ge." Therefore, it is Dest to avoid the ‘ransfusion is anticipated in an al munized woman (Fig. Target Puncture Cordocentesis Many operators prefer the placental origin of the umbille cal cord, approximately + om from the olacent nal in pur close to or sharply advanced the remaining distance. A slow push the tissue away, even at After the needle tip is visualize the lumen of the umbilical cord, the stylet is remov dle 's ideally sited, ring is applied tightly to the hub, ar 7iml may ve samplec. out needle tip has gassed through the lumen or peraps is located n Whartan’s ell. 's sharply advanced or gently withctan (otated 180 degrees between the operator's finger anc thumb while suction is ma ntainec. sionally, amniotic fluid is obtained when the needle tio appears intraluminal. With the freehand tect= nique, the reedle d sidero-side n search of le guide, an upanddown needle praduces the same result (© movement. indicat needle has passed through the cord. Itis withdrawn until ne more amniotic ‘u's aspirated, the syringe is changed (because even a small amount’ of amniotic fluid is @ very powerful coagviant}, and the procedure 3 continued. if the .d through the side of the cord without pats aclusted. if the tip is lateral to the umbilical it is withgrawn and the needle used to touch the vein before the puncture attempt is “epeatec the puncture | fetal orign of the umbilical cord, t be identified by the cirection of turbulence after rapid injection of ud to 4 mL of normal saline" if fetal paralysis Is desired, intravascular admoisteaton of pancuronium (0.2-0.3 mg/xg estimated fetal weight) serves the same puroose as saline for ientifcation Intrahepatic or Heart If We intahepate vein or the reart is the intended sampling site, fetal paralysis with intramuscular gan- curonium (0.2-0.3 mg/kg estimated fetal we grt) may be usec. The effect is rapid (within minutes) and lasts: for 90 to 120 minutes. The techniques for needle aath selection and guidance are similar to those described for the umbilical cord. However, the fetal chest or abdomen is entered first, the direction is ch the needle 's advanced nto the sampling site as separate mavernent.. The heart is best entered through the anterior chest, through the thick muscle of the ventricles to reduce leakage and avoid demage I canguction system chnigue Nasalse been described. “ure the fetal bocy cavit the small caliper of the sampling needle Postprocedure Monitoring The puncture site is after the needle is mon after ransamniotic comocentesis, Out 3 usually briet and without clinical sgn fcance. After bleeding has stopnec., the fetal heart rate is measured. Bradyea‘dia is the most comman complication of cordacentesis, but it is, usually tansient, If the fetus 's oreviagle, the woman, should wait in the hospital until sne feels well and chen retuin nome, There are no special orecautions or restrict 2 local anesthetic is used, she should bbe warned to exoect a bruised sensation i Cr ited in about 10% of ally for bleeding ition analge- fely. If the fetus is viable, the heart assessed oy cardiotocography for at least 30 minutes before discharge. Pancuronium causes 8 nonreactive tracing, with mid fetal tachyoar dia, The mother should be warned thet oerceptivle rate pattem movement mignt not return for several hours, In tne rare. nt that bleeding fram the puncture sit © heavy, maternal blood may be col parinized syringes for an emer fetal transfusion. This is most likely with alloimmune thrombocytooenia when the fetus is profoundly thrombacytopenie, Laboratory Testing | laboratory techniques are available to ravialy im that the blood sample is fetal and p. ‘they may be unnecessary if the descrikec previously is used. Further, they meCuapr unusable ifthe fetal blood nas been replaced with adult blood by transfusion. ‘t is prudent to send small sample of blood for a hematology profile to confirm that ‘the mean cell volume is nereased and that the hemo lobin concentration, white blood cel! count, and piate- let count are norma Complications and Risks FETAL The principal complications well being are, TBS that threaten fetal 1 onder of frerurey, fetal bradycardia Iprabobly asa test of smooth muscle spasm afer nade tent parcture ot the umbilical artery), hemorthage of an obstructing hematoma at the puncture site,” and intrauter ine infection! Chorioamnionts selten caused by Sth Ince aver It apically causes maiz, arial, an 2 lowe lever 4 hy 1 days ater the procedure There te no evidence (0 suppert prophylactic antibiotic administration, Sid most the anabrotc agents ase achieve oar amniotic Hid levels so prophase ws unnecessary Phcental abn tion shory after condnceness has heen repented andl PPROAT has 9 Irenueney sian to that of amniocentesis There is a risk ef transmitting infection from the mothers: blood ‘eg, hepstitis, HIV te the fetus, but this sks probe abby lise and possbiy lower wath the use of antec Ueatment in-patients with HIV’ Tt has not yet been dlocumented. Nevertheless. invasive procedures should vad when » nother has 9 ke threatening vil less unless the fetal andiatiom warrants the aahional rsh! A case of fetal hepatic necross in a Srithin 24 ours of an been repute POSTPROCEDURE LOSS RATES Several well recognized factors alfect_postprocedure loss ratherestricted fetus hepatic vein blood sampling, has rates, Loss and complication rates are clearly related to the inglicavionfer sampling andshe hnalretaliagposis 0" The background risk of intrauterine death is high when there is 2 severe structural malformation or 3 major chramesama abnormality. The rsk of proiound bradycardia is signiti- cantly sncreased by fetal hypoxemia and areal puncture There does pot appear ta be an increased risk ater condom ccentesis in fewises with a single umbilical arten!” Gestae tional age at sampling #8 also an important deceiminant hhecause a viable fetus can be delivered af a complicasion Indications: Diagnostic 9 # Invasive Procedures for Antenatal Disgnass 155 Fetal death ct slelivery is arises, Fmenency cesarean section may prey but by the time the problem is recognized accomplished, the neonate may survive permanently damaged or die in the neonatal period, Pestorming the pri cedure near the delivery ste minimizes these risks, it dlive ‘ery can be accomplished within 15 minutes The liverature must be interpreted carefully because post. procedare loss rates. are described after the appheation of ‘ualifcts. Its essential co control for the indication or fina liggnsis when comparing loss rates. [tis only by doing so ani! by limiting the comparison to healthy tetuses that the risk of the technique is shown Reports oF procedures per formed frechand shaw 2 tatal procedure loss rate of approxi mately 1% to 2%, depensting on the mix of indications. Ir done stualy of 202 pregnancies, the loss rate was 1 of 76 (45%) fetuses sampled for antenatal diagnosis, 5 of 76 (79% sampled lor an anomaly, 4 of 29-14%) sampled for Fea! assessment, and 9 of 49 (234%) sampled for noninmune hydraps:” The fetal loss rate was similarly low in more recent sts." Tansfusion caries a constderably higher procearetelaced risk than FPS MATERNAL The main maternal nish asnciatel wih FAS i red calli mmunization, The lel lol (ype should be teste in at sk ‘women, and anti-D immunogleulin shoul be given if the feuis is Rhesus positive. Chorioamnionitis or emergency cesarean section can create securadary maternal rks When TiS or transfusion is undertaken and the leis is considered Viable, maternal aspects of emergency delivery should considered. Needle injury to the macernal nara ablomins aigans, such as stestines, or wesels may be mre commer than recagnized, but sunificant morbidity has not reperted alter FES. Maternal iners-ahdvinal infection and bleding woul! be epee acura the same ate sa Conclusion HHS ig indicated! when the potential benelits of a change outweigh che procedure-related risks, The risks and benelits tw both the fetus and the mother should be considered. Most prefer FES by ulvrasound guided needling of the umbilica The fetal heart ant intrahepatic veir are alternate sampling sites. None. of these cechniaues should be attempted unless the eperator has considerabl experience with relaied pracedures, The most imponant determinant of the fesal less rate iS the indication ler sampling cord (cordocentesis Evidence Quality and Recommendation Chromosomal abirmalties DNA abnormality or single-gene defects Fetal anemia Fetal thrombocytopenia —/spP _ —/GPP - —yapp =156 SECTION TWO Lary Prenatal Evidence Quality and Recommendation Fetal hypoxia or aeidosss —/GPP Fetal infection =) - lhe effeots of fetal therapy yp ventesi} OPP = yap? - —yapP = Complications Fetal logs rate related to © Gestational age nye: 138,139,151, © Operator experiance ve. 138,239 ‘© Number of needle insertions ue. 138,139,451, # Invication fay, intrauterine ve. 198,139,151 restiction, chromosomal abnormality) ope Fetal Tissue Biopsy Although progress in molecular biology allaws more die eases to be diagnnsed fram fetal DNA, some cankltions st require testing af fetal ussue, such as skin, liver, and muscle These tests are rarely indicated) because the diseases ar rate Only experienced feal medicine specials should periorm them. Rapid advances in the teld mandace close contact wich # clinical geneticist to stay abreast of new developments ‘Skin Biopsy INDICATION Hila examination of a fecal skin biopsy specimen is uscful fn the diagnosis same Dos disorders fcongensa bullous epidermolysis, epidermalssis bullosa dystrophies epiermalysisbullesa lethals)°"hyperkeraotie dite ders congenital ichthyesitor exythrodeym, epidermelytic byperkerstoss, Flarlenuin ichthyosis" figs. 9-8 and 95, or oculocutanecus albinism” A molecular under standing of these diseases has made early diganosis by CVS possible. and therelore, the number of shah biopsies per fomed has decreased since the early 19908!” Occasionally fetal skin biopsy can confirm sme leral sais. Fetoscopy is rarely performed disgnostically, out the development of new fiberopte scopes has decreased the pregnancy loss rate 10 less then the rote of 2% 10 FIGURE +8 5% associated with classic fetoscopic method Anivartnthhavequn erieCuaetes 9 # Invasive Procedures for Antenatal Diegnoss 157 These scope: fetal procedures. ar popular aids for some therapeutic in}. For skin laced by ultra scund-guided biopsy. commonly performed with 2 20-gauke biopsy forceps introduced thraugh a 16- to 18-gauge oeedle. Obtaining mult ple small biopsy spec- imens of skin fram the scalo over the aceiput or fram the outtocks is recommended." The fetal sain heals well after bios} LABORATORY TECHNIQUES Histologic and biochemical tools lke elecsron microscopy and immunshistochemistry™’ are used to diagnase skin cor ditions Several ichthyoses and genetic condivans assoc, ated with ichthyoses are diagrosabie with fetal ellsobiained, from CS, amniocentesis, or FPS. Fetal Liver Biopsy Ampictic fluid cells and placental cissue may be used to diagnose most fetal metabolic diseases." However, some inherizable inborn errors of metabolivm show defects in enzyme activity cuntined to the liver and require a fetal hver biopsy Fetosconic**” and ultrasoundguiced'™ procedures are used (Fig. 9-10), Eitner a hollow needle or a TuCut biopsy needle is inserted through the skin, over the right upper quadrant of the ‘etal abdomen, an into the Iver (Fig. 9-11}. The diopsy specimen is sent to a labo- ratory. Normal overall activity of a number of enzymes, but low activity of @ specific enzyme is considered eve dence of disease. FIGURE 9-10 Feta ner boosypetorrea wth ae Fetal Muscle Biopsy ‘The mast common inhertable major muscular dystrophy is Duchennes muscular dystraphy, which is caused by 2 defeet in the gene lor dystrophin" Although icis often diagnos able antenatal DNA ebtained by: CVS with molecular analysis secking either a deletion mutaiion er a linkage analysis, the gene is large, with many possible defect sites! In some cases, no deletion «6 thud) and. bapsy is the only recourse. '"* Other myapathies can also be agnosed " LABORATORY TECHNIQUES Awide range of studies is possible, For Duchennes muscular dlystraphs, the biopsy specimen is examined te cantirm the presence of muscle and treated with an inmunofluorescent nuboaly for dysicophin protein thig 9-12). FIGURE 9-11 Raving neslewth an as FIGURE 9-12 ‘eta musseticpeysoeomen cia inmurstuces raph ie thetrsine wa ih sejotPrt & Lop Desstentethewsoatilegs rs Lé158 SECTION TWO* Early Prenatal Enea Risks of the provedure include fetal ‘These uncommon procedures shoule be performed only damage, and pregnancy loss. There re reports of by exoerienced fetal medicine specialists." The mater maternal contamination."° but this can de prevented ral abdominal skin is anesthetized, and a small nick with a double-needle technique. is made with a scalpel to facilitate the entry of a TuCut biopsy gun”? (Fig, 9-13). Under ultrasound guidance the tp is aovanced into the fetal buttock or thigh in 2 downand-cut grection. The ecring guide is extendec, Other Organ Biopsy Histologic dianesis af feral tumors would be helptul an many cases, and! there are eports of biopsy of fetal media Linal and renal camors "However binpsy nf any tumor can cause uncontrollable bleeding, leading tosevere teal damaxe dordeath. In many cases, the histologic features vary in dif= ferent locations. Asa reall, biopsy fa fers! mass is rarely advised Conclusion Most antenatal fetal diagnases are based on fetal DNA. obtained by CVS, anmiocentesis, or FBS: However, feta skin, fiver, and muscle biopsy specimens are required far some lethal or severely. disabling condisions, These are complex procedures, with significant risk tv the pregnancy FIGURE 9-13 and they should be performed only in terciany Fetal medcin sarkosy gun centers by experienced clinicians Evidence Quality and Recommendation References Indications Possible or potential Ifethreatening disease in —/cpP = the fetal skin, liver, and muscie Procedural Options etoscopy and biopsy =/ePP = Utrasoune guided aspiration cpp = Ultrasound guided TurCut biopsy =/8PP = Complication Fetal oss: =/e9P = Fetal injury (searring} {SPP - Preterm cupture of the membranes and/or oligahydramnios —/ePP = ‘GPP = Choricamniantis ‘pe go Hielund CK, Jorgaser FS, Petersen OB, ota Danish F Resenuh Coa: Fret anew sation see Armiogentets, RCOC Corsent dabtce 6. London, Reyal Colese of to Desmurk Popbtion hased coh ‘Obsteviians and Gymecongats 2K Seon Sarat Amrincamess and Croronie Wiis Sapling, RCOG Green TopCatdelse — fnning KML Slaran PG, Scothil PNY Avent ND, Pre Loran, Roysl Cillge of Obssencars and Gymauclgss, 4 Datos stort tater lana, vwdacton of 2 new nom Fddleman KA, Malone FD. Suliyan Ie al. Pregnancy lose ces fetal RHD uenorvoing serve Tarstnon 24042107041 Competes of Fe (Chk 8, Sepulveda W, ecko CI, Ror ura ‘Noo sampling im tel CynecalChavtes 9 # Invasive Procedures for Antenatal Diagnosis 159 Naval K, Kyle P. Sooshll PW. A Cassieton of pretnaney loses — Wainer CP. Grose © Prensa dno son ysis alti fon amc P. ry | Ose Ga Cmparoon af'unis wih 2 irene exe avs, Prenat Dia Pasi Nusol Culsborstiog Cente fue Woes and Meath Ay he Healy Prego: Woman, nde London, Royal College of Obstet ard G 8, pp 14-17, slows es” REFERENCES S, Phi Landstees C, etal. Randomised companion of Tora complete list of eerencs, lag aio mww.expertcon emesis st trasshson tal an anscerva) crore as