WHATS NEW IN PRENATAL DIAGNOSIS?

Goal
Provide informed reproductive choice and optimal medical care It is achieved by: (i) Assessment of risk, (ii)Transfer of information to the patient, (iii)Guidance and Assistance with the testing process

Prenatal Diagnosis

Why screen? Who to screen? How to screen? When to screen? When and how to do invasive testing What is the societal impact?

Down Syndrome

80% of invasive diagnosis are in women of Advanced Maternal Age ( i.e. > 35 years) but 70% of T-21 occurs in women < 35 years In India women are delaying childbirth in middle to high class society. 7.5% AMA in USA, 15% in Switzerland and Britain

Detection of Aneuploidy: Goal

Sensitivity approaches : 100% Specificity approaches : 100% Low false positives High likely hood ratios Minimal invasive diagnosis / high abnormal rate

Test Accuracy Parameters

Sensitivity

: the % of affected with the feature Specificity : the % of normal who are normal False positive : the % of tests with a normal outcome False negative : the % of tests with an abnormal outcome

Likelihood ratio

Sensitivity / False positive rate : - comparison of positive test in affected individuals to positive tests in normal individuals

How to screen: methods

Risk factors ( i.e. age, ethnic gp, history, etc) Morphology : ultrasound Analytes : PAPP-A, hcG, AFP, inhibin, estriol Combinations Fetal cells

The Non-Invasive First Trimester Diagnosis of Aneuploidy

Adv: Early interruption of pregnancy minimizes maternal medical risk Minimizes emotional and social aspects of pregnancy termination Outpatient procedure medical or surgical Reduce non specific invasive diagnosis (fewer losses)

The Non-Invasive First Trimester Diagnosis of Aneuploidy

Disadv: False positive rate of U/S is high (~14%) A proportion of interventions unnecessary False negative results occur

The First Trimester Diagnosis of Aneuploidy

Standard Approach

Either deferred to 2nd Trimester or CVS based on maternal age / history 1st Trimester amniocentesis abandoned as unsafe

The First Trimester Diagnosis of Aneuploidy

Emerging Approach:

U/S measurement of nuchal lucency + nasal bone Maternal Analyte screen (PAPP-A1, free beta-hcG, inhibin) Age specific anatomic survey Invasive testing based on specific risk profile

Estimates for the rate of Spontaneous Loss in Fetuses with Various Chromosomal Defects
Estimated Loss Rate Chromosomal Defects Trisomy 21 From 12 wks to 40 wks 32% From 16 wks to 40 wks 20%

Trisomy 18
Trisomy 13 47, XXX or XXY or XYY Triploidy

85%
80% ~5% >99%

75%
70%

Turner Syndrome 75%

50%
~3% >99%

Adjusted Risk 10-14 weeks scan

The higher the NT, the higher the risk for trisomies The higher the maternal serum hCG , the higher the risk for Trisomy 21 The lower the maternal serum PAPP-A, the higher is the risk for Trisomy 21

How to measure NT?

Nuchal Translucency

The right way to measure

Prediction of Trisomy 21
Detection Rate

Maternal Age
Maternal serum free hCG

11
10

31%
28%

Fetal nuchal Translucency

Maternal serum free hCG and age

28
15

78%
42%

Fetal NT and age

Maternal serum free hCG, age and fetal NT

28
32

78%
86%

Comparison of detection rates for Trisomy 21, for a false positive rate of 5%, by maternal age, maternal serum free hCG, fetal NT and by a combination of parameters, in a prospective study, involving 5,434 pregnancies

Absent Nasal Bone: Trisomy 21 Detection

11 14 weeks* # of cases 3829 16 26 weeks** 151

Successful # of T-21
Sensitivity Specificity

3788 (98.9%) 242

66.9% 98%

29
41% 100%

*Cicero et al Ultrasound Obstet Gynecol 22:31-5, 2003 **Virtzilieos et al Obstet Gynecol, 101:905-8, 2003

Increased NT and Normal Karyotype

Cardiac defects, Diaphragmatic hernia, Skeletal Dysplasias Risk increases with increasing NT 65% of fetal cardiac defects have NT >95th percentile and 40% greater than 99th percentile Fetal echocardiogram recommended for NT >99th percentile

Current Status

Test accuracy parameters vary by operator experience and adherence to protocol 85% detection of T-21 is normal Analyte assay access more wide spread Automated rapid (office) analyte assay and computer derived risk analysis available The test is becoming routine

First Trimester Tissue Diagnosis of Aneuploidy: Methods

Chorionic Villus Sampling Amniocentesis Fetal cells from Maternal Circulation

Total Fetal Loss Rate in Four Randomized Studies Comparing First trimester Chorionic Villus Sampling with Second Trimester Amniocentesis
Study Canadian Danish Finnish European CVS 7.6% 6.3% 6.3% 14% Amniocentesis 7.1% 7.0% 6.4% 9.0%

1 in 100 procedures

The Second Trimester Diagnosis of Aneuploidy

U/S characteristics of specific aneuploidies Maternal serum analyte profile (AFP, hCG, Estriol, inhibin A) Maternal age (Age of Ova Provider) Genetic History

Minor markers for T- 21

Second Trimester Screen: Analytes

Low AFP and Aneuploidy first described by Merkatz et al (AJOB / GYN 148:886, 1984) 2nd Trimester analyte screening (triple or quad screening) now routine and recommended Specific analyte pattern for specific karyotypic and non-karyotypic abnormalities

Second Trimester Screen: Analytes

MSAFP: Maternal age < 35 yrs, Weight adjusted, Individualized risk figure based on age, Analysis of only one serum sample, USG for date confirmation (eliminates 40% of initial positives) Detects 20% (>35 yrs) + 25% (<35 yrs) = 45 %

Second Trimester Screen: Analytes

Triple Screen: In addition to MSAFP hCG: Levels twice as normal in Aneuploidy MSuE3: decreases False positives by 3% and increases detection rate by11% When to screen: 15 to 20 weeks: Rationale

Screening Protocol: Triple Screen

Obtain sample 15 20 weeks If Down Syndrome Risk > 1 / 190: Do USG for dating If Dates incorrect (9 or more days different from LMP): Recalculate risk based on BPD or repeat Test after 15 weeks If Dates are correct (within 8 days of LMP): Offer amniocentesis or other invasive procedure for fetal Karyotype

Second Trimester Screen: Analytes

Sensitivity varies with age: from 67% (<35 yrs) to 87% (>35 yrs) Adding inhibin A (quad Screen) increases sensitivity to 70% in age <35 years Urine Analyte measures: Hyperglycosylate hCG, urine beta-core hCG are promising but not yet clinically useful

Increased AFP
Anomaly All open Neural Tube Defects All open peritoneal Defects All exudative anomalies Some renal Diseases (nephrosis) Twins Fetal Death U/S Diagnosis 100% 100% >50% 50% 100% 100%

Abnormal Analytes: Normal Karyotype

Unexplained high AFP associated with at least a 10X increase in placental disease and fetal consequence Unexplained high hCG associated with modest increase in placental disease Unexplained low serum estriol associated with placental sulfatase deficiency (5% MR), Smith-Hemli-Opitz Syndrome, Congenital Adrenal Hypoplasia, Adrenocorticotrophic Deficiency, Hypothalamic defect, Anencephaly

Trisomy 21: Phenotypic Features

Brachycephaly Mild Ventriculomegaly Nasal Bridge Hypoplasia Nuchal Oedema AV Defects Duodenal Atresia

Echogenic Bowel Mild Hydronephrosis Short Femur / Humerus Sandal Toe Clinodactyly

Nuchal Oedema / Echogenic Bowel

Ultrasound Criteria and Likelihood Ratios Assigned for Detection of Trisomy 21 U/S Findings Criteria Likelihood ratio
25

Structural Defect

Cardiac defect, cystic hygroma with or without hydrops, cerebral ventricular dilatation >5mm AP

Nuchal Thickening Echogenic Bowel Short Humerus

18.6

Subjectively increased grades 2 5.5 or 3 Observed 2.5

Echogenic intra cardiac focus

Renal Pyelectatsis Normal Ultrasound

Present or Absent
>3mm AP None of the Above

2
1.6 0.4

Snijders RJM, Nicolaides KH Ultrasound markers for fetal chromosomal defects. 1996; Parthenon Publishing, London

Trisomy 18
Strawberry Skull Choroid plexus Cysts Absent Corpus Callosum Large Cysterna Magna Facial cleft Micrognathia Heart defects (VSD) Diaphragmatic hernia

Esophageal Atresia Omphalocele Renal defects Myelomeningocele IUGR Radial aplasia Overlapping fingers Talipes / Rocker bottom feet

Ultrasound Findings Associated with Trisomy 18

Finding
Growth Restriction Hand / Feet Abnormalities Rocker bottom feet Overlapping Fingers

Percentage
46% 39%

Cardiac Abnormalities
CNS abnormalities Diaphragmatic hernia Ventral wall defect Facial Abnormality

31%
29% 13% 10% 7%

At least one abnormality

90%

Trisomy 13

Holoprosencephaly Facial Clefts Microcephaly Cardiac Defects Echogenic kidneys Post Axial polydactyly (USG identifies nearly 100% of the above anomalies)

Typical Facies T-13

Typical Facies T-13

Turners Syndrome (XO): Phenotypic Features

75% cases end in fetal death Cystic Hygroma Non-Immune Hydrops Cardiac Anomalies Non-lethal type has no markers (Normal intellect with short stature + infertility)

Triploidy: Phenotypic Features

Molar Pregnancy (Paternal) Severe Asymmetric IUGR Cardiac Myelomeningocele Syndactyly

Third Trimester

All anomalies discussed in 2nd trimester when missed Some Fetal Anomalies progressively worsens with gestational age: (i) Ebsteins Anomaly (ii) Chylothorax (iii) PUJ Obstruction Upper GI obstruction: (i)Esophageal Atresia (ii) Cong Diaphragmatic hernia (iii) Impaired Fetal Swallowing from Neurological causes

Single Gene Disorder

Identifiable Factors: Previous child affected with single gene disorder Family history of single gene disorder A parent having chromosomal anomaly Structural anomalies found on USG (Possum Data Base : Australian)

Single Gene Disorders

Common Diseases in India Thalassaemia Muscular Dystrophies Skeletal Disorders Cystic Fibrosis Inborn Errors of Metabolism, etc Work up index case: Counsel for the diagnostic test as an individual case