Maternal serum free alpha- and free beta-human chorionic gonadotrophin in pregnancies with insulin-dependent diabetes mellitus: implications for screening for Down's syndrome

Maternal serum marker medians in Aboriginal Canadian women

OBJECTIVES

The study evaluates the differences between Aboriginal and Caucasian women in the levels of maternal serum markers used in second-trimester Down syndrome screening (alpha-fetoprotein, unconjugated estriol, and total human chorionic gonadotrophin).

METHODS

A case-control study compared the levels of serum markers in 401 Aboriginal women and 1565 matched controls selected from 7717 Caucasian women. The cases and controls were screened in a single centre and matched for maternal age, parity, and sample date. Women with multiple pregnancies and pregnancies associated with Down syndrome, open neural tube defects, trisomy 18, and insulin-dependent diabetes mellitus as well as women without weight recorded were excluded from the study.

RESULTS

No differences in the levels of maternal serum alpha-fetoprotein and total human chorionic gonadotrophin were observed between the two groups. Maternal serum unconjugated estriol was 12% higher in Aboriginal women.

DISCUSSION

Since Aboriginal women make up only a small proportion of women screened, correcting the level of uE3 for this group will have little effect on the overall screening performance. However, if these results are confirmed by further study, individual centres may consider making this correction, so optimal screening performance can be achieved in Aboriginal women.

Biochemical screening for chromosomal disorders and neural tube defects (NTD): is adjustment of maternal alpha-fetoprotein (AFP) still appropriate in insulin-dependent diabetes mellitus (IDDM)?

Maternal serum alpha-fetoprotein (AFP) has been reported to be decreased in insulin-dependent diabetes mellitus (IDDM). The objective of the present study was to reinvestigate this finding in detail. Maternal serum levels of AFP, human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) in 114 diabetic women, of whom 84 had IDDM, were compared to those of 19,251 control pregnancies in the second trimester (15th to 20th gestational weeks). The mean body weight at the date of sampling was 73.7 kg in all diabetic women, 72.7 kg in women with IDDM and 68.3 kg in non-diabetic women, respectively. Body weights were significantly (p < 0.001) elevated in all diabetic pregnancies. Using weight-adjusted MoM (multiple of the median) values no statistical difference of serum levels in diabetic and non-diabetic pregnant women was found. Median MoM levels were 1.01 (hCG), 1.01 (uE3), 1.06 (AFP) in all diabetic women, and 0.95 (hCG), 0.96 (uE3), 0.96 (AFP) in women with IDDM, respectively. Ignoring adjustment for maternal weight leads to a reduction of all serum parameters in diabetic pregnancies. However, median MoM values of all three analytes are not statistically different when compared to non-diabetic pregnancies. This finding is contrary to the results of former studies from the 1970s and 1980s. It is concluded that progress in insulin adjustment and blood glucose surveillance of diabetic patients on the whole has balanced out serum levels. Therefore adjustment of serum AFP values for diabetic status no longer seems reasonable.

Antenatal screening for Down's syndrome

BACKGROUND

In 1968 the first antenatal diagnosis of Down's syndrome was made and screening on the basis of selecting women of advanced maternal age for amniocentesis was gradually introduced into medical practice. In 1983 it was shown that low maternal serum alpha fetoprotein (AFP) was associated with Down's syndrome. Later, raised maternal serum human chorionic gonadotrophin (hCG), and low unconjugated oestriol (uE3) were found to be markers of Down's syndrome. In 1988 the three biochemical markers were used together with maternal age as a method of screening, and this has been widely adopted. PRINCIPLES OF ANTENATAL SCREENING FOR DOWN'S SYNDROME: Methods of screening need to be fully evaluated before being introduced into routine clinical practice. This included choosing markers for which there is sufficient scientific evidence of efficacy, quantifying performance in terms of detection and false positive rates, and establishing methods of monitoring performance. Screening needs to be provided as an integrated service, coordinating and managing the separate aspects of the screening process. SERUM MARKERS AT 15-22 WEEKS OF PREGNANCY: A large number of serum markers have been found to be associated with Down's syndrome between 15 and 22 weeks of pregnancy. The principal markers are AFP, hCG or its individual subunits (free alpha- and free beta-hCG), uE3, and inhibin A. Screening performance varies according to the choice of markers used and whether ultrasound is used to estimate gestational age (table 1). When an ultrasound scan is used to estimate gestational age the detection rate for a 5% false positive rate is estimated to be 59% using the double test (AFP and hCG), 69% using the triple test (AFP, hCG, uE3), and 76% using the quadruple test (AFP, hCG, uE3, inhibin A), all in combination with maternal age. Other factors that can usefully be taken into account in screening are maternal weight, the presence of insulin dependent diabetes mellitus, multiple pregnancy, ethnic origin, previous Down's syndrome pregnancy, and whether the test is the first one in a pregnancy or a repeat. Factors such as parity and smoking are associated with one or more of the serum markers, but the effect is too small to justify adjusting for these factors in interpreting a screening test.

URINARY MARKERS AND FETAL CELLS IN MATERNAL BLOOD

Urinary beta-core hCG has been investigated in a number of studies and shown to be raised in pregnancies with Down's syndrome. This area is currently the subject of active research and the use of urine in future screening programmes may be a practical possibility. Other urinary markers, such as total oestriol and free beta-hCG may also be of value. Fetal cells can be identified in the maternal circulation and techniques such as fluorescent in situ hybridisation can be used to identify aneuploidies, including Down's syndrome and trisomy 18. This approach may, in the future, be of value in screening or diagnosis. Currently, the techniques available do not have the performance, simplicity, or economy needed to replace existing methods.

DEMONSTRATION PROJECTS

Demonstration projects are valuable in determining the feasibility of screening and in refining the practical application of screening. They are of less value in determining the performance of different screening methods. Several demonstration projects have been conducted using the triple and double tests. In general, the uptake of screening was about 80%. The screen positive rates were about 5-6%. About 80% of women with positive screening results had an invasive diagnostic test, and of those found to have a pregnancy with Down's syndrome, about 90% chose to have a termination of pregnancy. ULTRASOUND MARKERS AT 15-22 WEEKS OF PREGNANCY: There are a number of ultrasound markers of Down's syndrome at 15-22 weeks, including nuchal fold thickness, cardiac abnormalities, duodenal atresia, femur length, humerus length, pyelectasis, and hyperechogenic bowel. (ABSTRA

Maternal serum inhibin-A in pregnancies with insulin-dependent diabetes mellitus: implications for screening for Down's syndrome

A nested case-control study using stored serum samples collected as part of a prospective study of the outcome of pregnancy was performed to investigate concentrations of (dimeric) inhibin-A in maternal serum between 15 and 22 weeks of pregnancy in 126 pregnancies among 92 women with insulin-dependent diabetes mellitus (IDDM). Each IDDM pregnancy was matched with two control singleton pregnancies for gestational age (same completed week) and duration of sample storage (same calendar quarter). The median inhibin-A level in the IDDM pregnancies was 0.88 multiples of the median (MOM) for pregnancies without IDDM at the same gestational age (P = 0.05) (95 per cent confidence interval 0.78-1.00) or 0.91 MOM after adjustment for maternal weight. These results enable inhibin-A values to be adjusted so that prenatal screening for Down's syndrome can be performed using this marker in IDDM pregnancies as well as in non-diabetic pregnancies.