Pandora's pregnancy: NIPT, CMA, and genome sequencing-A new era for prenatal genetic testing

"The anxiety coming up to every scan-It destroyed me": A qualitative study of the lived experience of cytomegalovirus infection during pregnancy

BACKGROUND

Emerging evidence supporting the use of valaciclovir to reduce fetal infection after maternal primary cytomegalovirus (CMV) infection has stimulated interest in routine CMV serological screening in pregnancy. It is important to understand the healthcare consumer perspective of a CMV infection during pregnancy to minimize unintended harms of screening.

METHODS

We conducted a qualitative study using semi-structured interviews with Australian women who had a lived experience of CMV infection following serological testing during pregnancy. Participants were recruited via social media and healthcare consumer networks, and purposively selected to capture a range of perinatal outcomes. Interview transcripts were analyzed using inductive content analysis.

RESULTS

Twelve participants were interviewed: 6 had a live birth, 4 had terminations of pregnancy, 1 had a neonatal death and 1 was pregnant at the time of interview. Four major categories emerged from the analysis. Women reported a lack of CMV awareness among themselves, their social networks, and among their health care providers. The participants described their experience as "hard" and "stressful". Uncertainty and variability characterized their clinical decision-making process. The pregnancy and postpartum periods were marked by ongoing anxiety about the long-term impacts of CMV. Women supported screening for CMV, decision making and reproductive choice, but acknowledged that routine testing may not be desired by everyone and may increase stress and terminations of pregnancy. Important coping strategies included obtaining support from partners, family, and other families with lived experience of CMV, as well as having access to knowledgeable and sensitive healthcare professionals.

CONCLUSION

Serological diagnosis of maternal CMV infection during pregnancy can have severe and prolonged psychological impacts on parents, regardless of the pregnancy outcome. Improving healthcare professionals' knowledge and public awareness are essential before widespread serological screening can be responsibly introduced. Healthcare administrators that are considering implementing a prenatal screening program for secondary prevention of fetal CMV infection should pay attention to consumer perspectives to minimize unintended harms to women and their families.

Women's attitudes towards disclosure of genetic information in pregnancy with varying levels of penetrance

BACKGROUND

Chromosomal-microarray-analysis (CMA) may reveal susceptibility-loci (SL) of varied penetrance for autism-spectrum-disorder (ASD) and other neurodevelopmental conditions. Attitudes of women/parents to disclosure of SL during pregnancy are understudied.

METHODS

A multiple-choice questionnaire was distributed to postpartum women. Data were collected on women's interest to receive prenatal genetic information with various levels of penetrance.

RESULTS

Women's (n = 941) disclosure choices were dependent on the magnitude of risk: approximately 70% supported disclosure of either full or 40% penetrance, 53% supported disclosure at a 20% risk threshold, and 40% supported disclosure at 10% or less. Although most women supported, rejected or were indecisive about disclosure consistently across all risk levels, nearly one-quarter (24%) varied their responses based on penetrance, and this was associated with religiosity, education, parity and concern about fetal health (p-values <0.04). Among those who varied their choices, the risk threshold was lower among secular women (20%) than among ultraorthodox women (40%). In a multivariable analysis, ultraorthodox women were much less likely to vary their choices on ASD disclosure compared with secular women (aOR = 0.37, p < 0.001).

CONCLUSION

Women's attitudes toward disclosure are influenced by the level of risk and their individual characteristics. We therefore encourage engaging women/couples in disclosure decisions regarding uncertain and probabilistic results from prenatal genomic tests.

"We are just not sure what that means or if it's relevant": Uncertainty when gathering family history information in South African prenatal genetic counseling consultations

Uncertainty impacts the process of health communication. The management and tolerance of uncertainty during healthcare discussions have gained renewed focus due to the growing challenge of obtaining and delivering complex health information, and the offer of health services in diverse contexts. Prenatal genetic counseling (GC) provides education, support and testing options for patients and couples facing a genetic or congenital diagnosis or risk during pregnancy. Gathering detailed and accurate family history information is essential to determine a patient's genetic risk. In South Africa, contextual factors such as patient literacy, language diversity, limited written patient health records, and a lack of familiarity with GC services may increase the potential for misunderstandings during GC consultations. This study uses a qualitative sociolinguistic approach to analyse 9 video-recorded South African prenatal GC consultations to understand the impact of uncertainty on the process of gathering family history information. The findings reveal uncertainty is introduced in different ways during family history taking. This includes when patients have no knowledge about their family history; when they have some knowledge but the details are unclear; or when patients have knowledge but the details are confusing. Uncertainty can lead to interactional trouble in the form of knowledge asymmetries, interrogative questioning, reversals in epistemic authority, and the potential for mistrust. Suggestions are made for how genetic specialists can manage uncertainty in GC family history taking. These include recognizing contextual sources of uncertainty, understanding how patients may respond to uncertainty and being aware of personal responses to moments of discomfort. Specific communication training recommendations and video-based sociolinguistic methods to enhance reflection and communication practice are highlighted. These approaches may enhance the effectiveness of GC communication and strengthen patient-specialist relationships, especially in diverse settings.

Western Australian women's expectations for expanded NIPT-An online survey regarding NIPT for single gene, recessive and chromosomal conditions

Prenatal screening has evolved rapidly following the introduction of non-invasive prenatal testing (NIPT), with screening now available for an increasing number of conditions. We explored the attitudes and expectations of women within the context of using NIPT to detect multiple different single gene and chromosome conditions during pregnancy. An online survey was used to assess these issues with a sample of 219 women from Western Australia. In our study, the majority of women (96%) support of the concept of expanded NIPT for single gene and chromosome conditions provided the test involves no risk to the pregnancy and can provide the parents with relevant medical information about the fetus at any stage of pregnancy. 80% believed that expanded NIPT for single gene and chromosome conditions should be available at any stage during pregnancy and 68% of women indicated that test cost would be a factor in determining their participation in testing. Under half (43%) of the women favored an option to terminate a pregnancy at any stage if the fetus had a medical condition that would interfere with day to day functioning. The majority (78%) of women believed that testing for multiple genetic conditions would provide reassurance and lead to the delivery of a healthy child.

"Overestimated technology - underestimated consequences" - reflections on risks, ethical conflicts, and social disparities in the handling of non-invasive prenatal tests (NIPTs)

New technologies create new complexities. Since non-invasive prenatal tests (NIPTs) were first introduced, keeping pace with complexity constitutes an ongoing task for medical societies, politics, and practice. NIPTs analyse the chromosomes of the fetus from a small blood sample. Initially, NIPTs were targeted at detecting trisomy 21 (Down syndrome): meanwhile there are sequencing techniques capable of analysing the entire genome of the unborn child. These yield findings of unclear relevance for the child's future life, resulting in new responsibility structures and dilemmas for the parents-to-be.The industry's marketing strategies overemphasize the benefits of the tests while disregarding their consequences. This paper chooses the opposite path: starting with the underestimated consequences, it focuses on adverse developments and downsides. Disparities, paradoxes, and risks associated with NIPTs are illustrated, ethical conflicts described. Indications that new technologies developed to solve problems create new ones are examined. In the sense of critical thinking, seemingly robust knowledge is scrutinized for uncertainties and ambiguities. It analyses how the interplay between genetic knowledge and social discourse results in new dimensions of responsibility not only for parents-to-be, but also for decision-makers, authorities, and professional societies, illustrated by a review of different national policies and implementation programmes. As shown by the new NIPT policy in Norway, the consequences can be startling. Finally, a lawsuit in the United States illustrates how an agency can risk forfeiting its legitimation in connection with the inaccuracy of NIPTs.

Temporal sociomedical approaches to intersex* bodies

The history of the field of intersex bodies/bodies with variations of sex development (VSD) reflects the ongoing tension between sociomedical attempts to control uncertainty and reduce the duration of corporeal uncertainty by means of early diagnosis and treatment, and the embodied subjects who resist or challenge these attempts, which ultimately increase uncertainty. Based on various qualitative studies in the field of intersex, this article describes three temporal sociomedical approaches that have evolved over the last decade and aims to address the uncertainty surrounding intersex/VSD bodies. These approaches are (1) the corrective-concealing approach, which includes early surgeries and hormone therapies intended to "correct" intersex conditions and the deliberate concealment of the ambiguity and uncertainty associated with intersex conditions; (2) the preventive approach, which involves early genetic diagnostic methods aimed at regulating or preventing the recurrence of hereditary conditions under the umbrella of VSD; and (3) the wait-and-see approach, which perceives intersex bodies as natural variations and encourages parents to take time, wait, and give their children the right to bodily autonomy. A comparison of these approaches from biopolitical, phenomenological, and pragmatic perspectives reveals that time is an essential social agent in addressing and controlling uncertainty, a gatekeeper of social norms and social and physical orders, and, on the other hand, a sociopolitical agent that enables creative social change.

Postpartum women's attitudes to disclosure of adult-onset conditions in pregnancy

Background

Advanced prenatal genomic technologies can identify risks for adult‐onset (AO) conditions in the fetus, challenging the traditional purpose of prenatal testing. Professional guidelines commonly support disclosure of high‐penetrance AO actionable conditions, yet attitudes of women/parents to these findings and factors affecting their attitudes are understudied.

Methods

We explored 941 (77% response rate) postpartum women's attitudes towards receiving prenatal genetic information, and associations of sociodemographic, medical and psychological characteristics with their choices, focusing on AO conditions.

Results

Women largely support the disclosure of actionable AO findings (58.4%), in line with professional guidelines. A third of the women also supported the disclosure of non‐actionable AO conditions. Stronger religious observance (p < 0.001) and higher psychological distress (p = 0.024) were associated with decreased interest in receiving actionable AO conditions, whereas higher concern for fetal health yielded increased interest (p = 0.032). Attitudes towards disclosure were strongly associated with women's perceived benefit of such information for their own, partner's, and future child's health. Termination of pregnancy based on such information received very little support.

Conclusion

In‐light of the demonstrated understanding of nuanced genetic information and the observed diversity in attitudes, a culturally competent opt‐in/out policy could be considered. If full‐disclosure is practiced, support should be provided to those expressing higher levels of distress.

What is known

Advanced prenatal genomic technologies can identify risks for adult‐onset (AO) conditions.

Professional guidelines support disclosure of high‐penetrance AO actionable conditions in pregnancy, yet attitudes of women/parents towards receiving this information are understudied.

What this study adds

Investigating the attitudes of nearly 1000 postpartum women demonstrates that women largely support the disclosure of actionable AO findings in pregnancy.

Stronger religious observance and higher psychological distress predict decreased interest in receiving this information.

Fetal information as shared information: using NIPT to test for adult-onset conditions

The possibilities of non-invasive prenatal testing (NIPT) are expanding, and the use of NIPT for adult-onset conditions may become widely available in the near future. If parents use NIPT to test for these conditions, and the pregnancy is continued, they will have information about the child's genetic predisposition from birth. In this paper, we argue that prospective parents should be able to access NIPT for an adult-onset condition, even when they have no intention to terminate the pregnancy. We begin by outlining the arguments against testing in such a situation, which generally apply the same considerations that apply in the predictive testing of a minor to the fetus in utero. We then contend, firstly, that there are important practical considerations that support availability of testing for prospective parents regardless of their stated intentions. Secondly, we object to the ethical equation of a fetus in utero with a minor. We base our analysis on a view of pregnancy that conceptualises the fetus as a part of the gestational parent, as opposed to the more common 'container' model of pregnancy. We suggest that fetal information is best conceptualised as shared information between the gestational parent and future child. Thus, it should be approached in similar ways as other kinds of shared information (such as genetic information with implications for family members), where a person has a claim over their own information, but should be encouraged to consider the interests of other relevant parties.

You can't keep a bad idea down: Dark history, death, and potential rebirth of eugenics

"Be careful what you wish for": This adage guides both how this project came to life, and how the topic covered in this review continues to unfold. What began as talks between two friends on shared interests in military history led to a 4-year discussion about how our science curriculum does little to introduce our students to societal and ethical impacts of the science they are taught. What emerged was a curricular idea centered on how "good intentions" of some were developed and twisted by others to result in disastrous consequences of state-sanctioned eugenics. In this article, we take the reader (as we did our students) through the long and soiled history of eugenic thought, from its genesis to the present. Though our focus is on European and American eugenics, we will show how the interfaces and interactions between science and society have evolved over time but have remained ever constant. Four critical 'case studies' will also be employed here for deep, thoughtful exploration on a particular eugenic issue. The goal of the review, as it is with our course, is not to paint humanity with a single evil brush. Instead, our ambition is to introduce our students/readers to the potential for harm through the misapplication and misappropriation of science and scientific technology, and to provide them with the tools to ask the appropriate questions of their scientists, physicians, and politicians.

„Selektive“ Fortpflanzung durch pränatale Diagnostik?

Die breite Einführung nicht-invasiver pränataler Tests (NIPT) sowie die Ausweitung der Testziele über Trisomien hinaus machen es notwendig, Sinn und Ziel der pränatalen Diagnostik (PND) als emergente soziale Praxis grundsätzlich zu diskutieren. Wenn, wie angenommen wird, PND nicht zu eugenischen Zwecken, sondern zur Stärkung der Autonomie dienen soll, muss gefragt werden, welche Bedeutung die Entscheidungen haben, ein bestimmtes zukünftiges Kind (nicht) zu gebären. Stephen Wilkinson hat vorgeschlagen, PND als eine Form „selektiver Reproduktion“ zu verstehen. In diesem Paper wird geprüft, ob die Charakterisierung der Entscheidung nach PND als „Selektion“ zutrifft und welche moralischen Vorannahmen ihr zugrunde liegen.

Es zeigt sich, dass das Konzept der „selektiven Reproduktion“ die Handlungen der PND inakkurat repräsentiert. Es beinhaltet zudem sowohl eine Abstrahierung als auch eine Distanzierung. Es nimmt an, dass Frauen und Paare entweder falls nötig mehrere Schwangerschaften planen, um ein gesundes Kind zu erzeugen, oder sich als Ausführende einer selektiven Strategie auf der Populationsebene verstehen. Die Einschränkung der ethischen Diskussion auf das Problem der Selektion verdeckt zwei wichtige Problemfelder, die die konflikthaltige Situation der PND aus der Perspektive der Frau oder des Paares charakterisieren: die Schwangerschaft als persönliche Beziehung und den Akt des Abbruchs der Schwangerschaft. Aufgrund seiner impliziten Normativität wird „selektive Fortpflanzung“ als sinnvolle Bezeichnung für die Praxis der PND zurückgewiesen.

Chromosomal microarray analysis for pregnancies with abnormal maternal serum screening who undergo invasive prenatal testing

Recently, chromosomal microarray analysis (CMA) has been implemented as a first-tier test in pregnancies with ultrasound anomalies. However, its application for pregnancies with abnormal maternal serum screening (AMSS) only is not widespread. This study evaluated the value of CMA compared to traditional karyotyping in pregnancies with increased risk following first- or second-trimester maternal serum screening. Data from 3973 pregnancies with referral for invasive prenatal testing following AMSS were obtained from April 2016 to May 2020. Routine karyotyping was performed and single nucleotide polymorphism array was recommended. The foetuses were categorized according to the indications as AMSS only (group A) and AMSS with ultrasound anomalies (group B). CMA was performed on 713 prenatal samples. The proportion of women opting for CMA testing in both groups increased over the years. The incremental yield of clinically significant findings for pregnancies with high risk of screening results was similar to that for the foetuses with ultrasound soft markers (P > 0.05), but significantly lower than that for the foetuses with structural anomalies (P < 0.05). The total frequencies of variants of unknown significance in groups A and B showed no significant difference (P > 0.05). CMA should be performed for pregnant women undergoing prenatal invasive testing due to AMSS, especially with high-risk results, regardless of ultrasound findings.

Understanding False Negative in Prenatal Testing

A false negative can happen in many kinds of medical tests, regardless of whether they are screening or diagnostic in nature. However, it inevitably poses serious concerns especially in a prenatal setting because its sequelae can mark the birth of an affected child beyond expectation. False negatives are not a new thing because of emerging new tests in the field of reproductive, especially prenatal, genetics but has occurred throughout the evolution of prenatal screening and diagnosis programs. In this paper we aim to discuss the basic differences between screening and diagnosis, the trade-offs and the choices, and also shed light on the crucial points clinicians need to know and be aware of so that a quality service can be provided in a coherent and sensible way to patients so that vital issues related to a false negative result can be appropriately comprehended by all parties.

How are uncertain prenatal genetic results perceived and managed two years after they were received? A qualitative interview study

Chromosomal microarray has considerably improved our ability to identify or dismiss genetic conditions in the unborn child. However, this detailed analysis also reveals copy number variants (CNVs) of unknown or uncertain significance, in which the specific child's prognosis can be difficult to predict. Little is known about the longer-term impacts of receiving an uncertain prenatal CNV result. Our qualitative study explored how such a result was perceived and managed in everyday life, 2 years after it was received. From an original sample of 16 couples, nine women participated in a semi-structured follow-up phone interview. Transcripts were analyzed using thematic analysis. The results show that these women did not perceive the CNV result to be a part of their everyday lives. They managed the CNV result by focusing on the child's positive development, by not sharing the CNV information in wider social networks, and by emphasizing parental values such as taking life as it comes, welcoming human variation, and accepting that dealing with a child's struggles is an inherent part of parenthood. Overall, the women expressed a positive attitude toward prenatal genetic information about serious disorders but considered 'their' CNV to be close to normal; several women suggested that such findings should not be reported. However, they also recognized the difficulties in making such decisions, given variable penetrance and that couples' definitions of 'serious' could vary significantly. The diagnostic process during pregnancy was remembered as being highly stressful, and many expressed a need for more control in a future pregnancy. Our study provides insight into how mothers reconfigure CNV results to fit their values and everyday lives. When delivering uncertain CNV results in a prenatal setting, genetics healthcare providers should present and discuss long-term coping strategies with expecting parents.

Prenatal Exome Sequencing: Background, Current Practice and Future Perspectives-A Systematic Review

The introduction of Next Generation Sequencing (NGS) technologies has exerted a significant impact on prenatal diagnosis. Prenatal Exome Sequencing (pES) is performed with increasing frequency in fetuses with structural anomalies and negative chromosomal analysis. The actual diagnostic value varies extensively, and the role of incidental/secondary or inconclusive findings and negative results has not been fully ascertained. We performed a systematic literature review to evaluate the diagnostic yield, as well as inconclusive and negative-result rates of pES. Papers were divided in two groups. The former includes fetuses presenting structural anomalies, regardless the involved organ; the latter focuses on specific class anomalies. Available findings on non-informative or negative results were gathered as well. In the first group, the weighted average diagnostic yield resulted 19%, and inconclusive finding rate 12%. In the second group, the percentages were extremely variable due to differences in sample sizes and inclusion criteria, which constitute major determinants of pES efficiency. Diagnostic pES availability and its application have a pivotal role in prenatal diagnosis, though more homogeneity in access criteria and a consensus on clinical management of controversial information management is envisageable to reach widespread use in the near future.

Prenatal screening diagnosis and management in the era of coronavirus: the Sardinian experience

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new coronavirus, was first identified in December 2019 in Wuhan, China and spread rapidly, affecting many other countries. The disease is now referred to as coronavirus disease 2019 (COVID-19).The Italian government declared a state of emergency on 31st January 2020 and on 11th March World Health Organization (WHO) officially declared the COVID-19 outbreak a global pandemic. Although the COVID-19 incidence remained considerably lower in Sardinia than in the North Italy regions, which were the most affected, the field of prenatal screening and diagnosis was modified because of the emerging pandemic. Data on COVID-19 during pregnancy are so far limited. Since the beginning of the emergency, our Ob/Gyn Department at Microcitemico Hospital, Cagliari offered to pregnant patients all procedures considered essential by the Italian Ministry of Health. To evaluate the influence of the COVID-19 pandemic on the activities of our center, we compared the number of procedures performed from 10th March to 18th May 2020 with those of 2019. Despite the continuous local birth rate decline, during the 10-week pandemic period, we registered a 20% increment of 1st trimester combined screening and a slight rise of the number of invasive prenatal procedures with a further increase in chorionic villi sampling compared to amniocentesis. Noninvasive prenatal testing remained unvariated. The request for multifetal pregnancy reduction as a part of the growing tendency of voluntary termination of pregnancy in Sardinia increased. The COVID-19 pandemic provides many scientific opportunities for clinical research and study of psychological and ethical issues in pregnant women.

Personalized prenatal genomic testing: Couples' experience with choice regarding uncertain and adult-onset findings from chromosomal-microarray-analysis

BACKGROUND

Chromosomal-microarray-analysis (CMA) can identify variants of uncertain clinical significance, susceptibility-loci for neurodevelopmental conditions, and risk for adult-onset conditions. We explored choices made by couples undergoing prenatal CMA, their understanding of these findings, reasons for and against receiving them, and whether they believe parents or professionals should decide which are disclosed.

METHODS

Semi-structured interviews were conducted with women (n = 27) or their partners (n = 15) during the week following prenatal CMA testing and analyzed using grounded theory.

RESULTS

Over half the interviewees (55%) recalled at least two of the three types of CMA results they chose whether to receive. Sixty-four percent found the choice simple, whereas 36% found it difficult. All participants could clearly explain their choices, which were based on the perceived actionability and psychological impact of the information. Sixty percent viewed their choice favorably, whereas ~21% would have preferred clinicians to decide for them. More women than men, and more decisive than indecisive participants supported parental choice.

CONCLUSION

Overall, expectant parents can make informed choices about which uncertain findings about their fetuses they wish to receive, and value the opportunity to tailor results to their values and wishes. Arguments presented provide the basis for a decision-aid tool for expecting parents.

What is the meaning of a 'genomic result' in the context of pregnancy?

Prenatal genetic testing and analysis in the past was usually only offered when a particular fetal phenotype was noted or suspected, meaning that filtering and interpretation of genetic variants identified could be anchored in attempts to explain an existing health concern. Advanced genomic testing is now increasingly used in "low-risk" pregnancies, producing information on genotype adrift of the phenotypic data that is necessary to give it meaning, thus increasing the difficulty in predicting whether and how particular genetic variants might affect future development and health. A challenge to healthcare scientists, clinicians, and parents therefore is deciding what qualities prenatal genotypic variation should have in order to be constructed as a 'result.' At the same time, such tests are often re requested in order to make binary decisions about whether to continue a pregnancy or not. As a range of professional organizations develop guidelines on the use of advanced genomic testing during pregnancy, we highlight the particular difficulties of discovering ambiguous findings such as variants with uncertain clinical significance, susceptibility loci for neurodevelopmental problems and susceptibility to adult-onset diseases. We aim to foster international discussions about how decisions around disclosure are made and how uncertainty is communicated.

Non-invasive prenatal testing: A diagnostic innovation shaped by commercial interests and the regulation conundrum

Non-invasive prenatal testing (NIPT) is grounded in the analysis of free circulating fetal DNA (cfDNA) in pregnant women's blood. The rolling out of this screening method was in large part driven by commercial firms, which hoped to reach a huge potential market by offering a test that was expected to be risk-free, reliable, inexpensive, and able to detect a wide range of genetic traits of the future child. To date, most predictions about the scope and uses of NIPT have not materialized: in 2020 NIPT detects only a limited number of genetic anomalies, while results have to be confirmed by amniocentesis. NIPT has become a commercial success. Nevertheless the implementation of NIPT has tended to diverge across different national settings. In countries that already have state-sponsored screening for Down risk, NIPT has been offered by the state health insurance to women defined as "high risk", using a variant of the test that detects only three autosomal aneuploidies: trisomy 21, 13 and 18. These countries effectively regulate the supply of NIPT on grounds of cost-effectiveness and reliability. In countries without state-sponsored screening for Down risk, in contrast, multiple versions of NIPT covering a wider range of birth defects are commonly available on the free market, and purchased by women at low as well as high risk of having an affected child. Market-based healthcare systems tend to present women who can afford to pay for NIPT with a largely unregulated choice of technologies - though reimbursement rules imposed by private insurance providers may serve in effect to regulate use by those consumers who cannot afford to pay for tests from their own pockets. This regulatory divergence is shaped by the presence or absence of prior state-sponsored screening programs for Down risk.

Non-Invasive Prenatal Screening: Navigating the Relevant Legal Norms

The implementation of non-invasive prenatal screening (NIPS) in Canada will be affected by legal norms. The law can shape physician behaviour, help to crystallize standards of care, influence utilization patterns, and reflect and reinforce patient expectations. In Canada, failure to inform a patient about NIPS, or misinterpretation of NIPS results, could result in a successful "wrongful birth" claim if the patient subsequently gives birth to a child with a condition that had been detectable. Given that research shows that physicians' decisions are influenced by concerns about liability, malpractice law seems likely to encourage increased recommendation and use of NIPS. Physicians' fiduciary and negligence-based disclosure standards require they consider both objective factors as well as a specific patient's subjective and reasonable beliefs, fears, desires, and expectations. Thus, physicians likely must address dominant public discourses and controversies relevant to NIPS. Given the existence of spin, hype, and misinformation about NIPS, there is an increasing need for a robust consent process and, when appropriate, genetic counselling. In sum, the law will define and bound the acceptable behaviour of physicians recommending or administering NIPS, and nudge the technology's implementation forward. Physicians and policymakers should be aware of the potential impact of these legal norms on both utilization and public expectations.

The decline of amniocentesis and the increase of chorionic villus sampling in modern perinatal medicine

Objective The aims of this study were to determine the rate of change by type of diagnosis by transabdominal chorionic villus sampling (TA-CVS) vs. amniocentesis for aneuploidy and to describe a successful and intensive international training program for TA-CVS in ongoing pregnancies. Methods We conducted a retrospective cohort study of all deliveries from 2010 to 2018 in Sardinia. All invasive diagnostic procedures are conducted at a single regional perinatal referral center. Descriptive statistics were used to compare data across groups, and inter-correlations between variables were investigated by Pearson's correlation coefficient. We subsequently describe the international trainee experiences in TA-CVS over a 35-year period. Results A total of 101,025 deliveries occurred over 9 years. The number of deliveries (13,413-9143, P < 0.0001) and total invasive diagnostic procedures (1506-858 per year, P = 0.019) declined over this period. The percentage of deliveries undergoing invasive diagnostic procedures remained steady (mean: 12.2%). In 2010, TA-CVS made up 32.3% of all invasive diagnostic procedures, while amniocentesis made up 67.7%. By 2018, TA-CVS made up 61.3% of the invasive diagnostic procedures, and amniocentesis, only 38.7%. The rate of TA-CVS increased over 9 years, while the rate of amniocentesis declined. A total of 236 trainees from 39 different countries and 5 different continents rotated through this site. The average length of stay was 2.4 weeks. Conclusion We demonstrate an increasing prevalence of TA-CVS vs. amniocentesis in the current era of prenatal testing and underscore the importance of continuing to train specialists skilled in TA-CVS. Our global operative experience is feasible and sustainable and will have a lasting impact on physicians conducting invasive fetal procedures.