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Morgan T, Tan CD, Della-Torre M, Jackson-Bey T, DiGiovanni L, Enakpene CA. Determinant of Prenatal Diagnostic Testing among Women with Increased Risk of Fetal Aneuploidy and Genetic Disorders. Am J Perinatol 2024; 41:470-477. [PMID: 34753182 PMCID: PMC10881272 DOI: 10.1055/a-1692-0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to assess factors that influence patients' decisions in accepting prenatal diagnostic testing following genetic counseling for increased risk of fetal aneuploidy. METHODS This is a retrospective cohort study of women at increased risk of fetal aneuploidy and genetic disorders who had genetic counseling from January 2012 to December 2016 at a single academic center. Demographics, indications for genetic counseling, and rates of diagnostic testing were collected and compared between those who accepted diagnostic testing and those who chose cell free DNA. The variables were analyzed using Chi-square, Fisher's exact test, and multiple logistic regression. RESULT Of the 2,373 pregnant women who underwent genetic counseling for increased risk of fetal aneuploidy and genetic disorders during the study period, 321 women had diagnostic testing (13.5%). Women at 35 years and older accepted diagnostic testing more than women younger than 35 years (20.7 vs. 11.5%, p < 0.001). Asian women accepted diagnostic testing at 27.7% more than white, non-Hispanic Black, and Hispanic women at 18.0, 12.1, and 11.7%, respectively, p = 0.002. Number of indications for genetic counseling influenced the likelihood of accepting diagnostic testing. Women with one indication had 11.5% acceptance of diagnostic testing, and with two and three indications, it was 17.0 and 29.2%, respectively. The commonest indication for diagnostic testing was cystic hygroma (risk ratio [RR] = 7.5, 95% confidence interval [CI]: 3.12-8.76 p < 0.001). The relative risk of diagnostic testing for fetuses with shortened long bones, femur and humerus, thickened nuchal fold, echogenic bowel, single umbilical artery, and increased nuchal translucency were 4.0, 3.3, 3.1, 2.7, and 2.7, respectively. Abnormal serum analyte alone was associated with less acceptance of diagnostic testing (RR = 0.8, 95% CI: 0.7-0.96, p = 0.017). CONCLUSION Age, race, ethnicity, and cumulative number of indications for genetic counseling influenced acceptance of diagnostic testing in at-risk women of fetal aneuploidy and genetic disorders. KEY POINTS · Genetic counseling.. · Fetal aneuploidy.. · Genetic disorders.. · Prenatal diagnostic testing. Prenatal diagnostic testing in women with increased risk of fetal aneuploidy and genetic disorders..
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Affiliation(s)
- Tamandra Morgan
- Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California
| | - Catherine D. Tan
- Department of Obstetrics and Gynecology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Micaela Della-Torre
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beacon Memorial Hospital, South Bend Indiana
| | - Tia Jackson-Bey
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mount Sinai School of Medicine, New York, New York
| | - Laura DiGiovanni
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beacon Memorial Hospital, South Bend Indiana
| | - Christopher A. Enakpene
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, Texas Tech University Health Sciences Center, Permian Basin, Texas
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Abstract
OBJECTIVE Perinatal palliative care (PPC) is an option for patients who discover that their infant has a life-limiting fetal condition, which decreases the burden of the condition using a multidisciplinary approach. STUDY DESIGN This review discusses the landmark literature in the past two decades, which have seen significant growth and development in the concept of PPC. RESULTS The literature describes the background, quality, and benefits of offering PPC, as well as the ethical principles that support its being offered in every discussion of fetal life-limiting diagnoses. CONCLUSION PPC shares a similar risk profile to other options after life-limiting diagnosis, including satisfaction with choice of continuation of pregnancy. The present clinical opinion closes by noting common barriers to establishing PPC programs and offers a response to overcome each one. KEY POINTS · Perinatal palliative care serves patients who continue pregnancies with life-limiting fetal anomaly.. · Perinatal palliative care has a risk profile similar to other options such as termination.. · Health care providers can serve as champions to extend PPC to patients in their region..
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Affiliation(s)
- Cara Buskmiller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Byron C Calhoun
- Perinatal Diagnostic Center, Charleston Area Medical Center, Charleston, West Virginia
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3
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Tarui T, Im K, Madan N, Madankumar R, Skotko BG, Schwartz A, Sharr C, Ralston SJ, Kitano R, Akiyama S, Yun HJ, Grant E, Bianchi DW. Quantitative MRI Analyses of Regional Brain Growth in Living Fetuses with Down Syndrome. Cereb Cortex 2021; 30:382-390. [PMID: 31264685 DOI: 10.1093/cercor/bhz094] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/04/2019] [Accepted: 04/14/2019] [Indexed: 01/06/2023] Open
Abstract
Down syndrome (DS) is the most common liveborn autosomal chromosomal anomaly and is a major cause of developmental disability. Atypical brain development and the resulting intellectual disability originate during the fetal period. Perinatal interventions to correct such aberrant development are on the horizon in preclinical studies. However, we lack tools to sensitively measure aberrant structural brain development in living human fetuses with DS. In this study, we aimed to develop safe and precise neuroimaging measures to monitor fetal brain development in DS. We measured growth patterns of regional brain structures in 10 fetal brains with DS (29.1 ± 4.2, weeks of gestation, mean ± SD, range 21.7~35.1) and 12 control fetuses (25.2 ± 5.0, range 18.6~33.3) using regional volumetric analysis of fetal brain MRI. All cases with DS had confirmed karyotypes. We performed non-linear regression models to compare fitted regional growth curves between DS and controls. We found decreased growth trajectories of the cortical plate (P = 0.033), the subcortical parenchyma (P = 0.010), and the cerebellar hemispheres (P < 0.0001) in DS compared to controls. This study provides proof of principle that regional volumetric analysis of fetal brain MRI facilitates successful evaluation of brain development in living fetuses with DS.
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Affiliation(s)
- Tomo Tarui
- Mother Infant Research Institute, Fetal Neonatal Neurology Program, Pediatric Neurology, Tufts Medical Center, Boston, MA, USA
| | - Kiho Im
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neel Madan
- Radiology, Tufts Medical Center, Boston, MA, USA
| | - Rajeevi Madankumar
- Maternal Fetal Medicine, Obstetrics and Gynecology, Long Island Jewish Medical Center Northwell Health, New Hyde Park, NY, USA
| | - Brian G Skotko
- Down Syndrome Program, Genetics, Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Allie Schwartz
- Down Syndrome Program, Genetics, Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Christianne Sharr
- Down Syndrome Program, Genetics, Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Steven J Ralston
- Maternal Fetal Medicine, Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rie Kitano
- Mother Infant Research Institute, Fetal Neonatal Neurology Program, Pediatric Neurology, Tufts Medical Center, Boston, MA, USA
| | - Shizuko Akiyama
- Mother Infant Research Institute, Fetal Neonatal Neurology Program, Pediatric Neurology, Tufts Medical Center, Boston, MA, USA
| | - Hyuk Jin Yun
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana W Bianchi
- Prenatal Genomics and Fetal Therapy Section, Medical Gen etics Branch, National Human Genome Research Institute, Bethesda, MD, USA
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Van Den Bogaert K, Lannoo L, Brison N, Gatinois V, Baetens M, Blaumeiser B, Boemer F, Bourlard L, Bours V, De Leener A, De Rademaeker M, Désir J, Dheedene A, Duquenne A, Fieremans N, Fieuw A, Gatot JS, Grisart B, Janssens K, Janssens S, Lederer D, Marichal A, Menten B, Meunier C, Palmeira L, Pichon B, Sammels E, Smits G, Sznajer Y, Vantroys E, Devriendt K, Vermeesch JR. Outcome of publicly funded nationwide first-tier noninvasive prenatal screening. Genet Med 2021; 23:1137-1142. [PMID: 33564150 DOI: 10.1038/s41436-021-01101-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Noninvasive prenatal screening (NIPS) using cell-free DNA has transformed prenatal care. Belgium was the first country to implement and fully reimburse NIPS as a first-tier screening test offered to all pregnant women. A consortium consisting of all Belgian genetic centers report the outcome of two years genome-wide NIPS implementation. METHODS The performance for the common trisomies and for secondary findings was evaluated based on 153,575 genome-wide NIP tests. Furthermore, the evolution of the number of invasive tests and the incidence of Down syndrome live births was registered. RESULTS Trisomies 21, 18, and 13 were detected in respectively 0.32%, 0.07%, and 0.06% of cases, with overall positive predictive values (PPVs) of 92.4%, 84.6%, and 43.9%. Rare autosomal trisomies and fetal segmental imbalances were detected in respectively 0.23% and 0.07% of cases with PPVs of 4.1% and 47%. The number of invasive obstetric procedures decreased by 52%. The number of trisomy 21 live births dropped to 0.04%. CONCLUSION Expanding the scope of NIPS beyond trisomy 21 fetal screening allows the implementation of personalized genomic medicine for the obstetric population. This genome-wide NIPS approach has been embedded successfully in prenatal genetic care in Belgium and might serve as a framework for other countries offering NIPS.
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Affiliation(s)
- Kris Van Den Bogaert
- Center for Human Genetics, University Hospitals Leuven-KU Leuven, Leuven, Belgium
| | - Lore Lannoo
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Nathalie Brison
- Center for Human Genetics, University Hospitals Leuven-KU Leuven, Leuven, Belgium
| | - Vincent Gatinois
- Center for Human Genetics, University Hospitals Leuven-KU Leuven, Leuven, Belgium
| | - Machteld Baetens
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Bettina Blaumeiser
- Center for Medical Genetics, Universiteit Antwerpen, Antwerp, Belgium.,Center for Medical Genetics, University Hospital Antwerp, Edegem, Belgium
| | - François Boemer
- Center for Medical Genetics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Laura Bourlard
- Center for Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Bours
- Center for Medical Genetics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Anne De Leener
- Center for Human Genetics, Université Catholique de Louvain, Brussels, Belgium
| | | | - Julie Désir
- Center for Human Genetics, Université Libre de Bruxelles, Brussels, Belgium.,Center for Medical Genetics, Institut de Pathologie et de Génétique Gosselies, Charleroi, Belgium
| | - Annelies Dheedene
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Armelle Duquenne
- Center for Human Genetics, Université Catholique de Louvain, Brussels, Belgium
| | - Nathalie Fieremans
- Center for Medical Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Annelies Fieuw
- Center for Medical Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jean-Stéphane Gatot
- Center for Medical Genetics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bernard Grisart
- Center for Medical Genetics, Institut de Pathologie et de Génétique Gosselies, Charleroi, Belgium
| | - Katrien Janssens
- Center for Medical Genetics, Universiteit Antwerpen, Antwerp, Belgium
| | - Sandra Janssens
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Damien Lederer
- Center for Medical Genetics, Institut de Pathologie et de Génétique Gosselies, Charleroi, Belgium
| | - Axel Marichal
- Center for Medical Genetics, Institut de Pathologie et de Génétique Gosselies, Charleroi, Belgium
| | - Björn Menten
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Colombine Meunier
- Center for Medical Genetics, Institut de Pathologie et de Génétique Gosselies, Charleroi, Belgium
| | - Leonor Palmeira
- Center for Medical Genetics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bruno Pichon
- Center for Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
| | - Eva Sammels
- Center for Medical Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Guillaume Smits
- Center for Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
| | - Yves Sznajer
- Center for Human Genetics, Université Catholique de Louvain, Brussels, Belgium
| | - Elise Vantroys
- Center for Medical Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Koenraad Devriendt
- Center for Human Genetics, University Hospitals Leuven-KU Leuven, Leuven, Belgium
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Choe SA, Seol HJ, Kwon JY, Park CW, Kim M, Lee JY, Kim MA, Hwang HS, Na S, Shim JY, Kim K, Ryu HM. Clinical Practice Guidelines for Prenatal Aneuploidy Screening and Diagnostic Testing from Korean Society of Maternal-Fetal Medicine: (1) Prenatal Aneuploidy Screening. J Korean Med Sci 2021; 36:e27. [PMID: 33496086 PMCID: PMC7834900 DOI: 10.3346/jkms.2021.36.e27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/11/2020] [Indexed: 01/06/2023] Open
Abstract
In 2019, the Korean Society of Maternal-Fetal Medicine developed the first Korean clinical practice guidelines for prenatal aneuploidy screening and diagnostic testing. These guidelines were developed by adapting established clinical practice guidelines in other countries that were searched systematically, and the guidelines aim to assist in decision making of healthcare providers providing prenatal care and to be used as a source for education and communication with pregnant women in Korea. This article delineates clinical practice guidelines specifically for maternal serum screening for fetal aneuploidy and cell-free DNA (cfDNA) screening. A total of 19 key questions (12 for maternal serum and 7 for cfDNA screening) were defined. The main recommendations are: 1) Pregnant women should be informed of common fetal aneuploidy that can be detected, risks for chromosomal abnormality according to the maternal age, detection rate and false positive rate for common fetal aneuploidy with each screening test, limitations, as well as the benefits and risks of invasive diagnostic testing, 2) It is ideal to give counseling about prenatal aneuploidy screening and diagnostic testing at the first prenatal visit, and counseling is recommended to be given early in pregnancy, 3) All pregnant women should be informed about maternal serum screening regardless of their age, 4) cfDNA screening can be used for the screening of trisomy 21, 18, 13 and sex-chromosome aneuploidy. It is not recommended for the screening of microdeletion, 5) The optimal timing of cfDNA screening is 10 weeks of gestation and beyond, and 6) cfDNA screening is not recommended for women with multiple gestations. The guideline was reviewed and approved by the Korean Academy of Medical Sciences.
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Affiliation(s)
- Seung Ah Choe
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyun Joo Seol
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ji Young Kwon
- Department of Obstetrics and Gynecology, College of Medicine,The Catholic University of Korea, Seoul, Korea
| | - Chan Wook Park
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Minhyoung Kim
- Department of Obstetrics and Gynecology, MizMedi Hospital, Seoul, Korea
| | - Ji Yeon Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min A Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Han Sung Hwang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sunghun Na
- Department of Obstetrics and Gynecology, Kangwon National University Hospital, School of Medicine Kangwon National University, Chuncheon, Korea
| | - Jae Yoon Shim
- Mirae & Heemang Obstetrics and Gynecology Clinic, Seoul, Korea
| | | | - Hyun Mee Ryu
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
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6
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Sofer L, D'Oro A, Rosoklija I, Leeth EA, Goetsch AL, Moses S, Chen D, Finlayson C, Johnson EK. Impact of cell-free DNA screening on parental knowledge of fetal sex and disorders of sex development. Prenat Diagn 2020; 40:1489-1496. [PMID: 32683746 DOI: 10.1002/pd.5801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/01/2020] [Accepted: 07/14/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Discrepancies between cfDNA and ultrasound predicted fetal sex occur, possibly indicating disorders/differences of sex development (DSDs). Among expectant/recent parents, this study assessed cfDNA knowledge/use, fetal sex determination attitudes/behaviors, general knowledge of DSD, and possible psychological impact of discrepancy between fetal sex on cfDNA and ultrasound. METHOD Parents were surveyed about fetal sex determination methods, knowledge of cfDNA and DSD, distress related to possible cfDNA inaccuracy. RESULTS Of 916 respondents, 44% were aware of possible discrepancy between cfDNA and ultrasound, 22% were aware of DSD. 78% and 75% would be upset and worried, respectively, with results showing fetal sex discrepancy. Most (67%) revealed predicted fetal sex before delivery. 38% were offered cfDNA. Of those revealing fetal sex, 24% used cfDNA results, 71% ultrasound, and 7% both. cfDNA users were more frequently aware of possible discrepancy between cfDNA and ultrasound (76% vs 41%, P < .0001), but not of DSD (29% vs 23%, P = .29). CONCLUSION Fetal sex determination is favored, and cfDNA is frequently used for predicting fetal chromosomal sex. Many parents are unaware of possible discrepancies between cfDNA and ultrasound, and potential for DSD. Most would be distressed by discordant results. Accurate counseling regarding limitations cfDNA for fetal sex determination is needed.
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Affiliation(s)
- Laurel Sofer
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Anthony D'Oro
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Elizabeth A Leeth
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Graduate Program in Genetic Counseling, Northwestern University, Chicago, Illinois, USA
| | - Allison L Goetsch
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Graduate Program in Genetic Counseling, Northwestern University, Chicago, Illinois, USA
| | - Scott Moses
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Diane Chen
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Courtney Finlayson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Samura O. Update on noninvasive prenatal testing: A review based on current worldwide research. J Obstet Gynaecol Res 2020; 46:1246-1254. [PMID: 32558079 DOI: 10.1111/jog.14268] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/11/2020] [Indexed: 12/25/2022]
Abstract
Eight years have passed since noninvasive prenatal testing (NIPT) was clinically evaluated and data on NIPT for trisomy 21, 18 and 13 were collected. The data revealed that NIPT is more accurate than conventional first-trimester screening. However, there is still insufficient data regarding the clinical use of NIPT results in detecting sex chromosome aneuploidies or whole-genome regions. NIPT is already being used as a clinical screening method globally. However, it is an unconfirmed diagnostic test and the results must be interpreted with caution as they may yield false negatives, false positives or inconclusive results. Therefore, the aim of this review is to highlight the current status of information, including the different methodologies, shortcomings and implications, regarding NIPT after its adoption worldwide. It is important to include genetic counseling when implementing NIPT. Going forward, the knowledge obtained to date, including the associated shortcomings, must be considered in evaluating the effectiveness of NIPT in detecting genetic abnormalities.
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Affiliation(s)
- Osamu Samura
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Tokyo, Japan
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8
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Grossman TB, Chasen ST. Abortion for Fetal Genetic Abnormalities: Type of Abnormality and Gestational Age at Diagnosis. AJP Rep 2020; 10:e87-e92. [PMID: 32190411 PMCID: PMC7075712 DOI: 10.1055/s-0040-1705173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/20/2019] [Indexed: 10/26/2022] Open
Abstract
Background Advances in genetic screening can identify patients at high risk for common genetic conditions early in pregnancy and can facilitate early diagnosis and early abortion. Less common abnormalities might only be diagnosed with invasive testing is performed after structural abnormalities are identified. Objective Our objective was to compare gestational age (GA) at diagnosis and abortion for genetic abnormalities identified based on screening with abnormalities that were not discovered after screening. Study Design All prenatal diagnostic procedures from 2012 to 2017 were reviewed, and singleton pregnancies terminated following diagnosis of genetic abnormalities were identified. Cases diagnosed as the result of screening tests were compared with remaining cases. Conditions were considered "screened for" if they can be suspected by cell-free DNA testing, biochemistry, carrier screening, or if the patient was a known carrier of a single-gene disorder. When abnormal karyotype, microarray, or Noonan's syndrome was associated with abnormal NT, these cases were considered "screened for." GA at abortion was the primary outcome. Fisher's exact test and Mann-Whitney's U test were used for statistical comparison. Results In this study, 268 cases were included. A total of 227 (85%) of abortions were performed for "screened for" disorders, with 210 (93%) of these for karyotype abnormalities, 5 (2%) for microarray abnormalities, and 12 (5%) for single-gene disorders. Forty-one (15%) of abortions were performed for conditions not included in screening, with 8 (19%) of those for karyotype abnormalities, 25 (61%) for microarray abnormalities, and 8 (19%) for single-gene disorders. Invasive testing and abortion occurred at earlier median GA for those with conditions that were screened for: 12 2/7 versus 15 5/7 weeks, p ≤0.001 and 13 5/7 versus 20 0/7 weeks; p ≤0.001. Conclusion Most abortions were for abnormalities that can be suspected early in pregnancy. As many structural abnormalities associated with rare conditions are not identifiable until the mid-trimester, prenatal diagnosis and abortion occurred significantly later. Physicians and patients should be aware of the limitations of genetic screening.
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Affiliation(s)
- Tracy B. Grossman
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Stephen T. Chasen
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
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9
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Grossman TB, Bodenlos KL, Chasen ST. Abnormal nuchal translucency: residual risk with normal cell-free DNA screening. J Matern Fetal Neonatal Med 2019; 33:3062-3067. [PMID: 30669906 DOI: 10.1080/14767058.2019.1568405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective: To determine the proportion of genetic abnormalities that could be identified by cell-free DNA screening in pregnancies with an abnormal nuchal translucency.Methods: From 2015-2017, pregnancies with nuchal translucency ≥ 3.0 mm on ultrasounds were identified. Pregnancies with genetic testing results were included, whether or not cell-free DNA screening was performed. Comparisons of the proportion of genetic abnormalities detectable on cell-free DNA screening versus not detectable were made based on nuchal translucency values (3.0-3.4 mm; ≥3.5 mm) and maternal age (≥35 versus <35 years). Chi-square analysis, Fisher's exact test, and Mann-Whitney U were used for statistical comparison.Results: One hundred ten patients were included, 60 had genetic abnormalities (54.5%), with 44 (73.3%) detectable on cell-free DNA screening and 16 (26.7%) not. In those with nuchal translucency ≥3.5 mm, only 40 of 56 (71.4%) of abnormalities could be detected by cell-free DNA screening. Cell-free DNA screening could identify 27 of 31 abnormalities with nuchal translucency ≥3.5 mm in women ≥35 years but could identify only 13 of 25 genetic abnormalities in younger women (87.1 versus 52.0%; p = .005).Conclusion: A significant proportion of abnormalities in those with nuchal translucency ≥3.5 mm would not be detected by cell-free DNA, especially in younger women.
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Affiliation(s)
- Tracy B Grossman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kimberly L Bodenlos
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Stephen T Chasen
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Weill Cornell Medical College, New York, NY, USA
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10
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Le Conte G, Letourneau A, Jani J, Kleinfinger P, Lohmann L, Costa JM, Benachi A. Cell-free fetal DNA analysis in maternal plasma as screening test for trisomies 21, 18 and 13 in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:318-324. [PMID: 28833712 DOI: 10.1002/uog.18838] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/11/2017] [Accepted: 08/09/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate in twin pregnancy the utility of non-invasive prenatal testing using circulating cell-free fetal DNA (cfDNA) in screening for the three main autosomal fetal trisomies. METHODS cfDNA testing was offered to 492 patients with a twin pregnancy without ultrasound anomaly as a first-line screening test or after routine serum screening. Data were collected prospectively and a retrospective analysis was performed. cfDNA analysis was performed by massively parallel sequencing. The fetal-fraction threshold used for test evaluation was 8%. Regression analysis was performed to investigate the effect on the test failure rate of maternal and pregnancy characteristics, and the performance of the test was also reported. RESULTS cfDNA analysis was performed as a first-line test (after the first-trimester scan) in 377 patients and following serum screening in 115. Of the 420 pregnancies for which outcome was available and cfDNA screening was assessed, 78.7% were dichorionic-diamniotic. The test failed on the first attempt in 12 (2.9%) pregnancies, and regression analysis demonstrated that only maternal weight was a significant independent predictor of test failure. A result was subsequently achieved in the 10 cases for which a second sample was obtained. cfDNA analysis identified all three cases of trisomy 21 and the only case of trisomy 18. For trisomy 21, the specificity was 99.8% (95% CI, 98.7-100.0%). When considering pregnancies according to whether they were conceived spontaneously or after assisted reproductive technology, there were no significant differences in terms of maternal weight or no-result rate for cfDNA screening between these two groups. CONCLUSIONS In twin pregnancy without fetal ultrasound abnormality, cfDNA screening for trisomies 21, 18 and 13 had a high success rate and good performance. Therefore, in routine practice, cfDNA analysis could be considered as a first- or second-line screening test. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Le Conte
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France
- Université Paris Sud, Kremlin Bicêtre, France
| | - A Letourneau
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France
- Université Paris Sud, Kremlin Bicêtre, France
| | - J Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - L Lohmann
- Laboratoire CERBA, Saint-Ouen l'Aumône, France
| | - J-M Costa
- Laboratoire CERBA, Saint-Ouen l'Aumône, France
| | - A Benachi
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France
- Université Paris Sud, Kremlin Bicêtre, France
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Malan V, Bussières L, Winer N, Jais JP, Baptiste A, Le Lorc’h M, Elie C, O’Gorman N, Fries N, Houfflin-Debarge V, Sentilhes L, Vekemans M, Ville Y, Salomon LJ. Effect of Cell-Free DNA Screening vs Direct Invasive Diagnosis on Miscarriage Rates in Women With Pregnancies at High Risk of Trisomy 21: A Randomized Clinical Trial. JAMA 2018; 320:557-565. [PMID: 30120476 PMCID: PMC6583003 DOI: 10.1001/jama.2018.9396] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Cell-free DNA (cfDNA) tests are increasingly being offered to women in the first trimester of pregnancies at a high risk of trisomy 21 to decrease the number of required invasive fetal karyotyping procedures and their associated miscarriages. The effect of this strategy has not been evaluated. OBJECTIVE To compare the rates of miscarriage following invasive procedures only in the case of positive cfDNA test results vs immediate invasive testing procedures (amniocentesis or chorionic villus sampling) in women with pregnancies at high risk of trisomy 21 as identified by first-trimester combined screening. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from April 8, 2014, to April 7, 2016, in 57 centers in France among 2111 women with pregnancies with a risk of trisomy 21 between 1 in 5 and 1 in 250 following combined first-trimester screening. INTERVENTIONS Patients were randomized to receive either cfDNA testing followed by invasive testing procedures only when cfDNA tests results were positive (n = 1034) or to receive immediate invasive testing procedures (n = 1017). The cfDNA testing was performed using an in-house validated method based on next-generation sequencing. MAIN OUTCOMES AND MEASURES The primary outcome was number of miscarriages before 24 weeks' gestation. Secondary outcomes included cfDNA testing detection rate for trisomy 21. The primary outcome underwent 1-sided testing; secondary outcomes underwent 2-sided testing. RESULTS Among 2051 women who were randomized and analyzed (mean age, 36.3 [SD, 5.0] years), 1997 (97.4%) completed the trial. The miscarriage rate was not significantly different between groups at 8 (0.8%) vs 8 (0.8%), for a risk difference of -0.03% (1-sided 95% CI, -0.68% to ∞; P = .47). The cfDNA detection rate for trisomy 21 was 100% (95% CI, 87.2%-100%). CONCLUSIONS AND RELEVANCE Among women with pregnancies at high risk of trisomy 21, offering cfDNA screening, followed by invasive testing if cfDNA test results were positive, compared with invasive testing procedures alone, did not result in a significant reduction in miscarriage before 24 weeks. The study may have been underpowered to detect clinically important differences in miscarriage rates. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02127515.
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Affiliation(s)
- Valérie Malan
- Department of Histology-Embryology and Cytogenetics, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
- INSERM U1163, Hôpital Necker–Enfants Malades, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Laurence Bussières
- Department of Obstetrics and Gynecology, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
- Clinical Unit Research/Clinic Investigation Center, Paris Descartes, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, CHU de Nantes, UMR 1280 PHAN (Physiologie des Adaptations Nutritionnelles), INRA University, Nantes, France
- Groupe de Recherche en Obstétrique et Gynécologie (GROG), Paris, France
| | - Jean-Philippe Jais
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
- Department of Biostatistics and Medical Informatics, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Amandine Baptiste
- Clinical Unit Research/Clinic Investigation Center, Paris Descartes, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Marc Le Lorc’h
- Department of Histology-Embryology and Cytogenetics, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Caroline Elie
- Clinical Unit Research/Clinic Investigation Center, Paris Descartes, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Neil O’Gorman
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Nicolas Fries
- Department of Obstetrics and Gynecology, CHU de Montpellier, Montpellier, France
- Collège Français d’Echographie Fœtale (CFEF), Chateaubriand, France
| | - Véronique Houfflin-Debarge
- Groupe de Recherche en Obstétrique et Gynécologie (GROG), Paris, France
- Department of Obstetrics and Gynecology, CHU de Lille, Lille, France
| | - Loic Sentilhes
- Groupe de Recherche en Obstétrique et Gynécologie (GROG), Paris, France
- Department of Obstetrics and Gynecology, CHU d’Angers, Angers, France
- Department of Obstetrics and Gynecology, CHU de Bordeaux, Bordeaux, France
| | - Michel Vekemans
- Department of Histology-Embryology and Cytogenetics, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Yves Ville
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
| | - Laurent J. Salomon
- Paris Descartes University, Sorbonne Paris Cité, Institut Imagine, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Necker–Enfants Malades, AP-HP, Paris, France
- Groupe de Recherche en Obstétrique et Gynécologie (GROG), Paris, France
- Collège Français d’Echographie Fœtale (CFEF), Chateaubriand, France
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Genome-wide detection of additional fetal chromosomal abnormalities by cell-free DNA testing of 15,626 consecutive pregnant women. SCIENCE CHINA-LIFE SCIENCES 2018; 62:215-224. [PMID: 30076564 DOI: 10.1007/s11427-017-9344-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/21/2018] [Indexed: 12/18/2022]
Abstract
Cell-free DNA (cfDNA) testing for common fetal trisomies (T21, T18, T13) is highly effective. However, the usefulness of cfDNA testing in detecting other chromosomal abnormalities is unclear. We evaluated the performance of cfDNA testing for genome-wide abnormalities, and analyzed the incremental yield by reporting extra abnormalities. We performed genome-wide cfDNA testing in 15,626 consecutive pregnancies prospectively enrolled in this study. cfDNA testing results were reported and counseling was given depending on the presence of extra chromosomal abnormalities. cfDNA testing identified 190 cases (1.2%) of chromosomal abnormalities including 100 common trisomies and 90 additional abnormalities. By expanding the cfDNA reporting range to genome-wide abnormalities, the false positive rate increased to 0.39% (P<0.001) and positive predictive value (PPV) was reduced to 65.58% (P=0.42). However, the detection yield increased from 0.44% to 0.65% (P=0.014), and cfDNA testing detected 38.61% (39/101) additional abnormalities with no ultrasound and biochemical screening findings. cfDNA testing outperformed biochemical screening by showing 60 times higher true positive rate and fewer false negative results. Genome-wide cfDNA testing significantly increased the diagnostic yield by detecting extra abnormalities, especially those without diagnostic indications. Genome-wide cfDNA testing has fewer false positive and false negative results compared with biochemical screening.
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Le Conte G, Letourneau A, Jani J, Kleinfinger P, Lohmann L, Costa JM, Benachi A. [Cell-free fetal DNA analysis in maternal plasma as a screening test for trisomy 21 in twin pregnancies]. ACTA ACUST UNITED AC 2018; 46:580-586. [PMID: 29929941 DOI: 10.1016/j.gofs.2018.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To evaluate the performance of noninvasive prenatal testing by cell-free circulating fetal DNA in maternal blood (cfDNA) in screening for trisomies 21 in twin pregnancies. METHODS CfDNA was performed in 492 patients with twin pregnancies without ultrasound anomalies in the first trimester as a first-line screening test or after serum screening. Data were collected prospectively and a retrospective analysis was done. CfDNA was executed by massive parallel technique. The fetal fraction threshold for test evaluation was 8%. Regression analysis was performed to evaluate the effect of different parameters on the test failure rate. Performance of the test was also considered. RESULTS In 377 patients, the test was prescribed first line and in 115 after standard serum screening. Twelve tests (2.9%) have initially failed on the 420 pregnancies with available outcomes and regression analysis found only maternal weight as a significant independent factor of test failure. A second test was performed on 10 patients, all of them had an available result. cfDNA identified all 3 cases of trisomy 21. The sensitivity was 100.0% (95% CI [29.2-100.0%]) and specificity was 99.8% (95% CI [98.7-100.0%]). There was no significant difference between spontaneous pregnancies and those induced by assisted reproductive technologies (ART), in terms of fetal fraction percentage, no-call results for cfDNA screening, maternal weight, or test performance between the two groups. CONCLUSION In twin pregnancies without fetal ultrasound abnormalities, the performance and success rate of the cfDNA are excellent. Therefore, cfDNA could be offered in routine practice as a first-line screening test in this population.
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Affiliation(s)
- G Le Conte
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Sud, 94270 Kremlin-Bicêtre, France.
| | - A Letourneau
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Sud, 94270 Kremlin-Bicêtre, France
| | - J Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, université Libre de Bruxelles, 1020 Brussels, Belgique
| | - P Kleinfinger
- Laboratoire CERBA, 95310 Saint-Ouen-l'Aumône, France
| | - L Lohmann
- Laboratoire CERBA, 95310 Saint-Ouen-l'Aumône, France
| | - J-M Costa
- Laboratoire CERBA, 95310 Saint-Ouen-l'Aumône, France
| | - A Benachi
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Sud, 94270 Kremlin-Bicêtre, France
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Gray KJ, Wilkins-Haug LE. Have we done our last amniocentesis? Updates on cell-free DNA for Down syndrome screening. Pediatr Radiol 2018; 48:461-470. [PMID: 29550862 PMCID: PMC7088458 DOI: 10.1007/s00247-017-3958-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/11/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022]
Abstract
Prenatal aneuploidy screening changed significantly in 2012 when cell-free fetal deoxyribonucleic acid (DNA) was introduced as a noninvasive prenatal test. A noninvasive prenatal test detects cell free fragments of fetal DNA from the placenta circulating in maternal blood that coexist with cell-free DNA (cfDNA) of maternal origin. Using next-generation sequencing, the noninvasive prenatal test compares maternal and fetal cfDNA ratios for chromosomes of interest (i.e., 21, 18, 13, X, and Y) to assess chromosomal aneuploidy. Compared to traditional screening using ultrasound and serum markers, the noninvasive prenatal test has superior test characteristics, including a higher detection rate and positive predictive value, and a lower false-positive rate. The noninvasive prenatal test is already used for primary screening in high-risk women and is rapidly expanding to all women. Given its increasing use, understanding the noninvasive prenatal test's limitations is critical. Discordant results (i.e. noninvasive prenatal test is positive for aneuploidy with a normal fetal karyotype) can occur because of biological processes such as aneuploidy confined to the placenta, a vanished twin, maternal aneuploidy or maternal cancer. Use of the noninvasive prenatal test for screening beyond the most common aneuploidies is not recommended. The noninvasive prenatal test is a major advance in prenatal aneuploidy screening but it is not diagnostic and does not replace invasive testing (i.e. chorionic villous sampling or amniocentesis) for confirmation of fetal chromosomal disorders.
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Affiliation(s)
- Kathryn J Gray
- Division of Maternal-Fetal Medicine, Brigham & Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Louise E Wilkins-Haug
- Division of Maternal-Fetal Medicine, Brigham & Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
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15
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Costa JM, Letourneau A, Favre R, Bidat L, Belaisch-Allart J, Jouannic JM, Quarello E, Senat MV, Broussin B, Tsatsaris V, Demain A, Kleinfinger P, Lohmann L, Agostini H, Bouyer J, Benachi A. Cell-free fetal DNA versus maternal serum screening for trisomy 21 in pregnant women with and without assisted reproduction technology: a prospective interventional study. Genet Med 2018; 20:1346-1353. [DOI: 10.1038/gim.2018.4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/27/2017] [Indexed: 01/17/2023] Open
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Wolfberg AJ. Conflict of interest related to clinical practice is underreported: The case of noninvasive prenatal testing. Prenat Diagn 2018; 38:219-221. [PMID: 29318630 DOI: 10.1002/pd.5209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/23/2017] [Accepted: 12/30/2017] [Indexed: 11/08/2022]
Abstract
Authors of policy statements from the American College of Obstetricians and Gynecologists and from the Society for Maternal-Fetal Medicine do not acknowledge the potential for their clinical income to influence their opinions, or the positions of the societies they represent. These policy statements were published in Obstetrics and Gynecology and the American Journal of Obstetrics and Gynecology, again, without acknowledgment of the potential for conflict of interest. The case of noninvasive prenatal testing, which has threatened the role of maternal-fetal medicine in the practice of prenatal screening and diagnosis, and has significantly reduced the demand for invasive prenatal diagnosis, illustrates the importance of identifying this potential conflict.
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Affiliation(s)
- Adam J Wolfberg
- Newton-Wellesley Hospital, Ovia Health, Boston, MA, 02110, USA
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17
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LEWKOWITZ AK, Kaimal AJ, THAO K, O’LEARY A, NSEYO O, KUPPERMANN M. Sociodemographic and attitudinal predictors of simultaneous and redundant multiple marker and cell-free DNA screening among women aged ⩾35 years. J Perinatol 2017; 37:772-777. [PMID: 28492524 PMCID: PMC5562526 DOI: 10.1038/jp.2017.66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/21/2017] [Accepted: 04/03/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify characteristics associated with undergoing cell-free DNA (cfDNA) and multiple marker screening (MMS) simultaneously or redundantly (after receiving negative results from the first screening test) among women aged ⩾35 years. STUDY DESIGN Participants presenting for prenatal testing completed a questionnaire that included measures of pregnancy worry and attitudes toward potential testing outcomes; data on prenatal test use was obtained via medical record review. We used multivariable logistic regression to identify factors associated with redundant or simultaneous screening. RESULTS Among 164 participants, 69 (42.1%) had cfDNA redundantly (n=51) to, or simultaneously (n=18) with, MMS. Compared with the 46 MMS-negative women who did not undergo further testing, those who underwent redundant or simultaneous cfDNA/MMS screening were more likely to have annual family incomes >$150 000, to feel having a miscarriage would be worse than having an intellectually disabled child, to desire comprehensive testing for intellectual disability and to have more pregnancy worry. CONCLUSION Providers who counsel patients on prenatal aneuploidy screening tests should explain the appropriate utilization of these screening tests to avoid unnecessary or minimally informative use of multiple tests.
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Affiliation(s)
- Adam K LEWKOWITZ
- Department of Obstetrics & Gynecology, Washington University in St. Louis,Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Anjali J Kaimal
- Department of Obstetrics & Gynecology, Massachusetts General Hospital
| | - Kao THAO
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Allison O’LEARY
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Onouwem NSEYO
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Miriam KUPPERMANN
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
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Dervan AP, Deverka PA, Trosman JR, Weldon CB, Douglas MP, Phillips KA. Payer decision making for next-generation sequencing-based genetic tests: insights from cell-free DNA prenatal screening. Genet Med 2017; 19:559-567. [PMID: 27657682 PMCID: PMC5362360 DOI: 10.1038/gim.2016.145] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/09/2016] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Cell-free DNA (cfDNA) prenatal screening tests have been rapidly adopted into clinical practice, due in part to positive insurance coverage. We evaluated the framework payers used in making coverage decisions to describe a process that should be informative for other sequencing tests. METHODS We analyzed coverage policies from the 19 largest US private payers with publicly available policies through February 2016, building from the University of California San Francisco TRANSPERS Payer Coverage Policy Registry. RESULTS All payers studied cover cfDNA screening for detection of trisomies 21, 18, and 13 in high-risk, singleton pregnancies, based on robust clinical validity (CV) studies and modeled evidence of clinical utility (CU). Payers typically evaluated the evidence for each chromosomal abnormality separately, although results are offered as part of a panel. Starting in August 2015, 8 of the 19 payers also began covering cfDNA screening in average-risk pregnancies, citing recent CV studies and updated professional guidelines. Most payers attempted, but were unable, to independently assess analytic validity (AV). CONCLUSION Payers utilized the standard evidentiary framework (AV/CV/CU) when evaluating cfDNA screening but varied in their interpretation of the sufficiency of the evidence. Professional guidelines, large CV studies, and decision analytic models regarding health outcomes appeared highly influential in coverage decisions.Genet Med advance online publication 22 September 2016.
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Affiliation(s)
- Andrew P Dervan
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Patricia A Deverka
- American Institutes for Health Research and Innovation, Chapel Hill, North Carolina, USA
- Eshelman School of Pharmacy, Center for Pharmacogenomics and Individualized Therapy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Julia R Trosman
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
- Center for Business Models in Healthcare, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christine B Weldon
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
- Center for Business Models in Healthcare, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, California, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
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Norton ME, Biggio JR, Kuller JA, Blackwell SC. The role of ultrasound in women who undergo cell-free DNA screening. Am J Obstet Gynecol 2017; 216:B2-B7. [PMID: 28108156 DOI: 10.1016/j.ajog.2017.01.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 11/30/2022]
Abstract
The introduction of cell-free DNA screening for aneuploidy into obstetric practice in 2011 revolutionized the strategies utilized for prenatal testing. The purpose of this document is to review the current data on the role of ultrasound in women who have undergone or are considering cell-free DNA screening. The following are Society for Maternal-Fetal Medicine recommendations: (1) in women who have already received a negative cell-free DNA screening screen, ultrasound at 11-14 weeks of gestation solely for the purpose of nuchal translucency measurement (Current Procedural Terminology code 76813) is not recommended (grade 1B); (2) we recommend that diagnostic testing should not be recommended to patients solely for the indication of an isolated soft marker in the setting of a negative cell-free DNA screen (grade 2B); (3) in women with an isolated soft marker without other clinical implications (ie, choroid plexus cyst or echogenic intracardiac focus) and a negative cell-free DNA screen, we recommend describing the finding as not clinically significant or as a normal variant (grade 2B); (4) in women with an isolated soft marker that has no other clinical implication (ie, choroid plexus cyst or echogenic intracardiac focus) and a negative first- or second-trimester screening result, we recommend describing the finding as not clinically significant or as a normal variant (grade 2B); (5) we recommend that all women in whom a structural abnormality is identified by ultrasound should be offered diagnostic testing with chromosomal microarray (grade 1A); and (6) we recommend against routine screening for microdeletions with cell-free DNA screening (grade 1B).
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Affiliation(s)
- Mary E Norton
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA
| | - Joseph R Biggio
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA
| | - Jeffrey A Kuller
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA
| | - Sean C Blackwell
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA
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Darney BG, Biel FM, Quigley BP, Caughey AB, Horner-Johnson W. Primary Cesarean Delivery Patterns among Women with Physical, Sensory, or Intellectual Disabilities. Womens Health Issues 2017; 27:336-344. [PMID: 28109562 DOI: 10.1016/j.whi.2016.12.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about the relationship between disability and mode of delivery. Prior research has indicated elevated risk of cesarean delivery among women with certain disabilities, but has not examined patterns across multiple types of disability or by parity. OBJECTIVE This study sought to determine whether physical, sensory, or intellectual and developmental disabilities are independently associated with primary cesarean delivery. METHODS We conducted a retrospective cohort study of all deliveries in California from 2000 to 2010 using linked birth certificate and hospital discharge data. We identified physical, sensory, and intellectual and developmental disabilities using International Classification of Diseases, 9th revision, clinical modification codes. We used logistic regression to examine the association of these disabilities and primary cesarean delivery, controlling for sociodemographic characteristics and comorbidities, and stratified by parity. RESULTS In our sample, 0.45% of deliveries (20,894/4,610,955) were to women with disabilities. A greater proportion of women with disabilities were nulliparous, had public insurance, and had comorbidities (e.g., gestational diabetes) compared with women without disabilities (p < .001 for all). The proportion of primary cesarean in women with disabilities was twice that in women without disabilities (32.7% vs. 16.3%; p < .001; adjusted odds ratio, 2.05; 95% confidence interval, 1.94-2.17). The proportion of deliveries by cesarean was highest among women with physical disabilities due to injuries compared with women without disabilities (57.8% vs. 16.3%; p < .001; adjusted odds ratio, 6.83; 95% confidence interval, 5.46-8.53). CONCLUSIONS Women across disability subgroups have higher odds of cesarean delivery, and there is heterogeneity by disability type. More attention is needed to this population to ensure better understanding of care practices that may impact maternal and perinatal outcomes.
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Affiliation(s)
- Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; National Institute of Public Health, Center for Health Systems Research, Cuernavaca, Mexico
| | - Frances M Biel
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Brian P Quigley
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Willi Horner-Johnson
- Institute on Development and Disability, Oregon Health & Science University, Portland, Oregon.
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Michie M, Kraft SA, Minear MA, Ryan RR, Allyse MA. Informed decision-making about prenatal cfDNA screening: An assessment of written materials. ACTA ACUST UNITED AC 2016; 2:362-371. [PMID: 27699200 DOI: 10.1016/j.jemep.2016.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The introduction of prenatal cfDNA screening for fetal aneuploidy and other genetic conditions has exacerbated concerns about informed decision-making in clinical prenatal testing. To assess the information provided to patients to facilitate decisions about cfDNA screening, we collected written patient education and consent documents created by laboratories and clinics. METHODS Informed consent documents (IC) were coded by two independent coders. Each IC was assessed for readability, attention to elements of informed consent, and completeness of information about the test and the screened conditions. RESULTS We found variance between IC produced by commercial laboratories versus those provided by local clinics or health care systems, and considerable variance among materials from all sources. "Commercial" IC were longer and written at a more difficult reading level than "non-commercial" IC, and were less likely to state explicitly that cfDNA only screens for certain conditions. About one-third of IC were combined with laboratory order forms. Though most IC recommended confirmatory testing for positive results, only about half clearly stated that results could be incorrect-including mentions of false positives or false negatives. About one-third of IC explicitly stated that cfDNA screening was optional. While nearly all IC from any source listed the conditions screened by the test, only about half of the IC included any phenotypic descriptions of these conditions. Few IC mentioned psychosocial considerations, and only one IC mentioned the availability of support groups for families of children with genetic conditions. CONCLUSIONS Based on our findings, we recommend that written and well-informed consent be sought before performing cfDNA screening, and we offer minimal and recommended standards for patient education and consent materials.
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Affiliation(s)
- Marsha Michie
- Institute for Health & Aging, University of California, San Francisco
| | | | | | - Roberta R Ryan
- Institute for Health & Aging, University of California, San Francisco
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Gregg AR, Skotko BG, Benkendorf JL, Monaghan KG, Bajaj K, Best RG, Klugman S, Watson MS. Noninvasive prenatal screening for fetal aneuploidy, 2016 update: a position statement of the American College of Medical Genetics and Genomics. Genet Med 2016; 18:1056-65. [PMID: 27467454 DOI: 10.1038/gim.2016.97] [Citation(s) in RCA: 439] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 12/17/2022] Open
Abstract
DISCLAIMER This statement is designed primarily as an educational resource for clinicians to help them provide quality medical services. Adherence to this statement is completely voluntary and does not necessarily assure a successful medical outcome. This statement should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed toward obtaining the same results. In determining the propriety of any specific procedure or test, the clinician should apply his or her own professional judgment to the specific clinical circumstances presented by the individual patient or specimen. Clinicians are encouraged to document the reasons for the use of a particular procedure or test, whether or not it is in conformance with this statement. Clinicians also are advised to take notice of the date this statement was adopted and to consider other medical and scientific information that becomes available after that date. It also would be prudent to consider whether intellectual property interests may restrict the performance of certain tests and other procedures.Noninvasive prenatal screening using cell-free DNA (NIPS) has been rapidly integrated into prenatal care since the initial American College of Medical Genetics and Genomics (ACMG) statement in 2013. New evidence strongly suggests that NIPS can replace conventional screening for Patau, Edwards, and Down syndromes across the maternal age spectrum, for a continuum of gestational age beginning at 9-10 weeks, and for patients who are not significantly obese. This statement sets forth a new framework for NIPS that is supported by information from validation and clinical utility studies. Pretest counseling for NIPS remains crucial; however, it needs to go beyond discussions of Patau, Edwards, and Down syndromes. The use of NIPS to include sex chromosome aneuploidy screening and screening for selected copy-number variants (CNVs) is becoming commonplace because there are no other screening options to identify these conditions. Providers should have a more thorough understanding of patient preferences and be able to educate about the current drawbacks of NIPS across the prenatal screening spectrum. Laboratories are encouraged to meet the needs of providers and their patients by delivering meaningful screening reports and to engage in education. With health-care-provider guidance, the patient should be able to make an educated decision about the current use of NIPS and the ramifications of a positive, negative, or no-call result.Genet Med 18 10, 1056-1065.
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Affiliation(s)
- Anthony R Gregg
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
| | - Brian G Skotko
- Department of Pediatrics, Harvard Medical School and Division of Medical Genetics, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Komal Bajaj
- New York City Health + Hospitals/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert G Best
- University of South Carolina School of Medicine, Greenville Health System, Greenville, South Carolina, USA
| | - Susan Klugman
- Montefiore Medical Center, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael S Watson
- American College of Medical Genetics and Genomics, Bethesda, Maryland, USA
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