Population-based study of long-term outcomes after amniocentesis

The choice of detecting Down syndrome: does money matter?

The prenatal diagnosis of Down syndrome (amniocentesis) presents parents with a complex dilemma which requires comparing the risk of giving birth to an affected child and the risk of losing an unaffected child through amniocentesis-related miscarriage. Building on the specific features of the French Health insurance system, this paper shows that variation in the monetary costs of the diagnosis procedure may have a very significant impact on how parents solve this ethical dilemma. The French institutions make it possible to compare otherwise similar women facing very different reimbursement schemes and we find that eligibility to full reimbursement has a largely positive effect on the probability of taking an amniocentesis test. By contrast, the sole fact of being labelled 'high-risk' by the Health system seems to have, as such, only a modest effect on subsequent choices. Finally, building on available information on post-amniocentesis outcomes, we report new evidence suggesting that amniocentesis increases the risk of premature birth and low weight at birth.

Randomised trial to assess safety and fetal outcome of early and midtrimester amniocentesis. The Canadian Early and Mid-trimester Amniocentesis Trial (CEMAT) Group

BACKGROUND

Most published reports on early amniocentesis are of cohort studies rather than randomised trials. This study was designed to assess the safety and cytogenetic accuracy of early amniocentesis in-contrast to midtrimester amniocentesis in a randomised multicentre setting.

METHODS

Pregnant women were randomly allocated early amniocentesis (between 11(+0) and 12(+6) gestational weeks(days)) or midtrimester (between 15(+0) and 16(+6) gestational weeks(days)) amniocentesis. A detailed fetal ultrasound examination was done between 15 and 20 gestational weeks in all women. All amniocenteses were done under continuous ultrasound guidance: 11 mL (early amniocentesis) or 20 mL (midtrimester amniocentesis) of amniotic fluid were removed for cytogenic analysis. No more than two needle insertions were done on the same day. All fetal losses (spontaneous or induced abortions) were counted as outcome events and post-procedural losses had cytogenic analysis. Maternal and fetal health were assessed at 20-22 weeks and 5 weeks after delivery. Logistic regression analysis was used to assess the significance of the differences between the early amniocentesis and midtrimester amniocentesis groups.

FINDINGS

4374 pregnant women took part in the study. 1916 (87.8%) of 2183 women in the early amniocentesis group had their amniocentesis before 13 gestational weeks. 1775 (81.2%) of 2185 women in the midtrimester group had their amniocentesis after 15 gestational weeks. There was a significant difference in total fetal losses for early amniocentesis compared with midtrimester amniocentesis (7.6% vs 5.9%; difference 1.7%, one-sided CI 2.98%, p = 0.012). There was a significant increase in talipes equinovarus in the early amniocentesis group compared with the midtrimester amniocentesis group (1.3% vs 0.1%, p = 0.0001). There was a significant difference in postprocedural amniotic-fluid leakage (early amniocentesis 3.5% vs midtrimester amniocentesis 1.7%, p = 0.0007).

INTERPRETATION

Our study shows that early amniocentesis is associated with an increased risk of fetal loss and talipes equinovarus. Our results should be taken into consideration when invasive prenatal diagnosis is being offered.

Prenatal diagnosis of orbital heterotopic brain tissue

Biopsy of fetal tissues is a relatively new procedure for the diagnosis of congenital malformations. The authors report the first case in which this technique has been applied to an orbital mass, in which heterotopic brain tissue was diagnosed by prenatal biopsy and excised in infancy. The wider implications of such intrauterine procedures are discussed.

Early and midtrimester genetic amniocenteses. Safety and outcomes

Prenatal diagnosis, the in utero determination of fetal disease, has become an important aspect of genetic counseling. The advances in technology coupled with developments in the field of molecular biology and genetics have made possible the detection of an increasing number of diseases in utero. Although not without some risk, midtrimester amniocentesis has been, and will continue to be, an important technique in this regard.

Risk factors for childhood sensorineural hearing loss in the Oxford region

We have used a comprehensive register of hearing-impaired children born in the former Oxford Health Region to study risk factors for sensorineural hearing loss. The occurrence of a wide variety of risk factors was documented from the case notes of 145 children; these were all the cases known at the time of the study with all degrees of hearing loss born between 1984 and 1988. Comparison with the normal Regional population showed that maternal age over 35 years and Asian ethnic origin were significant risk factors for congenital (non-acquired) hearing loss (odds ratio 1.7 and 2.5 respectively). Black/Asian children were also significantly more likely to have acquired losses. Low birthweight (below 2500 g) also gave a significantly increased risk, with an odds ratio of 4.5, rising to 9.6 for birthweight less than 1500 g. We also found that significantly more hearing-impaired cases were in lower social classes compared with the general population. A high proportion of cases (24%) had cranio-facial abnormalities (CFA), including many non-aural abnormalities and dysmorphic features, which therefore should be counted as high risk. Hearing losses acquired due to perinatal causes were almost all mild or moderate. Four factors-admission to special care baby unit for more than 72 hours, CFA, family history, and meningitis-accounted for 69% of all cases in this study. Targeted neonatal screening based on the first three factors, plus obligatory testing following meningitis, therefore, should be highly efficient at detecting deafness early.

Children whose mothers had second trimester amniocentesis: follow up at school age

OBJECTIVE

To explore potential long term consequences of second trimester amniocentesis.

DESIGN

Children exposed to second trimester amniocentesis have been followed prospectively from birth to school age and compared with children whose mothers declined the test.

SETTING

The Hospital for Sick Children, Toronto.

SAMPLE

Eighty-six children exposed to amniocentesis and 44 children whose mothers declined the test.

INTERVENTIONS

Second trimester amniocentesis for the late maternal age indication.

MAIN OUTCOME MEASURES

Standardised tests of intelligence, academic achievement, speech articulation, visual-perceptual-motor ability and fine motor coordination were administered. Parents reported on child behaviour using standardised measures of behaviour problems, social competence, hyperactivity and temperament. Physical growth was also measured, and parents reported on child health.

RESULTS

Group differences were not observed.

CONCLUSIONS

Second trimester amniocentesis does not appear to compromise child development, behaviour, growth or health.