PRENATAL DIAGNOSIS

By Dr. JY Ho (Manipal)

REFERENCES

Hacker & Moore. Essentials of Obstetrics & Gynaecology 5th Edition, 2010. Royal College of Obstetrics & Gynaecology (RCOG) Guidelines. Medscape. Prenatal Diagnosis : Congenital Malformations and Genetic Disorders, 2011. http://www.who.int/whosis/mort/profiles/mort_wpro_mys_ malaysia.pdf. WHO Mortality Country Fact Sheet 2006. American College of Obstetricians and Gynecologists (ACOG). Screening for fetal chromosomal abnormalities. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2007 Jan. 11 p. (ACOG practice bulletin; no. 77).

INTRODUCTION

Congenital anomalies account for 20-25% of perinatal deaths worldwide. In Malaysia, congenital anomalies account for 13% of neonatal deaths (WHO Mortality Country Fact Sheet 2006) Prenatal diagnosis employs various non-invasive and invasive techniques to determine the health or any abnormality in an unborn fetus

BENEFITS OF PRENATAL DIAGNOSIS

Determines

outcomes of pregnancy Helpful for couples to decide whether to continue pregnancy Indicates possible complications that can arise at birth process Helpful for managing remaining weeks of pregnancy Prepares the couples for the birth of a child with an abnormality Helpful for the improvement of the outcomes of pregnancy using fetal treatment

PREREQUISITES OF PRENATAL DIAGNOSIS

Pregnant woman > 35years A previous child or family history of birth defects, chromosomal anomaly or genetic disorder A previous child with mental retardation Multiple fetal losses Abnormal serum marker screening results Consanguinity Maternal conditions predisposing to fetal abnormality Teratogenic exposure Suspected abnormal ultrasound findings A parent who is a known carrier of genetic disorder

TECHNIQUES
NON-INVASIVE

INVASIVE

NON-INVASIVE TECHNIQUES
    

Fetal visualization Ultrasound Fetal echocardiography MRI Radiographs Screening for neural tube defects (NTDs) Maternal serum -fetoprotein (MSAFP) Screening for fetal Down syndrome MSAFP, maternal unconjugated estriol, maternal serum -hCG, serum inhibin A

 Separation

of fetal cells from mothers

blood
Assessment

of fetal-specific DNA methylation ratio

ULTRASOUND TVS/TAS
Harmless Developing TVS

to both fetus and mother embryo can be visualized at 6 wks gestation

- accurate dating, fetal location & number, nuchal translucency - cervical length in mid-trimester (identify risk of preterm delivery - placental location in 2nd or 3rd trimester

 TAS

- 16-20weeks structural abnormalities - 3rd trimester fetal growth (fetal biometry), amniotic fluid index - biophysical profile (risk of fetal death within a week following BPP score of >8 is less than 1%)
Doppler Guide


: umbilical & fetal middle cerebral artery

invasive sampling

amniocentesis, chorionic villus sampling, cordocentesis, fetal biopsies

FETAL ECHOCARDIOGRAPHY

Can be performed at 15 weeks gestation & beyond Can identify major structural cardiac defects and rhythm disturbances with duplex or colour flow doppler Recommended when cardiac defects are suspected:
Identification of extracardiac malformations on routine ultrasound y Family history of congenital heart disease y Suspected genetic disease or fetal chromosome abnormality associated with heart defects y Exposure to potentially teratogenic agents
y

SCREENING TESTS
MSAFP Time (Wks) Observation 15-18 Triple Test 15-18 MSAFP &UE3 -hCG Open NTD 65% Downs syn 60% -hCG + PAPP-A 10-14 -hCG PAPP-A Downs syn 65% Nuchal Translucency 11-14 Nuchal thickness 3mm Downs syn 70%

Anomaly to Detect Test Sensitivity Rate False Positive Rate

3-5%

5%

5%

5-6%

Inhibin A serum level

in Down s syndrome

MSAFP : maternal serum -fetoprotein UE3 : maternal unconjugated estriol -hCG : maternal -human chorionic gonadotropin PAPP-A : pregnancy-associated plasma protein A

SEPARATION OF FETAL CELLS FROM MOTHERS BLOOD

Fetal blood cells make access to maternal circulation through placental villi Can be collected at 18 weeks gestation Can be analyzed for the diagnosis of genetic disorders using molecular genetic techniques by isolating DNA and amplifying it by PCR Successfully used in the diagnosis of cystic fibrosis, sickle cell anemia and thalassemia in fetus

INVASIVE
Fetal

TECHNIQUES

visualization - Embryoscopy - Fetoscopy tissue sampling - Amniocentesis - Chorionic villous sampling (CVS) - Cordocentesis (Percutaneous Umbilical Blood Sampling-PUBS) genetic diagnosis (PGD)

Fetal

Preimplantation

 Cytogenetic

 

investigations Detection of chromosomal aberrations Fluorescent in situ hybridization

Molecular genetic techniques  Linkage analysis using microsatellite markers  Restriction fragment length polymorphisms (RFLPs)  Single nucleotide polymorphisms (SNPs)  DNA chip  Dynamic allele-specific hybridization (DASH)

EMBRYOSCOPY
Performed A

in the 1st trimester

rigid endoscope is inserted via the cervix in the space between amnion and chorion, under sterile conditions & USG guidance to visualize the embryo for diagnosis of congenital malformations

FETOSCOPY

Performed in the 2nd trimester A fine caliber endoscope is inserted into the amniotic cavity through a small maternal abdominal incision, under USG guidance Visualize fetus for structural abnormalities Also used for fetal blood and tissue sampling 3-5% risk of miscarriage

AMNIOCENTESIS
Performed

between 14-20 weeks 22-gauge needle is passed through mothers lower abdomen into clear pocket of amniotic fluid under USG guidance 10-20ml of amniotic fluid obtained 0.5-1.0% fetal loss and maternal Rh isoimmunization (anti-D Ig given to Rh ve mothers) Amniotic cells require 1-2 weeks culture for chromosomal analysis

 Genetic

diagnosis - diagnose chromosomal anomalies (trisomy21) - DNA amplification by PCR allow molecular analysis of genetic disorders (cystic fibrosis, sickle cell disease) testing - Amniotic fluid -fetoprotein (AFAFP) - in fetal dorsal / ventral wall defect (NTD, gastrochisis) of perinatal infections - by culture / PCR (CMV,VZV,Parvovirus B19, toxoplasmosis)

Biochemical

Diagnosis

 3rd

trimester fetal lung maturity - phosphatidylgycerol, lecithinsphingomyelin ratio amniocentesis - polyhydramnios & twin-twin transfusion syndrome

Therapeutic

CHORIONIC VILLOUS SAMPLING

Performed between 10-12 weeks gestation Transcervically or transabdominally A catheter is passed through the cervix or abdominal wall into uterus under USG guidance A sample of chorionic villi surrounding the sac is obtained Chromosome analysis can be carried out within 3 days

Information obtained is the same as in Amniocentesis

ADVANTAGES AND DISADVANTAGES OF

CVS OVER AMNIOCENTESIS
Advantages Quicker results Abnormalities can be detected early More acceptable decisions about termination of pregnancy can be taken (abortion much safer) Disadvantages Higher risk of miscarriage (2-3%) Risk of fetal limb defects Higher rate of maternal cell contamination and confined placental mosaicism leads to diagnostic ambiguity

CORDOCENTESIS (PUBS)
Features Information obtained

Performed after 16 weeks A 25 gauge needle is inserted into the umbilical cord under USG guidance Fetal blood is collected from umbilical vein for chromosome analysis and genetic diagnosis

Same as in Amniocentesis (but more rapid using fetal leukocyte culture result available in 3 days) Fetal anaemia (superseded by doppler of fetal MCA)

Risk : Fetal loss rate 1% Chorioamnionitis Cord hematoma Thrombosis of umbilical vessels

Preimplantation Genetic Diagnosis (PGD)

Features a technique used to identify genetic defects in embryos created through IVF before pregnancy for selective transfer and implantation of pregnancies into the uterus that are not affected by a specific genetic disorder Advantages more acceptable to those couples who oppose abortions preventing heritable genetic disease, thereby eliminating the dilemma of pregnancy termination following unfavorable prenatal diagnosis

1ST TRIMESTER SCREENING

Maternal age Fetal nuchal translucency (NT) thickness Maternal serum -hCG Pregnancy-associated plasma protein-A (PAPP-A) Visualization of nasal bone by USG

* Combination of the above : Increase Down syndrome detection rate to 93%



Women found to have increased risk of aneuploidy should be offered genetic counselling and option of CVS / amniocentesis
Hacker & Moore. Essentials of Obstetrics & Gynaecology 5th Edition, 2010.

2ND TRIMESTER SCREENING

Triple screening tests - MSAFP - Maternal unconjugated estriol - Maternal serum -hCG Anomaly scan Amniocentesis - AFAFP - Acetylcholinesterase (present only in open NTD)

* MSAFP detect 80-85% of all open NTDs * Triple screen detect 70% of Down syndrome * Triple screen + Serum Inhibin A detect 81% of Down syndrome
Hacker & Moore. Essentials of Obstetrics & Gynaecology 5th Edition, 2010

COMBINED 1ST AND 2ND TRIMESTER

SCREENING

Integrated screening - single risk calculation - not reported until after 2nd trimester results are available - highest sensitivity and most most effective Sequential screening - disclosure of 1st trimester results for clinical management

Hacker & Moore. Essentials of Obstetrics & Gynaecology 5th Edition, 2010