Merck Manual

Please confirm that you are a health care professional

Yes No

Leave this Site?

The link you have selected will take you to a third-party website. We do not control or have responsibility for the content of any third-party site.

Continue Cancel
honeypot link
Merck Manual
Professional Version
The trusted provider of medical information since 1899
Medical Topics & Chapters
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Professional /
Gynecology and Obstetrics /
Prenatal Genetic Counseling and Evaluation /
... /
Genetic Evaluation /
IN THIS TOPIC

General reference

Fetal genetic diagnostic tests

Procedures for prenatal diagnosis

Prenatal Ultrasonography Amniocentesis Chorionic Villus Sampling Percutaneous Umbilical Blood Sampling Preimplantation Genetic Testing (PGT)

Noninvasive Maternal Screening Strategies

1st-Trimester Screening 2nd-Trimester Screening Sequential 1st- and 2nd-Trimester Screening

OTHER TOPICS IN THIS CHAPTER

Prenatal Genetic Counseling and Evaluation
Prenatal Genetic Counseling
Genetic Evaluation

ADDITIONAL CONTENT

Test your knowledge

Management of Normal Delivery
Options for pain management during normal delivery include regional, local, and general anesthesia. Of these types of anesthesia, which of the following is a safe and simple method for uncomplicated spontaneous vaginal deliveries in women who wish to bear down and push?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

More Content

Genetic Evaluation

By

Jeffrey S. Dungan

, MD, Northwestern University, Feinberg School of Medicine

Last full review/revision Oct 2019| Content last modified Oct 2019
Click here for Patient Education
Topic Resources

Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as

  • The probability of a fetal abnormality based on risk factors and the results of any previous testing

  • The probability of a complication from invasive fetal testing

  • The importance of knowing the results (eg, would the pregnancy be terminated if an abnormality was diagnosed, would not knowing the results cause anxiety)

For these reasons, the decision is individual, and recommendations often cannot be generalized to all women, even those with similar risk.

A screening history is part of the evaluation. The history is summarized as a pedigree (see figure Symbols for constructing a family pedigree Symbols for constructing a family pedigree A gene, the basic unit of heredity, is a segment of DNA containing all the information necessary to synthesize a polypeptide (protein). Protein synthesis, folding, and tertiary and quaternary... read more ). Information should include the health status and presence of genetic disorders or carrier status of both parents, of 1st-degree relatives (parents, siblings, offspring), and of 2nd-degree relatives (aunts, uncles, grandparents), as well as ethnic and racial background and consanguineous matings. Outcomes of previous pregnancies are noted. If genetic disorders are suspected, relevant medical records must be reviewed.

Genetic screening tests for potential parents are best done before conception. Traditionally, tests are offered to parents at risk of being asymptomatic carriers for certain common mendelian disorders (see table Genetic Screening for Some Ethnic Groups Genetic Screening for Some Ethnic Groups Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Genetic Screening for Some Ethnic Groups ). Diagnostic tests for specific abnormalities are offered to parents when appropriate (see table Indications for Fetal Genetic Diagnostic Tests Indications for Fetal Genetic Diagnostic Tests Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Indications for Fetal Genetic Diagnostic Tests ). Because parent ethnicity is more complex and less well-defined than previously thought and because prenatal genetic testing is becoming much less expensive and quicker, some clinicians are starting to screen all potential (and expectant) parents, regardless of ethnicity (called universal carrier screening). Another approach is called expanded carrier screening. In this form of screening, a large number of genes—many more than those associated with specific ethnicities—are analyzed. Often, dozens of genes and disorders (some with more severe phenotypic consequences than others) are included (1 General reference Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more General reference ). Consensus on which disorders should be tested for does not yet exist. Increasing the amount of testing and evaluation is expected to increase the complexity of pre-test counseling.

After conception, pregnant women should be offered screening for fetal chromosome disorders using one of several methods. One method uses multiple maternal serum markers Maternal serum screening for chromosomal abnormalities Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Maternal serum screening for chromosomal abnormalities (alpha-fetoprotein, beta-human chorionic gonadotropin [beta-hCG], estriol, inhibin A) to detect neural tube defects Maternal serum screening for neural tube defects Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Maternal serum screening for neural tube defects , Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more Down Syndrome (Trisomy 21) (and other chromosomal abnormalities), and some other birth defects. This screening is called analyte screening. It is done at 15 to 20 weeks of pregnancy. An increasingly popular method of screening for fetal Down syndrome, trisomy 18 Trisomy 18 Trisomy 18 is caused by an extra chromosome 18 and is usually associated with intellectual disability, small birth size, and various congenital anomalies, including severe microcephaly, heart... read more Trisomy 18 , and trisomy 13 Trisomy 13 Trisomy 13 is caused by an extra chromosome 13 and causes abnormal forebrain, midface, and eye development; severe intellectual disability; heart defects; and small birth size. Diagnosis is... read more Trisomy 13 is with analysis of cell-free DNA Cell-free fetal nucleic acid testing Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Cell-free fetal nucleic acid testing (cfDNA) in maternal plasma. Detection rates using this technology are higher than those with older methods.

(See also Prenatal Genetic Counseling Prenatal Genetic Counseling Prenatal genetic counseling is provided for all prospective parents, ideally before conception, to assess risk factors for congenital disorders. Certain precautions to help prevent birth defects... read more .)

General reference

Fetal genetic diagnostic tests

Fetal genetic diagnostic tests are usually done via chorionic villus sampling Chorionic Villus Sampling Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Chorionic Villus Sampling , amniocentesis Amniocentesis Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Amniocentesis , or, rarely, percutaneous umbilical blood sampling Percutaneous Umbilical Blood Sampling Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Percutaneous Umbilical Blood Sampling . They can detect all trisomies, many other chromosomal abnormalities, and several hundred mendelian abnormalities. Submicroscopic chromosomal abnormalities are missed by traditional karyotype testing and can be identified only by microarray technologies, such as array comparative genomic hybridization and single nucleotide polymorphism (SNP)-based arrays.

Tests are usually recommended if risk of a fetal chromosomal abnormality is increased (see table Indications for Fetal Genetics Indications for Fetal Genetic Diagnostic Tests Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Indications for Fetal Genetic Diagnostic Tests ). Fetal genetic diagnostic tests, unlike screening tests, are usually invasive and involve fetal risk. Thus, in the past, these tests were not routinely recommended for women without risk factors. However, because fetal genetic diagnostic tests are now more widely available and safety has improved, offering fetal genetic testing to all pregnant women, regardless of risk, is recommended. Array comparative genomic hybridization in prenatal testing is most frequently used to evaluate fetuses with structural abnormalities. Arrays detect numeric chromosome abnormalities (eg, trisomies) as well as unbalanced structural chromosome disorders, such as microdeletions. Studies have reported about 6% incidence of array abnormalities that would have been missed with traditional karyotyping in structurally abnormal fetuses.

Preimplantation genetic diagnosis Preimplantation Genetic Testing (PGT) Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Preimplantation Genetic Testing (PGT) may be available for couples who are using in vitro fertilization In vitro fertilization (IVF) Assisted reproductive techniques (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. ARTs may result in multifetal pregnancy, but risk is... read more In vitro fertilization (IVF) .

Table
icon
Table
icon

Procedures for prenatal diagnosis

All procedures used to diagnose genetic disorders, except ultrasonography, are invasive and involve slight fetal risk. If testing detects a serious abnormality, the pregnancy can be terminated, or in some cases, a disorder can be treated (eg, fetal surgery to repair spina bifida Spina Bifida Spina bifida is defective closure of the vertebral column. Although the cause is not known, low folate levels during pregnancy increase risk. Some children are asymptomatic, and others have... read more ). Even if neither of these possibilities is anticipated, some women prefer to know of fetal abnormalities before birth.

Prenatal Ultrasonography

Some experts recommend ultrasonography routinely for all pregnant women. Others use ultrasonography only for specific indications, such as checking for suspected genetic or obstetric abnormalities or helping interpret abnormal maternal serum marker levels. If ultrasonography is done by skilled operators, sensitivity for major congenital malformations is high. However, some conditions (eg, oligohydramnios, maternal obesity, fetal position) interfere with obtaining optimal images. Ultrasonography is noninvasive and has no known risks to the woman or fetus.

Basic ultrasonography is done to

  • Confirm gestational age

  • Determine fetal viability

  • Detect a multifetal pregnancy

  • During the 2nd or 3rd trimester, possibly identify major malformations in the fetal intracranial structures, spine, heart, bladder, kidneys, stomach, thorax, abdominal wall, long bones, and umbilical cord

Although ultrasonography provides only structural information, some structural abnormalities strongly suggest genetic abnormalities. Multiple malformations may suggest a chromosomal disorder.

Targeted ultrasonography, with high-resolution ultrasonography equipment, is available at certain referral centers and provides more detailed images than basic ultrasonography. This test may be indicated for couples with a family history of a congenital malformation (eg, congenital heart defects Overview of Congenital Cardiovascular Anomalies Congenital heart disease is the most common congenital anomaly, occurring in almost 1% of live births (1). Among birth defects, congenital heart disease is the leading cause of infant mortality... read more Overview of Congenital Cardiovascular Anomalies , cleft lip and palate Cleft Lip and Cleft Palate Cleft lip, cleft lip and palate, and isolated cleft palate, are collectively termed oral clefts (OCs). OCs are the most common congenital anomalies of the head and the neck with a total prevalence... read more Cleft Lip and Cleft Palate , pyloric stenosis Hypertrophic Pyloric Stenosis Hypertrophic pyloric stenosis is obstruction of the pyloric lumen due to pyloric muscular hypertrophy. Diagnosis is by abdominal ultrasonography. Treatment is surgical. Hypertrophic pyloric... read more ), particularly one that may be treated effectively before birth (eg, posterior urethral valves with megacystis) or at delivery (eg, diaphragmatic hernia Diaphragmatic Hernia Diaphragmatic hernia is protrusion of abdominal contents into the thorax through a defect in the diaphragm. Lung compression may cause persistent pulmonary hypertension. Diagnosis is by chest... read more Diaphragmatic Hernia ). High-resolution ultrasonography may also be used if maternal serum marker levels are abnormal. High-resolution ultrasonography may allow detection of the following:

During the 2nd trimester, identifying structures that are statistically associated with increased risk of fetal chromosomal abnormalities helps refine risk estimate.

Amniocentesis

In amniocentesis, a needle is inserted transabdominally, using ultrasonographic guidance, into the amniotic sac to withdraw amniotic fluid and fetal cells for testing, including measurement of chemical markers (eg, alpha-fetoprotein, acetylcholinesterase). The safest time for amniocentesis is after 14 weeks gestation. Immediately before amniocentesis, ultrasonography is done to assess fetal cardiac motion and determine gestational age, placental position, amniotic fluid location, and fetal number. If the mother has Rh-negative blood and is unsensitized, Rho (D) immune globulin 300 mcg is given after the procedure to help prevent Rh sensitization Prevention Erythroblastosis fetalis is hemolytic anemia in the fetus (or neonate, as erythroblastosis neonatorum) caused by transplacental transmission of maternal antibodies to fetal red blood cells.... read more .

Amniocentesis has traditionally been offered to pregnant women > 35 because their risk of having an infant with Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more Down Syndrome (Trisomy 21) or another chromosomal abnormality is increased. However, with the widespread availability and improved safety of amniocentesis, the American College of Obstetricians and Gynecologists recommends all pregnant women be offered amniocentesis to assess the risk of fetal chromosomal disorders.

Occasionally, the amniotic fluid obtained is bloody. Usually, the blood is maternal, and amniotic cell growth is not affected; however, if the blood is fetal, it may falsely elevate amniotic fluid alpha-fetoprotein level. Dark red or brown fluid indicates previous intra-amniotic bleeding and an increased risk of fetal loss. Green fluid, which usually results from meconium staining, does not appear to indicate increased risk of fetal loss.

Amniocentesis rarely results in significant maternal morbidity (eg, symptomatic amnionitis). With experienced operators, risk of fetal loss is about 0.1 to 0.2%. Vaginal spotting or amniotic fluid leakage, usually self-limited, occurs in 1 to 2% of women tested. Amniocentesis done before 14 weeks gestation, particularly before 13 weeks, results in a higher rate of fetal loss and an increased risk of talipes equinovarus Talipes Equinovarus (Clubfoot) and Other Foot Abnormalities Talipes equinovarus, sometimes called clubfoot, is characterized by plantar flexion, inward tilting of the heel (from the midline of the leg), and adduction of the forefoot (medial deviation... read more Talipes Equinovarus (Clubfoot) and Other Foot Abnormalities (clubbed feet) and is rarely done.

Chorionic Villus Sampling

In chorionic villus sampling (CVS), chorionic villi are aspirated into a syringe and cultured. CVS provides the same information about fetal genetic and chromosomal status as amniocentesis Amniocentesis Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Amniocentesis and has similar accuracy. However, CVS is done between 10 weeks gestation and the end of the 1st trimester and thus provides earlier results. Therefore, if needed, pregnancy may be terminated earlier (and more safely and simply), or if results are normal, parental anxiety may be relieved earlier.

Unlike amniocentesis, CVS does not enable clinicians to obtain amniotic fluid, and alpha-fetoprotein cannot be measured. Thus, women who have CVS should be offered maternal screening for serum alpha-fetoprotein at 16 to 18 weeks to assess risk of fetal neural tube defects Maternal serum screening for neural tube defects Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Maternal serum screening for neural tube defects .

Depending on placental location (identified by ultrasonography), CVS can be done by passing a catheter through the cervix or by inserting a needle through the woman’s abdominal wall. After CVS, Rho(D) immune globulin 300 mcg is given to Rh-negative unsensitized women.

Errors in diagnosis due to maternal cell contamination are rare. Detection of certain chromosomal abnormalities (eg, tetraploidy) may not reflect true fetal status but rather mosaicism confined to the placenta. Confined placental mosaicism is detected in about 1% of CVS specimens. Consultation with experts familiar with these abnormalities is advised. Rarely, subsequent amniocentesis is required to obtain additional information.

Rate of fetal loss due to CVS is similar to that of amniocentesis (ie, about 0.2%). Transverse limb defects and oromandibular-limb hypogenesis have been attributed to CVS but are exceedingly rare if CVS is done after 10 weeks gestation by an experienced operator.

Percutaneous Umbilical Blood Sampling

Fetal blood samples can be obtained by percutaneous puncture of the umbilical cord vein (funipuncture) using ultrasound guidance. Chromosome analysis can be completed in 48 to 72 hours. For this reason, percutaneous umbilical blood sampling (PUBS) was formerly often done when results were needed rapidly. This test was especially useful late in the 3rd trimester, particularly if fetal abnormalities were first suspected at that time. Now, genetic analysis of amniotic fluid cells or chorionic villi via interphase fluorescent in situ hybridization (FISH) allows preliminary diagnosis (or exclusion) of more common chromosomal abnormalities within 24 to 48 hours, and PUBS is rarely done for genetic indications.

Procedure-related fetal loss rate with PUBS is about 1%.

Preimplantation Genetic Testing (PGT)

Preimplantation genetic testing (PGT) is sometimes possible before implantation when in vitro fertilization In vitro fertilization (IVF) Assisted reproductive techniques (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. ARTs may result in multifetal pregnancy, but risk is... read more In vitro fertilization (IVF) is done; polar bodies from oocytes, blastomeres from 6- to 8-cell embryos, or a trophectoderm sample from the blastocyst is used. These tests are available only in specialized centers and are expensive. However, newer techniques may reduce costs and make such tests more widely available.

There are 3 forms of PGT:

PGT-M is used primarily for couples when the risk of certain mendelian disorders (eg, cystic fibrosis Cystic Fibrosis Cystic fibrosis is an inherited disease of the exocrine glands affecting primarily the gastrointestinal and respiratory systems. It leads to chronic lung disease, exocrine pancreatic insufficiency... read more Cystic Fibrosis ) in the fetus is high. PGT-A or PGT-SR is used for couples when chromosomal abnormalities in the fetus is a risk.

PGT-A is used primarily for embryos from older women, but routine use is controversial (1).

Preimplantation genetic testing reference

Noninvasive Maternal Screening Strategies

Noninvasive maternal screening, unlike invasive testing, has no risk of test-related complications. By more precisely assessing the risk of fetal abnormalities, noninvasive maternal screening can help women decide whether to have invasive testing. Noninvasive maternal screening for fetal chromosomal abnormalities should be offered to all pregnant women who have not already decided to have amniocentesis or CVS. However, even if CVS is to be done, maternal serum screening should still be offered to check for fetal neural tube defects Maternal serum screening for neural tube defects Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Maternal serum screening for neural tube defects .

Normal values vary with gestational age. Corrections for maternal weight, diabetes mellitus, race, and other factors may be necessary. Screening can be done during the 1st trimester, 2nd trimester, or both (called sequential or integrated screening). Any of the 3 approaches is acceptable. Maternal levels of alpha-fetoprotein should be measured during the 2nd trimester to check for neural tube defects.

Pearls & Pitfalls

  • Measure maternal levels of alpha-fetoprotein during the 2nd trimester to check for neural tube defects regardless of other tests planned and the timing of those tests.

1st-Trimester Screening

Traditionally, 1st-trimester combined screening includes measurement of

  • Maternal serum beta-hCG (total or free)

  • Pregnancy-associated plasma protein A (PAPP-A)

  • Fetal nuchal translucency (by ultrasonography)

Fetal Down syndrome is typically associated with high levels of beta-hCG, low levels of PAPP-A, and enlarged fetal nuchal translucency (NT). Although enlarged NT is associated with increased risk of fetal Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more Down Syndrome (Trisomy 21) , no threshold NT value is considered diagnostic.

In large prospective US trials involving women of various ages, overall sensitivity for detection of Down syndrome was about 85%, with a false-positive rate of 5%. Specialized ultrasound training and adherence to rigorous quality-assurance monitoring of NT measurements are necessary to achieve this level of screening accuracy.

First-trimester screening should be offered to all pregnant women. It provides information early so that a definitive diagnosis can be made with CVS. An important advantage of 1st-trimester screening is that termination of pregnancy is safer during the 1st rather than the 2nd trimester.

Cell-free fetal nucleic acid testing

An increasingly used approach, called noninvasive prenatal screening or cell-free DNA (cfDNA) screening, can identify fetal chromosomal abnormalities in singleton pregnancies by analyzing circulating cell-free fetal nucleic acids in a maternal blood sample. This test can be done as early as 10 gestational weeks and is replacing traditional 1st- and 2nd-trimester noninvasive screening in many centers.

Cell-free fetal nucleic acids, most commonly DNA fragments, are shed into the maternal circulation during normal breakdown of placental trophoblast cells. Variation in amounts of fragments from particular chromosomes predicts fetal chromosomal abnormalities with higher accuracy than traditional 1st- and 2nd-trimester combined screening using serum analytes and ultrasound. Also, sex chromosomal abnormalities (X, XXX, XYY, and XXY) can be identified in singleton pregnancies, although with somewhat lower accuracy. Early validation trials reported > 99% sensitivity and specificity for the identification of Down syndrome (trisomy 21) and trisomy 18 Trisomy 18 Trisomy 18 is caused by an extra chromosome 18 and is usually associated with intellectual disability, small birth size, and various congenital anomalies, including severe microcephaly, heart... read more Trisomy 18 in high-risk pregnancies. Trisomy 13 Trisomy 13 Trisomy 13 is caused by an extra chromosome 13 and causes abnormal forebrain, midface, and eye development; severe intellectual disability; heart defects; and small birth size. Diagnosis is... read more Trisomy 13 can also be detected, although the sensitivity and specificity are somewhat lower (1) General reference Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more General reference .

Cell-free DNA (cfDNA) screening is currently recommended for women with preexisting risk factors for fetal trisomy. However, in a recent large multicenter trial that studied the effectiveness of cfDNA screening in a low-risk population, sensitivity for detection of fetal Down syndrome was equivalent to that in a high-risk population. Given the lower incidence of fetal Down syndrome in younger pregnant women, the specificity and positive predictive value were lower than if screening only high-risk women. However, cfDNA screening was superior to traditional analyte screening in low-risk women in overall performance. Cell-free DNA screening has largely replaced serum analyte screening in high-risk women, but screening approaches in low-risk women still rely primarily on traditional, and less expensive, 1st- and 2nd-trimester combined screening with serum analytes and ultrasound (1 General reference Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more General reference ).

Abnormal results from cfDNA screening should be confirmed with diagnostic karyotyping using fetal specimens obtained through invasive techniques. Negative results from cfDNA screening has reduced the use of routine invasive testing.

General reference

2nd-Trimester Screening

Second-trimester screening may include cfDNA or the multiple marker screening approach, which includes

Second-trimester multiple marker screening is used to help assess the risk of Down syndrome, trisomy 18 Trisomy 18 Trisomy 18 is caused by an extra chromosome 18 and is usually associated with intellectual disability, small birth size, and various congenital anomalies, including severe microcephaly, heart... read more Trisomy 18 , and a few rarer single-gene syndromes (eg, Smith-Lemli-Opitz syndrome). Maternal serum tests are widely available, but detection rates for Down syndrome are not as high as those obtained with 1st-trimester screening or with cfDNA. Also, termination of pregnancy is riskier in the 2nd trimester than in the 1st trimester.

Second-trimester screening may also include

  • Targeted ultrasonography

Maternal serum screening for neural tube defects

An elevated level of MSAFP may indicate a fetal malformation such as open spina bifida Spina Bifida Spina bifida is defective closure of the vertebral column. Although the cause is not known, low folate levels during pregnancy increase risk. Some children are asymptomatic, and others have... read more . Results are most accurate when the initial sample is obtained between 16 and 18 weeks gestation, although screening can be done from about 15 to 20 weeks. Designating a cutoff value to determine whether further testing is warranted involves weighing the risk of missed abnormalities against the risk of complications from unnecessary testing. Usually, a cutoff value in the 95th to 98th percentile, or 2.0 to 2.5 times the normal pregnancy median (multiples of the median, or MOM), is used. This value is about 80% sensitive for open spina bifida and 90% sensitive for anencephaly Anencephaly Anencephaly is absence of the cerebral hemispheres. The absent brain is sometimes replaced by malformed cystic neural tissue, which may be exposed or covered with skin. Parts of the brain stem... read more . Closed spina bifida is usually not detected. Amniocentesis Amniocentesis Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Amniocentesis is eventually required in 1 to 2% of women originally screened. Lower cutoff values of MSAFP increase sensitivity but decrease specificity, resulting in more amniocenteses. Women who have been screened for fetal chromosome disorders by cfDNA should have serum screening with MSAFP alone, not with multiple marker screening.

Ultrasonography is the next step if further testing is warranted. Targeted ultrasonography Targeted ultrasonography Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Targeted ultrasonography with or without amniocentesis is done if no explanation can be determined with basic ultrasonography. Ultrasonography can

  • Confirm gestational age (which may be underestimated)

  • Detect multifetal pregnancy, fetal death, or congenital malformations

In some women, ultrasonography cannot identify a cause for elevated alpha-fetoprotein levels. Some experts believe that if high-resolution ultrasonography done by an experienced operator is normal, further testing is unnecessary. However, because this test occasionally misses neural tube defects, many experts recommend further testing by amniocentesis regardless of ultrasonography results.

Amniocentesis with measurement of alpha-fetoprotein and acetylcholinesterase levels in amniotic fluid is done if further testing is needed. Elevated alpha-fetoprotein in amniotic fluid suggests

  • A neural tube defect

  • Another malformation (eg, omphalocele, congenital nephrosis, cystic hygroma, gastroschisis, upper gastrointestinal atresia)

  • Contamination of the sample with fetal blood

Presence of acetylcholinesterase in amniotic fluid suggests

  • A neural tube defect

  • Another malformation

Elevated alpha-fetoprotein plus presence of acetylcholinesterase in amniotic fluid is virtually 100% sensitive for anencephaly Anencephaly Anencephaly is absence of the cerebral hemispheres. The absent brain is sometimes replaced by malformed cystic neural tissue, which may be exposed or covered with skin. Parts of the brain stem... read more and 90 to 95% sensitive for open spina bifida Spina Bifida Spina bifida is defective closure of the vertebral column. Although the cause is not known, low folate levels during pregnancy increase risk. Some children are asymptomatic, and others have... read more . Abnormal amniotic fluid markers indicate that a malformation is likely even if high-resolution ultrasonography (which can detect most of these malformations) does not detect a malformation, and parents should be informed.

Maternal serum screening for chromosomal abnormalities

During the 2nd trimester, the most common approach to screening is with cfDNA or multiple serum markers. These markers, adjusted for gestational age, are used mainly to refine estimates of Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more Down Syndrome (Trisomy 21) risk beyond that associated with maternal age. With triple screening (ie, alpha-fetoprotein, hCG, and unconjugated estriol), sensitivity for Down syndrome is about 65 to 70%, with a false-positive rate of about 5%.

Quad screening is triple screening plus measurement of inhibin A. Quad screening increases sensitivity to about 80%, with a 5% false-positive rate.

If maternal serum screening suggests Down syndrome, ultrasonography is done to confirm gestational age, and risk is recalculated if the presumed gestational age is incorrect. If the original sample was drawn too early, another one must be drawn at the appropriate time. Amniocentesis is offered particularly if risk exceeds a specific prespecified threshold (usually 1 in 270, which is about the same as risk when maternal age is > 35).

Triple screening can also assess risk of trisomy 18 Trisomy 18 Trisomy 18 is caused by an extra chromosome 18 and is usually associated with intellectual disability, small birth size, and various congenital anomalies, including severe microcephaly, heart... read more Trisomy 18 , indicated by low levels of all 3 serum markers. Sensitivity for trisomy 18 is 60 to 70%; the false-positive rate is about 0.5%. Combining ultrasonography and serum screening increases sensitivity to about 80%.

Analysis of cfDNA does not depend on gestational age and thus is not prone to dating errors.

Targeted ultrasonography

Targeted ultrasonography is offered at some perinatal centers and is used to assess risk of chromosomal abnormalities by searching for structural features associated with fetal aneuploidy (so-called soft markers). However, no structural finding is diagnostic for a given chromosomal abnormality, and all soft markers may also be seen in fetuses that are chromosomally normal. If results from prior trisomy screening were negative (risk-reducing), many of these soft markers have no clinical relevance and may be ignored (1 2nd-trimester screening reference Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more 2nd-trimester screening reference ). Nonetheless, the discovery of such a marker may lead to offering the woman amniocentesis Amniocentesis Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Amniocentesis to confirm or exclude a chromosomal abnormality. If a major structural malformation is present, a fetal chromosomal abnormality is more likely.

Disadvantages include unnecessary anxiety if a soft marker is detected and unnecessary amniocentesis. Several experienced centers report high sensitivity, but whether a normal ultrasound indicates a substantially reduced risk of fetal chromosomal abnormalities is unclear.

2nd-trimester screening reference

Sequential 1st- and 2nd-Trimester Screening

Noninvasive 1st-trimester and 2nd-trimester quad screening can be combined sequentially, with invasive fetal genetic testing withheld until results of 2nd-trimester screening are available—whether 1st-trimester test results are abnormal or not. Sequential screening followed by amniocentesis for high-risk patterns increases sensitivity for Down syndrome to 95%, with a false-positive rate of only 5%.

A variation of sequential screening, called contingent sequential screening, is based on the level of risk indicated by 1st-trimester screening:

  • High risk: Invasive testing is offered without doing 2nd-trimester screening.

  • Intermediate risk: 2nd-trimester screening is offered.

  • Low risk (eg, < 1 in 1500): 2nd-trimester screening for Down syndrome is not offered because the 1st-trimester risk is so low.

Patients with abnormal 1st-trimester, 2nd-trimester, or sequential screening may choose to pursue further testing for fetal trisomy with cfDNA (cell free DNA) analysis. Results of cfDNA testing may indicate low risk and be reassuring but are not definitive. Also, cfDNA testing may be inordinately expensive, and awaiting results of cfDNA testing delays definitive testing such as CVS or amniocentesis (1 Sequential 1st- and 2nd trimester screening reference Genetic evaluation is part of routine prenatal care and is ideally done before conception. The extent of genetic evaluation a woman chooses is related to how the woman weighs factors such as... read more Sequential 1st- and 2nd trimester screening reference ).

Sequential 1st- and 2nd trimester screening reference

Drugs Mentioned In This Article

Drug Name Select Trade
immune globulin
 Gammagard S/D
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
© 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA
Prenatal Genetic Counseling
Overview of Female Sexual Function and Dysfunction

OTHER TOPICS IN THIS CHAPTER

Prenatal Genetic Counseling and Evaluation
Prenatal Genetic Counseling
Genetic Evaluation
Professionals also read
Prenatal Genetic Counseling Prenatal Genetic Counseling
Evaluation and Care of the Normal Neonate Evaluation and Care of the Normal Neonate
Evaluation of the Obstetric Patient Evaluation of the Obstetric Patient

Test your knowledge

Management of Normal Delivery
Options for pain management during normal delivery include regional, local, and general anesthesia. Of these types of anesthesia, which of the following is a safe and simple method for uncomplicated spontaneous vaginal deliveries in women who wish to bear down and push?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Merck and the Merck Manuals

Merck & Co., Inc., Kenilworth, NJ, USA is a global healthcare leader working to help the world be well. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.  The Merck Manual was first published in 1899 as a service to the community.  The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America.  Learn more about our commitment to Global Medical Knowledge.

This icon serves as a link to download the eSSENTIAL Accessibility assistive technology app for individuals with physical disabilities. It is featured as part of our commitment to diversity and inclusion. M
View Privacy Shield Verification Status
View APEC CBPR Privacy Certification Status

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:  
verify here.

© 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA
TOP