J Genet Counsel (2013) 22:4–15

DOI 10.1007/s10897-012-9545-3

PROFESSIONAL DEVELOPMENT PAPER

NSGC Practice Guideline: Prenatal Screening and Diagnostic

Testing Options for Chromosome Aneuploidy
K. L. Wilson & J. L. Czerwinski & J. M. Hoskovec &
S. J. Noblin & C. M. Sullivan & A. Harbison &
M. W. Campion & K. Devary & P. Devers &
C. N. Singletary

Received: 1 June 2012 / Accepted: 17 September 2012 / Published online: 22 November 2012
# National Society of Genetic Counselors, Inc. 2012

Abstract The BUN and FASTER studies, two prospec- screening previously reported abroad. These studies, cou-
tive multicenter trials in the United States, validated the pled with the 2007 release of the American College of
accuracy and detection rates of first and second trimester Obstetricians and Gynecologists (ACOG) Practice Bulle-
tin that endorsed first trimester screening as an alternative
K. L. Wilson (*)
to traditional second trimester multiple marker screening,
Department of Ob/Gyn, Division of Gynecologic Oncology, led to an explosion of screening options available to
The University of Texas Health Science Center at Houston, pregnant women. ACOG also recommended that invasive
6410 Fannin St, Suite 1217, diagnostic testing for chromosome aneuploidy be made
Houston, TX 77030, USA
e-mail: Kate.L.Wilson@uth.tmc.edu
available to all women regardless of maternal age. More
recently, another option known as Non-invasive Prenatal
S. J. Noblin : C. N. Singletary
Testing (NIPT) became available to screen for chromo-
Department of Pediatrics,
The University of Texas Health Science Center at Houston, some aneuploidy. While screening and testing options
6410 Fannin Street, Suite 1217, may be limited due to a variety of factors, healthcare
Houston, TX 77030, USA providers need to be aware of the options in their area
in order to provide their patients with accurate and reli-
P. Devers
Department of Obstetrics and Gynecology, able information. If not presented clearly, patients may
Division of Maternal-Fetal Medicine, feel overwhelmed at the number of choices available. The
University of North Carolina at Chapel Hill, following guideline includes recommendations for health-
CB# 7516,
care providers regarding which screening or diagnostic
Chapel Hill, NC 27599-7516, USA
test should be offered based on availability, insurance
A. Harbison coverage, and timing of a patient’s entry into prenatal
Deparment of Ob/Gyn, Division of Maternal
Fetal Medicine, The University of Texas care, as well as a triage assessment so that a general
Health Science Center at Houston, process can be adapted to unique situations.
5656 Kelley Street,
Houston, TX 77026, USA
M. W. Campion Keywords Prenatal screening . Prenatal testing .
Boston University School of Medicine, Chromosome aneuploidy . Genetic counseling . National
85 E. Newton St, M913,
Boson, MA 02118, USA
Society of Genetic Counselors . Practice guidelines

K. Devary
EvergreenHealth Maternal Fetal Medicine,
12333 NE 130th Lane, Suite Tan 240, Purpose
Kirkland, WA 98034, USA
J. L. Czerwinski : J. M. Hoskovec : C. M. Sullivan To provide information that assists physicians and allied health
Department of Ob/Gyn, Division of Maternal Fetal Medicine, professionals in making decisions about different screening and
The University of Texas Health Science Center at Houston,
6410 Fannin St, Suite 1217, diagnostic testing for chromosome aneuploidy throughout
Houston, TX 77030, USA pregnancy.
NSGC Practice Guideline
Disclaimer
The practice guidelines of the National Society of Genetic
Counselors (NSGC) are developed by members of the NSGC
to assist genetic counselors and other health care providers in
making decisions about appropriate management of genetic
concerns; including access to and/or delivery of services. Each
practice guideline focuses on a clinical or practice-based issue,
and is the result of a review and analysis of current profes-
sional literature believed to be reliable. As such, information
and recommendations within the NSGC practice guidelines
reflect the current scientific and clinical knowledge at the time
of publication, are only current as of their publication date,
and subject to change without notice as advances emerge.
In addition, variations in practice, which take into account
the needs of the individual patient and the resources and
limitations unique to the institution or type of practice, may
warrant approaches, treatments, and/or procedures that differ
from the recommendations outlined in this guideline. There-
fore, these recommendations should not be construed as dic-
tating an exclusive course of management, nor does the use of
such recommendations guarantee a particular outcome. Ge-
netic counseling practice guidelines are never intended to
displace a health care provider’s best medical judgment based
on the clinical circumstances of a particular patient or patient
population. Practice guidelines are published by NSGC for
education and informational purposes only, and NSGC does
not “approve” or “endorse” any specific methods, practices, or
sources of information.
Background
The landscape of prenatal screening changed in 2007 with
the release of two ACOG Practice Bulletins stating all
women should be offered maternal serum screening (MSS)
and diagnostic testing regardless of maternal age, and that
healthcare providers should determine which screening
options would best serve their patients (ACOG Practice
Bulletin No. 77 & 88, 2007). ACOG’s assertion was subse-
quently echoed by the American College of Medical Genet-
ics (ACMG), leaving providers to reassess their screening
and diagnostic testing practices (Driscoll and Gross 2008).
Prenatal screening strategies have evolved greatly over the
years. Various combinations of first and second trimester
maternal serum analytes and fetal ultrasound findings have
been proposed as part of an ongoing quest to create a screen-
ing test with the highest detection and lowest false positive
rates. Recently, NIPT has been made commercially available
as an alternative option for chromosome aneuploidy screen-
ing. Screening options for chromosome aneuploidy are non-
invasive, which may make them attractive options for patients
who desired more individualized risk assessment information
5
prior to making a decision about whether or not to undergo
invasive diagnostic testing. The primary limitation of screen-
ing is that it does not provide a definitive diagnosis, leading to
the potential of increased anxiety in women with an unaffect-
ed pregnancy and the potential of false reassurance in women
who have a pregnancy with a chromosome aneuploidy. An-
other limitation of screening is the variability in the detection
rates, false positive rates, screening cut-offs, and anatomical
ultrasound markers included in the screen based on the par-
ticular laboratory and/or provider involved. In addition, detec-
tion rates for screening in multiple gestations are generally
decreased from those of singletons (Wald and Rish 2005). For
a more comprehensive review of the advantages and limita-
tions of the types of screening, refer to the individual sections
below and to Tables 1, 2, and 3. A decision tree to assist
providers in selecting a screening method that is most suitable
for their practice is presented in Fig. 1.
In addition to the various prenatal screening options, diag-
nostic testing for chromosomal abnormalities (Table 4) is
available. Chorionic villus sampling, or CVS, is typically
performed between 10-13w6d of gestation, and involves a
transcervical or transabdominal aspiration of chorionic villi
from the developing placenta (Wapner 2005). Another option
for diagnostic testing is amniocentesis. Amniocentesis is tra-
ditionally performed after 15 weeks of gestation by trans-
abdominal removal of amniotic fluid (CDC 1995). Samples
obtained through CVS and amniocentesis are typically used
for chromosomal analysis by karyotyping, but may also be
used for rapid interphase fluorescence in situ hybridization
(FISH) to screen for chromosome aneuploidy, metaphase
FISH to evaluate for specific microdeletions or microduplica-
tions, chromosomal microarray, or other molecular testing.
A referral for genetic counseling has traditionally been
made for patients who have an increased risk for chromosome
aneuploidy, including those with a positive maternal serum
screen result, positive family history, a fetal anomaly identi-
fied on ultrasound, or those who are 35 years of age or older at
delivery. However, as screening options have expanded, it has
become more routine to refer patients for genetic counseling
when they are having difficulty deciding on a course of action
for screening or diagnostic testing. Appropriate screening and
diagnostic testing options are typically presented to patients in
the context of a prenatal genetic counseling session (CDC
1995). Genetic counselors are uniquely trained to explain
complex information in an understandable format to patients
and to facilitate the informed decision-making process.
First Trimester Screening Options
The first trimester analytes pregnancy associated plasma
protein-A (PAPP-A) and free beta-human chorionic gonad-
otropin (β-hCG) may be measured between 9w0d-13w6d of
gestation, while the nuchal translucency (NT) measurement
 6

Table 1 Screening options for chromosome aneuploidy in pregnancy

First Combined Integrated Serum Integrated Stepwise Contingency Multiple Non Invasive
Trimester First Sequential Marker Prenat al
Analyte Trimester Serum Testing
First Second First visit Second First visit Second First visit Second Screening9
visit visit6 visit6 visit7 visit7

Gestational 9w0d- 9w0d- 9w0d- 15w0d- 9w0d- 15w0d- 9w0d- 15w0d- 9w0d- 15w0d- 15w0d- 10w0d -
Age at 13w6d 13w6d 13w6d 21w6d 13w6d 21w6d 13w6d 21w6d 13w6d 21w6d 21w6d 21w6d
Blood Draw

Maternal PAPP-A PAPP-A PAPP-A AFP PAPP-A AFP PAPP-A b-hCG AFP PAPP-A b-hCG AFP AFP Circulating
Serum b-hCG b-hCG hCG hCG (or hCG)1 hCG (or hCG)1 hCG hCG Cell Free
Analytes (or hCG)1 (or hCG)1 uE3 uE3 uE3 uE3 uE3 Fetal DNA10
DIA DIA DIA DIA DIA
ITA9

NT Utilized No Yes4 Yes4 No Yes4 Yes4 No No

Down Syndrome 62–63 %2 78–91 %2 n/a5 94–96 %2 n/a5 87–88 %2 91–95 %2 91–92 %2 75–83 %2 99–100 %11, 12
Detection Rate

Trisomy 18 82 %3 91–96 %3 n/a5 91–96 %3 n/a5 82 %3 91–96 %3 91–96 %3 60–70 %3 97–100 %11, 12
Detection Rate

Provides No No n/a5 Yes n/a5 Yes No Yes8 No Yes8 Yes No

ONTD Risk

•Sources: Barkai et al. (1993); Bianchi et al. (2012); Cole et al. (1999); Cuckle et al. (2008); Haddow et al. (1998); Malone et al.(2005); Norton et al. (2012); Palomaki et al. (2006); Palomaki et al.
(2012); Spencer and Nicolaides (2002); Wald et al. (2003); Wald et al. (2004); Wapner et al. (2003)
1. Whole molecule hCG used in place of free b-hCG by some laboratories and some laboratories add additional analytes such as DIA, both of which may change detection rates
2. Typically at 5 % false positive rate (FPR) with 1/270 cut-off for screen positive; if other FPR or cut-off used, may change detection rate; FPR averages 15–20 % if AMA
3. Typically at 0.5 % FPR with 1 in 100 cut-off, if other FPR or cut-off used, may change detection rate; some laboratories quote combined t18/t13 risk & detection rate
4. The timing of assessment for the NT measurement is between 10w4d and 13w6d
5. Results not provided after first visit
6. Second blood draw is required for all patients
7. Second blood draw is indicated for a portion of patients after the first step of the screen, but not all patients
8. NTD risk assessment is performed for those patients who need a second step and thus get a blood draw that contains AFP as an analyte
9. ITA is included by one laboratory along with AFP, hCG, uE3, and DIA and referred to as the Penta Screen; detection rates are similar to the Quadruple Screen
10. Cell free fetal DNA is found in maternal blood but is not considered an analyte like traditional serum screening
11. While initial studies show a range of detection rates up to 100 % for trisomy 18 & 21, NIPT is not yet considered diagnostic and follow-up CVS or amnio is recommended for a positive NIPT
12. Typically <1 % FPR (from 0.1 to 0.97 %); laboratories generally report trisomy 13 as well, with detection ranging 79-92% at <1 % FPR.
Wilson et al.
NSGC Practice Guideline 7

Table 2 Aneuploidy screening options comparison table

Advantages Limitations Physician likely to utilize screen

First • 1st trimester result • Lower detection rate compared to other Physician with an early-to-care patient
Trimester • NT not required screening options that include NT population who does not have access
Analyte • 1 visit to a certified NT provider, but does
Screening • CVS is an option if screen positive have access to CVS, and prefers to
complete screening in one visit.

Combined • 1st trimester result • NT required Physician with an early-to-care patient

First • 1 visit • Lower detection rate compared to integrated population who has access to certified
Trimester • CVS is an option if screen positive screen NT provider and to CVS, and prefers
Screening to complete screening in one visit.

Integrated • Highest detection rates out of all of • 2 visits Physician with an early-to-care patient
Screening maternal serum screening tests • NT required population who has access to certified
• Results given in 2nd trimester NT provider, but does not have access
to CVS.

Serum • Highest detection rates for screening • 2 visits Physician with an early-to-care patient
Integrated when the NT is not available • Results given in 2nd trimester population who does not have access
Screening • NT not required • Lower detection rate compared to screens that to certified NT provider or to CVS.
include NT, such as integrated screen

Stepwise • 1st trimester result for highest risk
Sequential patients allows option of CVS
Screening • Detection rate higher than combined
FTS while still allowing for some 1st
trimester results
• 2 visits for most patients Physician with an early-to-care popu-
• NT required lation and high follow-up compliance
• Lower detection rate compared to integrated who has access to a certified NT pro-
screen vider and to CVS, who wants infor-
mation early enough to offer CVS if
risk is high, and wants to avoid mod-
erate risk group created by contingency
screening.

Contingency • 1st trimester results for high and low • 2 visits for moderate risk group Physician with an early-to-care patient
Screening patients, minimizing number of patients • NT required population and high follow-up com-
needing a second visit • Initial moderate risk group may not feel as pliance who has access to a certified
reassured with 2nd trimester negative screen NT provider and to CVS, and who
results as initial low risk group feels the benefit of a one visit screen
for most patients outweighs anxiety
caused for patients who fall into the
moderate risk group and are later re-
stratified to a low-risk group.

Multiple • Allows for screening in women • Results given in 2nd trimester Physician who has patients who
Marker presenting for care after the first • Lower detection rate compared to screens that present primarily in second trimester
Serum trimester include first trimester components and/or NT for screening or patients whose
Screening • 1 visit insurance does not cover NT screening.

Non Invasive • 1st or 2nd trimester result in 1 visit • New technology with shorter publication Physician comfortable with new
Prenatal without NT required history and less information on payer coverage technology who wants a screening test
Testing • Highest detection rates across all non with high detection rate and low false
invasive options positive rate that can be applied in
both first and second trimester.

is valid when measured between 10w4d-13w6d of gestation.
It is important to note that some laboratories substitute hCG
for β-hCG, which may impact detection rates. Most labora-
tories target a 5 % false positive rate for serum screening
options.
There are three options for first trimester screening. NT
only with maternal age relies upon the size of the fetal NT
and the patient’s age to calculate a risk estimate. First
trimester analyte screening relies upon the levels of mater-
nal serum PAPP-A and free β-hCG or total hCG combined
8 Wilson et al.

Table 3 Ultrasound screening options for aneuploidy

Nuchal Translucency FetalAnatomy Ultrasound

Gestational Age 10w4d–13w6d 18w0d–20w6d (ideal)

16w0d–24w6d (at some centers)
Ultrasound Markers Increased Nuchal Structural Defects, e.g., congenital heart defects, hydrocephalus, holoprosencephaly, cystic
Evaluated Translucency 1,2 hygroma, cleft lip, duodenal atresia, omphalocele, kidney malformations, intrauterine growth
restriction, clenched hands, etc.4
Soft Markers, e.g., increased nuchal fold, choroid plexus cyst, echogenic bowel, hydronephrosis,
echogenic focus/foci, single umbilical artery, clinodactyly of the 5th finger, shortened long bones 4
Down Syndrome 60–82 %3,4 50–70 %4,5
Detection Rate
Trisomy 18 71–82 %3,4 80%4,5
Detection Rate
Provides ONTD No Yes
Risk Assessment

•Sources: ACOG, 2009; Malone et al. 2005; Nicolaides et al. 2002; Nyberg and Souter 2001; Sanders et al. (2002); Taslimi et al. 2005; Wald et al.
2003; Wapner et al. 2003
1. Defined as>95th percentile or >3.0 mm by the majority of studies
2. Other ultrasound markers such as nasal bone and tricuspid regurgitation remain early in investigation and are not included
3. False positive rate 20–25 %; includes age in detection rate; without age detection is lower
4. Detection rate is affected by gestational age, quality of ultrasound images, operator experience, equipment used, referral indication, criteria for
positive findings, maternal habitus and fetal position
5. Adjustment of a priori risk based on the association between a given ultrasound finding and aneuploidy varies by center. The magnitude of
increased risk is impacted by the specific findings and the strength of their association with aneuploidy

with maternal age for risk estimation. The third method is
referred to as combined first trimester screening, because it
combines the use of the NT measurement, the first trimester
maternal serum analytes (PAPP-A, and free β-hCG or total
hCG) and maternal age. Combined first trimester screening
has been demonstrated to have higher detection rates for
Down syndrome (78–91 %) and trisomy 18 (91–96 %)
compared to NT only or serum analyte only methods
(Malone et al. 2005; Wald et al. 2003; Wapner et al.
2003), (Refer to Tables 1 and 3). Some studies have
reported that pregnancies affected with trisomy 13 have
an analyte and NT pattern similar to trisomy 18; thus, it
may also be possible to use combined first trimester
screening to screen for trisomy 13 (Spencer et al. 2000).
When the NT measurement is significantly elevated (typi-
cally considered to be an NT≥3.0 mm or the 95th percentile),
the possibility of chromosome aneuploidy is significantly
increased, and it is appropriate to offer the option of diagnostic
testing at that point without performing or waiting for the
results of the MSS (Comstock et al. 2006). In addition to
chromosome aneuploidies, NT ≥3.5 mm is also associated
with an increased risk of a congenital heart defect. In such
cases, fetal echocardiography is recommended during the
second trimester. It is important to note that once an elevated
NT is seen, the risk for an adverse pregnancy outcome remains
increased even if normal fetal karyotype is confirmed (Bilardo
et al. 2010).
As none of the first trimester screening options allow for
a calculation of the risk for open neural tube defects
(ONTD), a maternal serum alpha-fetoprotein (MSAFP)
sample should be drawn in the second trimester in patients
undergoing first trimester screening. ONTDs may also be
detected on second trimester ultrasound. It is not recom-
mended that an independent risk assessment for chromo-
some aneuploidy be performed in both the first and second
trimesters due to the high false positive rate (Platt et al.
2004).
The presence or absence of the fetal nasal bone and of
tricuspid regurgitation on first trimester ultrasound have
been proposed as additional ultrasound markers for chromo-
some aneuploidy (Kagan et al. 2009; Ozkaya et al. 2010).
However, at the present time, the use of these anatomical
markers to determine chromosome aneuploidy risk is not
universally recommended.
Non-Invasive Prenatal Testing (NIPT) NIPT uses circulat-
ing cell free fetal DNA in maternal plasma to evaluate for
Down syndrome, trisomy 18, and trisomy 13. Published
studies show a low false positive rate (<1 %) and a very
high detection rate for Down syndrome (99–100 %), triso-
my 18 (97–100 %) and trisomy 13 (79–92 %), (Bianchi et
al. 2012; Norton et al. 2012; Palomaki et al. 2012), (see
Table 1). In addition, Bianchi et al. found a 94 %
detection rate for monosomy X and reported several
NSGC Practice Guideline 9

Following appropriate counseling, does patient

wish to pursue prenatal screening or testing?

YES NO

Patient elects screening 2 prior

Patient elects to making a decision about
1diagnostic testing
diagnostic testing

Patient fits current Patient elects maternal

criteria for NIPT & serum screening
elects NIPT

< 14 > 14
weeks weeks
Chorionic
NIPT
Villus Amnio - 1st or 2nd
Sampling Quadruple
centesis trimester
between >15 weeks result NT 3 NOT NT 3 Marker
10 and 13 available/feasible available/feasible Screening
weeks 1 visit
1 visit

First Stepwise Integrated Contingency

Serum Sequential
Trimester 2nd trimester 1st trimester
Integrated Combined 1st trimester
Analyte result result if highor
2nd trimester FTS result if very low risk
1st trimester 2 visits
result 1st trimester high risk
result 2nd trimester
2 visits result 2nd trimester Greatest
1 visit analyte result for
1 visit result if less moderate risk
risk detection
1 See Table 4 for more information about diagnostic testing. rate 1-2 visits
2 See Table 1 for more information about screening options. 1-2 visits
3 NT= Nuchal translucency

Fig. 1 Decision tree for selecting between screening and diagnostic testing options

cases of mosaicism for trisomy 21, trisomy 18, and mono-
somy X (2012). The landmark NIPT studies recruited
women who were otherwise pursuing invasive testing.
Thus, the majority were from high-risk populations that
had an increased risk to have a fetus affected with chromo-
some aneuploidy. At this time, NIPT is only recommended for
patients from high-risk populations, including advanced ma-
ternal age, positive screening test, abnormal ultrasound sug-
gestive of aneuploidy, or prior pregnancy with chromosome
aneuploidy (Devers et al. 2012). It is recommended that a
positive NIPT be followed by confirmatory diagnostic
testing prior to making pregnancy decisions (Benn et al.
2011; Devers et al. 2012). NIPT is validated between
10w0d–21w6d gestation, making it an option for wom-
en that present in either the first or the second trimester.
Many practices are using NIPT in addition to their
already established screening practices to provide high-
risk patients with more information prior to making a
decision about invasive diagnostic testing. If NIPT is
performed, additional serum screening for chromosome
aneuploidy is not recommended. While NIPT has prom-
ise for the future and may potentially replace other
screening methods as the standard of care, there is still
much to learn about this technology and its clinical
utility. For more information regarding NIPT, please refer
to the fact sheet published in 2012 by the National
Coalition for Health Professional Education in Genetics
and NSGC.
Integrated, Serum Integrated, Stepwise Sequential
and Contingency Screening
Screening strategies that combine both first and second
trimester serum analytes and ultrasound markers have been
proposed as a means of increasing detection rates while
decreasing false positive rates. Since these screening options
involve multiple steps, it may be difficult to ensure that all
10 Wilson et al.

Table 4 Diagnostic testing options

Chorionic Villus Sampling (CVS) Early Amniocentesis4 Amniocentesis

Gestational Age at 10w0d–13w6d 11w0d–13w0d 15w0d–23w6d

Time of Procedure1
Test Methodology Transcervical or transabdominal Abdominal withdrawal of amniotic
aspiration of chorionic villi from fluid from gestational sac
developing placenta
Risk of Miscarriage 0.5–1.0 % 2.0 % 0.2–0.3 %5
Additional Associated Risks 2
• Mosaicism: <1 % • Mosaicism: 0.2 % • Mosaicism: 0.2 %
• Maternal Cell Contamination: <1 % • Club foot: 1.3%–1.7 % • Club foot:<0.1 %
• Spotting & Cramping: 15 % • Amniotic Fluid Leakage: • Amniotic Fluid Leakage: 1.7 %
3.5 %–4.4 %
Down Syndrome Detection Rate3 98–99 % 99.80 % 99.90 %
Trisomy 18 Detection Rate 3 98–99 % 99.80 % 99.90 %
Provides ONTD Detection No Yes Yes

Sources: ACOG Practice Bulletin No. 88, 2007; Brambati et al. 1992; Canadian Collaborative CVS Amniocentesis Clinical Trial Group, 1989;
Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, 1995; Eddleman et al. 2006; Jackson et al. 1992; Ledbetter et
al. 1992; Sundberg et al. 1997; The Canadian Early and Mid-trimester Amniocentesis Trial Group, 1998; Wapner et al. 2003; Winsor et al. 1999
1. May be performed at other gestational ages, but risks and benefits may vary
2. An increased risk for limb reduction defects has been associated with CVS performed prior to 10 weeks gestation
3. Detection rates based on karyotyping; other detection rates may apply when utilizing fluorescence in situ hybridization or chromosomal
microarray
4. Early amniocentesis is not recommended by ACOG
5. Range of 0.06–1.0 % [or 1 in 1600 to 1 in 100] reported in literature

patients return for the multiple visits required to complete
the screening process (Wald et al. 2003).
Integrated Screening uses a two-step process to adjust the
maternal age-related risk for Down syndrome and trisomy
18. The first step involves NT and PAPP-A measurements in
the first trimester, and the second step involves serum analyte
measurements of AFP, hCG, unconjugated estriol (uE3), and
dimeric inhibin A (DIA) in the second trimester (Cuckle et al.
2008; Malone et al. 2005; Wald et al. 2003). The patient is
given a single risk assessment after both steps have been
completed. Integrated screening has a high detection rate for
Down syndrome (94–96 %) and trisomy 18 (91–96 %); how-
ever, patients must wait until the second trimester for results,
which eliminates the opportunity for early diagnostic testing
such as CVS (Malone et al. 2005; Spencer and Nicolaides
2002; Wald et al. 2004; Wapner et al. 2003). When an NT
measurement is not possible, serum integrated screening may
still be performed at a lower detection rate for Down syndrome
(87–88 %) and trisomy 18 (82 %), (Malone et al. 2005; Wald
and Rish 2005; Wapner et al. 2003).
Stepwise Sequential Screening also involves two steps,
with the first step combining the NT measurement, serum
analytes PAPP-A and β-hCG (or hCG), and maternal age in
the first trimester. Patients are initially stratified into a
“high” or “low” risk group as determined by the screening
laboratory’s risk cut-off figures. These initial results are
disclosed to patients who fall into the high risk group, and
they are subsequently offered diagnostic testing. Initial results
may or may not be disclosed to patients who fall into the low
risk group, and they proceed with a second blood draw per-
formed in the second trimester. In this second step, the serum
analytes AFP, hCG, uE3, and DIA are incorporated into the
risk assessment, and the patient is given a risk for chromo-
some aneuploidy based on the combined results of both of the
screening steps. The overall detection rate for stepwise se-
quential screening is 91–95 % for Down syndrome and 91–
96 % for trisomy 18 (Malone et al. 2005; Palomaki et al. 2006;
Spencer and Nicolaides 2002; Wapner et al. 2003). Stepwise
sequential screening allows the patients with the highest risk
to consider diagnostic testing in the first trimester of pregnan-
cy while retaining some of the increase in detection rates seen
with integrated screening.
Contingency Screening is another two-step screening option.
As with stepwise sequential screening, the first step adjusts
maternal age-related risk for chromosome aneuploidy based
on the NT measurement and serum analytes. However, after
the first step, patients are divided into low, moderate, and high
risk groups based on their risk assessment for chromosome
abnormality. The high risk group is offered diagnostic testing,
the moderate risk group continues to the second serum analyte
screening step, and the low risk group is not offered further
serum analyte screening. Once the moderate risk group under-
goes second trimester analyte screening (AFP, hCG, uE3, and
NSGC Practice Guideline
DIA), these patients are then stratified again into a high risk
group who is offered diagnostic testing and a low risk group
who is not considered at great enough risk to warrant diagnostic
testing. The overall detection rate for contingency screening
when both steps are performed is 91–92 % for Down syndrome
and 91–96 % for trisomy 18 (Cuckle et al. 2008; Palomaki et al.
2006; Spencer & Nicolaides 2002; Wapner et al. 2003). Con-
tingency screening lowers the number of patients proceeding to
the second trimester serum analyte screening step compared to
stepwise sequential screening, while still identifying the major-
ity of high risk pregnancies in the first trimester. However,
patients identified as initially having a moderate risk may retain
some anxiety even if the second step places them back into the
low risk group.
Second Trimester Screening Options
Second trimester MSS options include the triple screen, the
quadruple (quad) screen, and the penta screen. The triple
screen consists of maternal serum AFP, hCG, and uE3 com-
bined with an a priori risk based on maternal age to screen for
Down syndrome, trisomy 18, and ONTDs. The quad screen
adds DIA, which increases the detection rate for Down syn-
drome (Benn et al. 2003). One laboratory has added invasive
trophoblast antigen (ITA) to the quad screen and named it the
penta screen, although detection rates are not substantially
different from the quad screen (Cole et al. 1999). Second
trimester maternal serum screens are typically performed be-
tween 15w0d-21w6d gestation (Wald et al. 2004). Detection
rates for Down syndrome (75–83 %) and trisomy 18 (60–70 %)
are highest with the quad screen or penta screen (Table 1),
(Wald et al. 2003). Detection rates for ONTDs are the same
for all second trimester screening options (Barkai et al. 1993;
Haddow et al. 1998; Wald et al. 2004). Second trimester screens
are helpful for women who first present for prenatal care in their
second trimester, but all second trimester MSS have lower
detection rates compared to screening options that incorporate
first trimester serum analytes. NIPT may represent a viable
alternative for screening with a high detection rate for eligible
patients who present in the second trimester.
A fetal ultrasound in the second trimester may also be used
to screen for chromosome aneuploidy by identifying both true
structural defects and structural variants, which are commonly
referred to as “soft markers” (Table 3). Ultrasound may also
detect isolated structural defects not typically associated with
chromosome aneuploidy. The optimal time to perform an
ultrasound to survey fetal anatomy is between 18-20w6d
gestation (ACOG Practice Bulletin No. 101, 2009). The risk
for chromosome aneuploidy is dependent upon not only the
combination of soft markers and/or structural defects seen, but
also the expertise of the provider interpreting the ultrasound
11
(Nyberg and Souter 2001; Sanders et al. 2002). Chromosome
aneuploidy screening by ultrasound can further be limited by
maternal habitus and fetal position. Approximately 50–70 %
of pregnancies with Down syndrome and 80 % of pregnancies
with trisomy 18 will have anatomical defects and/or markers
identified by the detailed or targeted ultrasound (Nyberg and
Souter 2001). Based on these detection rates, second trimester
anatomy ultrasound alone is not as accurate as MSS or NIPT.
Other ultrasounds, such as growth scans, may also detect
structural anomalies that are associated with chromosome
aneuploidy, but these ultrasounds are not routinely used for
chromosome aneuploidy screening.
Diagnostic Testing Options
Current procedures available for the diagnosis of chromo-
some aneuploidy during pregnancy include: CVS, early
amniocentesis, and amniocentesis (Table 4).
Chorionic Villus Sampling (CVS)
CVS is used for the detection of fetal chromosome aneuploidy
in the first trimester. The accuracy for detection of fetal chro-
mosome abnormalities by CVS is estimated to be 98–99 % due
to the <1 % chance for a mosaic result, defined as some cells
studied showing an abnormality and some cells not showing an
abnormality, and the<1 % chance for maternal cell contami-
nation, defined as studying the mother’s cells instead of the
fetus’ (Ledbetter et al. 1992). CVS may also be used to test for
biochemical abnormalities, single gene conditions, and colla-
gen abnormalities (Pepin et al. 1997; Wapner 2005). CVS
cannot be used to evaluate the risk for ONTDs. The
procedure-related risk of miscarriage is estimated to be approx-
imately 0.5–1 %, or 1/200–1/100, whether in a singleton or
twin gestation (Canadian Collaborative CVS-Amniocentesis
Clinical Trial Group 1989; CDC, 1995; Jackson et al. 1992).
Recent data, however, has shown that the procedure-related
loss rate of CVS may be similar to the rate for mid-trimester
amniocentesis, but this data is only valid in experienced centers
(ACOG Practice Bulletin No. 88, 2007). Of note, there appears
to be an increased risk for limb reduction defects when CVS is
performed prior to 10 weeks gestation (Brambati et al. 1992).
The primary benefit of CVS is that it can be performed at an
earlier gestational age, allowing for earlier decision-making.
Amniocentesis
Amniocentesis is used for the detection of chromosome
aneuploidy in the second and third trimester of pregnancy.
The accuracy for detection of fetal chromosome abnormal-
ities by amniocentesis is estimated to be 99.8–99.9 %
(ACOG Practice Bulletin No. 88, 2007). Amniocentesis
12
may also be used to test for ONTDs, biochemical abnormal-
ities and single gene conditions (CDC, 1995; Winsor et al.
1999). In 1995, the Centers for Disease Control and Preven-
tion released a statement which estimated the procedure-
related risk for miscarriage to be 1/200 or 0.5 % based on
previous studies. Since that time, this number has remained
the universally quoted risk for amniocentesis in the United
States. However, more recent studies actually suggest that
amniocentesis has a much lower risk than the long-accepted
1/200 figure. Data from the First And Second Trimester
Evaluation of Risk for Aneuploidy (FASTER) trial showed
that the miscarriage risk associated with amniocentesis was
approximately 1 in 1600, or less than 0.1 % (Eddleman et al.
2006). In 2007, ACOG released a Practice Bulletin stating
that all women should be offered the option of diagnostic
testing for chromosome aneuploidy, regardless of age, citing
a 1/300 to 1/500 or 0.2–0.3 % risk for miscarriage associat-
ed with amniocentesis based on more recent studies. Many
centers have since adopted this lower, ACOG-endorsed
figure (ACOG Practice Bulletin No. 88, 2007). While am-
niocentesis is associated with a lower risk for miscarriage
compared to CVS, one of the primary limitations is the later
gestational age at which the procedure is performed. Waiting
until the third trimester to perform amniocentesis is not
associated with a decreased procedure-related risk; however,
the risk shifts from miscarriage in the second trimester to
preterm delivery in the third trimester once viability is
reached. Amniocentesis and CVS may be performed in twin
and higher order gestation pregnancies, although the risk for
miscarriage may be increased compared to that associated
with singleton procedures (ACOG Practice Bulletin No. 88).
Early Amniocentesis
Early amniocentesis is available in some centers but is not
typically recommended. It may be performed prior to 15 weeks
of gestation, and is associated with an increased risk for
pregnancy loss (2 %), clubfoot (1.3–1.7 %) and fluid leakage
(3.5–4.4 %) compared to routine amniocentesis (<0.1 % for
clubfoot and 1.7 % for leakage), (ACOG Practice Bulletin No.
88, 2007; Canadian Early and Mid-trimester Amniocentesis
Trial, 1998; CDC, 1995; Sundberg et al. 1997).
Screening and Diagnostic Testing Options: Practical
Considerations
Despite numerous potential benefits associated with screening
and testing for chromosome aneuploidy, there are also limita-
tions. Available options may be limited by a number of factors,
including: gestational age of the patient at entry into the health-
care system, state regulations impacting available options, in-
surance coverage and out-of-pocket costs to the patient,
laboratory contracts, availability of laboratory draw sites,
Wilson et al.
access to certified NT providers, and access to physicians
who perform CVS or amniocentesis. One of the main barriers
faced in screening is insurance coverage, as each private and
public insurance plan has specific requirements for coverage of
screening and diagnostic testing for chromosome aneuploidy.
Additionally, there is often a time lapse between the publication
of guidelines recommending the incorporation of a new test and
routine coverage of that test by insurance companies. These
issues should be considered when assessing a patient’s access to
various prenatal screening and diagnostic testing options.
In addition to external factors that impact testing options,
patient-specific factors also impact decision-making. For
example, patients typically do not view prenatal diagnostic
testing as a routine procedure (Hunt et al. 2005), and may
have conflicting feelings about the possibility of having a
child with a chromosome aneuploidy versus the possibility
of losing a chromosomally normal pregnancy as the result of
a diagnostic procedure (Kupperman et al. 2000). It is up to
the healthcare provider to explore these feelings and discuss
factors that influence decision-making, such as family, so-
cial, and personal history, maternal age, and possible out-
comes in order to obtain informed consent (Centers for
Disease Control and Prevention 1995). Current practice is
moving away from a maternal age-based risk stratification
for offering diagnostic testing and moving toward custom-
ized risk assessment through the use of the various screen-
ing methods discussed above (ACOG Practice Bulletin
No.88, 2007; Eddleman et al. 2006).
The purpose of the following recommendations is to
assist physicians and allied health professionals in identify-
ing appropriate screening and diagnostic testing options for
chromosome aneuploidy for their patients. Patients may
have differing levels of interest in the available options
based on how they feel they might utilize the information.
Recommendations
The information presented above, along with the data sum-
marized in Fig. 1, and Tables 1, 2, 3 and 4 supports the
following recommendations:
Recommendations for all patients
& Providers should offer the options of maternal serum
screening (MSS) and diagnostic testing for chromosome
aneuploidy to every patient.
– Providers should engage in a discussion with their
patients about the benefits, limitations, and risks
of MSS and diagnostic testing so that patients may
make informed and autonomous decisions.
– If the provider feels a patient would benefit from
additional discussion prior to making a decision, a
NSGC Practice Guideline
referral to a genetic counselor or other qualified
provider may be appropriate.
– Documentation of the patient’s decision to elect
or to decline screening and testing should be
made in the patient’s medical record.
– Providers should be aware of factors that may
impact the options available to their patients, such
as the patient’s gestational age, insurance cover-
age and access to services and providers.
& An ultrasound to assess the fetal anatomy is suggested at
approximately 18w0d-20w0d gestation for all patients
regardless of whether or not they choose to have screen-
ing or diagnostic testing.
Recommendations for low risk patients less than 14 weeks
of gestation:
& For patients who may consider CVS or amniocentesis,
stepwise sequential screening or combined first trimes-
ter screening should be considered because:
– Both are tailored to fit the needs of patients
who desire early detection of chromosome
aneuploidy but wish to employ a screening meth-
od prior to making a decision about diagnostic
testing.
– Both allow for the option of CVS in higher risk
pregnancies while deferring testing of lower risk
pregnancies to the second trimester without caus-
ing increased anxiety.
– Of the screening options that provide risk infor-
mation in the first trimester, stepwise sequential
screening has the highest detection rates for Down
syndrome and trisomy 18.
& If CVS is not an option, integrated screening may be
considered in order to maximize detection rates.
& If a patient completes combined first trimester screening,
a separate second trimester MSS for chromosome aneu-
ploidy is NOT indicated. Screening for chromosome
aneuploidy in the second trimester in patients who
present prior to 14 weeks should ONLY be performed
as a part of integrated, serum integrated, stepwise
sequential, or contingency screening. Independent
screening in first and second trimesters increases the
false positive rate of screening.
& Patients who have an increased NT (≥ 95th% or≥
3.0mm) should be offered diagnostic testing by ei-
ther CVS or amniocentesis. A referral for a fetal
echocardiogram should also be considered if the
NT ≥3.5mm.
& Early amniocentesis (prior to 15 weeks of gestation) is
not recommended due to the increased risks for preg-
nancy loss, clubfoot, and fluid leakage. CVS should be
13
offered as the diagnostic testing option for chromosome
aneuploidy in the first trimester.
Recommendations for low risk patients after 14 weeks of
gestation:
& Patients who desire MSS but did not have MSS in the
first trimester should be offered a quad or penta screen
rather than a triple screen due to the increased detection
rates.
& Amniocentesis should be offered as the diagnostic test-
ing option for chromosome aneuploidy for patients after
15 weeks of gestation.
Recommendations for patients at increased risk for
chromosome aneuploidy
& Patients who desire screening information may be of-
fered NIPT due to the high detection rates and low false
positive rates. NIPT should only be offered in the con-
text of informed consent, education, and counseling by a
qualified provider, such as a genetic counselor. Standard
confirmatory diagnostic testing should be offered as
follow-up to positive NIPT results. High risk patients
who decline NIPT but remain interested in screening
should be made aware of alternate screening options as
appropriate based on gestational age and screening
availability.
& If the patient presents prior to 14 weeks gestation, CVS
and amniocentesis should both be offered as diagnostic
testing options for chromosome aneuploidy.
& If the patient presents after 14 weeks gestation, amnio-
centesis should be offered as the diagnostic testing op-
tion for chromosome aneuploidy.
Summary
This practice guideline provides a summary of screening
and diagnostic testing options for chromosome aneuploi-
dy and gives realistic recommendations on how to em-
ploy these options. A decision tree and comparison
tables are presented for providers to select the screening
or diagnostic test which best suits their patient’s needs.
Specific recommendations are given for certain clinical
circumstances. However, these options are dependent on
logistical factors such as timing of entry into healthcare,
insurance coverage, overall cost, and screening/testing
availability. Patients will make decisions regarding these
options based not only on the facts and the data, but
also based on personal feelings, past experiences, and
current perceptions. A referral to a genetic counselor or
other qualified provider may be appropriate if a patient
may benefit from additional discussion prior to making
14
a decision regarding screening and diagnostic testing
options.
References
American College of Obstetricians and Gynecologists. (2007a).
Practice bulletin No. 77: screening for fetal chromosomal abnor-
malities. Obstetrics and Gynecology, 109, 217–227.
American College of Obstetricians and Gynecologists. (2007b).
Practice bulletin No. 88: invasive prenatal testing for aneuploidy.
Obstetrics and Gynecology, 110, 1459–1467.
American College of Obstetricians and Gynecologists. (2009). Practice
bulletin No. 101: ultrasonography in pregnancy. Obstetrics and
Gynecology, 113, 451–461.
Barkai, G., Goldman, B., Ries, L., Chaki, R., Zer, T., & Cuckle, H.
(1993). Expanding multiple marker screening for Down’s syn-
drome to include Edward’s syndrome. Prenatal Diagnosis, 13,
843–850.
Benn, P. A., Fang, M., Egan, J. F., Horne, D., & Collins, R. (2003).
Incorporation of inhibin-A in second-trimester screening for
Down syndrome. Obstetrics and Gynecology, 101, 451–454.
Benn, P. A., Borrell, A., Crossley, J et al. (2011). Aneuploidy screening: a
position statement on behalf of the Board of the International
Society for Prenatal Diagnosis. Prenatal Diagnosis, 31, 519–522.
Bianchi, D. W., Platt, L. D., Goldberg, J. D., Abuhamad, A. Z.,
Sehnert, A. J., & Rava, R. P. (2012). Genome-wide fetal aneu-
ploidy detection by maternal plasma DNA sequencing. Obstetrics
and Gynecology, 119, 1–12.
Bilardo, C. M., Timmerman, E., Pajkrt, E., & van Maarle, M. (2010).
Increased nuchal translucency in euploid fetuses—what should
we be telling the parents? Prenatal Diagnosis, 30, 93–102.
Brambati, B., Simon, G., Travi, M., Danesino, C., Tului, L., Privitera, O.,
& Primignani, P. (1992). Genetic diagnosis by chorionic villus
sampling before 8 gestational weeks: efficiency, reliability, and risks
on 317 completed pregnancies. Prenatal Diagnosis, 12, 789–799.
Canadian Collaborative CVS-Amniocentesis Clinical Trial Group.
(1989). Multicentre randomized clinical trial of chorion villus
sampling and amniocentesis. Lancet, 1, 1–6.
Canadian Early and Mid-trimester Amniocentesis Trial (CEMAT) group.
(1998). Randomized trial to assess safety and fetal outcome of early
and midtrimester amniocentesis. Lancet, 351, 242–247.
Centers for Disease Control and Prevention. (1995). Chorionic villus
sampling and amniocentesis: recommendations for prenatal counsel-
ing. Morbidity and Mortality Weekly Report, 44(RR-9), 1–12.
Cole, L. A., Shahabi, S., Oz, U. A., Bahado-Singh, R. O., & Mahoney, M.
J. (1999). Hyperglycosylated human chorionic gonadotropin (inva-
sive trophoblast antigen) immunoassay: a new basis for gestational
Down syndrome screening. Clinical Chemistry, 45, 2109–2119.
Comstock, C. H., Malone, F. D., Ball, R. H., Nyberg, D. A., Saade, G.
R., Berkowitz, R. L., & D’Alton, M. E. (2006). Is there a nuchal
translucency millimeter measurement above which there is no
added benefit from first trimester serum screening? American
Journal of Obstetrics and Gynecology, 195, 843–847.
Cuckle, H. S., Malone, F. D., Wright, D., Porter, F., Nyberg, D.,
Comstock, C. H., & D’Alton, M. E. (2008). Contingent screening
for Down syndrome- results from the FaSTER trial. Prenatal
Diagnosis, 28, 89–94.
Devers, P.L., Cronister, A., Ormond, K.E., Facio, F., Brasington, C.K.,
& Flodman, P. (2012). Noninvasive prenatal testing/noninvasive
prenatal diagnosis: the position of the National Society of Genetic
Counselors. http://www.nsgc.org/Portals/0/Advocacy/
NSGC%20Noninvasive%20Prenatal%20Testing%204-17-
2012.pdf
Wilson et al.
Driscoll, D. A., & Gross, S. J. (2008). American College of Medical
Genetics practice guidelines: first trimester diagnosis and screen-
ing for fetal aneuploidy. Genetics in Medicine, 10, 73–75.
Eddleman, K., Malone, F., Sullivan, L., Dukes, K., Berkowitz, R.,
Kharbutli, Y., D’Alton, M. E., & For the First and Second
Trimester Evaluation of Risk (FASTER) Trial Research
Consortium. (2006). Pregnancy loss rates after midtrimester am-
niocentesis. American Journal of Obstetrics and Gynecology,
108, 1067–1072.
Haddow, J. E., Palomaki, G. E., Knight, G. J., Foster, D. L., & Neveux,
L. M. (1998). Second trimester screening for Down’s syndrome
using maternal serum dimericinhibin A. Journal of Medical
Screening, 5, 115–199.
Hunt, L. M., de Voogd, K. B., & Catendeda, H. (2005). The routine and
the traumatic in prenatal genetic diagnosis: does clinical informa-
tion impact patient decision-making? Patient Education and
Counseling, 56, 302–312.
Jackson, L. G., Zachary, J. M., Fowler, S. E., Desnick, R. J., Golbus,
M. S., Ledbetter, D. H., & The U.S. National Institute of Child
Health and Human Development Chorionic-Villus Sampling and
Amniocentesis Study Group. (1992). A randomized comparison
of transcervical and transabdominal chorionic-villus sampling.
The New England Journal of Medicine, 327, 594–598.
Kagan, K. O., Cicero, S., Staboulidou, I., Wirght, D., & Nicolaides, K.
H. (2009). Fetal nasal bone in screening for trisomies 21, 18, and
13 and Turner syndrome at 11–13 weeks of gestation. Ultrasound
in Obstetrics & Gynecology, 33, 259–264.
Kupperman, M., Nease, R. F., Learman, L. A., Gates, E., Blumberg, B., &
Washington, A. E. (2000). Procedure-related miscarriages and Down
syndrome-affected births: implications for prenatal testing based on
women’s preferences. Obstetrics and Gynecology, 96, 511–516.
Ledbetter, D. H., Zachary, J. M., Simpson, J. L., Golbus, M. S.,
Pergament, E., Jackson, L., & De La Cruz, F. (1992). Cytogenetic
results from the US collaborative study on CVS. Prenatal
Diagnosis, 12, 317–345.
Malone, F. D., Canick, J. A., Ball, R. H., Nuberg, D. A., Comstock, C. H.,
Bukowski, R., D’Alton, M. E., & For the First-and Second-Trimester
Evaluation of Risk (FASTER) Research Consortium. (2005). First-
trimester or second-trimester screening, or both, for Down’s syn-
drome. The New England Journal of Medicine, 352, 2001–2011.
Nicolaides, K. H., Health, V., & Cicero, S. (2002). Increased fetal nuchal
translucency at 11–14 weeks. Prenatal Diagnosis, 22, 308–315.
Norton, M. E., Brar, H., Weiss, J., Karimi, A., Laurent, L. C.,
Caughery, A. B., & Song, K. (2012). Non-invasive chromosomal
evaluation (NICE) study: results of a multicenter prospective
cohort study for detection of fetal trisomy 21 and trisomy 18.
American Journal of Obstetrics and Gynecology, 207, 1.e1–1.e8.
Nyberg, D. A., & Souter, V. L. (2001). Sonographic markers of fetal
trisomies: second trimester. Journal of Ultrasound in Medicine, 20,
655–674.
Ozkaya, O., Sezik, M., Ozbasar, D., & Kaya, H. (2010). Abnormal
ductusvenosus flow and tricuspid regurgitation at 11–14 weeks’
gestation have high positive predictive values for increased risk in
first-trimester combined screening test: results of a pilot study.
Taiwanese Journal of Obstetrics and Gynecology, 49, 145–150.
Palomaki, G. E., Steinort, K., Knight, G. J., & Haddow, J. E. (2006).
Comparing three screening strategies for combining first- and
second- trimester Down syndrome markers. Obstetrics and
Gynecology, 107, 367–375.
Palomaki, G. E., Deciu, C., Kloza, E. M., Lambert-Messerlian, G. M.,
Haddow, J. E., Neveux, L. M., Canick, J. A. (2012). DNA
sequencing of maternal plasma reliably identifies trisomy 18 and
trisomy 13 as well as Down syndrome: an international collabo-
rative study. Genetics in Medicine, 1–10.
Pepin, M., Atkinson, M., Starman, B., & Byers, P. (1997). Strategies
and outcomes of prenatal diagnosis for osteogenesis imperfecta: a
NSGC Practice Guideline
review of biochemical and molecular studies completed in 129
pregnancies. Prenatal Diagnosis, 17, 559–570.
Platt, L. D., Greene, N., Johnson, A., Zachary, J., Thom, E., Krantz, D.,
& First Trimester Maternal Serum Biochemistry and Fetal Nuchal
Translucency Screening (BUN) Study Group. (2004). Sequential
pathways of testing after first-trimester screening for trisomy 21.
Obstetrics and Gynecology, 104, 661–666.
Sanders, R. C., Blackmon, L. R., Hogge, W. A., Spevak, P., &
Wulfsberg, E. A. (Eds.). (2002). Structural fetal abnormalities:
The total picture (2nd ed.). Missouri: Mosby, Inc.
Spencer, K., & Nicolaides, K. H. (2002). A first trimester trisomy 13/
trisomy 18 algorithm combining fetal nuchal translucency thick-
ness, maternal serum free beta-hCG and PAPP-A. Prenatal
Diagnosis, 22, 877–879.
Spencer, K., Ong, C., Skentou, H., Liao, A. W., & Nicolaides, K. H.
(2000). Screening for trisomy 13 by fetal nuchal translucency and
maternal serum free beta-hCG and PAPP-A at 10–14 weeks of
gestation. Prenatal Diagnosis, 20, 411–416.
Sundberg, K., Bang, J., Smidt-Jensen, S., Brocks, V., Lundsteen, C.,
Parner, J., & Philip, J. (1997). Randomised study of risk of fetal
loss related to early amniocentesis versus chorionic villus sam-
pling. Lancet, 350, 697–703.
Taslimi, M. M., Acosta, R., Chueh, J., Hudgins, L., Hunter, K., Druzin,
M., & Chitkara, U. (2005). Detection of sonographic markers of
15
fetal aneuploidy depends on maternal and fetal characteristics.
Journal of Ultrasound in Medicine, 24, 811–815.
Wald, N. J., & Rish, S. (2005). Prenatal screening for Down syndrome
and neural tube defects in twin pregnancies. Prenatal Diagnosis,
25, 740–745.
Wald, N. J., Rodeck, C., Hackshaw, A. K., Walters, J., Chitty, L., &
Makinson, A. M. (2003). First and second trimester antenatal
screening for Down’s syndrome: the results of the serum, urine,
and ultrasound screening study (SURUSS). Journal of Medical
Screening, 10, 56–104.
Wald, N. J., Rodeck, C., Hackshaw, A. K., & Rudnicka, A. (2004).
SURUSS in perspective. British Journal of Obstetrics and
Gynaecology, 111, 521–531.
Wapner, R. J. (2005). Invasive prenatal diagnostic techniques.
Seminars in Perinatology, 29, 401–404.
Wapner, R. J., Thorn, E., Simpson, J. L., Pergament, E., Silver, R., Filkins,
K., Jackson, L., & For the First Trimester Maternal Serum
Biochemistry and Fetal Nuchal Translucency Screening (BUN)
Study Group. (2003). First-trimester screening for trisomies 21 and
18. The New England Journal of Medicine, 349, 1405–1413.
Winsor, E. J. T., Tomkins, D. J., Kalousek, D., Farrell, S., Wyatt, P.,
Fan, Y., & Wilson, R. D. (1999). Cytogenetic aspects of the
Canadian early and mid-trimester amniotic fluid trial (CEMAT).
Prenatal Diagnosis, 19, 620–627.