ANTENATAL SCREENING OF FETAL

CHROMOSOMAL ABNORMALITIES

PRESENTER :DR.NIKHILA
MODERATOR:DR.SJ PATIL
➢ PRENATAL DIAGNOSIS IS THE SCIENCE OF IDENTIFYING STRUCTURAL
AND FUNCTIONAL ABNORMALITIES IN THE DEVELOPING FETUS
➢ ANTENATAL SCREENING TESTS ASSESS THE DEGREE OF RISK, OR
CHANCE OF A FETUS THAT MAY POTENTIALLY HAVE CERTAIN BIRTH
DEFECTS
➢ ALL PREGNANT WOMEN, REGARDLESS OF AGE ,SHOULD BE OFFERED,
THROUGH AN INFORMED COUNSELLING PROCESS ,THE OPTION OF A
PRENATAL SCREENING TEST FOR THE MOST COMMON CLINICALLY
SIGNIFICANT FETAL ANEUPLOIDIES
➢ ANEUPLOIDY SCREENING METHODS INCLUDE AGE OF THE
MOTHER,MATERNAL SERUM MARKERS, GENETIC SONOGRAM AND
NIPT(NONINVASIVE PRENATAL TESTING)
➢ IF SCREENING TEST IS POSITIVE , SHE SHOULD HAVE GENETIC
COUNSELLING AND SHOULD UNDERGO INVASIVE DIAGNOSTIC TESTING
➢ WOMEN AT INCREASED RISK OF HAVING A FETUS WITH CHROMOSOMAL
ABNORMALITY CAN BE REFERRED EARLY IN THE PREGNANCY FOR
DIAGNOSTIC TESTING(AMNIOCENTESIS,CVS) DIRECTLY
Women with high risk of fetal aneuploidy

➢ SINGLETON PREGNANCY AND MATERNAL AGE >35 AT DELIVERY

➢ DIZYGOTIC TWIN PREGNANCY AND MATERNAL AGE >31 AT DELIVERY
➢ PREVIOUS AUTOSOMAL TRISOMY BIRTH
➢ PREVIOUS 47,XXX OR 47,XXY BIRTH
➢ PATIENT OR PARTNER IS CARRIER OF CHROMOSOMAL TRANSLOCATION
➢ PATIENT OR PARTNER IS CARRIER OF CHROMOSOMAL INVERSION
➢ SOME CASES OF REPETITIVE EARLY PREGNANCY LOSSES
➢ MAJOR FETAL STRUCTURAL DEFECT BY SONOGRAPHY
RISK ASSESSMENT APPROACHES

➢ FIRST TRIMESTER

DOUBLE SCREEN: PAPP-A(pregnancy associated plasma protein A),Beta

hCG

COMBINED: NT, PAPP-A,Beta hCG

➢ SECOND TRIMESTER

TRIPLE SCREEN: MSAFP, Beta hCG, uE3(unconjugated estriol)

QUADRUPLE SCREEN: MSAFP, Beta hCG, uE3, Inh-A

GENETIC SONOGRAM: ULTRASOUND MARKERS

EXTENDED SONOGRAM:SERUM+ULTRASOUND MARKERS

Combined first and second trimester screening

➢ INTEGRATED (NON DISCLOSURE OF FIRST TRIMESTER RESULTS)

FULL INTEGRATED (NT, PAPP-A,QUAD SCREEN)

SERUM INTEGRATED (PAPP-A, QUAD SCREEN)

➢ SEQUENTIAL (DISCLOSURE OF FIRST TRIMESTER RESULTS)

FIRST TRIMESTER SCREENING
USG BIOCHEMICAL

➢ NUCHAL TRANSLUCENCY ➢ DUAL MARKERS

➢ NASAL BONE
a)FREE BETA hCG
➢ DUCTUS VENOSUS
➢ TRICUSPID REGURGITATION b)PAPP-A
➢ STRUCTURAL ANOMALIES
MATERNAL SERUM SCREENING

FREE BETA HCG

➢ PRODUCED BY THE TROPHOBLAST CELLS

➢ MATERNAL SERUM CONCENTRATION PROGRESSIVELY RISE AND
REACH MAXIMUM BY ABOUT 8-10 WEEKS(100000 IU/L)
➢ IT THEN FALLS UNTIL ABOUT 18-20 WEEKS AND REMAINS AT LOW
LEVELS (10,000-20,000 IU/L) UPTO TERM
➢ FREE BETA HCG ARE INCREASED TWICE THE NORMAL VALUE DURING
SECOND TRIMESTER IN ANEUPLOIDY FETUS
PREGNANCY ASSOCIATED PLASMA PROTEIN A (PAPP-A)

➢ PRODUCED BY DEVELOPING PLACENTA

➢ ITS CONCENTRATION IN MATERNAL BLOOD INCREASES FROM 7
WEEKS OF PREGNANCY
➢ IT IS LOWER IN PREGNANCIES OF TRISOMY 21
➢ USED ALONE IN THE FIRST TRIMESTER ALLOWS FOR TRISOMY 21
DETECTION RATE 40% WITH A FALSE POSITIVE RATE OF 5%
Summary of markers in fetal chromosomal aneuploidies

Marker Site of Measured T 21 T 18 T 13

synthesis at
AFP Fetal liver 15-20 wks Decreases by Decreases by Slightly raised
25% 35-55%

uE3 Fetus + 15-20 wks Decreases by Decreases by Decreases by

placenta 30% 35-55% 30%

Inhibin A Ovary 15-20 wks Raised x 2 Raised x 2

Free beta hCG Placenta 8-20 wks Raised x 2 Decreases by Decreases by

50% 50%

PAPP-A Placenta 8-13 wks Decreases by Decreases by Decreases by

50% 50% 50%
FIRST TRIMESTER NUCHAL TRANSLUCENCY

➢ IT IS THE SONOGRAPHIC APPEARANCE (LUCENT ZONE ) OF COLLECTION OF FLUID

UNDER THE SKIN BEHIND THE FETAL NECK
➢ 11-13+6 WEEKS / CRL 45-84 MM
➢ AN ENLARGED NT( >3 MM OR > 99TH PERCENTILE FOR CRL) IS INDEPENDENTLY
ASSOCIATED WITH FETAL ANEUPLOIDY & STRUCTURAL MALFORMATIONS
➢ IF NT IS ABNORMALLY INCREASED, APPROXIMATELY 1/3RD OF SUCH FETUSES WILL HAVE
CHROMOSOMAL ABNORMALITY, AND HALF OF THESE ARE DOWN SYNDROME
➢ INCREASED NT ITSELF IS NOT A FETAL ABNORMALITY, BUT A MARKER THAT CONFERS
INCREASED RISK
➢ FALSE POSITIVE RATE 5%
Screening for fetal defects at 11-13+6 weeks
11 weeks? 13+6 weeks?

1) cranial vault not ossified prior to 11 1)Effectiveness of NT diminishes with

weeks gestational age

2)nasal bone not ossified prior to 11 2)The position of the fetus makes NT
weeks measurement difficult

3)50% of fetuses have incompetent 3)Benefits of early diagnosis and

tricuspid valves <11 weeks treatment reduced
➢ NT MEASUREMENT CAN BE COMBINED WITH SERUM MARKERS TO
CALCULATE AN ACCURATE COMPOSITE RISK
➢ IN ALL CASES OF INCREASED NT ,ECHOCARDIOGRAPHY IS OFFERED
TO AVOID MAJOR CARDIAC DEFECTS
➢ MAJOR DRAWBACKS OF NT MEASUREMENT -REQUIRES SPECIFIC
TRAINING, STANDARDIZATION ,USE OF APPROPRIATE USG
EQUIPMENT
Absent Nasal bone
➢ NASAL BONE SEEN SEPARATE FROM THE NASAL SKIN
➢ NORMALLY THE ECHOGENICITY OF NASAL BONE IS GREATER THAN
THE SKIN OVERLYING IT
➢ WHEN THE NASAL BONE LINE IS THIN LINE,LESS ECHOGENIC THAN
THE OVERLYING SKIN, SUGGEST THAT NASAL BONE IS NOT YET
OSSIFIED, AND HENCE CLASSIFIED AS BEING ABSENT
➢ IT IS MORE DIFFICULT THAN NT
➢ POOR SCREENING TOOL IN THE GENERAL POPULATION
Ductus venosus doppler at 11-13+6 wks

➢ DISCRIMINATE B/W CHROMOSOMALLY NORMAL & ABNORMAL FETUS

➢ ABNORMAL DUCTAL BLOOD FLOW SEEN IN

69% OF FETUSES WITH TRISOMY 21

71% OF FETUSES WITH TRISOMY 18

64% OF FETUSES WITH TRISOMY 13 &

76% OF FETUSES WITH TURNER SYNDROME

Tricuspid valve doppler and fetal aneuploidy

➢ PREVALENCE OF TR VARIES WITH GESTATIONAL AGE AND INCREASES

AS THE NT MEASUREMENT INCREASES
➢ THE PREVALENCE OF TR IN FETUSES WITH TRISOMIES 21,18,13 IS
56%, 33% ,30% RESPECTIVELY
➢ IN EUPLOID FETUSES PREVALENCE IS 1%
Second Trimester Screening

TRIPLE SCREEN: Beta hCG,MSAFP, uE3

QUADRUPLE SCREEN:( Beta hCG,MSAFP, uE3) ,Inh-A

GENETIC SONOGRAM: ULTRASOUND MARKERS

EXTENDED SONOGRAM:SERUM+ULTRASOUND MARKERS

Sonographic screening for Aneuploidy (2 ND Trimester)
MAJOR STRUCTURAL DEFECTS
➢ Cystic hygroma
➢ Holoprosencephaly
➢ Cleft lip/palate
➢ Cardiac defects
➢ Diaphragmatic hernia
➢ Esophageal/duodenal/jejunal/ileal
atresia
➢ Gastroschisis,omphalocele
➢ Clubfoot
SECOND TRIMESTER SONOGRAPHIC
MARKERS “SOFT SIGNS”
➢ Nuchal fold thickening
➢ Nasal bone absence or hypoplasia
➢ Shortened frontal lobe or
brachycephaly
➢ Short ear length
➢ Echogenic intracardiac focus
➢ Echogenic bowel
➢ Widened gap b/w 1st & 2nd toes
“sandal gap”
➢ Clinodactyly, hypoplastic mid phalanx
of 5th digit
➢ Single transverse palmar crease
➢ Short femur & Short humerus
Cystic Hygroma

➢ Congenital malformation of the lymphatic system in which lymph accumulates

in the jugular lymphatic sacs of the nuchal region
➢ Are multilocular fluid filled cavities ,largest in the nuchal region ,but may
extend along the entire length of the fetus & contain multiple septae
➢ First trimester cystic hygroma are often associated with trisomies 21,18,13,
whereas second trimester cystic hygromas are often associated with
monosomy X
➢ Chromosomal abnormalities more frequent in septated cystic hygromas
Nuchal fold thickness
➢ Measurement of the thickness of the skin of the posterior neck >6mm b/w
16-21 weeks
➢ Present in 0.5% of pregnancies, most have a normal outcome
➢ Associated with increased risk of fetal chromosomal anomalies ,trisomy
21(20-30%) & congenital heart disease
Echogenic intracardiac foci
➢ Calcified papillary muscle seen as bright dot
➢ Present in 5 % of normal pregnancies
➢ 13-18% of Down syndrome gestations
Echogenic Bowel
➢ Fetal bowel with an echogenicity similar to or greater than surrounding
bone(iliac bone)
➢ Found in about 0.6-2.4 % normal fetuses
➢ Associated with increased risk of chromosomal anomalies
Noninvasive prenatal test(NIPT)

Cell free foetal DNA (cffDNA) in maternal plasma

➢ cffDNA in maternal plasma is the latest test ,also known as noninvasive

prenatal test (NIPT)
➢ Detection rate 99-100%
➢ cffDNA is present in maternal blood from early pregnancy(10 wks)& represent
entire fetal genotype
➢ Can be used to screen trisomy 21, trisomy 18 & trisomy 13
➢ As such NIPT is not diagnostic, and confirmation of a positive result by
invasive testing (chorionic villus sampling or amniocentesis) is required
Diagnostic techniques

➢ Chorionic villus sampling after 11 completed weeks, amniocentesis after 16

weeks or cordocentesis after 18-20 week gestation are the methods used to
obtain foetal samples for definitive testing
➢ These procedure need training and expertise and have inherent risks of
abortion reported to be 0.2-1.3 % and 0.1-0.9 % for CVS and amniocentesis,
respectively
➢ Conventionally ,chromosomal fluorescent in situ hybridization (FISH) and
karyotype analysis is performed
➢ Another technology driven revolution in chromosomal analysis is cytogenetic
microarray (CMA) that is a molecular cytogenetic technique to visualize
chromosome at a very high resolution
Amniocentesis

➢ Amniocentesis for genetic diagnosis usually performed b/w 15-20 weeks

➢ Under USG guidance, 20-22 gauge spinal needle is passed into amnionic
sac while avoiding placenta , umbilical cord and fetus
➢ 20 ml of fluid is collected for fetal karyotyping and the needle is removed
➢ Fetal cardiac motion is documented at the end of the procedure
➢ Complications are infrequent and include transient vaginal spotting or
amniotic fluid leakage in 1-2 %
➢ Procedure related fetal loss is approx 1 in 300-500
Chorionic villus sampling

➢ Performed at 10-13 weeks

➢ Samples may be obtained transcervically or transabdominally
➢ Advantage - results are available earlier in pregnancy which allows earlier and
safer termination of pregnancy when results are abnormal
➢ Complications- transient vaginal spotting or amniotic fluid leakage ( <0.5%)
Cordocentesis

➢ Percutaneous umbilical blood sampling/ or cordocentesis can be used to

obtain cells for genetic analysis when CVS or amniocentesis results are
confusing or when rapid diagnosis is necessary
➢ Under USG guidance a 22 G needle is used to puncture the umbilical vein,
usually at or near its placental origin ,and blood is withdrawn
➢ Complications- cord vessel bleeding, cord hematoma, fetal maternal
hemorrhage, fetal bradycardia
➢ Procedure related fetal death 1.4%
Rapid test for karyotype analysis
Fluorescence in situ hybridization (FISH)

➢ Allows visualization of small region on chromosome too small to be identified

by karyotyping
➢ Results available within 24-72 hrs (as compared to karyotyping around 21
days)
➢ Fluorescent DNA probes are used with same nucleotide sequence as the
stretch of chromosomal DNA of interest
➢ Probe will hybridise at >2 places reflecting homologous nature normally
➢ If probe hybridizes at >2 places ,detects trisomy