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EMERY AND RIMOIN’S
PRINCIPLES AND PRACTICE
OF MEDICAL GENETICS AND
GENOMICS
This page intentionally left blank
     
EMERY AND RIMOIN’S
PRINCIPLES AND PRACTICE
OF MEDICAL GENETICS AND
GENOMICS
Perinatal and Reproductive Genetics
Seventh Edition

Edited by
Reed E. Pyeritz
Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, United States

Bruce R. Korf
University of Alabama at Birmingham, Birmingham, AL, United States

Wayne W. Grody
UCLA School of Medicine, Los Angeles, CA, United States
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 CONTENTS

List of Contributors ix 3.3 Chorionic Villus Sampling 43

Preface to the Seventh Edition of Emery and Rimoin’s 3.4 Fetal Blood Sampling 49
Principles and Practice of Medical Genetics and 3.5 Fetal Skin and Tissue Biopsy
Genomics xi Procedures 50
Preface to Perinatal and Reproductive Genetics xiii Acknowledgments 51
References 51
Introduction to Perinatal Disorders and
1  4 Neonatal Screening 57
Reproductive Genetics 1 Inderneel Sahai and Richard W. Erbe
Susan J. Gross 4.1 Introduction 57
1.1 Introduction 1 4.2 Historical Aspects 58
1.2 Imaging During Pregnancy—A First 4.3 Components of Screening Programs 59
Look 1 4.4 Potential Problems in Newborn
1.3 Prenatal Diagnostics—Confirming Screening 65
Genetic Disorders 3 4.5 Disorders and Conditions Detected by
1.4 Prenatal Screening for Genetic Newborn Blood Screening: Inborn Errors
Disorders—Aneuploidy and Single of Metabolism 67
Gene 4 4.6 Other Congenital Disorders and
1.5 The End of the Beginning and What Lies Conditions Detected by Newborn Blood
Ahead 5 Screening 77
1.6 Conclusion 6 4.7 Issues and Concerns in Screening 79
References 6 References 80
Further Reading 8 Further Reading 86
Web Resources 86
2 Prenatal Screening for Neural Tube Defects and
Aneuploidy 9 5 Hypogonadotropic and Hypergonadotropic
Robert G. Best Hypogonadism in Females: Disorders of
2.1 Introduction 9 Reproductive Ducts 87
2.2 Prenatal Screening for Birth Defects 10 Joe Leigh Simpson
2.3 Risk Determination and Thresholds 19 5.1 Kallmann Syndrome and Idiopathic
2.4 Modalities of Testing for NTD and Down (Congenital) Hypogonadotropic
Syndrome 21 Hypogonadism 87
2.5 Follow-up to Positive Screens—NTD 22 5.2 Hypergonadotropic Hypogonadism:
2.6 Maintaining and Monitoring Screening Historical Overview and Evolution of
Performance 24 Scientific Approach 91
2.7 Keeping Screening in Perspective 25 5.3 Mechanism of Action for Genes Causing
2.8 Summary 26 Hypergonadotropic Hypogonadism 95
References 26 5.4 Related Gynecological Disorders Causing
Infertility 102
3 Techniques for Prenatal Diagnosis 35
5.5 Structural Anomalies of the Uterus and
Lee P. Shulman, Jeffrey S. Dungan and Andrew F. Wagner
Vagina 106
3.1 Introduction 35
References 110
3.2 Amniocentesis 36

v
vi CONTENTS

6 
Genetics of Male Infertility 121 Acknowledgments 228
Csilla Krausz, Viktoria Rosta, Ronald S. Swerdloff and References 228
Christina Wang 10 Noninvasive Prenatal Testing and Noninvasive
6.1 Male Infertility—Introduction 121 Prenatal Screening 235
6.2 Chromosome Anomalies 123 Charles M. Strom
6.3 Gene Defects Involved in Endocrine 10.1 Precision in Screening Tests 235
Forms of Infertility 128 10.2 Fetal Fraction 239
6.4 Monogenic Defects of Male Infertility 135 10.3 Sex Chromosome Aneuploidies and
6.5 Syndromic Monogenic Defects 138 Gender Determination 240
6.6 Conclusion 139 10.4 Segmental Aneuploidies 240
References 140 10.5 Triploidies and Haploidies 241
10.6 Mendelian Disorders in NIPS 241
7 The Genetics of Disorders Affecting the Premature 10.7 Gender Determination 241
Newborn 149 10.8 Multiple Pregnancies and Vanishing
Aaron R. Prosnitz, Jeffrey R. Gruen and Vineet Bhandari Twins 241
7.1 Introduction 149 10.9 Confined Placental Mosaicism 242
7.2 Respiratory Distress Syndrome 150 10.10 Maternal Factors 242
7.3 Bronchopulmonary Dysplasia 157 10.11 Inappropriate Use of NIPS 243
7.4 Patent Ductus Arteriosus 162 10.12 NIPT Paternity Testing 244
7.5 Intraventricular Hemorrhage 164 10.13 Noninvasive Whole Genome Fetal
7.6 Retinopathy of Prematurity 168 Sequencing 245
7.7 Necrotizing Enterocolitis 171 10.14 Conclusion 245
References 175 References 245
8 Fetal Loss 187 Further Reading 248
Rhona Schreck, John Paul Govindavari and John Williams III 11 Preimplantation Genetic Testing 249
8.1 Background 187 Svetlana A. Yatsenko and Aleksandar Rajkovic
8.2 Definition of Terms 187 11.1 Introduction 249
8.3 Early Pregnancy Loss 188 11.2 Milestones in PGT 250
8.4 Late Pregnancy Loss 202 11.3 Indications for Preimplantation Genetic
8.5 Evaluation and Management of Recurrent Testing 251
Abortion 204 11.4 Technical Approaches 253
8.6 Conclusions 205 11.5 Testing and Analysis of Embryonic
References 205 Nuclear DNA 254
Further Reading 215 11.6 Embryo Testing for Monogenic
Conditions (PGT-M) 254
9 Preeclampsia 217
11.7 PGT-M for Mitochondrial
Anthony R. Gregg
Conditions 256
9.1 The Preeclampsia Phenotype 217
11.8 Preimplantation Genetic Testing
9.2 Preeclampsia Is a Quantitative Trait
for Structural Chromosome
Disorder 218
Rearrangements 256
9.3 Preeclampsia and the Placenta 219
11.9 Preimplantation Genetic Testing for
9.4 Preeclampsia Biomarkers in Clinical
Aneuploidy 258
Use 224
11.10 Interpretation of PGT Results and
9.5 Preeclampsia Management and Future
Clinical Dilemmas 259
Health 225
11.11 PGT-A: Mosaicism 262
9.6 Genetic Basis of Preeclampsia 226
11.12 Advantages and Limitations of PGT 262
9.7 Preeclampsia and Animal Models 228
 CONTENTS vii

11.13 Prenatal Follow-Up and Confirmatory 12.6 Introduction of Expanded Carrier

Testing 263 Screening into Clinical Practice 285
11.14 Genetic Counseling 264 12.7 Process of Carrier Screening 286
11.15 Future Technological Advances in ART 12.8 Pretest Counseling 286
and PGT 265 12.9 Interpretation of Molecular
11.16 Regulatory Policies, Ethical Findings 287
Considerations, and Challenges in 12.10 Reproductive Options for Carrier
PGT 267 Couples Identified During
References 268 Pregnancy 290
12.11 Reproductive Options for
12 Expanded Carrier Screening 281
Carrier Couples Identified Before
Ronald J. Wapner, Katherine Johansen Taber, Gabriel Lazarin
Pregnancy 290
and James D. Goldberg
12.12 Posttest Counseling of Pregnant Carrier
12.1 Introduction 281
Couples 290
12.2 History of Reproductive Carrier
12.13 Preimplantation Genetic Testing for
Screening 281
Carrier Couples 291
12.3 Expanding Carrier Screening: One Gene
12.14 Use of PGT-M for Identifying Potential
at a Time 283
HLA Donor Embryos for Affected
12.4 Introduction of Expanded Carrier
Siblings 292
Screening Panels 284
12.15 Conclusions 292
12.5 Changes in Technology from Genotyping
References 292
to Sequencing Drive Carrier Screening
Performance Improvements 285 Index 295
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 LIST OF CONTRIBUTORS
Robert G. Best
Department of Biomedical Sciences, University
of South Carolina School of Medicine Greenville,
Greenville, SC, United States
Vineet Bhandari
Department of Pediatrics, Cooper Medical School of
Rowan University, The Children’s Regional Hospital at
Cooper, Camden, NJ, United States
Jeffrey S. Dungan
Department of Obstetrics and Gynecology, Division
of Clinical Genetics, Feinberg School of Medicine of
Northwestern University, Chicago, IL, United States
Richard W. Erbe
Departments of Pediatrics and Medicine, University
at Buffalo, Division of Genetics, Oishei Children’s
Hospital, Buffalo, NY, United States
James D. Goldberg
Department of Obstetrics and Gynecology, Vagelos
College of Physicians and Surgeons, Columbia
University Irving Medical Center, New York, NY,
United States; Myriad Women’s Health, South San
Francisco, CA, United States
John Paul Govindavari
Division of Molecular Pathology, Medical Genetics &
Pathology and Laboratory Medicine, Cedars-Sinai
Medical Center, Los Angeles, CA, United States
Anthony R. Gregg
Department of Obstetrics and Gynecology, PRISMA
Health, Columbia, SC, United States
Susan J. Gross
Department of Genetics and Genomic Sciences, Icahn
School of Medicine at Mount Sinai, New York, NY,
United States; Cradle Genomics, San Diego, CA,
United States
Jeffrey R. Gruen
Departments of Pediatrics, Genetics and Investigative
Medicine, Yale University School of Medicine, Yale
Child Health Research Center, New Haven, CT, United
States
Csilla Krausz
Department of Experimental and Clinical Biomedical
Sciences “Mario Serio”, University of Florence,
Florence, Italy
Gabriel Lazarin
Department of Obstetrics and Gynecology,
Vagelos College of Physicians and Surgeons,
Columbia University Irving Medical Center,
New York, NY, United States; Myriad Women’s Health,
South San Francisco, CA, United States
Aaron R. Prosnitz
Sanger Heart and Vascular Institute, Levine Children’s
Hospital at Atrium Health, Charlotte, NC, United States
Aleksandar Rajkovic
Department of Pathology, University of California
San Francisco, San Francisco, CA, United States;
Department of Obstetrics, Gynecology and
Reproductive Sciences, University of California San
Francisco, San Francisco, CA, United States;
Institute of Human Genetics, University of California
San Francisco, San Francisco, CA, United States
Viktoria Rosta
Department of Experimental and Clinical Biomedical
Sciences “Mario Serio”, University of Florence,
Florence, Italy
Inderneel Sahai
Department of Pediatrics, University of Massachusetts
Medical School, New England Newborn Screening
Program, Worcester, MA, United States
ix
x LIST OF CONTRIBUTORS
Rhona Schreck
Division of Molecular Pathology, Medical Genetics &
Pathology and Laboratory Medicine, Cedars-Sinai
Medical Center, Los Angeles, CA, United States
Lee P. Shulman
Department of Obstetrics and Gynecology, Division
of Clinical Genetics, Feinberg School of Medicine of
Northwestern University, Chicago, IL, United States
Joe Leigh Simpson
Departments of Human and Molecular Genetics and of
Obstetrics and Gynecology, Herbert Wertheim College
of Medicine, Florida International University Miami,
FL, United States
Charles M. Strom
UCLA School of Dentistry, Center for Head and Neck
Oncology, Los Angeles, CA, United States
Ronald S. Swerdloff
Division of Endocrinology, Department of Medicine,
Harbor-UCLA Medical Center and The Lundquist
Institute, Torrance, CA, United States
Katherine Johansen Taber
Department of Obstetrics and Gynecology, Vagelos
College of Physicians and Surgeons, Columbia
University Irving Medical Center, New York, NY,
United States; Myriad Women’s Health, South San
Francisco, CA, United States
Andrew F. Wagner
Department of Obstetrics and Gynecology, Division
of Clinical Genetics, Feinberg School of Medicine of
Northwestern University, Chicago, IL, United States
Christina Wang
Division of Endocrinology, Department of Medicine,
Harbor-UCLA Medical Center and The Lundquist
Institute, Torrance, CA, United States
Ronald J. Wapner
Department of Obstetrics and Gynecology, Vagelos
College of Physicians and Surgeons, Columbia
University Irving Medical Center, New York, NY,
United States
John Williams III
Division of Maternal-Fetal Medicine, Department
of Obstetrics and Gynecology, Cedars-Sinai Medical
Center, Los Angeles, CA, United States
Svetlana A. Yatsenko
Department of Pathology, University of Pittsburgh
School of Medicine, Pittsburgh, PA, United States;
Department of Obstetrics, Gynecology and
Reproductive Sciences, University of Pittsburgh School
of Medicine, Pittsburgh, PA, United States;
Magee-Womens Research Institute, Pittsburgh, PA,
United States; Department of Human Genetics,
Graduate School of Public Health, University of
Pittsburgh, Pittsburgh, PA, United States
 P R E FAC E TO T H E S E V E N T H
­E D I T I O N O F E M E R Y A N D
­R I M O I N ’ S P R I N C I P L E S A N D
PRACTICE OF MEDICAL
GENETICS AND GENOMICS
The first edition of Emery and Rimoin’s Principles and
Practice of Medical Genetics appeared in 1983. This was
several years prior to the start of the Human Genome
Project in the early days of molecular genetic testing,
a time when linkage analysis was often performed for
diagnostic purposes. Medical genetics was not yet a rec-
ognized medical specialty in the United States, or any-
where else in the world. Therapy was mostly limited to
a number of biochemical genetic conditions, and the
underlying pathophysiology of most genetic disorders
was unknown. The first edition was nevertheless pub-
lished in two volumes, reflecting the fact that genetics
was relevant to all areas of medical practice.
Thirty-five years later we are publishing the seventh
edition of Principles and Practice of Medical Genetics and
Genomics. Adding “genomics” to the title recognizes the
pivotal role of genomic approaches in medicine, with
the human genome sequence now in hand and exome/
genome-level diagnostic sequencing becoming increas-
ingly commonplace. Thousands of genetic disorders
have been matched with the underlying genes, often
illuminating pathophysiological mechanisms and in
some cases enabling targeted therapies. Genetic testing
is becoming increasingly incorporated into specialty
medical care, though applications of adequate family
history, genetic risk assessment, and pharmacogenetic
testing are only gradually being integrated into routine
medical practice. Sadly, this is the first edition of the
book to be produced without the guidance of one of the
founding coeditors, Dr. David Rimoin, who passed away
just as the previous edition went to press.
The seventh edition incorporates two major changes
from previous editions. The first is publication of the
text in 11 separate volumes. Over the years, the book
had grown from two to three massive volumes, until
the electronic version was introduced in the previous
edition. The decision to split the book into multiple
smaller volumes represents an attempt to divide the con-
tent into smaller, more accessible units. Most of these
are organized around a unifying theme, for the most
part based on specific body systems. This may make the
book more useful to specialists who are interested in the
application of medical genetics to their area but do not
wish to invest in a larger volume that covers all areas
of medicine. It also reflects our recognition that genetic
concepts and determinants now underpin all medical
specialties and subspecialties. The second change might
seem on the surface to be a regressive one in today’s
high-tech world—the publication of the 11 volumes
in print rather than strictly electronic form. However,
feedback from our readers, as well as the experience of
the editors, indicated that access to the web version via a
password-protected site was cumbersome, and printing
a smaller volume with two-page summaries was not use-
ful. We have therefore returned to a full print version,
although an eBook is available for those who prefer an
electronic version.
One might ask whether there is a need for a compre-
hensive text in an era of instantaneous Internet searches
for virtually any information, including authoritative
open sources such as Online Mendelian Inheritance in
Man and GeneReviews. We recognize the value of these
and other online resources, but believe that there is still
a place for the long-form prose approach of a textbook.
Here the authors have the opportunity to tell the story of
their area of medical genetics and genomics, including
in-depth background about pathophysiology, as well as
giving practical advice for medical practice. The willing-
ness of our authors to embrace this approach indicates
that there is still enthusiasm for a textbook on medical
genetics; we will appreciate feedback from our readers
as well.
xi
xii PREFACE TO THE SEVENTH EDITION OF EMERY AND RIMOIN’S PRINCIPLES

The realities of editing an 11-volume set have become
obvious to the three of us as editors. We are grateful to
our authors, many of whom have contributed to mul-
tiple past volumes, including some who have updated
their contributions from the first or second editions.
We are also indebted to staff from Elsevier, particu-
larly Peter Linsley and Pat Gonzalez, who have worked
patiently with us in the conception and production of
this large project. Finally, we thank our families, who
have indulged our occasional disappearances into writ-
ing and editing. As always, we look forward to feedback
from our readers, as this has played a critical role in
shaping the evolution of Principles and Practice of Med-
ical Genetics and Genomics in the face of the exponen-
tial changes that have occurred in the landscape of our
discipline.
 P R E FAC E TO P E R I N A T A L A N D
REPRODUCTIVE GENETICS
Mention the term “genetics” to most laypeople and
they will think first of “inheritance,” the transmission
of inborn traits from one generation to the next. In the
case of Homo sapiens, this process involves sexual repro-
duction via gametogenesis, fertilization, embryonic and
fetal development during gestation, followed by labor,
delivery, and the immediate newborn period. These
processes in aggregate comprise the perinatal period,
and the myriad ways in which any of these steps can
go wrong constitute the content of this volume. In that
sense, this volume represents the quintessential aspect
of genetics for many people.
This volume boasts state-of-the-art updates of key
chapters in previous editions dealing with prenatal
diagnosis, infertility, newborn screening, fetal loss, and
other critical topics. In addition, several new chapters
not present in the previous editions have been intro-
duced, reflecting the latest advances in molecular and
bioinformatic technology to enable such impressive
applications as noninvasive prenatal screening, preim-
plantation genetic testing, and highly expanded carrier
screening by next-generation DNA sequencing.
As with all such technological advances, ethical and
legal dilemmas often come to light, and the authors in
this volume do not shy away from discussion of those,
either. Some of the ethical/legal challenges are specific
to the particular techniques and their respective intel-
lectual property, while others are overarching across
the entire field of maternal–fetal medicine and genetics.
Included in that latter category are restrictions on access
to needed reproductive services, due either to inequities
in health insurance coverage for expensive procedures
or to politically motivated intrusions into reproductive
decision-making, such as legislative obstacles to preg-
nancy termination after specific (sometimes very early)
gestational ages or even for specific fetal diagnoses (such
as Down syndrome).
It is hoped that this volume will address the most
current needs of medical geneticists, genetic counsel-
ors, obstetricians, and all other healthcare profession-
als interested in this most fundamental area of clinical
genetics and patient care.
xiii
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Disorders and Reproductive
1Department
1.1 INTRODUCTION
There are multiple time points that one could point to
as signifying the “start” of the field of perinatal genetics.
Certainly, the concept of heritable disease appears early
in human history. The Talmud, an ancient legal text
compiled around 500 CE, rules against circumcising an
infant if his older brothers had died from uncontrolled
bleeding following their circumcisions—likely the first
description and management of an X-linked disorder,
specifically hemophilia (BT Yevamot 64b).
While clinical genetics as a focus area dedicated to
the management and understanding of heritable dis-
orders advanced considerably during the middle of
the last century, reproductive genetics remained hin-
dered by the very limited ability to evaluate the fetus
in any meaningful way. Fetal dysmorphology and even
the simplest metabolic or genetic tests were simply
not possible. Thus, the real breakthrough in the field
of reproductive genetics would have to wait for tech-
nological advances that would overcome these limita-
tions. This chapter will highlight key fetal imaging and
diagnostic and screening milestones that have brought
us to where we can now “see” what had been hidden
for millennia. Having achieved the ability to assess
the fetus, the future holds much promise but there
remain some important concerns that still need to be
addressed.
Emery and Rimoin’s Principles and Practice of Medical Genetics and Genomics. https://doi.org/10.1016/B978-0-12-815236-2.00001-1
Copyright © 2022 Elsevier Inc. All rights reserved.
1
Introduction to Perinatal
Genetics
Susan J. Gross1,2
of Genetics and Genomic Sciences, Icahn School of Medicine at
Mount Sinai, New York, NY, United States,
2Cradle Genomics, San Diego, CA, United States
1.2 IMAGING DURING
PREGNANCY—A FIRST LOOK
1.2.1 Radiography
While ultrasound is often the first technology that usu-
ally comes to mind when thinking of obstetrical imag-
ing, radiography in pregnancy was first reported in 1923
[1]. Abdominal X-rays to assess adequacy of a mater-
nal pelvis for delivery was first described in 1944 and,
despite concerns regarding teratogenic effects, remained
in use or under study until relatively recently [2]. This
modality can assess fetal osseous structures and there-
fore identify important birth defects, including single
gene disorders (e.g., skeletal dysplasias) as well as mul-
tifactorial anomalies (e.g., anencephaly). However, radi-
ography specifically for obstetrical reasons is usually
avoided due to concerns regarding potential teratoge-
nicity and limited clinical utility.
1.2.2 Ultrasound Imaging
There is no dispute among reproductive geneticists
that ultrasound was one of the breakout technologies
that changed the field forever. Based on the work of
Christian Doppler and other physicists in the 19th and
early 20th century, the first known medical applica-
tion was reported to the public in 1949 to detect gall-
stones, based on different echo signals from reflected
sound waves that were recorded on an oscilloscope
1
2 CHAPTER 1 Introduction to Perinatal Disorders and Reproductive Genetics
screen [3]. The next major technological step, and
what many consider the actual beginning of medical
ultrasound, begins with the report of 2D ultrasound in
the 1950s for breast anatomy and neck, although the
patient was immersed in water to overcome the artifi-
cial echoes that would otherwise be generated. Direct
skin “contact” 2D ultrasound arrived a few years later,
thanks to the Scottish Obstetrician Ian Donald and his
engineering colleague Tom Brown [4]. Reproductive
sonographers and geneticists will usually point to the
seminal paper by Donald, Brown, and gynecologist
John MacVicar [5] that described their findings related
to abdominal masses, which included not only ovar-
ian cancer but also the first ultrasound image of a fetal
head. While a sonographer with experience would be
able to make sense of these images, the resolution was
less than optimal. Furthermore, these images were gen-
erated over time and were “static” and were not actu-
ally captured in “real time.” Nevertheless, as described
by Dr. Stuart Campbell, a pioneer in the field in his
own right, the publication of this paper signaled that
“the starting gun had been fired and the ultrasound
race had begun” [3].
One cannot overstate the role of ultrasound in the
field of perinatal genetics. Below is a brief overview
as the technology has continued to advance from the
“snowstorm” images in the 1950s to current 3D (images
that add depth) and 4D (incorporates time, allowing for
assessment of movement) technologies.
Pregnancy Dating: Ultrasound dating, rather than
date of first menstrual period, has become the standard
of care for dating pregnancies. Precise dating is import-
ant for many reasons but is critical when trying to deter-
mine if a fetus is small for gestational age when working
up a potential genetic issue. Likewise, an erroneous ges-
tational age can result in false-positive or false-negative
fetal aneuploidy or neural tube defect screening test
results.
Fetal Dysmorphology: It is standard of care to offer
women routine fetal anatomy scanning during the first
half of pregnancy [6]. In many centers, this detailed
scan occurs between 18 and 20 weeks. However, as
the technology continues to improve, a detailed sono-
gram, including fetal echocardiogram, can be obtained
in the first trimester [7]. Abnormal fetal anatomy on
ultrasound exam remains one of the major reasons for
referral to centers with expertise in fetal medicine and
prenatal genetics.
Fetal Aneuploidy Screening: Standard screening for
fetal aneuploidy is still used as a frontline method in
many parts of the world and incorporates ultrasound
along with protein markers to determine risk for tri-
somy 21 and other chromosomal anomalies. Nuchal
translucency refers to a fluid-filled space normally seen
behind the fetal neck on ultrasound performed in the
first trimester of pregnancy. A measurement that is
enlarged relative to gestational age is associated with
Down syndrome, as well as other genetic disorders such
as Noonan syndrome [8] and skeletal dysplasias [9].
Some centers look for “soft markers” that are not consid-
ered structural anomalies, but do confer increased risk
for Down syndrome, such as increased renal pyelectasis
found on second trimester sonogram [10].
Ultrasound-Guided Diagnostic Procedures: Ultra-
sound was not initially used routinely to direct fetal
diagnostic procedures. Amniocentesis was available in
the 1960s, but the quality and availability of ultrasound
technology was still quite limited. Fetal injury from the
needle was a significant risk that was discussed with a
patient deciding whether to undergo a procedure. How-
ever, with the incorporation of ultrasound into prena-
tal care, use of this technology for needle guidance has
become standard of care. Perfumo and Jauniaux [11] in
their review point out the pivotal role of this technology
as “it is only the use of ultrasound-guided amniocentesis
in the 1980s that made it a very safe procedure during
the first half of pregnancy.” While amniocentesis in the
early days was possible without ultrasound guidance,
procedures such as chorionic villus sampling (CVS) of
the placenta or cordocentesis (also known as percuta-
neous umbilical blood sampling) would not have been
possible.
Counseling and Surgical Aid: 3D ultrasound that pro-
vides depth to the fetal image has provided geneticists
with a helpful tool when counseling patients for certain
fetal anomalies. For example, the surface rendering pro-
vides a clearer image of certain anomalies, especially
cleft lip and palate. In addition to defining the extent of
the finding for diagnostic purposes, having this more
recognizable image can help with patient counseling as
well as help the cleft lip and palate interdisciplinary care
team prepare [12].
1.2.3 MR Imaging
While CT imaging is sometimes used for maternal rea-
sons, due to increased risk for fetal radiation exposure,
 CHAPTER 1 Introduction to Perinatal Disorders and Reproductive Genetics
its use is limited prenatally. However, MRI can be an
important adjunct to prenatal ultrasound and has
demonstrated good sensitivity for fetal CNS malforma-
tions [13]. While neither ultrasound nor MRI is asso-
ciated with fetal risk, it is still recommended that this
technology be used judiciously, when the results could
provide medical benefit [14].
1.3 PRENATAL DIAGNOSTICS—
CONFIRMING GENETIC DISORDERS
Currently, amniocentesis and CVS remain the mainstays
when it comes to confirming genetic disease during the
prenatal period. In the past, cordocentesis was used
more frequently for genetic diagnoses. For example,
TAR syndrome that was suspected on prenatal ultra-
sound would be confirmed based on thrombocytopenia
and anemia observed in fetal cord blood analysis [15].
However, molecular diagnosis can now be made using
cells derived from an amniocentesis or CVS sample,
which is considered a safer alternative [16].
1.3.1 Amniocentesis
Amniocentesis was first described in the 1800s when
fluid was removed to treat polyhydramnios [17]. How-
ever, although used for other reasons over the inter-
vening years, it was really not until the 1950s that the
procedure became a part of obstetric care when it was
demonstrated that spectrophotometric analysis of bili-
rubin in the third trimester could be used to diagnose
and manage Rh disease [18]. This was quickly followed
by genetic diagnosis of sex using Barr body analysis [19].
However, the big hurdle that needed to be overcome
was the ability to culture the cells from the amniotic
fluid. With that achievement, prenatal diagnostics could
begin in earnest in the 1960s with a seminal publication
that described fetal chromosomal analysis [20]. 1968
saw the first reports of fetal Down syndrome as well
as galactosemia diagnoses [21,22]. Multiple case series
quickly followed, and amniocentesis has remained the
cornerstone for genetic screening confirmation and
diagnosis to the present day.
1.3.2 CVS
A limitation of traditional amniocentesis has remained
its timing during pregnancy. It is a second trimester
test, generally offered after 15 weeks gestation. Early
amniocentesis was proposed as a solution. However, a
3
randomized controlled trial demonstrated an increased
risk for talipes equinovarus in the early amniocentesis
group [23]. CVS, which entails sampling the placenta
either through an abdominal or transvaginal approach,
proved to be a first trimester diagnostic alternative. First
performed in 1983 [24], the technique has become well
established. While there is a small risk of false results due
to placental mosaicism, the chromosomal complement of
the placental cells used for this procedure closely mirrors
that of the fetal cells obtained through amniocentesis.
1.3.3 Preimplantation Genetic Testing
Preimplantation genetic testing has become more
widely available within IVF programs and is performed
prior to embryo transfer, following conception. Usually,
a biopsy is performed at the blastocyst stage, allowing
5 to 10 cells to be removed for further genetic testing.
The goal is to identify unaffected embryos for transfer
[25] and consequently avoid issues related to potential
termination of pregnancy.
1.3.4 Cytogenetic and Molecular Techniques
Used for Prenatal Diagnosis
Once fetal or placental cells could be retrieved, the
evolution of prenatal diagnosis tracked with available
cytogenetic and molecular technologies that were con-
currently available. The first paper documenting 46
chromosomes in humans was not published until 1956
[26]. In the early days of amniocentesis, G-banding was
not available and would not become part of cytogenetic
practice until the 1970s. The next major milestone was
the addition of molecular approaches to chromosomal
analysis. FISH probes allowed for the identification of
microdeletions that could not be seen using standard
karyotyping alone. Currently, microarrays are consid-
ered standard of care for prenatal diagnosis in the United
States, especially in the setting of fetal anomalies or still-
birth. If no structural anomalies are seen, conventional
karyotype and microarray should be discussed with the
patient [27]. Nor is prenatal exome sequencing still con-
sidered experimental. In the presence of fetal anomalies
or a single major anomaly suggestive of a genetic disor-
der where microarray is negative or unavailable, exome
sequencing becomes an option, similar to the postnatal
setting [28].
Noninvasive prenatal diagnosis is the next technolog-
ical phase that is garnering a lot of activity and attention.
It holds out the promise of removing the risk for fetal loss
4 CHAPTER 1 Introduction to Perinatal Disorders and Reproductive Genetics
that is associated with amniocentesis or CVS. While the
risk is low, 0.1%–0.3% in expert hands [29] and may not
even confer excess risk especially if the fetus is not anom-
alous [30], many women prefer to avoid invasive testing
if possible. The initial avenues explored were the isola-
tion of trophoblasts from the endocervical canal [31] and
fetal cells from the maternal circulation [32]. The focus
is on the separation and extraction of these cells, as once
isolated, current molecular sequencing techniques and
various analytic approaches become possible. Isolation of
intact fetal cells has now largely been superceded by direct
sequencing of cell-free fetal DNA, as discussed below.
1.4 PRENATAL SCREENING FOR GENETIC
DISORDERS—ANEUPLOIDY AND SINGLE
GENE
1.4.1 Fetal Aneuploidy Screening
It is notable that even during the 1960s and 1970s, when
amniocentesis was the only genetic testing option, women
were still involved in a screening program. Amniocente-
sis was not universally available and therefore age alone
was the clinical feature, absent any personal or family
risk, used to determine who would be offered a diagnostic
procedure. The age cut-off at 35 was used based on a few
factors including resource allocation and the “balance” of
1/200 risk of fetal loss versus 1/200 risk of any fetal chro-
mosomal anomaly at that maternal age. However, the
medical community always appreciated that despite the
increased risk in this older maternal age group, most chil-
dren with Down syndrome are born to women less than
35. Even in patients with affected offspring, the risk is
still only a few percentage points at most. Therefore, con-
ceptually, whether we are looking at the first “AFP only”
single marker aneuploidy screening test, standard first tri-
mester screening or the latest cell-free DNA noninvasive
prenatal screening (NIPS) approach, they all came about
to help refine the initial “age alone” risk algorithm [33].
NIPS has dramatically changed the landscape with pos-
itive predictive values (PPVs) that are several times bet-
ter than standard first trimester screening that combines
first trimester ultrasound NT and biomarkers (45.5% vs.
4.2% for trisomy 21% and 40.0% vs. 8.3% for trisomy 18)
[34]. However, despite this major leap forward in test
performance, NIPS has not been without controversy.
Additional disorders have been added with poor PPVs
and varied clinical utility, such as rare aneuploidies and
microdeletion syndromes [35]. Most problematic is an
ongoing confusion regarding the difference between a
screening test that can only provide a risk assessment
versus a true diagnostic test. In response, leading profes-
sional organizations have created open access calculator
tools to help healthcare professionals provide accurate
information to patients regarding PPVs and negative pre-
dictive values (NSGC PQF NIPT Calculator https://ww-
w.perinatalquality.org/Vendors/NSGC/NIPT/). It is also
worth noting that the entire fetal genome has already
been sequenced [36] using shotgun sequencing of mater-
nal plasma DNA. The approach is not practical for broad
clinical testing at this time, but it demonstrates that non-
invasive fetal sequencing can already be performed with
currently available technologies.
1.4.2 Carrier Screening for Genetic Disorders
Even prior to molecular diagnostics, fetal risk assess-
ment for Mendelian disorders was possible. A good
pedigree analysis could provide valuable information in
the case of a woman with a family history of Duchenne
Muscular Dystrophy or a previous child with cystic
fibrosis. The population-based Tay Sachs screening pro-
gram was successfully executed using maternal enzyme
analysis and was the first multi-disease panel as some
of the programs also screened for familial hypercholes-
terolemia using cholesterol levels. Hemoglobin electro-
phoresis and a simple MCV are considered the first-line
screening tests for hemoglobinopathies [37].
However, there is no doubt that molecular technol-
ogies, in particular next-generation sequencing (NGS),
have altered the carrier screening landscape. The cur-
rent approach is to sequence the mother and if a patho-
genic or likely pathogenic variant is identified, then the
father of the baby also undergoes genetic testing in the
case of an autosomal recessive disorder. While carrier
screening is on one hand a diagnostic for the mother
(if a pathogenic cystic fibrosis variant is found, she is
indeed a carrier), the term “screening” is used because
the purpose of the test is to assess the risk to fetus. The
benefits of NGS technology are manifold, including the
ability to test for more disorders in a highly precise and
efficient way. However, the larger the panels, the more
likely a patient will receive a “positive” screen result. As
more variants will be found in genes associated with
increasingly rare disorders, the odds that the other par-
ent will likewise have a pathogenic variant in that same
gene become more unlikely. Thus, there is significant
 CHAPTER 1 Introduction to Perinatal Disorders and Reproductive Genetics
concern that larger panels will result in downstream
anxiety and costs but will not necessarily provide useful
information specific to the current pregnancy. Similar to
aneuploidy screening, single gene variant detection has
already been reported using cell-free DNA in maternal
plasma [38] using droplet PCR. Other approaches have
also been reported [39,40]. A clinical test is already on
the market for select de novo and paternally inherited
variants, although it is not considered to be sufficiently
validated to be incorporated into standard of care [41].
1.5 THE END OF THE BEGINNING AND
WHAT LIES AHEAD
From a broad perspective, the above survey of prenatal
genetics tells us that we have attained what would have
seemed like a far-off achievement only a few decades
ago. We already have the technology to interrogate the
fetal genome during pregnancy and the preimplantation
period. Treatments will become available and newer
diagnostic methodologies seem poised to fulfill the
promise of noninvasive testing. There remains much to
be done with respect to scalability and cost reduction;
however, technological advances will continue and one
can expect within a few years to see prenatal diagnostics
move forward on all fronts as well, opening the door to
true precision medicine prior to delivery. While there
is much to celebrate, the same questions that have con-
cerned the specialty in the past have not diminished and
perhaps take on more urgency as our ability to finally
access the fetal genome has arrived.
1.5.1 We Can Do It, but Should We Do It?
There has always been the push and pull between our
ability to “do more” to benefit patients versus primum
non nocere—first do no harm. Thoughtful clinicians
and leaders in the field addressed this problem even
when screening panels were still just a few disorders in
size [42]. Andermann et al. [43], in a WHO bulletin,
applied the well-known Wilson and Jungner principles
of screening criteria to the genomic era. Many of the key
concepts still hold, including the “North Star” of clinical
utility. Even if a screening test works consistently well in
the laboratory and can even detect disorders of interest
in the clinical setting, should it be offered if there is no
demonstrable positive impact on outcomes? Certainly,
there are challenges as often specific genetic disorders
tend to be rare, and large broad-based research studies
5
comparable to diabetes or coronary heart disease may
not be feasible. Some screening and even diagnostic tests
may require more “shared decision-making” approaches
in the future. However, there is still the need for rigor-
ous analytic, clinical validity and ultimately clinical
utility studies if testing is to be provided to millions of
women worldwide who are or seek to become pregnant.
Professional bodies have tried to address the question
with an approach that does not necessarily provide a
defined panel of diseases, but rather seeks to specify
characteristics of disorders that may warrant screening,
for example, whether the condition could result in sig-
nificant disability or knowledge of the condition could
enhance delivery planning. Conversely, guidance also
can address what disorders should be excluded, such as
adult-onset disorders or high allele frequency variants
but low penetrance such as MTHFR [44]. Others have
looked closely at allele frequency and the identification
of carrier couples rather than just one parent. Assessing
only 40 genes with carrier rates >1.0% would identify a
substantial number of panethnic carrier couples, while
the addition of genes with lower carrier rates followed
the principle of “diminishing returns” [45]. Genome
sequencing will ensure that this conversation regard-
ing prenatal test expansion will become more, not less,
important in the future.
1.5.2 Women’s Autonomy
Related to the above discussion of what prenatal tests
should be offered is the question of who gets to decide.
For example, Canadian guidelines recommend invasive
prenatal diagnosis be offered to women at high risk [46],
while in the United States, all women have the option of
screening versus diagnostic testing [47]. Some authors
have approached the issue of women’s autonomy via the
lens of informed consent and the “routinization” of pre-
natal testing, such that women are making decisions but
based on limited knowledge. In addition, “[s]upport for
access to prenatal genetic tests and abortion services and
advocacy for robust informed consent processes grow
out of the same ethical commitment to respect for auton-
omy” [48]. Other authors have noted that historically,
the focus has been on the risk for fetal loss following
invasive testing. Rather, an autonomy-based approach
would help women identify what risk most concerns
them personally. For some it may indeed be the risk of
fetal loss but for other women, it may be the risk of hav-
ing a child with a significant genetic abnormality [49].
6 CHAPTER 1 Introduction to Perinatal Disorders and Reproductive Genetics
1.6 CONCLUSION
Advances in reproductive genetics have been inextri-
cably tied to the technologic achievements that have
greatly accelerated over the past decade. Not only can
we image the fetus, but we can sequence its genome
using both invasive and noninvasive approaches which
can conceivably lead to treatment and cures. However,
the same concerns are still present, no different than
decades ago when the field of reproductive genetics
was just beginning. In his landmark paper on the first
prenatal diagnosis of an inborn error of metabolism
(galactosemia) using amniocentesis, the author ends
his abstract with the following “… until consider-
ably more experience is gained with these techniques,
these procedures should be considered experimental
in nature” [21]. Despite ethical concerns, science and
medicine will continue to move forward with the goal
of enhancing the well-being of individuals and com-
munities. Further detail regarding the past milestones
and future promise of reproductive genetics will be
found in the pages of this volume. Nevertheless, while
celebrating the many achievements that have improved
the health of mothers and families, it is worth reflecting
on a key moment in Dr. Charles Epstein’s Presidential
Address to the American Society of Human Genetics
in 1996 [50]. The address was meaningful for many
reasons, not the least of which was the fact that Dr.
Epstein, a recognized expert in the genetics of Down
syndrome, had recently survived injuries caused by an
explosion set by the “Unabomber,” an individual who
was on a violent campaign to stop technology. Toward
the end of his presentation, and in very compassionate
terms, Dr. Epstein made the case that medical genet-
icists have a responsibility to educate and inform the
public about what medical geneticists actually do.
However, most important and especially relevant to
those in the field of prenatal genetics, he recommended
that the medical genetic community “continue to be –
and, if anything, become more – involved in the social
and ethical debate that increasingly surrounds every-
thing that we do.”
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FURTHER READING
Brock DJ, Bolton AE, Monaghan JM. Prenatal diagnosis of
anencephaly through maternal serum-alphafetoprotein
measurement. Lancet 1973;2(7835):923–4. https://doi.
org/10.1016/s0140-6736(73)92592-0.
Committee on Obstetric Practice, the American Institute of
Ultrasound in Medicine, and the Society for Maternal-Fe-
tal Medicine. Committee opinion no 700: methods for es-
timating the due date. Obstet Gynecol 2017;129(5):e150–
4. https://doi.org/10.1097/AOG.0000000000002046.
Cuckle H, Maymon R. Development of prenatal screening–A
historical overview. Semin Perinatol 2016;40(1):12–22.
https://doi.org/10.1053/j.semperi.2015.11.003.
Hobbins JC. Overview of imaging in pregnancy: history to
the present, including economic impact. Semin Perina-
tol 2013;37(5):290–1. https://doi.org/10.1053/j.sem-
peri.2013.06.002.
National Society of Genetic Counselors and Perinatal Quality
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Scott F, Chan FY. Assessment of the clinical usefulness of
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ing severity of rhesus iso-immunization. Prenat Diagn
1998;18(11):1143–8.

Prenatal Screening for Neural
Tube Defects and Aneuploidy*
Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville,
2.1 INTRODUCTION
Population-based prenatal screening using biomark-
ers began in the 1980s following successful pilot stud-
ies that demonstrated that open neural tube defects
(ONTDs) including spina bifida and anencephaly could
be effectively identified by studying the presence of
alpha-fetoprotein (AFP) in the maternal circulation in
the second trimester of pregnancy [1]. Soon thereafter,
it was discovered that AFP levels were statistically lower
in pregnancies affected with Down syndrome (DS),
and this observation was exploited to provide the first
maternal serum biomarker screening for aneuploidy
[2]. Clinical screening for these two conditions is based
on successful characterization of the different distribu-
tions of these biomarkers between the population as
a whole and the subset of pregnancies affected by the
condition for which screening is seen as valuable. This
approach has led to the discovery of dozens of other
biomarkers for which affected pregnancies exhibit dif-
ferences from the underlying population that can be
exploited for screening purposes alone, or in combina-
tion with other biomarkers. This is not only limited to
protein markers such as AFP but also smaller peptides
[3,4], steroid hormones [5], nucleic acids [6], fetal mor-
phometric measurements [7–10], and other attributes
of the maternal–fetal environment [11,12]. Although
neural tube defects (NTDs) and DS remain at the center
* This article is a revision of the previous edition article by
Amelia L.M. Sutton and Joseph R. Biggio, pp 1–23. © 2013,
Elsevier Ltd. All rights reserved.
Emery and Rimoin’s Principles and Practice of Medical Genetics and Genomics. https://doi.org/10.1016/B978-0-12-815236-2.00011-4
Copyright © 2022 Elsevier Inc. All rights reserved.
2
Robert G. Best
Greenville, SC, United States
of prenatal screening, the methodology extends well
beyond these two conditions.
Biomarker concentrations during pregnancy tend to
be dynamic, so it is generally necessary to standardize
measurements relative to gestational age by comparing
a patient’s measured value against the median value in
the overall pregnant population for that specific point
in pregnancy. A risk-based approach that is shared
among most of the conditions for which clinical prena-
tal screening is offered uses Bayesian probability mod-
ifications constructed from the statistical distributions
of the biomarkers to modify a priori risks from the
population to calculate a patient-specific risk for each
condition of interest. This construct has led to dramatic
improvements in the ability to detect DS prenatally and
has opened an approach to identify other birth defects
and potentially serious adverse pregnancy conditions
(e.g., preeclampsia, low birth weight, etc.).
This chapter is intended to highlight the general
approach to prenatal screening currently in use in clin-
ical settings with a central focus on ONTD and DS and
secondary focus on other aneuploidies and the great
variety of other conditions that can be identified in the
context of prenatal screening. This chapter begins with
an historical perspective and ends with a reminder of
the clinical public health context of prenatal screening.
The introduction of cell-free fetal DNA (cfDNA) as a
mode for screening has dramatically influenced pre-
natal screening for aneuploidies since its introduction
in practice in 2012 (see Chapter 10); however, multiple
marker testing remains as a vital component of prenatal
screening in the United States and around the world.
9
10 CHAPTER 2 Prenatal Screening for Neural Tube Defects and Aneuploidy
2.2 PRENATAL SCREENING FOR BIRTH
DEFECTS
Screening tests are designed to identify the potential for
health disorders from among an otherwise healthy pop-
ulation. Screening differs from diagnostic testing in that
false positives and negatives are expected and are incor-
porated into the schema. Prenatal screening focuses pri-
marily on the risk of adverse health conditions of the
fetus that are both serious and common. Current stan-
dards for healthcare screening advanced by the World
Health Organization based on iterative improvements of
earlier criteria proposed by Wilson and Junger [13,14]
require that the screening test responds to a recognized
need for a defined target population, reflects scientific
evidence that the screening program is effective, is
designed to be equitable across the entire target popula-
tion, that the benefits outweigh any harms, and that the
program integrates education, testing, clinical services,
and program management [13].
Research around the Health Belief Model exploring
the motivation of patients to accept available testing
identifies the patient’s own perceptions of susceptibility,
severity, benefits, and barriers as critically important,
conditioned on beliefs of self-efficacy (i.e., an ability to
take effective action) [15,16]. Decisions to participate are
also affected by a variety of modifying factors (e.g., race/
ethnicity, age, education, etc.) and internal or external
cues that trigger action (e.g., receiving information from
trusted sources). Thus, the mere availability of a test or
demonstration that screening is possible is not sufficient
in terms of public policy nor patient demand. Two pre-
natal conditions that seem to fully meet all criteria for
screening are ONTD and DS. In addition to these two
conditions, there are several other conditions for which
information arises while testing for ONTD or DS that
bear sufficient clinical utility to merit inclusion in the
overall screening program.
2.2.1 Neural Tube Defects
NTDs are among the most common of the serious birth
defects in the population. These are major structural
developmental defects affecting the central nervous sys-
tem that arise from an error in the maturation of the
neural tube early in pregnancy, between 14- and 28-days
postfertilization (4–6 weeks by menstrual dating).
During this 2-week period, the embryonic tissues that
give rise to the spine and brain begin with a relatively
flat geometry, develop a transverse fold that deepens
into a groove along the axis of development, that ulti-
mately circularizes to give rise to a tubular structure as
the leading edges of the neural fold begin to touch and
connect with each other [17,18], providing the founda-
tional structures for the brain and spine. Failure of the
neural tube to close completely results in a disruption of
these central structures of the nervous system. Although
failure to close can result in a complete failure of the for-
mation of the neural tube and all resulting structures
downstream (complete dysraphism), most commonly
the errors are confined to incomplete closure at one end
or the other. When the failure involves the caudal end,
the developmental failure results in an opening along
the spine (spina bifida), whereas failure at the cephalic
end results in a dramatic disruption of the primary
structures of the brain and cranial vault (encephalocele,
anencephaly). These two anomalies are almost equally
common and account for approximately 90% of all
NTDs [19].
Morbidity and mortality are variable depending upon
the size, location, and fine structure of the defect. Spina
bifida is typically associated with paralysis or weakness of
the lower structures of the body but the extent is highly
variable and ranges from a lack of clinical impairment to
fetal or neonatal death [18]. Anencephaly is considered to
be uniformly fatal with death early in the postnatal period
for babies that survive to term [20].
When NTDs are covered by skin or other membranes,
they are considered to be closed defects. Most often, NTD
lesions are not covered with skin, and are therefore con-
sidered to be open defects. This is an important distinc-
tion because the mechanism that leads to differences in
AFP concentrations between the affected and unaffected
populations is limited to open defects. Only 15%–20% of
spina bifida cases are closed defects but, in general, the
prognosis is more favorable [21,22], whereas most cases
of anencephaly are open [23]. Biochemical screening is
therefore restricted to open NTD because the open lesion
is directly related to the increased release of fetal protein
into maternal circulation. It is not the intent of this chap-
ter to fully characterize the range of NTDs and their vari-
ous clinical presentations.
Most commonly, NTDs occur without other struc-
tural anomalies unrelated to the development of the
neural tube and are considered to be isolated or non-
syndromic. Their occurrence is estimated to be 7/10,000
live births in the general population of the United
 CHAPTER 2 Prenatal Screening for Neural Tube Defects and Aneuploidy
States [24] with notable differences in birth prevalence
around the world [25] and variability related to race,
geographical location, and the availability of folic acid
in the diet [26]. Isolated NTDs are genetically complex
traits with a heritability of approximately 60% [27,28]
with many genes associated and few genes having
been identified that clearly demonstrate major effects
[29]. Like other complex traits, recurrence is increased
when there are affected first-degree relatives [30] at a
rate of approximately the square root of the population
birth prevalence and less so for more distant affected
relatives [28]. A number of environmental factors have
been identified that influence the development of the
neural tube including folic acid, folate antimetabolites,
and type I diabetes [31–33]. Since the great majority of
NTDs occur in the absence of a positive family history,
prenatal identification is largely dependent upon gen-
eral population screening through AFP or ultrasound
examination.
NTDs can also appear in syndromic forms asso-
ciated with structural defects unrelated to the neu-
ral tube. Recurrence risks for syndromic NTDs are
highly variable and are dependent on the etiologic
mechanisms. For example, Meckel–Gruber syndrome
is a rare disorder with a birth prevalence of 2.6 per
100,000, inherited in a single-gene autosomal recessive
pattern and is associated primarily with encephalo-
cele [34]. In contrast, complete or partial aneuploidy
may also involve disruption of the neural tube during
development, with recurrence risks dependent on
­ sonalities are frequently described as affectionate and
the mechanism through which the chromosomal
­imbalance arose. Most syndromic forms of NTDs are
relatively rare and are therefore challenging to study
for recurrence and the degree to which environmental
factors might be involved. While it is not the intent of
this chapter to address the fine points of the occurrence
and distribution of all forms of NTDs, it is important
to recognize differences in recurrence risks as a limit-
ing factor in the estimation of patient-specific risk cal-
culations in screening. Biomarker screening is effective
for any ONTD independent of its causal mechanism.
2.2.2 Down Syndrome and Aneuploidies in
Pregnancy
Studies in the 1970s showed that chromosomal abnor-
malities affect approximately 1 in 160 live births [35].
A more recent European study of second trimester
amniocenteses demonstrated that this incidence may
11
be higher when minor alterations such as mosaicism
are included [36]. The majority of chromosome abnor-
malities are sex chromosome alterations involving
extra copies of the X or Y chromosomes, monosomy X
or autosomal trisomies involving chromosomes 21, 18,
or 13. Approximately 1 in 700–800 children are born
with trisomy 21 (DS), 1 in 6000 are born with trisomy
18 (Edwards syndrome), and 1 in 10,000 with trisomy
13 (Patau syndrome) [37,38]. Most autosomal trisomies
are caused by nondisjunction during maternal meiosis,
a process that is more frequent with advancing mater-
nal age [39].
2.2.2.1 Down Syndrome
DS is a complex clinical phenotype that results from
trisomy of part or all of chromosome 21. DS is the most
common autosomal aneuploidy occurring in humans,
with a current birth prevalence of approximately 1:700
live births [38] and higher birth frequency among
older mothers. People with DS typically have an IQ
in the mildly to moderately low range with character-
istic facial features that may include epicanthal folds,
upward slanting palpebral fissures, flattened facial pro-
file, short neck and small ears, hypotonia, hyperflex-
ibility, single transverse palmar creases, and a variety
of other benign or mild features [40]. Individuals with
DS are susceptible to duodenal atresia, Hirschsprung
disease, patent ductus arteriosus, early-onset Alzhei-
mer disease, and acute leukemia [41,42]. Their per-
pleasant albeit somewhat complex [43]. The combina-
tion of a relatively high birth prevalence, complexity
of the clinical phenotype, older maternal age at birth,
and relatively long life expectancy no doubt contribute
to the high level of interest in prenatal screening and
diagnosis.
2.2.2.2 Trisomy 18
Another autosomal aneuploidy, trisomy 18 (Edwards
syndrome), demonstrates an altered biomarker profile
compared with unaffected pregnancies and is there-
fore also detectable in multiple marker screening [44].
Edwards syndrome has a significantly higher mor-
bidity and mortality compared with DS, is subject to
higher rates of spontaneous abortion, and is far less
common [45–47]. Because of its rarity and differences
in severity and life expectancy, the public health ratio-
nale for trisomy 18 screening is considerably weaker
12 CHAPTER 2 Prenatal Screening for Neural Tube Defects and Aneuploidy
than for DS and likely would not justify screening on
its own. Inasmuch as the markers that are employed
for trisomy 21 may also be informative for trisomy
18, this screening can be included without undertak-
ing any additional testing. As with all rare conditions,
the positive predictive value (PPV) is relatively low.
Selecting the risk cutoff for screen positives to keep
specificity high serves to reduce unnecessary diagnos-
tic testing.
2.2.2.3 Other Chromosome Abnormalities
There are several other chromosome abnormalities that
occur during pregnancy. A third autosomal aneuploidy
that sometimes survives to term is trisomy 13 (Patau
syndrome) [48]. This is more severe and significantly
less prevalent than either trisomy 18 or trisomy 21 [46].
While autosomal monosomies are uniformly lethal
prenatally, several other autosomal trisomies are known
to occur, but do not survive to term except in a mosaic
state. There is a very large number of partial aneuso-
mies that each are extremely rare, with highly variable
phenotypes that occasionally are live born, as well as
lethal triploidies and tetraploidies that include whole
extra sets of chromosomes [49]. Each in this group of
chromosomal disorders shares the properties of severe
phenotypes, low probability of survival, and low birth
prevalence such that screening would not meet the basic
features of disorders for which population screening
would be merited. Finally, there are quite a number of
sex chromosome aneuploidies including Turner syn-
drome (monosomy X) [50], which has a relatively mild
phenotype but a low chance of survival to term and birth
prevalence of 1 per 10,000; Klinefelter syndrome (male
with an extra X chromosome)—a syndrome involving
infertility and some comparatively mild phenotypic fea-
tures affecting 1 per 1000 live born males [51]; trisomy
X female and disomy Y males with similar birth prev-
alence to Klinefelter that demonstrate clinical features
sufficiently unremarkable as to not be considered to
constitute a physical syndrome [52,53]; and others with
multiple extra copies of the X and/or Y chromosome
[54,55]. While there might be some value and interest
in identifying one or more of these chromosome abnor-
malities prenatally, the costs would generally be consid-
ered to outweigh the benefits under most circumstances.
These might be considered to be off-target secondary
findings discovered during clinical screening for DS,
however.
2.2.2.4 Aneuploidy and Spontaneous Fetal Loss
Pregnancies affected by aneuploidy have a greater risk of
spontaneous abortion than unaffected pregnancies. True
estimates of this rate are difficult to ascertain as a propor-
tion of affected pregnancies that are detected by prenatal
screening programs will be terminated and some may
occur so early in development that the woman does not
recognize them as a pregnancy loss. A large-scale study
showed that 43% of pregnancies with DS detected by the
first trimester chorionic villus sampling (CVS) and 23%
of pregnancies with DS detected by the second trimester
amniocenteses will end in miscarriage or stillbirth [56].
Fetal loss rates in pregnancies affected by trisomy 13 or
18 are even higher with 49% of pregnancies diagnosed
with trisomy 13 in the first trimester and 42% diagnosed
with trisomy 13 in the second trimester will end in mis-
carriage or stillbirth. 72% of pregnancies diagnosed with
trisomy 18 in the first trimester and 65% of pregnancies
diagnosed with trisomy 18 in the second trimester will
end in miscarriage or stillbirth [57]. This information
is vital for counseling women regarding prognoses for
their affected pregnancies. Accurate determination of
fetal loss influences the a priori and posterior risk esti-
mates for the autosomal trisomies and is relevant to the
patient’s decision-making from the standpoint of the
value of screening and diagnosis under the Health Belief
Model.
2.2.3 Maternal Age as a Marker for
Aneuploidy
One of the earliest and most primitive forms of screen-
ing is to consider maternal age at the expected date of
delivery as a means of estimating risk for DS and other
aneuploidies. This is a simple, cost-free approach to
identifying pregnancies that merit consideration for
diagnostic testing to identify chromosome abnormali-
ties.
The association between advanced maternal age and
an increased risk of DS was first described in the 1930s
[58]. A multitude of subsequent studies have confirmed
this association and defined its magnitude. The risk of
DS and other aneuploidies increases with maternal age,
so that a 40-year-old woman has a more than 13-fold
higher risk of having a pregnancy affected by DS than
does a 20-year-old woman [59]. Nevertheless, in terms
of raw numbers, far more autosomal trisomies occur
to younger women who are not considered to be of
advanced maternal age.
 CHAPTER 2 Prenatal Screening for Neural Tube Defects and Aneuploidy 13

The molecular basis for the association between
maternal age and aneuploidy is an increased rate of mei-
otic nondisjunction in aging oocytes [39]. Oocytes are
suspended in the dictyotene stage of prophase I from
the time they are formed during fetal development until
they are fertilized in adulthood. During this protracted
time in prophase, the chromosomes are kept aligned on
the equatorial plate by chiasmata, the sites of recombi-
nation. In most cases of maternal nondisjunction, it is
thought that aging causes deterioration of the chiasmata
and subsequent misalignment of sister chromatids. This
results in missegregation of chromosome pairs to the
daughter oocytes [39].
2.2.4 AFP as a Biomarker of Fetal
Development in Maternal Circulation
2.2.4.1 AFP in Unaffected Pregnancies
AFP is a protein produced almost exclusively by the
fetus, and it is therefore mostly contained in the fetal cir-
culation. During the optimal gestational period for NTD
screening (16–18 weeks of gestation), AFP is also pres-
ent in amniotic fluid, but at approximately a 1000-fold
lower concentration than in fetal circulation, with entry
into the amniotic fluid primarily through the kidneys.
With rare exception, AFP is not produced in the healthy
adult [60], so the vast majority of AFP in maternal cir-
culation is fetal in origin, passing through the fetal kid-
neys into the amniotic fluid, and then through the fetal
membranes into maternal circulation [61]. Maternal
serum AFP (msAFP) appears at dramatically lower con-
centrations than amniotic fluid AFP (afAFP), demon-
strating approximately an additional 1000-fold gradient
comparing maternal circulation to amniotic fluid (Fig.
2.1). Thus, there is nearly a one-million-fold difference
between the fetal serum and maternal serum during
the second trimester. Throughout pregnancy, median
msAFP levels change predictably in unaffected pregnan-
cies according to gestational age [62,63].
Because of the gestational age dependence of AFP
in amniotic fluid and maternal serum, AFP levels are
normalized by first establishing median levels of AFP
for each week of gestation measured in International
Units (IU) per mL for amniotic fluid or mIU per mL
for msAFP. Alternatively, labs may express concentra-
tions in micrograms or nanograms per mL (afAFP and
msAFP, respectively). The patient-specific values are
then calculated as multiple of the median (MoM) by
dividing the patient’s measured AFP concentration by

Figure 2.1 Mean concentrations of alpha-fetoprotein (AFP) in maternal serum, amniotic fluid, and fetal serum
at various stages of pregnancy. (From Haddow, JE. prenatal screening for open neural tube defects, Down’s
syndrome, and other major fetal disorders. Semin. Perinatol. 1990;14:488–503, with permission.)
14 CHAPTER 2 Prenatal Screening for Neural Tube Defects and Aneuploidy
Figure 2.2 Distribution of maternal serum alpha-fetoprotein (AFP) (in MoM) in anencephalic, open spina
bifida, and unaffected pregnancies.
the appropriate median value. The distribution of val-
ues across all unaffected pregnancies is centered at 1.00
MoM, approximating a log-Gaussian distribution [64].
2.2.4.2 AFP in Pregnancies Affected with Neural
Tube Defects
The basis of msAFP as a screening test for ONTD is that
AFP in the amniotic fluid attains higher concentrations
when the fetus has an open defect because the protein
can pass directly into the amniotic fluid without having
to clear through the kidneys. This results in dramati-
cally higher levels in maternal circulation in pregnan-
cies affected with ONTDs. Maternal serum AFP values,
expressed in MoMs on a log10 scale approximate a Gauss-
ian distribution for the unaffected, open spina bifida and
anencephaly populations (Fig. 2.2). Because these values
are normally distributed, each distribution can be fully
described by the mean and variance or standard devia-
tion. A screening cutoff of 2.0–2.5 MoM is typically used
to discriminate pregnancies that are screen positive for
ONTD and which merit diagnostic testing or further
evaluation. Direct testing of afAFP levels requires an
invasive procedure (amniocentesis) and provides a diag-
nostic test for ONTDs when paired with acetylcholines-
terase (AChE) to eliminate rare false positives [65].
2.2.4.3 AFP in Pregnancies Affected with Down
Syndrome
The availability of population data on AFP levels during
pregnancy led to the discovery that msAFP values are
statistically lower when the fetus has DS/trisomy 21 [66].
Prior to the discovery of AFP as a potential biomarker
for DS, maternal age served as the only prenatal popula-
tion screening test. As a test for DS, maternal age is com-
bined with msAFP to identify pregnancies that merit
diagnostic testing or other follow-up [67]. Although the
sensitivity and specificity of msAFP plus maternal age
as a screening test is relatively poor, its adoption as a
screening test represented a major advancement for pre-
natal screening in that women of any age could benefit
from testing. While it is well known that the frequency
of DS is indeed positively correlated with increased
maternal age, it has been less well appreciated that most
DS is not identified when age alone is used as the pri-
mary screening test. Further study of other potential
biomarkers during pregnancy led to the discovery of
more than a dozen potential markers for DS and a wide
range of other birth defects, the details of which are pro-
vided below. AFP remains the only marker in clinical
use to screen for ONTD to date, however.
2.2.5 Prenatal Screening—Primary Focus on
NTD and Down Syndrome
Placing the many prenatal screening options into per-
spective requires one to step back and take stock of the
evolution of screening. Initially, screening was cen-
tered on AFP for NTD identification with calculation
of patient-specific risks for DS as a secondary benefit.
While AFP is a relatively poor prenatal marker for DS,
it was in essence free information obtained during NTD
Another random document with
no related content on Scribd:
abençerrajes, por donde les
leuantaron que ellos con otros
diez caualleros de su linaje se
auian conjurado de matar al Rey y
diuidir el reyno entre si, por
uengarse de la injuria alli reçibida.
Esta conjuraçion, ora fuesse
uerdadera, o que ya fuesse falsa,
fue descubierta antes que se
pusiesse en execuçion, y fueron
presos y cortadas las cabeças a
todos, antes que uiniesse a
notiçia del pueblo, el qual sin
duda se alçara, no consintiendo
en esta justiçia. Lleuandolos pues
a iustiçiar, era cosa estrañissima
uer los llantos de los unos, las
endechas de los otros, que de
conpassion de estos caualleros
por toda la çiudad se hazian.
Todos corrian al Rey,
comprauanle la misericordia con
grandes summas de oro y plata,
mas la seueridad fue tanta, que
no dio lugar a la clemençia. Y
como esto el pueblo uio, los
començo a llorar de nueuo;
llorauan los caualleros con quien
solian acompañarse, llorauan las
damas, a quien seruian; lloraua
toda la çiudad la honra y
autoridad que tales çiudadadanos
le dauan. Las bozes y alaridos
eran tantos que paresçian
hundirse. El Rey que a todas
estas lagrimas y sentimiento
çerraua los oydos, mandó que se
executasse la sentençia, y de
todo aquel linaje no quedó
hombre que no fuesse degollado
aquel dia, saluo mi padre y un tio
mio, los quales se halló que no
auian sido en esta conjuraçion.
Resultó más deste miserable
caso, derriballes las casas,
apregonallos el Rey por
traydores, confiscalles sus
heredades y tierras, y que ningun
abençerraje más pudiesse biuir
en Granada, saluo mi padre y mi
tio, con condiçion que si tuuiessen
hijos, a los uarones embiassen
luego en nasçiendo a criar fuera
de la çiudad, para que nunca
boluiessen a ella; y que si fuessen
henbras, que siendo de edad, las
casassen fuera del reyno.
Quando el Alcayde oyo el estraño
cuento de Abindarraez y las
palabras con que se quexaua de
su desdicha, no pudo tener sus
lagrimas, que con ellas no
mostrasse el sentimiento que de
tan desastrado caso deuia
sentirse. Y boluiendose al moro,
le dixo: Por çierto, Abindarraez, tú
tienes grandissima occasion de
sentir la gran cayda de tu linaje,
del qual yo no puedo creer que se
pusiesseen hazer tan grande
trayçion, y quando otra prueua no
tuuiesse, sino proçeder della un
honbre tan señalado como tú,
bastaria para yo creer que no
podria caber en ellos maldad.
Esta opinion que tienes de mí,
respondio el moro, Alá te la
pague, y él es testigo que la que
generalmente se tiene de la
bondad de mis passados, es essa
misma. Pues como yo nasçiesse
al mundo con la misma uentura
de los mios, me embiaron (por no
quebrar el edicto del Rey) a criar
a una fortaleza que fue de
christianos, llamada Cartama,
encomendandome al Alcayde
della, con quien mi padre tenía
antigua amistad, hombre de gran
calidad en el reyno, y de
grandissima uerdad y riqueza: y la
mayor que tenia era una hija, la
qual es el mayor bien que yo en
esta uida tengo. Y Alá me la quite
si yo en algun tiempo tuuiere sin
ella otra cosa que me dé
contento. Con esta me crié desde
niño, porque tambien ella lo era,
debaxo de un engaño, el qual era
pensar que eramos ambos
hermanos, porque como tales nos
tratauamos y por tales nos
teniamos, y su padre como a sus
hijos nos criaua. El amor que yo
tenia a la hermosa Xarifa (que
assi se llama esta señora que lo
es de mi libertad) no sería muy
grande si yo supiesse dezillo;
basta auerme traydo a tienpo que
mil uidas diera por gozar de su
uista solo vn momento. Yua
cresçiendo la edad, pero mucho
más cresçia el amor, y tanto que
ya paresçia de otro metal que no
de parentesco. Acuerdome que
un dia estando Xarifa en la huerta
de los jazmines conponiendo su
hermosa cabeça, mirela
espantado de su gran hermosura,
no sé cómo me peso de que
fuesse mi hermana. Y no
aguardando más, fueme a ella, y
con los braços abiertos, ansi
como me uio, me salió a reçebir, y
sentandome en la fuente iunto a
ella, me dixo: Hermano, ¿cómo
me dexaste tanto tienpo sola? Yo
le respondia: Señora mia, gran
rato ha que os busco: y nunca
hallé quien me dixesse do
estauades hasta que mi coraçon
me lo dixo: mas dezidme agora,
¿qué çertedad teneys uos de que
somos hermanos? Yo no otra
(dixo ella) más del grande amor
que os tengo, y uer que hermanos
nos llaman todos y que mi padre
nos trata a los dos como a hijos.
Y si no fueramos hermanos (dixe
yo) quisierades me tanto? ¿No
ueys (dixo ella) que a no lo ser, no
nos dexarian andar siempre
juntos y solos, como nos dexan?
Pues si este bien nos auian de
quitar (dixe yo) más uale el que
me tengo. Entonces encendiosele
el hermoso rostro, y me dixo:
¿Qué pierdes tu en que seamos
hermanos? Pierdo a mi y a uos
(dixe yo). No te entiendo (dixo
ella), mas a mí paresçeme que
ser hermanos nos obliga a
amarnos naturalmente. A mí (dixe
yo) sola uuestra hermosura me
obliga á quereros, que esta
hermandad antes me resfria
algunas uezes; y con esto
abaxando mis ojos de empacho
de lo que dixe, uila en las aguas
de la fuente tan al proprio como
ella era, de suerte que a do quiera
que boluia la cabeça, hallaua su
ymagen y trasunto, y la uia
uerdadera transladada en mis
entrañas. Dezia yo entonçes entre
mí: Si me ahogassen aora en esta
fuente a do ueo a mi señora,
quánto más desculpado moriria
yo que Narciso; y si ella me
amasse como yo la amo, qué
dichoso sería yo. Y si la fortuna
permitiesse biuir siempre juntos,
qué sabrosa uida sería la mia!
Estas palabras dezia yo a mi
mesmo, y pesárame que otro me
las oyera. Y diziendo esto
lebanteme, y boluiendo las manos
hazia vnos jazmines, de que
aquella fuente estaua rodeada,
mezclandolos con arrayanes hize
vna hermosa guirnalda, y
poniendomela sobre mi cabeça,
me bolui coronado y vençido;
entonçes ella puso los ojos en mí
más dulçemente al pareçer, y
quitandome la guirnalda la puso
sobre su cabeça, pareçiendo en
aquel punto más hermosa que
Venus, y boluiendo el rostro hazia
mí, me dixo: ¿Qué te pareçe de
mí, Abindarraez? Yo la dixe:
Pareçeme que acabays de vençer
a todo el mundo, y que os
coronan por reyna y señora dél.
Leuantandose me tomó de la
mano, diciendome: Si esso fuera,
hermano, no perdierades uos
nada. Yo sin la responder la segui
hasta que salimos de la huerta.
De ahi algunos dias, ya que al
crudo amor le pareçio que
tardaua mucho en acabar de
darme el desengaño de lo que
pensaua que auia de ser de mí, y
el tiempo queriendo descubrir la
çelada, venimos a saber que el
parentesco entre nosotros era
ninguno, y asi quedó la afiçion en
su verdadero punto. Todo mi
contentamiento estaua en ella: mi
alma tan cortada a medida de la
suya, que todo lo que en su rostro
no auia, me pareçia feo,
escusado y sin prouecho en el
mundo. Ya a este tiempo,
nuestros pasatiempos eran muy
diferentes de los pasados: ya la
mirava con reçelo de ser sentido:
ya tenia zelo del sol que la
tocaba, y aun mirandome con el
mismo contento que hasta alli me
auia mirado, a mí no me lo
pareçia, porque la desconfianza
propia es la cosa más çierta en vn
coraçon enamorado. Suçedio que
estando ella vn dia junto a la clara
fuente de los jazmines, yo llegué,
y comenzando a hablar con ella
no me pareçio que su habla y
contenencia se conformaua con lo
pasado. Rogome que cantasse,
porque era vna cosa que ella
muchas vezes holgaua de oyr: y
estaua yo aquella ora tan
desconfiado de mí que no creí
que me mandaua cantar porque
holgase de oyrme, sino por
entretenerme en aquello, de
manera que me faltase tiempo
para deçille mi mal. Yo que no
estudiaua en otra cosa, sino en
hazer lo que mi señora Xarifa
mandaua, comenze en lengua
arabiga a cantar esta cançion, en
la qual la di a entender toda la
crueldad que della sospechaua:

Si hebras de oro son

vuestros cabellos,
a cuia sombra estan los claros
ojos,
dos soles cuyo çielo es
vuestra frente;
faltó rubí para hazer la boca,
faltó el christal para el
hermoso cuello,
faltó diamante para el blanco
pecho.
Bien es el coraçon qual es
el pecho,
pues flecha de metal de los
cabellos,
iamas os haze que boluays el
cuello,
ni que deis contento con los
ojos:
pues esperad vn sí de aquella
boca
de quien miró jamas con leda
frente.
¿Hay más hermosa y
desabrida frente
para tan duro y tan hermoso
pecho?
¿Hay tan diuina y tan airada
boca?
¿tan ricos y auarientos ay
cabellos?
¿quién vio crueles tan serenos
ojos
y tan sin mouimiento el dulce
cuello?
El crudo amor me tiene el
lazo al cuello,
mudada y sin color la triste
frente,
muy cerca de cerrarse estan
mis ojos:
el coraçon se mueue acá en el
pecho,
medroso y erizado está el
cabello,
y nunca oyó palabra desa
boca.
O más hermosa y más
perfecta boca
 que yo sabré dezir: o liso
cuello,
o rayos de aquel sol que no
cabellos,
o christalina cara, o bella
frente,
o blanco ygual y diamantino
pecho,
¿quando he de uer clemencia
en esos ojos?
Ya siento el nó en el boluer
los ojos,
oid si afirma pues la dulce
boca,
mirad si está en su ser el duro
pecho,
y cómo acá y allá menea el
cuello,
sentid el ceño en la hermosa
frente;
pues ¿qué podre esperar de
los cabellos?
Si saben dezir no el cuello y
pecho,
si niega ya la frente y los
cabellos,
¿los ojos qué haran y hermosa
boca?

Pudieron tanto estas palabras que

siendo ayudadas del amor de
aquella a quien se dezian, yo ui
derramar vnas lagrimas que me
enternecieron el alma, de manera
que no sabre dezir si fue maior el
contento de uer tan uerdadero
testimonio del amor de mi señora
o la pena que reçibi de la ocasion
de derramallas. Y llamandome me
hizo sentar junto a si, y me
comenzo a hablar desta manera:
Abindarraez, si el amor a que
estoy obligada (despues que me
satisfize de tu pensamiento) es
pequeño o de manera que no
pueda acauarse con la uida, yo
espero que antes que dejemos
solo el lugar donde estamos, mis
palabras te lo den a entender. No
te quiero poner culpa de lo que
las desconfianzas te hazen sentir,
porque sé que es tan çierta cosa
tenellas que no ay en amor cosa
que más lo sea. Mas para
remedio de esto y de la tristeza,
que yo tenía en uerme en algun
tiempo apartada de tí; de oy más
te puedes tener por tan Señor de
mi libertad, como lo serás no
queriendo rehusar el vinculo de
matrimonio, lo qual ante todas
cosas impide mi honestidad y el
grande amor que tengo. Yo que
estas palabras oi, haçiendomelas
esperar amor muy de otra
manera, fue tanta mi alegria que
sino fue hincar los hinojos en
tierra besandole sus hermosas
manos, no supe hazer otra cosa.
Debajo de esta palabra viví
algunos dias con maior
contentamiento del que yo aora
sabre dezir: quiso la ventura
envidiosa de nuestra alegre vida
quitarnos este dulce y alegre
contentamiento, y fue desta
manera: que el Rey de Granada
por mejorar en cargo al Alcayde
de Cartama, embiole a mandar
que luego dexasse la fortaleza, y
se fuesse en Coyn, que es aquel
lugar frontero del uuestro, y me
dexasse a mí en Cartama en
poder del Alcayde que alli
viniesse. Sabida esta tan
desastrada nueua por mi señora y
por mí, juzgad vos si en algun
tiempo fuesses enamorado, lo
que podriamos sentir.
Juntamonos en un lugar secreto a
llorar nuestra perdida y
apartamiento. Yo la llamaua
señora mia, mi bien solo, y otros
diuersos nombres quel amor me
mostraua. Deziale llorando:
apartandose nuestra hermosura
de mi, ¿tendreys alguna uez
memoria deste uuestro captiuo?
Aqui las lagrimas y sospiros
atajauan las palabras, y yo
esforçandome para dezir más,
dezia algunas razones turbadas,
de que no me acuerdo: porque mi
señora lleuó mi memoria tras si.
¿Pues quién podra dezir lo que mi
señora sentía deste apartamiento,
y lo que a mi hazian sentir las
lagrimas que por esta causa
derramaua? Palabras me dixo ella
entonçes que la menor dellas
bastaua para dar en qué entender
al sentimiento toda la uida. Y no
te las quiero dezir (ualeroso
Alcayde), porque si tu pecho no
ha sido tocado de amor, te
paresçerían impossibles; y si lo
ha sido, ueriades que quien las
oyesse, no podra quedar con la
uida. Baste que el fin dellas fue
dezirme que en auiendo occasion,
o por enfermedad de su padre, o
ausençia, ella me embiaria a
llamar para que vuiesse effecto lo
que entre nos dos fue conçertado.
Con esta promessa mi coraçon se
assossego algo, y besé las
manos por la merçed que me
prometia. Ellos se partieron luego
otro dia, yo me quedé como quien
camina por vnas asperas y
fragosas montañas, y
passandosele el sol, queda en
muy escuras tinieblas: començe a
sentir su ausençia asperamente,
buscando todos los falsos
remedios contra ella. Miraua las
uentanas donde se solia poner, la
camara en que dormia, el jardin
donde reposaua y tenía la siesta,
las aguas donde se bañaua,
andaua todas sus estancias, y en
todas ellas hallaua vna cierta
representaçion de mis fatigas.
Verdad es que la esperança que
ma dio de llamarme me sostenia,
y con ella engañaua parte de mis
trabajos. Y aunque algunas uezes
de uer tanto dilatar mi desseo, me
causaua más pena, y holgara de
que me dexaran del todo
desesperado, porque la
desesperacion fatiga hasta que se
tiene por cierta, mas la esperança
hasta que se cumple, el desseo.
Quiso mi buena suerte que oy por
la mañana mi señora me cumplio
su palabra, embiandome, a
llamar, con vna criada suya, de
quien como de sí fiaua, porque su
padre era partido para Granada,
llamado del Rey, para dar buelta
luego. Yo resusçitado con esta
improuisa y dichosa nueua,
aperçibime luego para caminar. Y
dexando venir la noche por salir
más secreto y encubierto,
puseme en el habito que me
encontraste el más gallardo que
pude, por mejor mostrar a mi
señora la vfania y alegria de mi
coraçon. Por çierto no creyera yo
que bastaran dos caualleros
juntos a tenerme campo, porque
traya a mi señora comigo, y si tú
me vençiste no fue por esfuerço,
que no fue possible, sino que mi
suerte tan corta o la
determinaçion del çielo, quiso
atajarme tan supremo bien. Pues
considera agora en el fin de mis
palabras el bien que perdi y el mal
que posseo. Yo yua de Cartama a
Coyn breue jornada, aunque el
desseo la alargaua mucho, el más
vfano abencerraje que nunca se
uio, yua llamado de mi señora, a
uer a mi señora, a gozar de mi
señora. Veo me agora herido,
captiuo y en poder de aquel que
no sé lo que hará de mí: y lo que
más siento es que el término y
coyuntura de mi bien se acabó
esta noche. Dexame pues,
christiano, consolar entre mis
sospiros. Dexame desahogar mi
lastimado pecho, regando mis
ojos con lagrimas, y no juzgues
esto a flaqueza, que fuera harto
mayor tener animo para poder
suffrir (sin hazer lo que hago) en
tan desastrado y riguroso trançe.
Al alma le llegaron al ualeroso
Naruaez las palabras del moro, y
no poco espanto reçibio del
estraño sucçesso de sus amores.
Y paresçiendole que para su
negoçio, ninguna cosa podia
dañar más que la dilaçion, le dixo
a Abindarraez: quiero que ueas
que puede más mi uirtud que tu
mala fortuna, y si me prometes de
boluer a mi prision dentro del
terçero dia, yo te dare libertad
para que sigas tu començado
camino, porque me pesaria
atajarte tan buena empresa. El
abençerraje que aquesto oyó
quiso echarse a sus pies, y dixole:
Alcayde de Alora, si vos hazeys
esso, a mi dareys la vida, y uos
aureys hecho la mayor gentileza
de coraçon que nunca nadie hizo:
de mí tomad la seguridad que
quisieredes por lo que me pedis,
que yo cumplire con uos lo que
assentare. Entonces Rodrigo de
Naruaez llamó a sus compañeros,
y dixoles: Señores, fiad de mí
este prisionero, que yo salgo por
fiador de su rescate. Ellos dixeron
que ordenasse a su noluntad de
todo, que de lo que él hiziesse
serian muy contentos. Luego el
Alcayde tomando la mano
derecha a Abençerraje, le dixo:
Vos prometeys como cauallero de
uenir a mi castillo de Alora, a ser
mi prisionero dentro del terçero
dia? El le dixo: sí prometo: pues
yd con la buena uentura; y si para
nuestro camino teneys
neçessidad de mi persona, o de
otra cosa alguna, tambien se
hará. El moro se lo agradesçio
mucho, y tomó vn cauallo quel
Alcayde le dió, porque el suyo
quedó de la refriega passada
herido, y ya yua muy cansado y
fatigado de la mucha sangre que
con el trabajo del camino le salia.
Y buelta la rienda se fue camino
de Coyn a mucha priessa.
Rodrigo de Naruaez y sus
compañeros se boluieron a Alora,
hablando en la valentia y buenas
maneras del abençerraje. No
tardó mucho el moro, segun la
priessa que lleuaua, en llegar a la
fortaleza de Coyn, donde yendose
derecho como le era mandado, la
rodeó toda, hasta que halló una
puerta falsa que en ella auia: y
con toda su priessa y gana de
entrar por ella, se detuuo un poco
alli hasta reconosçer todo el
campo por uer si auia de qué
guardarse: y ya que uio todo
sossegado tocó con el cuento de
la lança a la puerta, porque
aquella era la señal que le auia
dado la dueña que le fue a llamar;
luego ella misma le abrio, y le
dixo: Señor mio, uuestra tardança
nos ha puesto en gran sobresalto,
mi señora ha gran rato que os
espera, apeaos y subid a donde
ella está. El se apeó de su
cauallo, y le puso en un lugar
secreto que allí halló, y arrimando
la lança a una pared con su
adarga y çimitarra, lleuandole la
dueña por la mano, lo mas passo
que pudieron, por no ser
conosçidos de la gente del
castillo, se subieron por una
escalera hasta el aposento de la
hermosa Xarifa. Ella que auia
sentido ya su uenida, con la
mayor alegria del mundo lo salió a
reçebir, y ambos con mucho
regozijo y sobresalto se
abraçaron sin hablarse palabra
del sobrado contentamiento,
hasta que ya tornaron en si. Y ella
le dixo: ¿En qué os aueys
detenido, señor mio, tanto que
uuestra mucha tardança me ha
puesto en grande fatiga y
confusion? Señora mia (dixo él)
uos sabeys bien que por mi
negligencia no aurá sido, mas no
siempre sucçeden las cosas
como hombre dessea, assi que si
me he tardado, bien podeys creer
que no ha sido más en mi mano.
Ella atajandole su platica, le tomó
por la mano, y metiendole en un
rico aposento se sentaron sobre
una cama que en él auia, y le
dixo: He querido, Abindarraez,
que ueays en qué manera
cumplen las captiuas de amor sus
palabras, porque desde el dia que
uos la di por prenda de mi
coraçon, he buscado aparejos
para quitarosla. Yo os mandé
uenir a este castillo para que
seays mi prisionero como yo lo
soy uuestra. He os traydo aqui
para hazeros señor de mi y de la
hazienda de mi padre, debaxo de
nombre de esposo, que de otra
manera ni mi estado, ni uuestra
lealtad lo consentiria. Bien sé yo
que esto será contra la uoluntad
de mi padre, que como no tiene
conosçimiento de uuestro ualor
tanto como yo, quisiera darme
marido más rico, más yo uuestra
persona y el conosçimiento que
tendreys con ella tengo por la
mayor riqueza del mundo. Y
diziendo esto baxó la cabeça,
mostrando vn çierto y nueuo
empacho de auerse descubierto y
declarado tanto. El moro la tomó
en sus braços, y besandole
muchas uezes las manos, por la
merçed que le hazia, dixole:
Señora de mi alma, en pago de
tanto bien como me offreçeys no
tengo qué daros de nueuo,
porque todo soy uuestro, solo os
doy esta prenda en señal, que os
reçibo por mi señora y esposa: y
con esto podeys perder el
empacho y verguença que
cobrastes quando uos me
reçebistes a mi. Ella hizo lo
mismo, y con esto se acostaron
en su cama, donde con la nueua
experiençia ençendieron el fuego
de sus coraçones. En aquella
empresa passaron muy amorosas
palabras y obras que son más
para contemplaçion que no para
escriptura. Al moro estando en
tan gran alegria, subitamente vino
vn muy profundo pensamiento, y
dexando lleuarse del, parose muy
triste, tanto que la hermosa Xarifa
lo sentio, y de uer tan subita
nouedad, quedó muy turbada. Y
estando attenta, sintiole dar vn
muy profundo y aquexado
sospiro, reboluiendo el cuerpo a
todas partes. No podiendo la
dama suffrir tan grande offensa de
su hermosura y lealtad,
paresçiendo que en aquello se
offendia grandemente,
leuantandose un poco sobre la
cama, con voz alegre y
sossegada, aunque algo turbada,
le dixo: ¿Qué es esto,
Abindarraez? paresçe que te has
entristeçido con mi alegria, y yo te
oy sospirar, y dar solloços
reboluiendo el coraçon y cuerpo a
muchas partes. Pues si yo soy
todo tu bien y contentamiento,
cómo no me has dicho por quién
sospiras, y si no lo soy, porqué
me engañaste? si as hallado en
mi persona alguna falta de menor
gusto que imaginauas, pon los
ojos en mi uoluntad que basta
encubrir muchas. Si sirues otra
dama dime quien es para que yo
la sirua, y si tienes otra fatiga de
que yo no soy offendida, dimela,
que yo morire o te sacaré della. Y
trauando dél con un impetu y
fuerça de amor le boluio. El
entonces confuso y auergonçado
de lo que auia hecho,
paresçiendole que no declararse
sería darle occasion de gran
sospecha, con un apassionado
sospiro le dixo: Esperança mía, si
yo no os quisiera más que a mí,
no uniera hecho semejante
sentimiento, porque el pensar,
que comigo traya, suffriera con
buen animo, quando yua por mi
solo, más aora que me obliga a
apartarme de uos, no tengo
fuerças para sufrillo, y porque no
esteys más suspensa sin auer
porqué, quiero deziros lo que
passa. Y luego le conto todo su
hecho, sin que la faltasse nada, y
en fin de sus razones le dixo con
hartas lagrimas: De suerte,
señora, que uuestro captiuo lo es
tambien del Alcayde de Alora; yo
no siento la pena de la prision,
que uos enseñastes a mi coraçon
a suffrir, mas biuir sin uos tendria
por la misma muerte. Y ansi
uereys que mis sospiros se
causan más de sobra de lealtad,
que de falta della. Y con esto, se
tornó a poner tan pensatiuo y
triste, como ante que començasse
a dezirlo. Ella entonçes con un
semblante alegre le dixo: No os
congoxeys, Abindarraez, que yo
tomo a mi cargo el remedio de
vuestra fatiga porque esto a mí
me toca, quanto mas que pues es
uerdad que qualquier prisionero
que aya dado la palabra de boluer
a la prision cumplira con embiar el
rescate que se le puede pedir,
ponelde uos mismo el nombre
que quisieredes, que yo tengo las
llaues de todos los cofres y
riquezas que mi padre tiene, y yo
las pondre todas en uuestro
poder, embiad de todo ello lo que
os paresçiere. Rodrigo de
Naruaez es buen cavallero y os
dió vna vez libertad, y le fiastes el