You are on page 1of 3

New ACOG guidelines: Invasive prenatal testing should be offered to all pregnant women

December 15th, 2007

From Obstetrics & Gynecology, Volume 110, No. 6, December 2007, page 1459 (ACOG membership or $20 payment required for articles.) Heralding a change in standard obstetric practice, the American College of Obstetricians and Gynecologists has recommended that pregnant women of all ages not just women aged 35 and over should be offered invasive prenatal diagnostic testing such as amniocentesis and chorionic villus sampling to detect possible genetic abnormalities in their fetuses. The recommendation, published in a practice bulletin in the December issue of the organizations journal Obstetrics & Gynecology, dramatically expands womens access to prenatal diagnosis, effectively making all prenatal tests and screens available to all of the 6 million American women who get pregnant each year. It will establish a new standard of care, and change expectations for insurance coverage and legal liability involving pregnancy. Until now, obstetricians have usually offered invasive testing just to women at or above age 35 at delivery. The age threshold was chosen because at that age the risk of miscarriage as a result of the testing was roughly equal to the risk of having a child with Down syndrome, the most common genetic abnormality occurring in live births. In addition, the medical community balanced the cost of offering the testing against their calculation of the cost savings associated with preventing the birth of an infant with Down syndrome. This past January, ACOG expanded the scope of prenatal testing by recommending for the first time that all pregnant women regardless of age be offered prenatal screening, a process in which a womans blood is used to calculate the risk that her fetus has an abnormality. The December ACOG bulletin will open prenatal testing access wider still. The current bulletin does not explain why the professional organization has now dramatically expanded access to prenatal testing twice within a year. Researchers have maintained that universal access to prenatal testing will allow women to make their own informed decisions regarding their pregnancies and minimize disparities in access to health care. The changes come at a time when growing numbers of medical malpractice lawsuits are pushing insurance costs for obstetricians and gynecologists to record highs, resulting in a situation that ACOG has called a medical liability crisis. In a statement posted on the groups website last year, ACOG executive vice president Ralph W. Hale said the rising tide of lawsuits was caused not by a high rate of medical wrongdoing but by unreasonable public expectations. Ob-gyns are vulnerable because they practice in a high-risk field, and all too often, doctors are held liable for less than perfect outcomes, he said.

ACOGs current recommendation seems to thrust the 49,000-member professional organization deeper into the cultural debate over public attitudes toward abortion, particularly about where to draw the line between preventing disability and accepting human diversity. The National Down Syndrome Congress (NDSC) last January condemned ACOGs recommendation for universally offered prenatal screening, saying it conveyed tacit approval for terminating pregnancies where the fetus has Down syndrome. Studies say that approximately 9 out of 10 pregnancies in the U.S. in which Down syndrome is diagnosed end in abortion. The NDSC also cited research noting that many doctors are not adequately prepared to deliver a diagnosis of Down syndrome, and often use negative language and out-of-date information. Down syndrome, which results when a person has three copies of the 21st chromosome instead of the usual pair, is longest known and most common genetic birth defect, as well as the most common cause of intellectual disability. Approximately 250,000-350,000 Americans have Down syndrome, which occurs once in every 733 to 1,000 births, according to the NDSC and the National Down Syndrome Society. Advocacy groups and parents say gains in health care and education have brought about markedly improved outcomes for these individuals over the past two decades, with many people with Down syndrome now completing high school, holding jobs and living semi-independently. But parents say these gains have not been adequately documented and are poorly understood within the obstetrics community. In an apparent nod to the NDSCs criticism, ACOG included in its December practice bulletin for the first time the recommendation that prospective parents who receive a diagnosis of a fetal disorder should be provided with detailed information, if known, about the natural history of individuals with the disorder. ACOG also noted that it may be very helpful to refer prospective parents to advocacy groups such as the NDSC or the NDSS. The bulletin does not, however, offer any recommendations for collecting or distributing information to doctors about the lives of people with Down syndrome or other chromosomal abnormalities, nor for training its 49,000 members in delivering and interpreting prenatal test information. A study published in ACOGs journal last year found that 45 percent of obstetricians rated their training about prenatal testing as barely adequate or nonexistent. As a result of the new ACOG bulletin, each pregnant woman will now need to decide which is greater: her fear of a chromosomal abnormality, or her fear that invasive testing could harm her fetus. The ACOG bulletin estimates that the risk of miscarriage as a result of the invasive tests is as low as one in 300-500, and may be even lower with experienced individuals or centers. Other estimates say that approximately one in every 200 women who undergoes invasive testing will miscarry her pregnancy. The risk of a fetus with a chromosomal abnormality varies with the mothers age. According to ACOG data, the lowest recorded risk goes to 19-year-olds, with a risk of 1 in 555, and the highest goes to a 49-year-old, with a risk of 1 in 6. The financial impact of the new ACOG bulletin is not known, but could extend above the billion-dollar mark. Amniocentesis and chorionic villus sampling (CVS), the invasive tests, are both more expensive and more accurate than the maternal blood test screens. The consumer cost of each

amniocentesis is more than $1,000. Chorionic villus sampling costs between $600 and $1200. More invasive tests would also call for an increase in costs for training, facilities and equipment. Amniocentesis and CVS each involve removing and examining material from inside the uterus during pregnancy with a long needle or plastic tube to check for chromosomal differences. The maternal blood-test screens do not deliver definitive results but only report the odds that a particular fetus may have an abnormality. They also carry a significant risk of both false positives and false negatives. In a tacit acknowledgment of the ongoing abortion debate, the bulletin notes that Prenatal diagnosis is not performed solely for assistance in the decision of pregnancy termination. It can provide useful information for the physician and the patient. The practice bulletin listed the recommendation for offering invasive diagnostic testing to all pregnant women as a Level C recommendation, one that is based primarily on consensus and expert opinion. This is the lowest rank used in justifying ACOG recommendations. Higher rankings that may be used for ACOG recommendations are Level A (based on good and consistent scientific evidence) and Level B (based on limited or inconsistent scientific evidence.)