To investigate pregnant women’s level of future interest in noninvasive prenatal diagnosis (NIPD) and what factors might affect expected uptake of this testing.
Written questionnaires were administered to women in their third trimester.
One hundred fourteen women returned the questionnaire (80.9% response rate). Of these, 71.9% reported interest in NIPD, 22.7% were ambivalent and 5.4% were uninterested. Safety of the fetus was the single most important factor in 75% of women’s decisions. Factors associated with increased interest in NIPD included: older age (p=0.036), higher education (p=0.013), Caucasian or Asian ethnicity (p=0.011), and higher likelihood to terminate an affected pregnancy (p=0.002). Nearly 20% of women reported that they would do whatever their doctor recommended regarding NIPD, and 94.4% of women wished to meet with a genetic counselor at some point to discuss NIPD.
The majority of pregnant women report hypothetical interest in NIPD, primarily due to increased safety for the fetus, although a significant minority are uninterested or ambivalent. Discussions with healthcare providers regarding NIPD, and their recommendations, are likely to be an important factor in women’s decisions about this testing. As such, adequate discussion of the implications of prenatal diagnostic testing will be critical.
prenatal testing; noninvasive prenatal diagnosis; prenatal screening; chromosome abnormalities; patient decision-making
To provide a preliminary assessment of obstetric healthcare provider opinions surrounding implementation of cell-free fetal DNA testing.
A 37-question pilot survey was used to address questions around the translation and use of non-invasive prenatal testing using cell-free fetal DNA. The survey was distributed and collected at a Continuing Medical Education course on obstetrics and gynecology.
Of 62 survey respondents, 73% are female and 87% hold MD/DO degrees. Respondents generally agree that patients want prenatal diagnostic information to help make decisions about a pregnancy and that cell-free fetal DNA testing will encourage the testing of more patients for more conditions. However, there is an overall lack of knowledge or conviction about using this technology. Genetic counseling and professional society approval are deemed important to implementation whereas the possibility of direct-to-consumer testing and government regulation produce mixed responses. Respondents indicate that they are more likely to offer cell-free fetal DNA testing for chromosomal abnormalities and single-gene disorders, but are cautious with respect to determination of sex and behavioral or late-onset conditions.
Preliminary assessment indicates uncertainty among obstetric providers about the details of implementing cell-free fetal DNA testing and suggests expanded research on perspectives of this stakeholder group.
Psychosocial; legal, and ethical implications; cell-free fetal DNA; cell-free fetal RNA; non-invasive prenatal diagnosis; healthcare provider perspectives; clinical translation
To identify the frequency of pregnancy and neonatal complications in pregnancies carrying fetuses affected with trichothiodystrophy (TTD).
We identified pregnancy and neonatal complications and serum screening results from mothers of TTD patients in a DNA repair diseases study from 2001 to 2011.
Pregnancy reports of 27 TTD patients and their 23 mothers were evaluated and81% of the pregnancies had complications: 56% had preterm delivery, 30% had preeclampsia, 19% had placental abnormalities, 11% had HELLP syndrome, 4% had an emergency c-section for fetal distress; while44% had two or more complications. Only19% of the pregnancies delivered at term without complications. Eight of the 10 pregnancies tested had abnormal multiple marker results including elevated levels of human chorionic gonadotropin. Eighty-five percent of the neonates had complications: 70 % were low birth weight (<2500g), 35% had birth weight <10 centile for gestational age, 70% had NICU admission, 67% had a collodion membrane, and 31% of the 16 males had cryptorchidism. Cataracts were present in 54% of the TTD patients examined.
TTD is a multisystem disease that predisposes mothers of affected patients to substantial risks for pregnancy complications and TTD neonates have a high incidence of multiple abnormalities.
Trichothiodystrophy; Pregnancy; Maternal Serum Screening; hCG; Preeclampsia; HELLP syndrome
Accumulating evidence suggests that genomic structural variations, particularly copy number variations (CNV), are a common occurrence in humans that may bear phenotypic consequences for living individuals possessing the variant. While precise estimates vary, large-scale karyotypic abnormalities are present in 6–12% of stillbirths (SB). However, due to inherent limitations of conventional cytogenetics, the contribution of genomic aberrations to stillbirth is likely underrepresented. High-resolution copy number variant (CNV) analysis by genomic array-based profiling may overcome such limitations.
Prospectively acquired SB cases >22 weeks underwent classification of "unexplained" stillbirth by Wigglesworth and Aberdeen criteria after extensive testing and rigorous multidisciplinary audit. Genome-wide analysis was conducted using high resolution Illumina SNP arrays (HumanCNV370 Duo) on placental and fetal samples. Potential alternate detection methods were completed by one or more of three independent means (quantitative PCR, Illumina1M or Agilent105K CGH arrays).
In our cohort of 54 stillbirths, 29 met strict unexplained criteria. Among these, we identified 24 putative novel CNVs. Subsequent interrogation detected18 of 24 CNVs (75%) in placental samples, 8 of which were also confirmed in available fetal samples; none were present in maternal blood.
We describe the potential of whole-genome placental profiling to identify small genomic imbalances which might contribute to a small proportion of well-characterized, unexplained stillbirths.
Stillbirth; copy number variants; deletion syndromes; duplication syndromes; fetal death
To determine if a simplified model for predicting pre-eclampsia can be developed by combining first trimester serum analytes, PAPP-A and free β-hCG, and maternal characteristics.
A retrospective cohort study of patients seen for first-trimester aneuploidy screening from 2003–2009. The 5th, 10th, 90th and 95th percentiles for the analyte-MoMs for our population were determined and evaluated for association with pre-eclampsia. Univariate and backward stepwise logistic regression analyses were performed and the area under the ROC curves (AUC) used to determine the best models for predicting pre-eclampsia.
Among 4,020 women meeting the inclusion criteria, outcome data was available for 3,716 (93%). There were 293 cases of pre-eclampsia. The final model identified a history of pre-gestational diabetes (aOR 2.6, 95% CI 1.7–3.9), chronic hypertension (aOR 2.6, 95% CI 1.7–3.9), maternal BMI >25 (aOR 2.5, 95% CI 1.9–3.4), African American race (aOR 1.8, 95% CI 1.3–2.6), and PAPP-A MoM <10th percentile (aOR 1.6, 95% CI 1.1–2.4) to be significant predictors of pre-eclampsia. (AUC= 0.70, 95% CI 0.65–0.72)
Low first-trimester PAPP-A levels are associated with the development of pre-eclampsia; however, the model was only modestly efficient in its predictive ability.
pre-eclampsia; PAPP-A; free β-hCG; first trimester screening
cytogenetics; array CGH; SNP arrays; DNA sequencing; structural variation; copy number variants; CNVs
Attitude of Health Personnel; Decision Making; Female; France; Humans; Interviews as Topic; Physician-Patient Relations; Placenta; Pregnancy; Pregnancy Reduction, Multifetal; psychology; Prenatal Care; Prenatal Diagnosis; Twins, Monozygotic
This study assessed decisional conflict about invasive prenatal testing among women pregnant after infertility.
We surveyed 180 pregnant women with a history of infertility using a mixed methods cross-sectional design. Difficulty in deciding whether to have prenatal testing was measured using the Decisional Conflict Scale.
A minority of women (31%) chose to have invasive prenatal testing. Most participants (72%) reported low decisional conflict (score <25; mean = 22.1; standard deviation = 23.2; range: 0–100). Half (53%) of the participants said that infertility made the testing decision easier. Qualitative data suggest that infertility makes the decision easier by clarifying relevant values and priorities. Most infertility characteristics studied were not significantly associated with decisional conflict. Variables associated with higher decisional conflict included infertility distress due to rejection of a childfree lifestyle, disagreement with others about testing, and choosing to have invasive testing after having had treatment for infertility.
For some women, infertility may make the invasive prenatal testing decision easier. Women with the greatest need for decisional support were those who have had treatment and choose invasive testing, who disagree with others about their testing choice, or who are particularly distressed about being childless.
prenatal testing; infertility; decisional conflict; decision making; genetic counseling
This study explores ambivalence toward undergoing amniocentesis among pregnant women with overall positive attitudes. Its novelty lies in the characterization of the type and origins of the ambivalence.
Thirty-six women between 35 and 44 years of age were recruited from a U.S. prenatal testing center to participate in structured telephone interviews.
Thirty women chose to undergo testing. Attitudes toward undergoing amniocentesis were generally positive, although all participants simultaneously described feeling ambivalent. The women desired the information that amniocentesis could provide yet did not want to place their fetus at risk. Participants cited religious, moral, ethical, and intellectual values important in shaping their attitudes toward undergoing amniocentesis. Important referents such as partners, other pregnant women, family members, and physicians influenced their decisions.
Tensions were evident among the intellectual, moral, and spiritual values that contribute to ambivalence toward undergoing amniocentesis. Illuminating and discussing such tensions during the genetic counseling sessions prior to testing may resolve some of this ambivalence and thereby increase the quality of decisions women make.
Informed Choice; Attitudes; Subjective Norms; Ambivalence; Amniocentesis
Cell-free fetal DNA (cffDNA) in maternal plasma results from degradation of fetal and/or placental cells. Our objective was to determine if chorionic villus sampling (CVS) causes increased release of fetal and/or maternal DNA.
Fifty-two pregnant women were recruited prior to CVS, performed for clinical indications, at 10 5/7 to 13 2/7 weeks. Maternal blood was collected before and within 15 minutes after CVS. cffDNA was extracted from plasma. Real-time polymerase chain reaction (PCR) amplification of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and the Y chromosome sequence DYS1 were used as measures of total and fetal DNA, respectively. All samples were analyzed in triplicate without knowledge of fetal gender.
Sensitivity of DYS1 detection in male fetuses was 100% (n=30); specificity in female fetuses was 100% (n=22). While a majority of women had >50% post-procedure increases in both fetal and total DNA, some showed post-procedure decreases. However, overall median proportional increases were not statistically significant. Gestational age (GA), placental location, and individual CVS operator did not correlate with changes in DNA levels.
While there were no statistically significant overall changes in DNA levels after CVS, as-yet undiscovered variables may influence the extent of post-procedure release of cell-free DNA in the circulation of pregnant women.
CVS; cell-free DNA; prenatal diagnosis
Recently, professionals in France have noticed an increase in newborns with Down syndrome being placed up for adoption. The aim of this study was to investigate DS babies given up at birth for adoption and to consider the possible determinants of this situation in order to assess social acceptance of DS. A retrospective cohort of all living DS babies was constituted from two birth-defect registries (Paris: 1981–90, Marseilles area: 1984–90). Follow-up data was collected: characteristics of baby, birth parents and maternity units, age when given up for adoption and type of foster care. Results showed that 19.4% of infants with DS (115/593) were rejected by th parents. Multiple regression analysis indicated that foreign origin of the mother, area of residence, no associated major malformation, maternal age (15–24), and birth rank (>2) variables were significantly associated with a lower placement rate. Among the 115 abandoned infants with DS, 88 came from unknown parentage (76.5%). For half of them, adoptive placement (88/115) occurred before the age of six months. Socio-cultural attitudes play a great part in these family decisions. Equally, important is the manner in which professionals propose adoption as an alternative to these DS parents. They should be encouraged to consider all options before making a decision so that the best solution can be found for the interest of all.
Adolescent; Adoption; Adult; Cohort Studies; Foster Home Care; France; Humans; Infant, Newborn; Maternal Age; Occupations; Retrospective Studies; Social Class; Down syndrome; human adoption; foster care
To report the first tertiary monosomy in a pregnancy loss to a female t(11;22) carrier.
The patient was a 34-year-old G10P1 female known to have a balanced translocation t(11;22)(q23;q11.2). She had one female livebirth (a translocation carrier) and eight miscarriages. Five female relatives known to be translocation carriers had a history of breast cancer, three of them premenopausally. The patient herself had a malignant melanoma.
During the 10th pregnancy, ultrasound showed a viable embryo at 6 weeks of gestation, but loss of embryonic heartbeat by 7.5 weeks. Culture of the products of conception at 8 weeks of gestation showed the karyotype: 46,XY,+2,der(11)t(11;22)(q23;q11.2)mat, −22/45,XY,der(11)t(11;22)(q23;q11.2)mat,−22, resulting from fertilization of the maternal 3 : 1 segregation product containing only the der(11) by a normal gamete. Subsequently, she became pregnant with a normal 46,XX fetus. FISH analysis indicated that the breakpoints on 11q and 22q in the patient were in the previously described region common to typical recurrent t(11;22). In addition, a nested-PCR-based approach showed that they were located within the same palindromic AT-rich sequence previously described.
This case demonstrates that the tertiary monosomy resulting from the 3 : 1 segregation is compatible with embryonic survival into the first trimester. It is also another example of apparent association of the constitutional translocation t(11;22) and breast cancer.
t(11;22); breast cancer; 3 : 1 segregation; tertiary monosomy
The FASTER trial compared 1st and 2nd trimester screening methods for aneuploidy. We examined relationships between maternal serum markers and common congenital anomalies in the pediatric outcome data set of 36,837 subjects.
We used nested case control studies, with cases defined by the most common anomalies in our follow-up database, and up to four controls matched by enrollment site, maternal age and race, enrollment gestational age, and infant gender. Serum markers were dichotomized to ≥ 2 or < 0.5 multiples of the median (MoM). Odds ratios and 95% confidence intervals (C.I.) were estimated.
Statistically significant (p < 0.05) associations were found between inhibin A ≥ 2 MoM and fetal multicystic dysplastic kidney (MCDK) (odds ratio (OR) =27.5, 95% C.I.: 2.8-267.7) and 2-vessel cord (OR=4.22, 95% CI:1.6-10.9), hCG of ≥ 2 MoM with MCDK (OR=19.56, 95% CI: 1.9-196.2) and hydrocele (OR=2.48, 95% CI: 1.3-4.6), and PAPPA ≥ 2.0 MoM with hydrocele (OR=1.88, 95% CI:1.1-3.3).
In this large prospective study, significant associations were found between several maternal serum markers and congenital anomalies. This suggests potential additional benefits to screening programs that are primarily designed to detect aneuploidy.
serum screening; FASTER trial; multicystic dysplastic kidney; 2-vessel cord; hydrocele
Walker-Warburg syndrome (WWS) is a genetically heterogeneous congenital muscular dystrophy caused by abnormal glycosylation of α-dystroglycan (α-DG) that is associated with brain malformations and eye anomalies. The Fukutin (FKTN) gene, which causes autosomal recessively inherited WWS is most often associated with Fukuyama congenital muscular dystrophy in Japan. We describe the clinical features of four nonconsanguinous Ashkenazi Jewish families with WWS and identify the underlying genetic basis for WWS.
We screened for mutations in POMGnT1, POMT1, POMT2, and FKTN, genes causing WWS, by dideoxy sequence analysis.
We identified an identical homozygous c.1167insA mutation in the FKTN gene on a common haplotype in all four families and identified 2/299 (0.7%) carriers for the c.1167insA mutation among normal American Ashkenazi Jewish adults.
These data suggest that the c.1167insA FKTN mutation described by us is a founder mutation that can be used to target diagnostic testing and carrier screening in the Ashkenazi Jewish population.
genetic screening; muscle-eye-brain disease
Our objective was to investigate whether serum concentrations of a novel anti-angiogenic factor, soluble endoglin (sEng), could predict placental abruption.
In a nested case control study of nulliparous pregnancies, we examined levels of sEng in serum collected prospectively from 31 women who later developed placental abruption and from 31 normal controls. All serum specimens were collected before the onset of hypertension or abruption and before labor or delivery. Serum sEng was compared within three gestational age intervals: early- (<20 weeks), mid- (21–32 weeks), and late (≥33 weeks) pregnancy.
There was no significant difference in sEng between abruption cases and controls in early pregnancy. sEng was significantly elevated among abruption cases at 21–32 weeks (10.7 versus 5.9 ng/mL, P<0.01). Subgroup analyses revealed no differences in sEng concentrations at any gestational age interval between cases with abruption without hypertension and healthy controls. Among women who developed hypertension and placental abruption, sEng was not significantly increased in early pregnancy, but was in mid-pregnancy (19.3 versus 5.5 ng/mL, P=0.002) and in late pregnancy (15.6 versus 9.5 ng/mL, P=0.04).
Serum levels of the anti-angiogenic factor sEng are elevated prior to the development of hypertension and placental abruption. These elevations are not apparent until the late second trimester (26 – 27 weeks, on average), but they persist from this time in gestation onward. sEng may be useful for identifying pregnant women at risk for abruption and hypertension.
Abruptio placentae; preeclampsia; gestational hypertension; endoglin; angiogenic factors
Larsen syndrome; atelosteogenesis; filamen B; FLNB; prenatal diagnosis; dislocation; genetic
Barth Syndrome (BTHS) is an X-linked multisystem disorder (OMIM 302060) usually diagnosed in infancy and characterized by cardiac problems [dilated cardiomyopathy (DCM) ± endocardial fibroelastosis (EFE) ± left ventricular non-compaction (LVNC)], proximal myopathy, feeding problems, growth retardation, neutropenia, organic aciduria and variable respiratory chain abnormalities. We wished to determine whether BTHS had a significant impact on fetal and perinatal health in a large cohort of family groups originating from a defined region.
Case note review on 19 families originating from the UK and known to the Barth Syndrome Service of the Bristol Royal Hospital for Children.
Details are presented on six kindreds (32%) with genetically and biochemically proven BTHS that demonstrate a wider phenotype including male fetal loss, stillbirth and severe neonatal illness or death. In these families, 9 males were stillborn and 14 died as neonates or infants but there were no losses of females. BTHS was definitively proven in five males with fetal onset of DCM ± hydrops/EFE/LVNC.
These findings stress the importance of considering BTHS in the differential diagnosis of unexplained male hydrops, DCM, EFE, LVNC or pregnancy loss, as well as in neonates with hypoglycemia, lactic acidosis and idiopathic mitochondrial disease. Copyright © 2010 John Wiley & Sons, Ltd.
Barth syndrome; fetal; hydrops; neonatal; perinatal
To demonstrate the usefulness of microarray testing in prenatal diagnosis based on our laboratory experience.
Prenatal samples received from 2004 to 2011 for a variety of indications (n = 5003) were tested using comparative genomic hybridization-based microarrays targeted to known chromosomal syndromes with later versions of the microarrays providing backbone coverage of the entire genome.
The overall detection rate of clinically significant copy number alterations (CNAs) among unbiased, nondemise cases was 5.3%. Detection rates were 6.5% and 8.2% for cases referred with abnormal ultrasounds and fetal demise, respectively. The overall rate of findings with unclear clinical significance was 4.2% but would reduce to 0.39% if only de novo CNAs were considered. In cases with known chromosomal rearrangements in the fetus or parent, 41.1% showed CNAs related to the rearrangements, whereas 1.3% showed clinically significant CNAs unrelated to the karyotype. Finally, 71% of the clinically significant CNAs found by microarray were below the resolution of conventional karyotyping of fetal chromosomes.
Microarray analysis has advantages over conventional cytogenetics, including the ability to more precisely characterize CNAs associated with abnormal karyotypes. Moreover, a significant proportion of cases studied by array will show a clinically significant CNA even with apparently normal karyotypes. © 2012 John Wiley & Sons, Ltd.
To develop a novel prenatal assay based on selective analysis of cell-free DNA in maternal blood for evaluation of fetal Trisomy 21 (T21) and Trisomy 18 (T18).
Two hundred ninety-eight pregnancies, including 39 T21 and seven T18 confirmed fetal aneuploidies, were analyzed using a novel, highly multiplexed assay, termed digital analysis of selected regions (DANSR™). Cell-free DNA from maternal blood samples was analyzed using DANSR assays for loci on chromosomes 21 and 18. Products from 96 separate patients were pooled and sequenced together. A standard Z-test of chromosomal proportions was used to distinguish aneuploid samples from average-risk pregnancy samples. DANSR aneuploidy discrimination was evaluated at various sequence depths.
At the lowest sequencing depth, corresponding to 204 000 sequencing counts per sample, average-risk cases where distinguished from T21 and T18 cases, with Z statistics for all cases exceeding 3.6. Increasing the sequencing depth to 410 000 counts per sample substantially improved separation of aneuploid and average-risk cases. A further increase to 620 000 counts per sample resulted in only marginal improvement. This depth of sequencing represents less than 5% of that required by massively parallel shotgun sequencing approaches.
Digital analysis of selected regions enables highly accurate, cost efficient, and scalable noninvasive fetal aneuploidy assessment. © 2012 John Wiley & Sons, Ltd.
DNA < fetal cells; nucleic acids and proteins; trisomy 21; trisomy 18; aneuploidy; next-generation sequencing; cell-free DNA
The aim of this study is to understand the diagnostic utility of comparative genomic hybridization (CGH)-based microarrays for pregnancies with abnormal ultrasound findings.
We performed a retrospective analysis of 2858 pregnancies with abnormal ultrasounds and normal karyotypes (when performed) tested in our laboratory using CGH microarrays targeted to known chromosomal syndromes with later versions providing backbone coverage of the entire genome. Abnormalities were stratified according to organ system involvement. Detection rates for clinically significant findings among these categories were calculated.
Clinically significant genomic alterations were identified in cases with a single ultrasound anomaly (n = 99/1773, 5.6%), anomalies in two or more organ systems (n = 77/808, 9.5%), isolated growth abnormalities (n = 2/76, 2.6%), and soft markers (n = 2/77, 2.6%). The following anomalies in isolation or with additional anomalies had particularly high detection rates: holoprosencephaly (n = 9/85, 10.6%), posterior fossa defects (n = 21/144, 14.6%), skeletal anomalies (n = 15/140, 10.7%), ventricular septal defect (n = 14/132, 10.6%), hypoplastic left heart (n = 11/68, 16.2%), and cleft lip/palate (n = 14/136, 10.3%).
Microarray analysis identified clinically significant genomic alterations in 6.5% of cases with one or more abnormal ultrasound findings; the majority were below the resolution of karyotyping. Larger data sets such as this allow for sub-stratification by specific anomalies to determine risks for genomic alterations detectable by microarray analysis. © 2012 John Wiley & Sons, Ltd.
abnormal ultrasound; microarray; Array CGH < PRENATAL CYTOGENETICS; prenatal; congenital anomalies; soft markers