11-13+6 Weeks Scan PDF

The 11–13+6 weeks scan The 11–13+6 weeks scan Kypros H. Nicolaides FMF-English cover.indd 2-3 2004-9-28 10:41:24 Th...

The 11–13+6 weeks scan The 11–13+6 weeks scan Kypros H. Nicolaides FMF-English cover.indd 2-3 2004-9-28 10:41:24 The 11–13+6 weeks scan Fetal Medicine Foundation, London 2004  Dedication to Herodotos & Despina Contents Introduction 1. First trimester diagnosis of chromosomal defects Rosalinde Snijders, Kypros Nicolaides......... 7 Diagnosis of chromosomal defects.......... 7 Screening for chromosomal defects.......... 11 Patient-specific risk for chromosomal defects...... 13 Nuchal translucency thickness........... 21 Womens’ attitudes to 1st versus 2nd trimester screening... 42 2. Sonographic features of chromosomal defects Victoria Heath, Kypros Nicolaides.......... 45 First trimester ultrasonography........... 45 Second trimester ultrasonography.......... 58 3. Increased nuchal translucency with normal karyotype Athena Souka, Constantin von Kaisenberg, Kypros Nicolaides 71 Outcome of fetuses with increased nuchal translucency.. 72 Abnormalities associated with increased nuchal translucency. 74 Pathophysiology of increased nuchal translucency..... 85 Management of pregnancies with increased nuchal translucency.................. 88 4. Multiple pregnancy Neil Sebire, Kypros Nicolaides........... 95 Prevalence and epidemiology............ 95 Determination of zygosity and chorionicity....... 97 Chorionicity and pregnancy complications....... 98 Chromosomal defects in multiple pregnancies...... 105 Introduction In 1866 Langdon Down noted that common characteristics of patients with trisomy 21 are skin deficient in elasticity, giving the appearance of being too large for the body, and flat face with a small nose. In the 1990s, it was realized that the excess skin of individuals with Down’s syndrome can be visualized by ultrasonography as increased nuchal translucency in the third month of intrauterine life. Fetal nuchal translucency thickness at the 11–13+6 weeks scan has been combined with maternal age to provide an effective method of screening for trisomy 21; for an invasive testing rate of 5%, about 75% of trisomic pregnancies can be identified. When maternal serum free ß-human chorionic gonadotropin and pregnancy-associated plasma protein-A at 11–13+6 weeks are also taken into account, the detection rate of chromosomal defects is about 85–90%. In 2001, it was found that in 60–70% of fetuses with trisomy 21 the nasal bone is not visible at the 11–13+6 weeks scan and examination of the nasal bone can increase the detection rate of screening by the first trimester scan and serum biochemistry to more than 95%. In addition to its role in the assessment of risk for trisomy 21, increased nuchal translucency thickness can also identify a high proportion of other chromosomal defects and is associated with major abnormalities of the heart and great arteries, and a wide range of genetic syndromes. Other benefits of the 11–13+6 weeks scan include confirmation that the fetus is alive, accurate dating of the pregnancy, early diagnosis of major fetal abnormalities, and the detection of multiple pregnancies. The early scan also provides reliable identification of chorionicity, which is the main determinant of outcome in multiple pregnancies. As with the introduction of any new technology into routine clinical practice, it is essential that those undertaking the 11–13+6 weeks scan are adequately trained and their results are subjected to rigorous audit. The Fetal Medicine Foundation, has introduced a process of training and certification to help to establish high standards of scanning on an international basis. The Certificate of Competence in the 11–13+6 weeks scan is awarded to those sonographers that can perform the scan to a high standard and can demonstrate a good knowledge of the diagnostic features and management of the conditions identified by this scan.  1 FIRST TRIMESTER DIAGNOSIS OF CHROMOSOMAL DEFECTS In 1866, Langdon Down reported that in individuals with trisomy 21, the condition that came to bear his name, the skin appears to be too large for the body, the nose is small and the face is flat. In the last decade it has become possible to observe these features by ultrasound examination in the third month of intrauterine life. About 75% of trisomy 21 fetuses have increased nuchal trans- lucency (NT) thickness and 60–70% have absent nasal bone (Figures 1 and 2). DIAGNOSIS OF CHROMOSOMAL DEFECTS Non-invasive diagnosis During the last 30 years, extensive research has aimed at devel- oping a non-invasive method for prenatal diagnosis based on the isolation and examination of fetal cells found in the maternal circulation. About 1 in 103–107 nucleated cells in maternal blood are fetal. The proportion of fetal cells can be enriched to about 1 in 10–100 by techniques such as magnetic cell sorting (MACS) or fluorescence activated cell sorting (FACS) after attachment of magnetically labelled or fluorescent antibodies on to specific fetal Chapter 1 First trimester diagnosis of chromosomal defects 7  Figure 1. Fetus with subcutaneous collection of fluid at the back of the neck. Image kindly provided by Dr Eva Pajkrt, University of Amsterdam. Figure 2. Ultrasound picture of a 12-week fetus with trisomy 21, demonstrating increased nuchal translucency thickness and absent nasal bone. cell surface markers. The resulting sample is unsuitable for tradi- tional cytogenetic analysis because it is still highly contaminated with maternal cells. However, with the use of chromosome- specific DNA probes and fluorescent in situ hybridization (FISH), it is possible to suspect fetal trisomy by the presence of 8 The 11–13+6 weeks scan three-signal nuclei in some of the cells of the maternal blood enriched for fetal cells. On the basis of currently available technology, examination of fetal cells from maternal peripheral blood is more likely to find an application as a method for assessment of risk, rather than the non-invasive prenatal diagnosis of chromosomal defects. The sensitivity of this method is comparable to serum screening. However, unlike serum biochemistry testing, which is relatively easy to apply for mass population screening, analysis of fetal cells from maternal blood is both labor intensive and requires highly skilled operators. The extent to which the techniques for enrich- ment of fetal cells could be improved, to achieve a higher yield of the necessary cells, as well as become automated, to allow simultaneous analysis of a large number of samples, remains to be seen. Recent interest has focused on the presence of cell-free fetal DNA in maternal plasma and the ability to quantify the concen- tration of male fetal DNA in pregnancies with male fetuses using real-time quantitative PCR. There is contradictory evidence concerning the concentration of cell-free fetal DNA in trisomy 21 pregnancies with some studies reporting that the levels are increased and in others there was no significant difference from chromosomally normal pregnancies. The extent to which cell-free fetal DNA will become another maternal serum marker in screening for trisomy 21 remains to be seen. Non-invasive diagnosis Examination of fetal cells from maternal peripheral blood is more likely to find an application as a method for assessment of risk, rather than the non-invasive prenatal diagnosis of chromosomal defects. There is contradictory evidence concerning the concentration of cell-free fetal DNA in trisomy 21 pregnancies. Chapter 1 First trimester diagnosis of chromosomal defects 9 Invasive diagnosis Amniocentesis There is only one randomized trial which compared the risks of amniocentesis to controls. In this study, 4,606 low-risk, healthy women, 25–34 years old, at 14–20 weeks of gestation, were randomly allocated to amniocentesis or ultrasound examination alone (Tabor et al 1986). The total fetal loss rate in the patients having amniocentesis was 1% higher than in the controls. The study also reported that amniocentesis was associated with an increased risk of respiratory distress syndrome and pneumonia. Amniocentesis is also possible at 10–14 weeks of gestation. However, randomized studies have demonstrated that after early amniocentesis the rate of fetal loss is about 2% higher and the incidence of talipes equinovarus is 1.6% higher than after first-trimester chorionic villus sampling or second-trimester amniocentesis. Chorionic villus sampling Randomized studies have demonstrated that the rate of fetal loss following first-trimester transabdominal chorionic villus sampling is the same as with second-trimester amniocentesis. There is controversy as to whether the rate of fetal loss after transcervical chorionic villus sampling is higher or not. It is likely that in centres with experience in ultrasound guided invasive procedures the risks of amniocentesis and chorionic villous sampling, irrespective of route, are the same. There is an association between chorionic villus sampling before 10 weeks and fetal transverse limb abnormalities, micrognathia and microglossia. It is therefore imperative that chorionic villus 10 The 11–13+6 weeks scan sampling is performed only after 11 weeks by appropriately trained operators. Invasive testing Diagnosis of fetal chromosomal defects requires invasive testing. The risk of miscarriage from chorionic villus sampling in the first trimester is the same as for amniocentesis in the second trimester. Amniocentesis should not be performed before 15 weeks. Chorionic villous sampling should not be performed before 11 weeks. Invasive tests should be carried out by appropriately trained and experienced operators. SCREENING FOR CHROMOSOMAL DEFECTS In prenatal screening for trisomy 21, the term screen positive rate is used interchangeably with the invasive testing rate, because most women with a positive screening test undergo an invasive test, and with false positive rate (FPR) because the vast majority of fetuses in this group are normal. The first method of screening for trisomy 21, introduced in the early 1970s, was based on the association with advanced maternal age. It was apparent that amniocentesis carried a risk of mis- carriage and this in conjunction with the financial cost impli- cations, meant that prenatal diagnosis could not be offered to the entire pregnant population. Consequently, amniocentesis was initially offered only to women with a minimum age of 40 years. Gradually, as the application of amniocentesis became more widespread and it appeared to be ‘safe’, the ‘high-risk’ group was redefined to include women with a minimum age of 35 years; this ‘high-risk’ group constituted 5% of the pregnant population. Chapter 1 First trimester diagnosis of chromosomal defects 11 In the last 30 years, two dogmatic policies have emerged in terms of screening. The first, mainly observed in countries with private healthcare systems, adhered to the dogma of the 35 years of age or equivalent risk; since the maternal age of pregnant women has increased in most developed countries, the screen-positive group now constitute about 15% of pregnancies. The second policy, instituted in countries with national health systems, has adhered to the dogma of offering invasive testing to the 5% group of women with the highest risk; in the last 20 years, the cut-off age for invasive testing has therefore increased from 35 to 38 years. In screening by maternal age with a cut-off age of 38 years, 5% of the population is classified as ‘high risk’ and this group contains about 30% of trisomy 21 babies. In the late 1980s, a new method of screening was introduced that takes into account not only maternal age but also the concentra- tion of various fetoplacental products in the maternal circulation. At 16 weeks of gestation the median maternal serum concentra- tions of a-fetoprotein (AFP), uconjugated estriol (uE3), human chorionic gonadotropin (hCG) (total and free-b) and inhibin-A in trisomy 21 pregnancies are sufficiently different from normal to allow the use of combinations of some or all of these substances to select a ‘high-risk’ group. This method of screen- ing is more effective than maternal age alone and, for the same rate of invasive testing (about 5%), it can identify about 50–70% of the fetuses with trisomy 21. In the 1990s, screening by a combination of maternal age and fetal NT thickness at 11–13+6 weeks of gestation was intro- duced. This method has now been shown to identify about 75% of affected fetuses for a screen-positive rate of about 5%. Subsequently, maternal age was combined with fetal NT and maternal serum biochemistry (free b-hCG and PAPP-A) in the 12 The 11–13+6 weeks scan  Screening Ultrasound Biochemistry Chorionic Villous Counselling Sampling Figure 3. Assessment of risk for chromosomal defects can be achieved by the combination of maternal age, ultrasound examination for measurement of fetal nuchal translucency and assessment for the presence/absence of the nasal bone and biochemical measurement of maternal serum free b-hCG and PAPP-A in an one-stop clinic at 11–13+6 weeks of gestation. After counselling, the patient can decide if she wants fetal karyotyping, which can be carried out by chorionic villus sampling in the same visit. first-trimester to identify about 85–90% of affected fetuses. Furthermore, the development of new methods of biochemical testing, within 30 min of taking a blood sample, made it possible to introduce One-Stop Clinics for Assessment of Risk (Figure 3). In 2001, it was found that in 60–70% of fetuses with trisomy 21 the nasal bone is not visible by ultrasound at 11–13+6 weeks and preliminary results suggest that this finding can increase the detection rate of the first trimester scan and serum biochemistry to more than 95% (Table 1). PATIENT-SPECIFIC RISK FOR CHROMOSOMAL DEFECTS Every woman has a risk that her fetus/baby has a chromosomal defect. In order to calculate the individual risk, it is necessary to take into account the background or a priori risk, which depends on maternal age and gestation, and multiply this by a series of factors or likelihood ratios, which depend on the results of a series Chapter 1 First trimester diagnosis of chromosomal defects 13  Table 1. Comparison of the detection rates (DR), for a false positive rate of 5%, of different methods of screening for trisomy 21. In prenatal screening, the term screen positive rate is used interchangeably with the invasive rate, because most women with a positive screening test undergo an invasive test, and with false positive rate (FPR) because the vast majority of fetuses in this group are normal. Method of screening DR (%) Maternal age (MA) 30 MA and maternal serum biochemistry at 15–18 weeks 50–70 MA and fetal nuchal translucency (NT) at 11–13+6 wks 70–80 MA and fetal NT and maternal serum free b-hCG and 85–90 PAPP-A at 11–13+6 wks MA and fetal NT and fetal nasal bone (NB) at 11–13+6 wks 90 MA and fetal NT and NB and maternal serum free b-hCG and 95 PAPP-A at 11–13+6 wks hCG human chorionic gonadotropin, PAPP-A: pregnancy-associated plasma protein A of screening tests carried out during the course of the pregnancy to determine the patient-specific risk. The likelihood ratio for a given sonographic or biochemical measurement is calculated by dividing the percentage of chromo- somally abnormal fetuses by the percentage of normal fetuses with that measurement. Every time a test is carried out the a priori risk is multiplied by the likelihood ratio of the test to calculate a new risk, which then becomes the a priori risk for the next test (Snijders and Nicolaides 1996). This process of sequential screening neces- sitates that the different tests are independent of each other. If the tests are not independent of each other then more sophisticated techniques, involving multivariate statistics, can be used to calculate the combined likelihood ratio. With the introduction of OSCAR, the process of sequential screening can all be achieved in one session at about 12 weeks of pregnancy (Figure 3). 14 The 11–13+6 weeks scan  Sequential screening Every woman has a risk that her fetus/baby has a chromo- somal defect. The background or a priori risk depends on maternal age and gestation. The individual patient-specific risk is calculated by multiplying the a priori risk with a series of likelihood ratios, which depend on the results of a series of screening tests carried out during the course of the pregnancy. Every time a test is carried out the a priori risk is multiplied by the likelihood ratio of the test to calculate a new risk, which then becomes the a priori risk for the next test. Maternal age and gestation The risk for many of the chromosomal defects increases with maternal age (Figure 4). Additionally, because fetuses with chromosomal defects are more likely to die in utero than normal fetuses, the risk decreases with gestational age (Figure 5). Risk % 10 Trisomy 21 1 XXX/XXY/XYY Trisomy 18 0.1 Trisomy 13 45XO 0.01 0.001 Triploidy 0.0001 20 25 30 35 40 44 Maternal age (yrs) Figure 4. Maternal age-related risk for chromosomal abnormalities. Chapter 1 First trimester diagnosis of chromosomal defects 15  100 XXX/XXY/XYY % 80 Trisomy 21 60 40 20 45XO Trisomy 18 Trisomy 13 Triploidy 0 10 15 20 25 30 35 40 Gestation (wks) Figure 5. Gestational age-related risk for chromosomal abnormalities. The lines represent the relative risk according to the risk at 10 weeks of gestation. Estimates of the maternal age-related risk for trisomy 21 at birth are based on surveys carried out before the introduction of prenatal diagnosis (Hecht and Hook 1994). In the last 15 years, with the introduction of maternal serum biochemical testing and ultrasound screening for chromosomal defects at different stages of pregnancy, it has become necessary to establish maternal age and gestational age-specific risks for chromosomal defects (Snijders et al 1995, 1999). Such estimates were derived by comparing, in women of the same age, the prevalence of trisomy 21 at birth to the prevalence at the time of second-trimester amniocentesis or first-trimester chorionic villus sampling. The rates of spontaneous fetal death in trisomy 21 between 12 weeks (when NT screening is carried out) and 40 weeks is about 30% and between 16 weeks (when second trimester maternal serum biochemical testing is carried out) and 40 weeks is about 20%. Similar methods were used to produce estimates of risks for other chromosomal defects. The risk for trisomies 18 and 13 increases with maternal age and decreases with gestation; the rate of 16 The 11–13+6 weeks scan miscarriage or fetal death between 12 weeks and 40 weeks is about 80% (Table 2). Turner syndrome is usually due to loss of the paternal X chromosome and, consequently, the frequency of conception of 45,XO embryos, unlike that of trisomies, is unrelated to maternal age. The prevalence is about 1 per 1500 at 12 weeks, 1 per 3000 at 20 weeks and 1 per 4000 at 40 weeks. For the other sex chromosome abnormalities (47,XXX, 47,XXY and 47,XYY), there is no significant change with maternal age and since the rate of fetal death is not higher than in chromo- somally normal fetuses, the overall prevalence (about 1 per 500) does not decrease with gestation. Polyploidy affects about 2% of recognized conceptions but it is highly lethal and thus very rarely observed in live births; the prevalences at 12 and 20 weeks are about 1 per 2000 and 1 per 250 000, respectively. Effect of maternal age and gestation on risk The risk for trisomies increases with maternal age. The risk for Turner syndrome and triploidy does not change with maternal age. The earlier the gestation, the higher the risk for chromosomal defects. The rates of fetal death in trisomy 21 between 12 weeks (when NT screening is carried out) and 40 weeks is about 30% and between 16 weeks (when second trimester maternal serum biochemical testing is carried out) and 40 weeks is about 20%. In trisomies 18 and 13 and Turner syndrome, the rate of fetal death between 12 and 40 weeks is about 80%. Previous affected pregnancy The risk for trisomies in women who have had a previous fetus or child with a trisomy is higher than the one expected on the basis of their age alone. In women who had a previous pregnancy with trisomy 21, the risk of recurrence in the subsequent Chapter 1 First trimester diagnosis of chromosomal defects 17  18 Table 2. Estimated risk for trisomies 21, 18 and 13 (1/number given in the table) in relation to maternal age and gestation. Maternal Trisomy 21 Trisomy 18 Trisomy 13 age (yrs) Gestation (wks) Gestation (wks) Gestation (wks) 12 16 20 40 12 16 20 40 12 16 20 40 20 1068 1200 1295 1527 2484 3590 4897 18013 7826 11042 14656 42423 25 946 1062 1147 1352 2200 3179 4336 15951 6930 9778 12978 37567 30 626 703 759 895 1456 2103 2869 10554 4585 6470 8587 24856 31 543 610 658 776 1263 1825 2490 9160 3980 5615 7453 21573 32 461 518 559 659 1072 1549 2114 7775 3378 4766 6326 18311 33 383 430 464 547 891 1287 1755 6458 2806 3959 5254 15209 34 312 350 378 446 725 1047 1429 5256 2284 3222 4277 12380 35 249 280 302 356 580 837 1142 4202 1826 2576 3419 9876 36 196 220 238 280 456 659 899 3307 1437 2027 2691 7788 37 152 171 185 218 354 512 698 2569 1116 1575 2090 6050 38 117 131 142 167 272 393 537 1974 858 1210 1606 4650 39 89 100 108 128 208 300 409 1505 654 922 1224 3544 40 68 76 82 97 157 227 310 1139 495 698 927 2683 41 51 57 62 73 118 171 233 858 373 526 698 2020 42 38 43 46 55 89 128 175 644 280 395 524 1516 The 11–13+6 weeks scan pregnancy is 0.75% higher than the maternal and gestational age-related risk for trisomy 21 at the time of testing. Thus, for a woman aged 35 years who has had a previous baby with trisomy 21, the risk at 12 weeks of gestation increases from 1 in 249 (0.40%) to 1 in 87 (1.15%), and, for a woman aged 25 years, it increases from 1 in 946 (0.106%) to 1 in 117 (0.856%). The possible mechanism for this increased risk is that a small proportion (less than 5%) of couples with a previously affected pregnancy have parental mosaicism or a genetic defect that inter- feres with the normal process of dysjunction, so in this group the risk of recurrence is increased substantially. In the majority of couples (more than 95%), the risk of recurrence is not actually increased. Currently available evidence suggests that recurrence is chromosome-specific and, therefore, in the majority of cases, the likely mechanism is parental mosaicism. Recurrence of chromosomal defects If a woman has had a previous fetus or baby with a trisomy, the risk in the current pregnancy is 0.75% higher than her a priori risk. Recurrence is chromosome-specific. Fetal nuchal translucency Fetal NT normally increases with gestation (crown–rump length). In a fetus with a given crown–rump length, every NT measurement represents a likelihood ratio which is multiplied by the a priori maternal and gestational age-related risk to calculate a new risk. The larger the NT, the higher the likelihood ratio becomes and therefore the higher the new risk. In contrast, the smaller the NT measurement, the smaller the likelihood ratio becomes and therefore the lower the new risk (Figure 6). Chapter 1 First trimester diagnosis of chromosomal defects 19  100 - 5.0 mm 3.5 mm 3.0 mm 2.5 mm 10 - a priori Risk (%) 1 - 0.1 - 0.01 - - - - - - - 20 25 30 35 40 45 Maternal age (yrs) Figure 6. Maternal age-related risk for trisomy 21 at 12 weeks of gestation (a priori) and the effect of fetal nuchal translucency thickness (NT). Nasal bone and other first-trimester sonographic markers At 11–13+6 weeks the nasal bone is not visible by ultra- sonography in about 60–70% of fetuses with trisomy 21 and in about 2% of chromosomally normal fetuses. Abnormalities in the flow velocity waveform from the ductus venosus are observed in about 80% of fetuses with trisomy 21 and in 5% of chromosomally normal fetuses. Similarly, the prevalence of other sonographic markers, such as exomphalos, megacystis and single umbilical artery, are higher in certain chromosomal abnormalities than in chromosomally normal fetuses. Each of these sonographic markers is associated with a likelihood ratio, which can be multiplied by the a priori risk to calculate a new risk. Maternal serum biochemistry in the first-trimester The level of free b-hCG in maternal blood normally decreases with gestation. In trisomy 21 pregnancies free b-hCG is 20 The 11–13+6 weeks scan increased. The level of PAPP-A in maternal blood normally increases with gestation and in trisomy 21 pregnancies the level is decreased. For a given gestation, each b-hCG and PAPP-A level represents a likelihood ratio that is multiplied by the a priori risk to calculate the new risk. The higher the level of b-hCG and the lower the level of PAPP-A the higher the risk for trisomy 21 (Figure 7). NUCHAL TRANSLUCENCY THICKNESS Cystic hygromas, nuchal edema and nuchal translucency During the second and third trimesters of pregnancy, abnormal accumulation of fluid behind the fetal neck can be classified as nuchal cystic hygroma or nuchal edema. In about 75% of fetuses with cystic hygromas, there is a chromosomal abnormality and, in about 95% of cases, the abnormality is Turner syndrome. Nuchal edema has a diverse etiology; chromosomal abnormalities are found in about one-third of the fetuses and, in about 75% of Risk (%) ß-hCG PAPP-A Risk (%) 100 100 4.0 MoM 0.25 MoM 3.0 MoM 0.33 MoM 2.0 MoM 0.50 MoM 10 10 a priori a priori 1 1 0.1 0.1 0.01 0.01 20 25 30 35 40 45 20 25 30 35 40 45 Maternal Age (yrs) Maternal Age (yrs) Figure 7. Maternal age-related risk for trisomy 21 at 12 weeks of gestation (a priori) and the effect of maternal serum free b-hCG (left) and PAPP-A (right). Chapter 1 First trimester diagnosis of chromosomal defects 21 cases, the abnormality is trisomy 21 or 18. Edema is also associ- ated with fetal cardiovascular and pulmonary defects, skeletal dysplasias, congenital infections and metabolic and hematological disorders; consequently, the prognosis for chromosomally normal fetuses with nuchal edema is poor. In the first trimester, the term translucency is used, irrespective of whether it is septated or not and whether it is confined to the neck or envelopes the whole fetus. During the second trimester, the translucency usually resolves and, in a few cases, it evolves into either nuchal edema or cystic hygromas with or without generalized hydrops. Neither the incidence of chromosomal defects nor the prognosis can be predicted by the ultrasono- graphic appearance of the lesion. Increased NT is associated with trisomy 21, Turner syndrome and other chromosomal defects as well as many fetal malformations and genetic syndromes. The incidence of these abnormalities is related to the thickness, rather than the appearance, of NT. Furthermore, it is possible to standardize and audit the results of a measurement but not those of a subjective appearance. Nuchal translucency – definition Nuchal translucency is the sonographic appearance of sub- cutaneous accumulation of fluid behind the fetal neck in the first trimester of pregnancy. The term translucency is used, irrespective of whether it is septated or not and whether it is confined to the neck or envelopes the whole fetus. The incidence of chromosomal and other abnormalities is related to the size, rather than the appearance of NT. During the second trimester, the translucency usually resolves and, in a few cases, it evolves into either nuchal edema or cystic hygromas with or without generalized hydrops. 22 The 11–13+6 weeks scan Measurement of nuchal translucency The ability to achieve a reliable measurement of NT is dependent on appropriate training and adherence to a standard technique in order to achieve uniformity of results among different operators. Gestation and crown-rump length The optimal gestational age for measurement of fetal NT is 11 weeks to 13 weeks and 6 days. The minimum fetal crown–rump length should be 45 mm and the maximum 84 mm. There are two reasons for selecting 11 weeks as the earliest gestation for measurements of NT. Firstly, screening necessitates the availability of a diagnostic test and chorionic villous sampling before this gestation is associated with transverse limb reduction defects. Secondly, many major fetal defects can be diagnosed at the NT scan, provided the minimum gestation is 11 weeks. For example, diagnosis or exclusion of acrania and therefore anence- phaly, cannot be made before 11 weeks because sonographic assessment of ossification of the fetal skull is not reliable before this gestation. Examination of the four-chamber view of the heart and main arteries is possible only after 10 weeks. At 8–10 weeks all fetuses demonstrate herniation of the midgut that is visualized as a hyperechogenic mass in the base of the umbilical cord, and it is therefore unsafe to diagnose or exclude exomphalos at this gestation. The fetal bladder can be visualized in only 50% of fetuses at 10 weeks, in 80% at 11 weeks and in all cases by 12 weeks. The reasons for selecting 13 weeks and 6 days as the upper limit are firstly, to provide women with affected fetuses the option Chapter 1 First trimester diagnosis of chromosomal defects 23 of first rather than second trimester termination, secondly, the incidence of abnormal accumulation of nuchal fluid in chromo- somally abnormal fetuses is lower at 14–18 weeks than before 14 weeks, and thirdly, the success rate for taking a measurement at 10–13 weeks is 98–100%, falling to 90% at 14 weeks because the fetus becomes vertical making it more difficult to obtain the appropriate image. Image and measurement In the assessment of fetal NT the ultrasound machine should be of high resolution with a video-loop function and callipers that provide measurements to one decimal point. Fetal NT can be measured successfully by transabdominal ultrasound examination in about 95% of cases; in the others, it is necessary to perform transvaginal sonography. The results from transabdominal and transvaginal scanning are similar. Only the fetal head and upper thorax should be included in the image for measurement of NT (Figure 8a). The magnification should be as large as possible and always such that each slight movement of the callipers produces only a 0.1 mm change in the measurement. In magnifying the image, either pre or post freeze zoom, it is important to turn the gain down. This avoids the mistake of placing the calliper on the fuzzy edge of the line which causes an underestimate of the nuchal measurement. A good sagittal section of the fetus, as for measurement of fetal crown–rump length, should be obtained and the NT should be measured with the fetus in the neutral position. When the fetal neck is hyperextended the measurement can be increased by 0.6 mm and when the neck is flexed, the measurement can be decreased by 0.4 mm. 24 The 11–13+6 weeks scan  (a) (b) (c) (d) (e) (f) Figure 8. Ultrasound pictures of 12-weeks fetus. In all six images there is a good sagittal section of the fetus. Image (a) is appropriate for measurement of the nuchal translucency (NT) because only the fetal head and upper thorax are included and the nuchal membrane, which is thin, can be seen separate from the amniotic membrane. In (b) the magnification is too small for accurate measurement of NT. In (c) the fetal neck is hyperextended and in (d) the neck is too flexed. In (e) the maximum measurement of NT should be taken. In (f) the umbilical cord is round the neck. In this case the NT should be measured both above and below the cord and the average of the two measurements should be used in the calculation of risk. Care must be taken to distinguish between fetal skin and amnion because, at this gestation, both structures appear as thin mem- branes (Figure 8a). This is achieved by waiting for spontaneous Chapter 1 First trimester diagnosis of chromosomal defects 25 fetal movement away from the amniotic membrane; alternatively, the fetus is bounced off the amnion by asking the mother to cough and/or by tapping the maternal abdomen. The maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine should be measured (Figure 8e). The callipers should be placed on the lines that define the NT thickness – the crossbar of the calliper should be such that it is hardly visible as it merges with the white line of the border and not in the nuchal fluid. During the scan, more than one measurement must be taken and the maximum one should be recorded. The umbilical cord may be round the fetal neck in 5–10% of cases and this finding may produce a falsely increased NT. In such cases, the measurements of NT above and below the cord are different and, in the calculation of risk, it is more appropriate to use the average of the two measurements (Figure 8f ). There are no clinically relevant effects on NT measurements by ethnic origin, parity or gravidity, cigarette smoking, diabetic control, conception by assisted reproduction techniques, bleeding in early pregnancy or fetal gender. The intra-observer and inter-observer differences in measure- ments of fetal NT are less than 0.5 mm in 95% of cases. Deviation in measurement from normal Fetal NT increases with crown–rump length and therefore it is essential to take gestation into account when determining whether a given NT thickness is increased. In a study involving 96,127 pregnancies, the median and 95th centile at a 26 The 11–13+6 weeks scan crown-rump-length of 45 mm were 1.2 and 2.1 mm and the respective values at crown rump length of 84 mm were 1.9 and 2.7 mm (Snijders et al 1998). In screening for chromosomal defects patient-specific risks are derived by multiplying the a priori maternal age and gestation- related risk by a likelihood ratio, which depends on the difference (Delta value in mm) in fetal NT measurement from the normal median for the same crown-rump length (Figures 9–11). In screening using maternal serum biochemical markers a differ- ent approach has been used to take into account the gestational age related change in marker levels. This method involves converting the measured concentration into a multiple of the median (MoM) of unaffected pregnancies of the same gestation. Essentially, the Gaussian distributions of log10 (NT MoM) in trisomy 21 and unaffected pregnancies are derived and the heights of the distributions at a particular MoM, which is the likelihood ratio for trisomy 21, is used to modify the a priori maternal age-related risk to derive the patient-specific risk. 8.0 7.0 Nuchal translucency (mm) 6.0 5.0 4.0 3.0 2.0 1.0 0.0 35 45 55 65 75 85 Crown-rump length (mm) Figure 9. Nuchal translucency measurement in 326 trisomy 21 fetuses plotted on the normal range for crown–rump length (95th and 5th centiles). Chapter 1 First trimester diagnosis of chromosomal defects 27  25 20 Frequency (%) 15 10 5 0 -1 0 1 2 3 4 5 6 Nuchal translucency deviation (mm) Figure 10. Distribution of fetal nuchal translucency thickness expressed as deviation from the normal median for crown–rump length in chromosomally normal fetuses (black bars) and 326 with trisomy 21 (blue bars). 60 50 Likelihood ratio 40 30 20 10 0 -0.5 0 0.5 1 1.5 2 2.5 Nuchal translucency deviation (mm) Figure 11. Likelihood ratios for trisomy 21 in relation to the deviation in fetal nuchal translucency thickness from the normal median for crown–rump length. In screening by NT the Delta approach provides accurate patient-specific risks (Spencer et al 2003). In contrast, the MoM approach was found to be inappropriate for this purpose, because none of the three basic assumptions that underpin this method are valid. Firstly, in the unaffected population the distributions of NT MoM and log10(NT MoM) are not Gaussian, secondly, 28 The 11–13+6 weeks scan the SD’s do not remain constant with gestation and thirdly, the median MoM in the trisomy 21 pregnancies is not a constant proportion of the median for unaffected pregnancies. The MoM approach results in women being given an overestimate of risk for trisomy at 11 weeks and a considerable underestimate of risk at 13 weeks. Nuchal translucency – measurement The gestation should be 11–13+6 weeks and the fetal crown– rump length should be 45–84 mm. A mid-sagittal section of the fetus should be obtained and the NT should be measured with the fetus in the neutral position. Only the fetal head and upper thorax should be included in the image. The magnification should be as large as possible and always such that each slight movement of the callipers produces only a 0.1 mm change in the measurement. The maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine should be measured. Care must be taken to distinguish between fetal skin and amnion. The callipers should be placed on the lines that define the NT thickness – the crossbar of the calliper should be such that it is hardly visible as it merges with the white line of the border and not in the nuchal fluid. During the scan, more than one measurement must be taken and the maximum one should be recorded. Training and quality assessment in the measurement of NT Appropriate training of sonographers and adherence to a standard technique for the measurement of NT are essential prerequisites for good clinical practice. Furthermore, the success of a screening program necessitates the presence of a system for Chapter 1 First trimester diagnosis of chromosomal defects 29 regular audit of results and continuous assessment of the quality of images. All sonographers performing fetal scans should be capable of reliably measuring the crown–rump length and obtaining a proper sagittal view of the fetal spine. For such sonographers, it is easy to acquire, within a few hours, the skill to measure NT thickness. However, the ability to measure NT and obtain reproducible results improves with training. Good results are achieved after 80 scans for the transabdominal route and 100 scans transvaginally. Several studies have demonstrated that ongoing regular audit of images and the distribution of measurements of NT is essential for assessing the quality of a centre and is also useful in identify- ing individual sonographers whose results deviate from the mean performance. The inter-examination variation in measurements is reduced considerably after an initial learning phase and after feedback to the sonographers on the distribution of their measurements and the quality of their images. The Fetal Medicine Foundation (FMF), which is a UK registered charity, has established a process of training and quality assurance for the appropriate introduction of NT screen- ing into clinical practice. Training is based on a theoretical course, practical instruction on how to obtain the appropriate image and make the correct measurement of NT, and presenta- tion of a logbook of images. These are examined to determine if the magnification is adequate, the section of the fetus is truly sagittal and the head is in the neutral position, the amnion is seen separately from the nuchal membrane and the callipers are placed appropriately. Ongoing quality assurance is based on assessment of the distribution of fetal NT measurements (Figure 12) and examination of a sample of images obtained by each sonographer involved in screening. 30 The 11–13+6 weeks scan  6.0 (a) Nuchal translucency (mm) 5.0 4.0 3.0 2.0 1.0 0.0 45 50 55 60 65 70 75 80 85 Crown- rump length (mm) 4.0 (b) Nuchal translucency (mm) 3.0 2.0 1.0 0.0 45 50 55 60 65 70 75 80 85 Crown- rump length (mm) 4.0 (c) Nuchal translucency (mm) 3.0 2.0 1.0 0.0 45 50 55 60 65 70 75 80 85 Crown- rump length (mm) Figure 12. Distribution of fetal nuchal translucency thickness. In (a) the distribution is good, in (b) the measurements are underestimated and in (c) the measurements are overestimated. Chapter 1 First trimester diagnosis of chromosomal defects 31  Nuchal translucency – training and quality assurance Appropriate training of sonographers and adherence to a standard technique for the measurement of NT are essential prerequisites for good clinical practice. The success of a screening program necessitates the presence of a system for regular audit of results and continuous assess- ment of the quality of images. Training is based on a theoretical course, practical instruction on how to obtain the appropriate image and make the correct measurement of NT, and presentation of a logbook of images. Ongoing quality assurance is based on assessment of the distribution of fetal NT measurements and examination of a sample of images obtained by each sonographer involved in screening. Nuchal translucency thickness and risk for chromosomal defects In 1992 a study, in which fetal NT was measured before CVS for fetal karyotyping, reported that in a high proportion of chromo- somally abnormal fetuses the NT thickness was increased (Nicolaides et al 1992). This association was subsequently confirmed in several other studies in the early 1990s. Thus, in the combined data from 17 series involving a total of 1,690 patients with increased fetal NT the incidence of chromosomal defects was 29% (Nicolaides 2004). However, there were large differences between the studies in the incidence of chromosomal defects, ranging from 11% to 88%, because of differences in the maternal age distributions of the populations examined and the definition of the minimum abnormal NT thickness, which ranged from 2 mm to 10 mm. Studies in the mid 1990’s demonstrated that firstly, in normal pregnancies, fetal NT thickness increases with gestation, 32 The 11–13+6 weeks scan secondly, in trisomy 21 and other major chromosomal defects fetal NT is increased, and thirdly, the risk for trisomies can be derived by multiplying the a priori maternal age and gestation- related risk by a likelihood ratio, which depends on the degree of deviation in fetal NT measurement from the normal median for that crown–rump length (Nicolaides et al 1994, Pandya et al 1995). It was estimated that, in a pregnant population with a mean maternal age of 28 years, using the risk cut-off of 1 in 300 to define the screen positive group would detect about 80% of trisomy 21 fetuses for a false positive rate of 5%. Nuchal translucency – calculation of patient-specific risk The risk for trisomies is derived by multiplying the a priori maternal age and gestation-related risk by the NT likelihood ratio. The NT likelihood ratio depends on the degree of deviation in fetal NT measurement from the normal median for that crown–rump length. Implementation of nuchal translucency screening in routine practice Several prospective interventional studies have examined the implementation of NT screening in routine practice (Nicolaides 2004). In some of the studies the screen positive group was defined by a cut-off in fetal NT or a combined risk derived from the maternal age and deviation in fetal NT from the normal median for fetal crown-rump length. The important findings of these studies are, firstly, fetal NT was successfully measured in more than 99% of cases, secondly, there were inevitable variations in false positive and detection rates between the studies because of differences in the maternal age Chapter 1 First trimester diagnosis of chromosomal defects 33 distribution of their populations and in fetal NT or risk cut-offs used, and thirdly, in the combined data on more than 200,000 pregnancies, including more than 900 fetuses with trisomy 21, fetal NT screening identified more than 75% of fetuses with trisomy 21 and other major chromosomal defects for a false posi- tive rate of 5%, or the detection rate was about 60% for a false positive rate of 1% (Nicolaides 2004). In the largest study, coordinated by the FMF, 100,311 singleton pregnancies were examined by 306 appropriately trained sonographers in 22 UK centers (Snijders et al 1998). In all cases the fetal NT and crown–rump length were measured and indi- vidual patient-specific risks, based on maternal age, gestational age and fetal NT were calculated. Follow-up was obtained from 96,127 cases, including 326 with trisomy 21 and 325 with other chromosomal defects (Table 3). The median gestation at the time Table 3. Multicentre study coordinated by the Fetal Medicine Foundation. Number of pregnancies with nuchal translucency (NT) thickness above the 95th centile and an estimated risk for trisomy 21, based on maternal age and fetal nuchal translucency and crown-rump length, of 1 in 300 or more (Snijders et al 1998). Fetal karyotype N NT >95th centile Risk ≥1 in 300 Normal 95,476 4,209 (4.4%) 7,907 (8.3%) Trisomy 21 326 234 (71.2%) 268 (82.2%) Trisomy 18 119 89 (74.8%) 97 (81.5%) Trisomy 13 46 33 (71.7%) 37 (80.4%) Turner syndrome 54 47 (87.0%) 48 (88.9%) Triploidy 32 19 (59.4%) 20 (62.5%) Other* 64 41 (64.1%) 51 (79.7%) Total 96,127 4,767 (5.0%) 8,428 (8.8%) *Deletions, partial trisomies, unbalanced translocations, sex chromosome aneuploidies 34 The 11–13+6 weeks scan of screening was 12 weeks and the median maternal age was 31 years. The estimated risk for trisomy 21 was 1 in 300 or more in 8% of the normal pregnancies, in 82% of those with trisomy 21 and in 78% with other chromosomal defects. For a screen-positive rate of 5%, the detection rate was 77% (95% confidence interval 72–82%). The issue of spontaneous fetal death Screening for chromosomal defects in the first, rather than the second trimester, has the advantage of earlier prenatal diagnosis and consequently less traumatic termination of pregnancy for those couples who choose this option. A potential disadvantage is that earlier screening preferentially identifies those chromo- somally abnormal pregnancies that are destined to miscarry. Approximately 30% of affected fetuses die between 12 weeks of gestation and term. This issue of preferential spontaneous death in fetuses with chromosomal defects is, of course, a potential criticism of all methods of antenatal screening, including second- trimester maternal serum biochemistry, because the rate of fetal death between 16 weeks and term is about 20%. In prenatal screening studies it is impossible to know how many of the trisomy 21 pregnancies that were terminated would have resulted in live births. However, it is possible to estimate the impact of prenatal screening on the prevalence of trisomy 21 in live births. This can be done by comparing the number of affected live births with the number estimated on the basis of the maternal age-related prevalence of trisomy 21 in live births and the maternal age distribution of the population screened. In the FMF screening study, by a combination of maternal age and fetal NT, a risk cut-off of 1 in 300 was associated with a false positive rate of 8% and a detection rate of 82% (Snijders et al Chapter 1 First trimester diagnosis of chromosomal defects 35 1998). It was estimated that prenatal screening followed by invasive diagnostic testing and selective termination of affected fetuses would have reduced the potential live birth prevalence of trisomy 21 by 78–82%. Nuchal translucency – effectiveness of screening for trisomy 21 Prospective studies in more than 200,000 pregnancies, including more than 900 fetuses with trisomy 21, have demonstrated that NT screening can identify more than 75% of fetuses with trisomy 21 for a false positive rate of 5%. Increased NT does not necessarily identify those trisomic fetuses that are destined to die in utero. The observed detection rate of trisomy 21 with first trimester NT screening is only 2–3% higher than the detection rate of affected pregnancies that would potentially result in livebirths. Observational studies The ability to achieve a reliable measurement of NT is dependent on appropriate training, adherence to a standard technique and motivation of the sonographer. All three components are well illustrated by the differences in results between interventional and observational studies, in which the sonographers were asked to record the fetal NT measurements but not act on the results (Nicolaides 2004). Thus, successful measurement of NT was achieved in more than 99% of cases in the interventional studies, but in only 75% of cases in the observational studies. Further- more in the interventional studies there was increased NT in 76.8% of the trisomy 21 and 4.2% of the chromosomally normal fetuses, compared to the respective rates of 38.4% and 5.0% in the observational studies. In the observational studies, the scans were often carried out at inappropriate gestations and the sonographers were either not trained adequately or they were not sufficiently motivated to 36 The 11–13+6 weeks scan measure NT. For example, in one of the studies, in which sonographers were instructed to take no extra scanning time other than that necessary for measurement of the crown-rump length, fetal NT was successfully measured in only 66% of cases (Roberts et al 1995). In another study, the fetal crown-rump length was less than 33 mm in 54% of cases and the sonographers, who were instructed to measure fetal NT within three minutes, were unable to do so in 42% of cases (Kornman et al 1996). These methodological problems are further high- lighted by a study of 47,053 singleton pregnancies examined at 6–16 weeks (Wald et al 2003a). In 23% of the patients no valid NT measurement was taken because the scans were carried out at inappropriate gestations or the sonographers were unable to obtain a measurement or none of the images were deemed to be of an acceptable quality. Further evidence on the difference between observational and interventional studies is provided by Crossley et al (2002). In this observational study, 17,229 pregnancies were recruited and fetal NT was successfully measured in 73% of cases. In a subsequent study of more than 2,000 pregnancies in which the results of the scan were given to the women, fetal NT was successfully measured in 99.8% of cases. Nuchal translucency and maternal serum biochemistry Trisomic pregnancies are associated with altered maternal serum concentrations of various feto-placental products, including AFP, free b-hCG, uE3, inhibin A and PAPP-A. Screening in the second trimester by maternal age and various combinations of free b-hCG, AFP, uE3 and Inhibin A can identify 50–75% of trisomy 21 pregnancies for a false positive rate of 5%. Screening in the first trimester by a combination of maternal age and serum free b-hCG and PAPP-A identifies about 60% of affected pregnancies for a false positive rate of 5%. However, an essential Chapter 1 First trimester diagnosis of chromosomal defects 37 component of biochemical screening is accurate dating of the pregnancy by ultrasound, otherwise the detection rate is reduced by about 10%. Fetal NT and maternal serum testing in the first-trimester In trisomy 21 pregnancies at 12 weeks, the maternal serum concentration of free b-hCG (about 2 MoM) is higher than in chromosomally normal fetuses whereas PAPP-A is lower (about 0.5 MoM). The difference in maternal serum free b-hCG between normal and trisomy 21 pregnancies increases with advancing gestation and the difference in PAPP-A decreases with gestation. These temporal variations in marker levels, their interrelation and their association with maternal weight should be taken into account when developing risk algorithms in order to produce accurate patient-specific risks. There is no significant association between fetal NT and maternal serum free b-hCG or PAPP-A in either trisomy 21 or chromosomally normal pregnancies and therefore the ultra- sononographic and biochemical markers can be combined to provide more effective screening than either method individually (Spencer et al 1999). Six prospective screening studies have confirmed the feasibility and effectiveness of combining fetal NT and maternal serum free b-hCG and PAPP-A. In the combined data on a total of 38,804 pregnancies, including 182 with trisomy 21, the detection rate for trisomy 21 at a 5% false positive rate was 86% (Nicolaides 2004). In trisomies 18 and 13 maternal serum free b-hCG and PAPP-A are decreased. In cases of sex chromosomal anomalies maternal serum free b-hCG is normal and PAPP-A is low. In paternally derived triploidy maternal serum free b-hCG is greatly increased, whereas PAPP-A is mildly decreased. Maternally derived triploidy is associated with markedly decreased maternal 38 The 11–13+6 weeks scan serum free b-hCG and PAPP-A. Screening by a combination of fetal NT and maternal serum PAPP-A and free b-hCG can identify about 90% of all these chromosomal abnormalities for a screen positive rate of 1%, in addition to the 5% necessary in screening for trisomy 21. An important development in biochemical analysis is the intro- duction of a new technique (random access immunoassay ana- lyzer using time-resolved-amplified-cryptate-emission), which provides automated, precise and reproducible measurements within 30 minutes of obtaining a blood sample. This has made it possible to combine biochemical and ultrasonographic testing as well as to counsel in one-stop clinics for early assessment of fetal risk (OSCAR) (Bindra et al 2002, Spencer et al 2003b). Fetal NT and maternal serum testing in the second-trimester In women having second-trimester biochemical testing following first-trimester NT screening the a priori risk needs to be adjusted to take into account the first-trimester screening results. Prospective studies of screening by a combination of fetal NT in the first trimester and maternal serum biochemistry in the second trimester reported that for a false positive rate of 5% the detection rate of trisomy 21 (85–90%) is similar to combined screening in the first trimester (Nicolaides 2004). Integration of first and second trimester testing A statistical model combining first-trimester fetal NT and maternal serum PAPP-A with second-trimester free b-hCG, uE3 and inhibin A, estimated that for a false positive rate of 5% the detection rate of trisomy 21 could be 94% (Wald et al 1999). This test assumes complete compliance by the pregnant women in firstly, participating in a two stage process separated by one month, secondly, in having an ultrasound scan without receiving Chapter 1 First trimester diagnosis of chromosomal defects 39 information as to whether the fetus looks normal or not, and thirdly, accepting second rather than first trimester diagnosis and termination. It is therefore likely that even if the estimates of this hypothetical test are found to be true in prospective studies, it will not gain widespread clinical acceptability. Some of the logistical problems in the implementation of an integrated test are highlighted by the results of a multicentre observational study (SURUSS) investigating first and second trimester screening for trisomy 21 (Wald et al 2003a). The aim was to obtain a measurement of fetal NT in the first trimester and collect maternal serum and urine samples in the first and second trimesters. Intervention was based on the second trimester serum results and all other data were analyzed retrospectively. However, of the 47,053 women that were recruited, only 60% completed all components of the protocol. In this study there were 101 fetuses with trisomy 21 and satisfactory NT images were obtained only from 75 of the cases. The data were used to derive a statistical model suggesting that for a 5% false positive rate, 93% of trisomy 21 fetuses could be detected by the integrated test. However, it is likely that this model is inaccurate. For example, the predicted detection rates, for a 5% false positive rate, were 71% for the double test, 77% for the triple test and 83% for the quadruple test, which are substantially higher than the respective rates of 61%, 66% and 75% reported by the same authors in their prospective screening studies (Wald et al 2003b). A similar study in the USA (FASTER trial), reported its findings in the subgroup of 33,557 pregnancies with complete first and second trimester data, including 84 cases of trisomy 21 (Malone et al 2004). It was estimated that, for a 5.4% false positive rate, 90% of trisomy 21 fetuses could be detected. Prospective studies have demonstrated that such results are achievable by screening with fetal NT and maternal serum 40 The 11–13+6 weeks scan free b-hCG and PAPP-A in the first-trimester (Bindra et al 2002, Spencer et al 2003b). It is therefore essential that, in screening, attention is paid to the provision of high quality sono- graphic and biochemical services for early diagnosis of chromo- somal defects, rather than the development of theoretical models which would delay diagnosis until the second trimester and are, in any case, unlikely to be implemented in clinical practice. Screening by nuchal translucency and serum biochemistry In trisomy 21 pregnancies at 11–13+6 weeks, the maternal serum concentration of free b-hCG is higher (about 2 MoM) and PAPP-A is lower (about 0.5 MoM) than in chromosomally normal fetuses. There is no significant association between fetal NT and maternal serum free b-hCG or PAPP-A in either trisomy 21 or chromosomally normal pregnancies. The ultrasononographic and biochemical markers can be combined to provide more effective screening than either method individually. Prospective studies, in more than 50,000 pregnancies, includ- ing more than 250 fetuses with trisomy 21, have demon- strated that screening by a combination of fetal NT and either first or second trimester maternal serum biochemistry can identify 85–90% of fetuses with trisomy 21 for a false positive rate of 5%. In trisomies 18 and 13 maternal serum free b-hCG and PAPP-A are decreased. In sex chromosomal anomalies mater- nal serum free b-hCG is normal and PAPP-A is low. In pater- nally derived triploidy maternal serum free b-hCG is greatly increased, whereas PAPP-A is mildly decreased. Maternally derived triploidy is associated with markedly decreased maternal serum free b-hCG and PAPP-A. Screening by a combination of fetal NT and maternal serum PAPP-A and free b-hCG can identify about 90% of all these chromosomal abnormalities for a screen positive rate of 1%, in addition to the 5% in screening for trisomy 21. Chapter 1 First trimester diagnosis of chromosomal defects 41 WOMENS’ ATTITUDES TO 1ST VERSUS 2ND TRIMESTER SCREENING Studies investigating the preference of pregnant women in terms of the methods of screening, have reported that the vast majority prefer this to be carried out in the first rather than in the second trimester. A criticism of NT screening has been that some women with increased fetal NT will face unnecessary decisions regarding invasive testing and ultimately pregnancy termination in an affected pregnancy that would otherwise have ended in spontaneous miscarriage. In a survey of women’s preferences, about 70% stated that they would still choose NT screening even if all the Down’s syndrome pregnancies identified by this method miscarried before the second trimester (Mulvey and Wallace 2000). The women wanted to know if their fetus had had Down’s syndrome regardless of the pregnancy outcome and they also valued the knowledge of an underlying reason for a miscarriage if it occurred. Clinical importance of respect for autonomy Respect for autonomy is a central principle in medical ethics and law. This ethical principle obliges the physician to elicit and implement the patient’s preferences. The relevance of respect for autonomy to first trimester screening is two-fold. Firstly, early diagnosis of fetal abnormality and the option of early termination of pregnancy are important to many women. Secondly, most first trimester screening tests provide reassurance for many women who would prefer not to have an invasive procedure if the risk is low. Consequently, the provision of a high-quality first trimester screening service significantly enhances the autonomy of pregnant women (Chasen et al 2001). The vast majority of pregnant women prefer screening and diagnosis to be performed in the first, rather than in the second trimester. 42 The 11–13+6 weeks scan REFERENCES Bindra R, Heath V, Liao A, Spencer K, Nicolaides KH. One stop clinic for assessment of risk for trisomy 21 at 11–14 weeks: A prospective study of 15,030 pregnancies. Ultrasound Obstet Gynecol 2002;20:219–25. Chasen ST, Skupski DW, McCullough LB, Chervenak FA. Prenatal informed consent for sonogram: the time for first-trimester nuchal translucency has come. J Ultrasound Med 2001;20:1147–52. Crossley JA, Aitken DA, Cameron AD, McBride E, Connor JM. Combined ultrasound and biochemical screening for Down’s syndrome in the first trimester: a Scottish multicentre study. BJOG 2002;109:667–76. Down LJ. Observations on an ethnic classification of idiots. Clin Lectures and Reports, London Hospital 1866;3:259–62. Hecht CA, Hook EB. The imprecision in rates of Down syndrome by 1-year maternal age intervals: a critical analysis of rates used in biochemical screening. Prenat Diagn 1994;14:729–38. Kornman LH, Morssink LP, Beekhuis JR, DeWolf BTHM, Heringa MP, Mantingh A. Nuchal translucency cannot be used as a screening test for chromosomal abnormali- ties in the first trimester of pregnancy in a routine ultrasound practice. Prenat Diagn 1996;16:797–805. Malone FD, Wald NJ, Canick JA, Ball RH, Nyberg DA, Comstock CH, Bukowski R, et al. First- and second-trimester evaluation of risk (FASTER) trial: principal results of the NICHD multicenter Down syndrome screening study. SMFM 2004, Abstract 1. Mulvey S, Wallace EM. Women’s knowledge of and attitudes to first and second trimester screening for Down’s syndrome. BJOG 2000;107:1302–5. Nicolaides KH, Azar G, Byrne D, Mansur C, Marks K. Fetal nuchal translucency: ultrasound screening for chromosomal defects in first trimester of pregnancy. BMJ 1992;304:867–9. Nicolaides KH, Brizot ML, Snijders RJM. Fetal nuchal translucency: ultrasound screen- ing for fetal trisomy in the first trimester of pregnancy. BJOG 1994;101:782–6. Nicolaides KH. Nuchal translucency and other first-trimester sonographic markers of chromosomal abnormalities. Am J Obstet Gynecol 2004;191:45–67. Pandya PP, Snijders RJM, Johnson SJ, Brizot M, Nicolaides KH. Screening for fetal trisomies by maternal age and fetal nuchal translucency thickness at 10 to 14 weeks of gestation. BJOG 1995;102:957–62. Roberts LJ, Bewley S, Mackinson AM, Rodeck CH. First trimester fetal nuchal trans- lucency: Problems with screening the general population 1. BJOG 1995;102:381–5. Chapter 1 First trimester diagnosis of chromosomal defects 43 Snijders RJM, Sebire NJ, Cuckle H, Nicolaides KH. Maternal age and gestational age-specific risks for chromosomal defects. Fetal Diag Ther 1995;10:356–67. Snijders RJM, Nicolaides KH. Sequential screening. In: Nicolaides KH, editor. Ultra- sound markers for fetal chromosomal defects. Carnforth, UK: Parthenon Publishing, 1996, pp109–13. Snijders RJM, Noble P, Sebire N, Souka A, Nicolaides KH. UK multicentre project on assessment of risk of trisomy 21 by maternal age and fetal nuchal translucency thickness at 10–14 weeks of gestation. Lancet 1998;351:343–6. Snijders RJM, Sundberg K, Holzgreve W, Henry G, Nicolaides KH. Maternal age and gestation-specific risk for trisomy 21. Ultrasound Obstet Gynecol 1999;13:167–70. Spencer K, Souter V, Tul N, Snijders R, Nicolaides KH. A screening program for trisomy 21 at 10–14 weeks using fetal nuchal translucency, maternal serum free b-human chorionic gonadotropin and pregnancy-associated plasma protein-A. Ultrasound Obstet Gynecol 1999;13:231–7. Spencer K, Bindra R, Nix ABJ, Heath V, Nicolaides KH. Delta- NT or NT MoM: which is the most appropriate method for calculating accurate patient-specific risks for trisomy 21 in the first trimester? Ultrasound Obstet GynecoI 2003a;22:142–8. Spencer K, Spencer CE, Power M, Dawson C, Nicolaides KH. Screening for chromo- somal abnormalities in the first trimester using ultrasound and maternal serum biochemistry in a one stop clinic: A review of three years prospective experience. BJOG 2003b;110:281–6. Tabor A, Philip J, Madsen M, Bang J, Obel EB, Norgaard-Pedersen B. Randomised controlled trial of genetic amniocentesis in 4,606 low-risk women. Lancet 1986;1:1287–93. Wald NJ, Watt HC, Hackshaw AK. Integrated screening for Down’s syndrome on the basis of tests performed during the first and second trimesters. N Engl J Med 1999;341:461–7. Wald NJ, Rodeck C, Hackshaw AK, Walters J, Chitty L, Mackinson AM; SURUSS Research Group. First and second trimester antenatal screening for Down’s syndrome: the results of the Serum, Urine and Ultrasound Screening Study (SURUSS). Health Technol Assess 2003a;7:1–77. Wald NJ, Huttly WJ, Hackshaw AK. Antenatal screening for Down’s syndrome with the quadruple test. Lancet 2003b;361:835–6. 44 The 11–13+6 weeks scan  2 SONOGRAPHIC FEATURES OF CHROMOSOMAL DEFECTS Each chromosomal defect has its own syndromal pattern of detectable abnormalities. This chapter describes the sonographic features of trisomy 21 and other major chromosomal defects in the first and second trimesters of pregnancy. FIRST TRIMESTER ULTRASONOGRAPHY At 11–13+6 weeks, all major chromosomal defects are associated with increased NT thickness (Snijders et al 1998). In trisomies 21, 18 and 13 the pattern of increase in NT is similar and the average NT in these defects is about 2.5 mm above the normal median for crown-rump length. In Turner syndrome, the median NT is about 8 mm above the normal median. In addition to increased NT, in trisomy 21, 60–70% of fetuses have absent nasal bone, 25% have a short maxilla, and 80% have abnormal Doppler waveforms in the ductus venosus. In trisomy 18, there is early onset fetal growth restriction, a ten- dency for bradycardia and exomphalos in 30% of cases, absent nasal bone in 55% and single umbilical artery in 75%. In trisomy 13, there is tachycardia in about 70% of the cases and early onset fetal growth restriction, megacystis, holoprosencephaly or exomphalos in about 40% of the cases. In Turner syndrome, there is tachycardia in about 50% of cases and early onset fetal growth restriction. In triploidy, there is early onset asymmetrical Chapter 2 Sonographic features of chromosomal defects 45 fetal growth restriction, bradycardia in 30% of cases, holopro- sencephaly, exomphalos or posterior fossa cyst in about 40% and molar changes in the placenta in about 30%. Absence of fetal nasal bone In 1866 Langdon Down noted that a common characteristic of patients with trisomy 21 is a small nose. Anthropometric studies in patients with Down’s syndrome have reported that the nasal root depth is abnormally short in 50% of cases (Farkas et al 2001). Similarly, post mortem radiological studies in aborted fetuses with trisomy 21 have reported absence of ossification or hypoplasia of the nasal bone in about 50% of cases. Sonographic studies at 15–24 weeks of gestation reported that about 65% of trisomy 21 fetuses have absent or short nasal bone. The fetal nasal bone can be visualized by sonography at 11–13+6 weeks of gestation (Cicero et al 2001). Several studies have demon- strated a high association between absent nasal bone at 11–13+6 weeks and trisomy 21, as well as other chromosomal abnormalities (Nicolaides 2004). In the combined data from these studies on a total of 15,822 fetuses the fetal profile was successfully examined in 97.4% cases and the nasal bone was absent in 1.4% of the chro- mosomally normal fetuses and in 69% of fetuses with trisomy 21. An important finding of these studies was that the incidence of absent nasal bone decreased with fetal crown-rump length, increased with NT thickness and was substantially higher in Afro-Caribbeans than in Caucasians. Consequently, in the calcu- lation of likelihood ratios in screening for trisomy 21 adjustments must be made for these confounding factors (Cicero et al 2004). Integrated first-trimester sonographic and biochemical screening A case-control study comprising of 100 trisomy 21 and 400 chromosomally normal singleton pregnancies at 11–13+6 weeks 46 The 11–13+6 weeks scan of gestation examined the potential performance of screening for trisomy 21 by a combination of sonography for measurement of fetal NT and assessment of the presence or absence of the fetal nasal bone and measurement of maternal serum free b-hCG and PAPP-A (Cicero et al 2003). It was estimated that for a false positive rate of 5%, the detection rate of trisomy 21 would be 97%. Examination of the nasal bone The gestation should be 11–13+6 weeks and the fetal crown–rump length should be 45–84 mm. The image should be magnified so that the head and the upper thorax only are included in the screen. A mid-sagittal view of the fetal profile should be obtained with the ultrasound transducer held in parallel to the direction of the nose. In the image of the nose there should be three distinct lines. The top line represents the skin and the bottom one, which is thicker and more echogenic than the overlying skin, repre- sents the nasal bone. A third line, almost in continuity with the skin, but at a higher level, represents the tip of the nose. At 11–13+6 weeks the fetal profile can be successfully examined in more than 95% of cases. In chromosomally normal fetuses the incidence of absent nasal bone is less than 1% in Caucasian populations and about 10% in Afro-Caribbeans. The nasal bone is absent in 60–70% of trisomy 21 fetuses, in about 50% of trisomy 18 fetuses and 30% of trisomy 13 fetuses. For a false positive rate of 5%, screening by a combination of sonography for fetal NT and nasal bone and maternal serum free b-hCG and PAPP-A can potentially identify more than 95% of trisomy 21 pregnancies. It is imperative that sonographers undertaking risk assessment by examination of the fetal profile receive appropriate training and certification of their competence in performing such a scan. Chapter 2 Sonographic features of chromosomal defects 47 Crown–rump length Trisomy 18 and triploidy are associated with moderately severe growth restriction, trisomy 13 and Turner syndrome with mild growth restriction, whereas in trisomy 21 growth is essentially normal (Figure 1; Nicolaides et al 1996). Crown-rump length and chromosomal defects Trisomy 18 and triploidy are associated with moderately severe growth restriction Trisomy 13 and Turner syndrome are associated with mild growth restriction In trisomy 21 growth is essentially normal 100 90 80 Crown-rump-length (mm) 70 60 50 40 30 20 70 75 80 85 90 95 100 Gestation (days) Figure 1. Fetal crown-rump length in fetuses with triploidy plotted on the reference range (mean, 95th and 5th centiles) with gestation of chromosomally normal fetuses. 48 The 11–13+6 weeks scan Maxillary length Langdon Down observed that in individuals with trisomy 21 ‘the face is flat’. This may be the consequence of under- development of the maxilla. Anthropometric and radiological studies in patients with Down’s syndrome have demonstrated underdevelopment of the maxilla in more than 50% of cases (Farkas et al 2001). The fetal maxilla can be easily visualized and measured by sonography at 11–13+6 weeks of gestation (Cicero et al 2004). A mid-sagittal view of the fetal profile is first obtained and the transducer is then gently angled laterally so that both the maxillary bone and mandible, including the ramus and condylar process, can be seen (Figure 2). In chromosomally normal fetuses maxillary length increases linearly with gestation by about 0.1 mm for each 1 mm increase in crown-rump length. In the trisomy 21 fetuses the median maxillary length is significantly below the normal median for crown-rump length by 0.7 mm. Figure 2. Ultrasound picture of a 12-weeks fetus demonstrating measurement of maxillary length. Chapter 2 Sonographic features of chromosomal defects 49 However, there is a significant association between maxillary bone length and NT thickness and in fetuses with absent nasal bone the maxilla is shorter than in those with present nasal bone. Consequently, the independent contribution of maxillary length in screening for trisomy 21 remains to be determined. In fetuses with other chromosomal defects there are no significant differences from normal in the maxillary length. Ear length In postnatal life, short ears constitute the most consistent clinical characteristic of patients with Down’s syndrome. The fetal ears can be easily visualized and measured by sonography at 11–13+6 weeks of gestation (Sacchini et al 2003). Although in trisomy 21 fetuses the median ear length is significantly below the normal median for crown-rump length, the degree of deviation from normal is too small for this measurement to be useful in screening for trisomy 21. Femur and humerus length Trisomy 21 is characterised by short stature and during the second trimester the condition is associated with relative short- ening of the femur and more so the humerus. At 11–13+6 weeks in trisomy 21 fetuses the median femur and humerus lengths are significantly below the appropriate normal median for crown-rump length but the degree of deviation from normal is too small for these measurements to be useful in screening (Longo et al 2004). Single umbilical artery A single umbilical artery, found in about 1% of deliveries, is associated with malformations of all major organ systems and 50 The 11–13+6 weeks scan chromosomal defects. In the first-trimester the umbilical arteries can be visualized by color flow mapping on either side of the bladder and in continuity with the umbilical cord insertion to the fetus in an oblique transverse section of the lower fetal abdomen. At 11–13+6 weeks single umbilical artery is found in about 3% of chromosomally normal fetuses and in 80% of fetuses with trisomy 18 (Rembouskos et al 2003). In the fetuses with single umbilical artery the observed number of cases of trisomy 21 is not significantly different from the number estimated on the basis of maternal age and fetal NT. In contrast, a single umbilical artery is associated with a seven fold increase in risk of trisomy 18. However, a high proportion of trisomy 18 fetuses have other major defects that are easily detectable at the 11–13+6 weeks scan and many other abnormalities that are detectable at 16–20 weeks. It is therefore unlikely that the finding of a single umbilical artery per se should be an indication for fetal karyotyping. Megacystis The fetal bladder can be visualized by sonography in about 80% of fetuses at 11 weeks of gestation and in all cases by 13 weeks. At this gestation the fetal bladder length is normally less than 6 mm. Fetal megacystis in the first-trimester, defined by a longi- tudinal bladder diameter of 7 mm or more, is found in about 1 in 1,500 pregnancies (Figure 3). When the longitudinal bladder diameter is 7–15 mm the incidence of chromosomal defects, mainly trisomies 13 and 18, is about 20%, but in the chromo- somally normal group there is spontaneous resolution of the megacystis in about 90% of cases (Liao et al 2003). In contrast, in megacystis with bladder diameter greater than 15 mm the incidence of chromosomal defects is about 10% and in the chro- mosomally normal group the condition is invariably associated Chapter 2 Sonographic features of chromosomal defects 51  Figure 3. Ultrasound picture of a 12-weeks fetus with megacystis. with progressive obstructive uropathy. Megacystis is associated with increased NT, which is observed in about 75% of those with chromosomal defects and in about 30% of those with normal karyotype. After taking into account maternal age and fetal NT the presence of megacystis increases the likelihood for trisomy 13 or 18 by a factor of 6.7. Exomphalos At 11–13+6 weeks the prevalence of exomphalos (Figure 4) is about 1 in 1000, which is four times higher than in live births. The incidence of chromosomal defects, mainly trisomy 18, is about 60%, compared to about 30% at mid-gestation and 15% in neonates. The risk for trisomy 18 increases with maternal age and, since this trisomy is associated with a high rate of intraute- rine death, its prevalence decreases with gestational age. In con- trast, the rate of fetal death in chromosomally normal fetuses with exomphalos is not higher than in fetuses without this abnormality. Consequently, the prevalence of exomphalos and the associated 52 The 11–13+6 weeks scan  Figure 4. Ultrasound picture of a 12-weeks trisomy 18 fetus with exomphalos and increased nuchal translucency thickness. risk for chromosomal defects increase with maternal age and decrease with gestational age (Snijders et al 1995). Choroid plexus cysts, pyelectasis and cardiac echogenic foci At 11–14 weeks the prevalences of choroid plexus cysts, pyelectasis and cardiac echogenic foci were 2.2, 0.9 and 0.6% (Whitlow et al 1998). Preliminary results suggest that, as in the second trimester, the prevalence of these markers may be higher in chromosomally abnormal than normal fetuses. However, calculation of likelihood ratios requires the study of many more chromosomally abnormal fetuses to determine the true prevalence of these markers. Placental volume The placental volume, determined at 11–13+6 by 3D ultrasound, increases with fetal crown-rump length. In trisomy 21 fetuses, Chapter 2 Sonographic features of chromosomal defects 53 placental volume is not significantly different from normal but in trisomy 18 placental volume is substantially decreased. Fetal heart rate In normal pregnancy, the fetal heart rate (FHR) increases from about 100 bpm at 5 weeks of gestation to 170 bpm at 10 weeks and then decreases to 155 bpm by 14 weeks. At 10–13+6 weeks, trisomy 13 and Turner syndrome are associated with tachycardia, whereas in trisomy 18 and triploidy there is fetal bradycardia (Figure 5; Liao et al 2001). In trisomy 21, there is a mild increase in FHR. Measurement of FHR is unlikely 200 190 180 170 Fetal heart rate (bpm) 160 150 140 130 120 110 40 50 60 70 80 Crown-rump length (mm) Figure 5. Fetal heart rate in fetuses with trisomy 13 plotted on the reference range (mean, 95th and 5th centiles) with crown-rump length of the chromosomally normal fetuses. 54 The 11–13+6 weeks scan to improve first trimester screening for trisomy 21 but it is a useful measurement in identifying fetuses with trisomy 13. Doppler in the ductus venosus The ductus venosus is a unique shunt directing well-oxygenated blood from the umbilical vein to the coronary and cerebral circulations by preferential streaming through the foramen ovale into the left atrium. Blood flow in the ductus has a characteristic waveform with high velocity during ventricular systole (S-wave) and diastole (D-wave), and forward flow during atrial contrac- tion (a-wave). In the second and third trimesters of pregnancy abnormal flow with absent or reverse a-wave is observed in impending or overt cardiac failure. At 10–13+6 weeks abnormal ductal flow (Figure 6) is associated with chromosomal defects, cardiac abnormalities and adverse pregnancy outcome (Matias et al 1998, Borrell et al 2003). Studies from specialist centres, in more than 5,000 pregnancies, including about 280 fetuses with trisomy 21, have demonstrated that at 10–13+6 weeks there is abnormal flow in the ductus venosus in about 80% of trisomy 21 fetuses and in about 5% of chromosomally normal fetuses (Nicolaides 2004). There is no or only a weak association between increased fetal NT and the incidence of abnormal ductal flow. These findings indicate that assessment of the ductus venosus can be combined with measurement of fetal NT to improve the effectiveness of early sonographic screening for trisomy 21. Examination of ductal flow is time-consuming and requires highly skilled operators and at present it is uncertain if this assessment will be incorporated into the routine first-trimester scan. However, it could be used in specialist centres to Chapter 2 Sonographic features of chromosomal defects 55  Figure 6. Flow velocity waveforms from the fetal ductus venosus at 12 weeks’ gestation demonstrating normal pattern (top) and abnormal a-wave (bottom). re-evaluate the risk in patients with borderline results after screening by fetal NT and maternal serum biochemistry. Abnormal flow in the ductus venosus and chromosomal defects At 11–13+6 weeks abnormal ductal flow is observed in 5% of chromosomally normal fetuses and in about 80% of fetuses with trisomy 21. Assessment of the ductus venosus can be combined with measurement of fetal NT to improve the effectiveness of early sonographic screening for trisomy 21. Examination of ductal flow is time-consuming and requires highly skilled operators. It is therefore unlikely to be used in routine screening, but it could be used in specialist centres to re-evaluate the risk in patients with borderline results after screening by fetal NT and maternal serum biochemistry. 56 The 11–13+6 weeks scan Doppler in other vessels Uterine arteries Uterine artery Doppler studies at 11–13+6 weeks found no signi- ficant differences in pulsatility index between chromosomally normal and abnormal fetuses. Consequently, the high rates of fetal death and fetal growth restriction of the major chromosomal defects are unlikely to be the consequence of impaired placentation in the first trimester of pregnancy. Uterine artery Doppler is not a useful screening test for chromosomal defects. Umbilical artery Umbilical artery Doppler is not useful in screening for trisomy 21. However, in trisomy 18, impedance to flow is increased and in about 20% of cases there is persistent reversal of end-diastolic flow (REDF). Umbilical vein In second and third-trimester fetuses, pulsatile umbilical venous flow is a late and ominous sign of fetal compromise. At 11–13+6 weeks there is pulsatile flow in the umbilical vein in about 25% of chromosomally normal fetuses and in 90% of fetuses with trisomy 18 or 13. However, in fetuses with trisomy 21, the prevalence of pulsatile venous flow is not significantly different from that in chromosomally normal fetuses. Jugular vein and carotid artery There are no significant associations between the pulsatility index in the fetal jugular vein and carotid artery and fetal NT and no significant differences between the chromosomally normal and abnormal fetuses. Chapter 2 Sonographic features of chromosomal defects 57 SECOND TRIMESTER ULTRASONOGRAPHY In the second trimester scan, as in the first trimester, each chromo- somal defect has its own syndromal pattern of detectable abnor- malities (Table 1; Snijders and Nicolaides 1996, Nicolaides et al 1992). It is therefore recommended that, when an abnormality/ marker is detected at routine ultrasound examination, a thorough check is made for the other features of the chromosomal defect known to be associated with that marker; should additional abnormalities be identified, the risk is dramatically increased. In the case of apparently isolated abnormalities, the decision of Table 1. Common chromosomal defects in fetuses with sonographic abnormalities. Trisomy 21 Trisomy 18 Trisomy 13 Triploidy Turner Ventriculomegaly + + + + Holoprosencephaly + Choroid plexus cysts + Dandy Walker complex + + Facial cleft + + Micrognathia + + Nasal hypoplasia + Nuchal edema + + + Cystic hygromas + Diaphragmatic hernia + + Cardiac defect + + + + + Exomphalos + + Duodenal atresia + Esophageal atresia + + Renal defects