Aneuploidy Screening at 11-14 Weeks

ANEUPLOIDY SCREENING AT 11-14 WEEKS

THE 11-14 WEEK OBSTETRICAL SCAN

Jude P. Crino, M.D.

Gynecology and Obstetrics Gynecology and Obstetrics

The skin is deficient in elasticity giving the appearance of being too large for the body..……. The face is flat and the nose is small.

Observations on an ethnic classification of idiots FIRST TRIMESTER SECOND TRIMESTER Langdon Down 1866 NUCHAL TRANSLUCENCY NUCHAL FOLD

Langdon Down 1828-1896

Gynecology and Obstetrics Gynecology and Obstetrics Courtesy Kypros Nicolaides, M.D.

NUCHAL Training and quality assurance in the 11-14 weeks scan TRANSLUCENCY Measurement of nuchal translucency

• First trimester correlate • Gestation 11-14 wks • Crown-rump length 45-84 mm of nuchal fold • Mid-sagittal view • Specific measurement • Image size: head and thorax • Neutral position technique • Away from amnion • Standardized training • Maximum lucency • Callipers on-to-on • Quality assurance

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NUCHAL TRANSLUCENCY NUCHAL TRANSLUCENCY CUTOFF VALUES AND GESTATIONAL AGE

NT >2.5 mm 10 4.0 3.5 3.0 2.5 8 • NT increases w/ gestational age 2.0 1.5 1.0 – 17% per week 0.5 6 0.0 NT (mm) NT 38 48 58 68 78 % • If single cutoff used false pos rate 4 increases w/ advancing gest age CRL (mm) 2 0 10 11 12 13 Gestation (wk)

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CONVERSION OF NT TO DOWN SYNDROME RISK Risk (%) 100 Calliper placement • NT measurement is compared to expected normal CRL: 54 mm median value for crown-rump length or gest age 10

• The deviation in fetal NT from the expected value 1: 100 is converted into a likelihood ratio • delta value method – based upon difference in 1

mm from normal regressed median for CRL 1: 600 • MoM-Gaussian method – uses multiples of the 0.1 1: 3,700 expected median (MoM) for gest age 1.5 2.9 • Risk for trisomy 21 = a priori maternal age and 0.01 gestation-related risk X likelihood ratio Which is the correct measurement? 20 25 30 35 40 45 Age (years) Gynecology and Obstetrics Gynecology and Obstetrics

Screening for trisomy 21 FIRST TRIMESTER Effectiveness of different methods of screening SERUM ANALYTES

100,000 pregnancies

Trisomy 21 N=200 TRISOMY 21 TRISOMY 18 Method of screening DR Detected PAPP-A ↓ ↓ Screen positive 5% Maternal age 30% 60 BETA HCG N=5,000 Nuchal translucency (NT) at 12 wks 75% 150 ↑ ↓ Quadruple screen at 16 wks 80% 160 INHIBIN A ↑ ! Fetal NT & ß-hCG & PAPP- A at 12 wks 85% 170

Gynecology and Obstetrics Gynecology and Obstetrics Courtesy Kypros Nicolaides, M.D. Screening for trisomy 21 STRATEGIES TO IMPROVE Additional sonographic markers at 11-13+6 wks Trisomy Normal 21 TEST PERFORMANCE Absent NB 60-70% 2% ↑ detection, ↓ false pos rate Abnormal ductus 70-80% 5% Tricuspid regurgitation 70% 7% • First trimester contingent screening using additional sonographic markers • Combining 1st and 2nd trimester tests – integrated – sequential

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FRONTOMAXILLARY SCREENING FOR ANEUPLOIDY FACIAL ANGLE OTHER THAN TRISOMY 21

Increased Crown-rump Free ß-hCG Fetal Ultrasound markers PAPP-A NT length heart rate

Omphalocele Trisomy 18 ↓ ↓ 75% ↓ ↓ Single umb. artery

Megacystis Trisomy 13 ↓ ↓ 72% ↔ ↑ Holoprosencephaly

Turner's ↔ ↔ 87% ↔ ↑

Triploidy ↓↓ /↑ ↑ ↓↓ / ↔ 59% ↓ ↓ Small / molar placenta

Gynecology and Obstetrics AJOG 2007;196:271.e1 Gynecology and Obstetrics Courtesy Kypros Nicolaides, M.D.

ADDITIONAL BENEFITS OF FIRST MULTIPLE GESTATION TRIMESTER SCREENING Assessment of Chorionicity 6-9 weeks monochorionic dichorionic • First trimester dating • Early diagnosis of multiples and chorionicity • Early diagnosis of some structural anomalies • Serum screening for adverse outcomes • Screening for congenital heart disease

Gynecology and Obstetrics Gynecology and Obstetrics

MULTIPLE GESTATION MULTIPLE GESTATION Assessment of Chorionicity Assessment of Chorionicity

10-14 weeks Frequency of lambda sign • Dividing membrane in dichorionic pregnancies – appearance of base Fused Separate Total monochorionic – “T” dichorionic – “twin peak” or “lambda” placenta placenta N 67 34 101 Τ 10-14 weeks 100% 100% 100% 16 weeks 100% 91% 97% Λ 20 weeks 93% 74% 87% Obstet Gynecol 1999;94:450 Gynecology and Obstetrics Gynecology and Obstetrics

MULTIPLE GESTATION The 11-14 weeks scan Assessment of Chorionicity Increased NT – Normal karyotype

Ultrasound Obstet Gynecol 2002;19:350

Gynecology and Obstetrics Gynecology and Obstetrics Courtesy Kypros Nicolaides, M.D.

OUTCOME OF INCREASED OUTCOME OF INCREASED NUCHAL TRANSLUCENCY NUCHAL TRANSLUCENCY Major Heart Defects

Nuchal Chromosomal Fetal Major fetal Alive and 30 30% translucency Defects death abnormalities well 20 <95th centile 0.2% 1.3% 1.6% 97% 20% % 95th-99th centiles 3.7% 1.3% 2.5% 93%

3.5-4.4 mm 21.1% 2.7% 10.0% 70% 10 7%

4.5-5.4 mm 33.3% 3.4% 18.5% 50% 0.16% 1% 3% 5.5-6.4 mm 50.5% 10.1% 24.2% 30% 0 >6.5 mm 64.5% 19.0% 46.2% 15% <2.5 2.5 - 3.4 3.5 - 4.4 4.5 - 5.4 5.5 - 6.4 > 6.5

Snijders et al 1998; Souka et al 1998; 2001; Michailidis & Economides 2001 Nuchal translucency (mm)

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INCREASED NT ANATOMICAL SURVEY NORMAL KARYOTYPE AT 11-14 WEEKS

Craniosynostosis Beckwith-Wiedemann syndrome Achondrogenesis Iniencephaly GM1-gangliosidosis Achondroplasia Agnathia/micrognathia Mucopolysaccharidosis type VII Asphyxiating thoracic dystrophy Cardiac defects Smith-Lemli-Opitz syndrome Blomstrand osteochondrodysplasia Diaphragmatic hernia Vitamin D resistant rickets Campomelic dysplasia Omphalocele Zellweger syndrome Hypophosphatasia Megacystis Jarcho-Levin syndrome Renal agenesis Nance-Sweeney syndrome Polycystic kidneys Brachmann-de Lange syndrome Osteogenesis imperfecta Multicystic kidneys Charge association Roberts syndrome Nephrotic syndrome di George syndrome Short-rib-polydactyly syndrome Body stalk anomaly EEC syndrome Sirenomelia Congenital lymphedema Fryn syndrome Thanatophoric dysplasia Noonan syndrome Perlman syndrome Stickler syndrome Blackfan Diamond anaemia Akinesia deformation sequence Treacher-Collins syndrome Dyserythropoietic anaemia Myotonic dystrophy Trigonocephaly C syndrome Thallasemia-α Spinal muscular atrophy VACTERL association Parvovirus B19 infection

Gynecology and Obstetrics Ultrasound Obstet Gynecol 2001;18:9-17 Gynecology and Obstetrics

The 11-13+6 week anomaly scan The 11-13+6 week anomaly scan CNS views

• What are the embryological limitations? • What abnormalities can be detected? • What are the sonographic limitations? • Develop a protocol for an early anatomic survey

Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 week anomaly scan Acrania / anencephaly Acrania / anencephaly

47 cases, prevalence 1 / 1,200 First 31 8 missed Last 16 0 missed

In the first trimester the brain may appear normal! Onset of ossification of the skull 11 wks

Johnson et al 1996

Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 week anomaly scan Holoprosencephaly Encephalocele

• Seen after 10 weeks • Bony defect 26 cases, prevalence 1 / 3,500

Prevalence T13 12 wks 1 : 3,500 65% 20 wks 1 : ~ 7,000 40% Birth 1 : ~10,000 ?

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Encephalocele Meckel Gruber Syndrome • AR lethal disorder • polydactyly Encephalocoele • echogenic kidneys

Low risk group: • 75% occipital 1 in 20,000 • 25% frontal or parietal High risk group: Recurrence 2/6 None missed Polycystic kidneys Sepulveda et al 1996 Polydactyly Gynecology and Obstetrics Gynecology and Obstetrics

Face

• Maxilla • Mandible Face

• Profile • Nasal bone • Orbits

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Spine Bilateral cleft lip • Vertebrae: neck to pelvis 12 w • Skin intact

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Spina bifida

29 cases in 61,972 singleton pregnancies Prevalence of 1 / 2,000 None diagnosed in first trimester Increased NT in 1 of 29 cases

High risk group: Lemon sign: 3 of 3

Sebire et al 1997 Cranial signs not fully evaluated in 1st trimester

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13 Lumbosacral meningocele w

13 w

Cannot rule out spina bifida in lumbosacral region before 18 w Sagittal Axial

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Chiari II malformation 13 w Banana sign & meningomyelocele

14 w

Lemon sign

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Posterior fossa Intracranial translucency

12 w Normal

axial coronal Cerebellar vermis may not close over 4th ventricle until 18 w Ultrasound Obstet Gynecol 2009;34:249 Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 weeks scan Intracranial translucency Omphalocele

Spina bifida Physiological Omphalocele Midline defect with bowel herniation into the base of the cord 8 wks Onset of herniation 10 wks Herniation in all cases Prevalence: 1 / 4,000 births Cause: Sporadic 11 wks Resolution Other defects: Trisomies 18 &13 Beckwith syndrome

Treatment: Surgical Prognosis: 80% survival

Ultrasound Obstet Gynecol 2009;34:249 Gynecology and Obstetrics Gynecology and Obstetrics

Normal cord insertion Physiologic midgut herniation

10 w 12 w

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Omphalocele Gastroschisis

Birth prevalence 1 : 5,000 Diagnosed when: CRL > 45 mm ● Sporadic Mass > 7mm ● Not associated with aneuploidy Contains Liver/stomach ● Very few diagnosed in 1st trimester

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Gastroschisis

13 w

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Body Stalk Anomaly The 11-13+6 weeks scan

Birth prevalence 1 : 14,000 Body stalk defect / Sporadic, lethal Amniotic band syndrome

• Major abdominal wall defect • Short cord • Kyphoscoliosis

• Early amnion rupture • Many present with increased NT

Daskalakis et al 1997 Gynecology and Obstetrics Gynecology and Obstetrics

Diaphragmatic Hernia Diaphragmatic Hernia

Birth prevalence 1 : 4,000 Bowel in chest, mediastinal shift, pleural effusion, polyhydramnios

● Development completed by 9 weeks

● Intrathoracic herniation of abdominal Isolated hernia 50% viscera may occur when gut returns Chromosomal defects 20% Other abnormalities 30% to abdomen at 10-12 weeks

● May be delayed until 2nd or 3rd trimester Survival of isolated 50%

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Diaphragmatic Hernia

78,639 singleton, live fetuses

Left 19 cases 1 / 4,000 Right

NT>95th 7 of 19

5 of 6 NND Sebire et al 1997

Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 weeks scan Megacystis Normal bladder Normal bladder > 7mm

90 % resolution obstructive 100 % 10 wks: visible in 50% uropathy 11 wks: visible in 98% 10 % 25 % 10 % abnormal 12 wks: visible in all karyotype 7-15 mm > 15 mm Liao et al 2003 n = 82 n = 26

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Kidneys Kidneys

● Visible in all by 12 weeks

● May appear echogenic

● Look for rim of fat

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Renal Agenesis Multicystic dysplastic kidney

Birth prevalence 1 : 4000 14 wk

● Absence of kidneys

● Absence of bladder

● 1st trimester - normal fluid

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Cloacal exstrophy

No bladder seen Irregular mass lower anterior abdominal wall

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FETAL SKELETON

Extremities

Femur Upper Limb • 4 limbs • Movements 10 wk: Ossiﬁcation centers of long bones seen 11 wk: Long bones measured with accuracy Limb movements readily seen

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Lethal skeletal dysplasia

Short femur Hitch-hiker thumb Diastrophic dysplasia

Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 weeks scan

Club foot & polydactyly Molar Placenta (1 in 2,500)

• Complete mole / normal twin

• Partial mole

• Mesenchymal dysplasia Gynecology and Obstetrics Gynecology and Obstetrics

Successful examination of fetal anatomy at 11-13+6 weeks

Molar Placenta Transabdominal and / or transvaginal scan

CRL n Head/ Face Spine Heart Abdomen Stomach Kidneys Bladder Extremities (mm) Brain 45-54 174 100% 98% 99% 25% 100% 95% 71% 98% 100% 55-64 400 100% 99% 99% 46% 100% 99% 85% 99% 100% 65-74 413 100% 99% 100% 58% 100% 100% 94% 100% 100% 75-84 157 100% 100% 100% 67% 100% 100% 96% 100% 100% Total 1,144 100% 99% 99% 50% 100% 99% 88% 99% 100%

Souka et al 2004

Gynecology and Obstetrics Gynecology and Obstetrics

The 11-13+6 weeks scan

Screening for structural defects

Author N Anomalies Prenatal diagnosis Total 11-13+6 weeks Hernandi and Torocsik, 1997 3,991 40 30 (75.0%) 11 (27.5%) Economides et al, 1998 1,632 13 10 (76.9%) 7 (53.8%) Carvalho et al, 2002 2,853 66 52 (78.8%) 25 (37.8%) Total 8,476 119 92 (77.3%) 43 (36.1%)

Head Acrania, encephalocele, holoprosencephaly, ventriculomegaly

Spine Spina bifida, kyphoscoliosis

Thorax Lungs: CDH, CCAM, sequestration; heart defects

Abdomen Omphalocele, gastroschisis, GI obstruction, renal defects

Extremities Skeletal dysplasias, amputations, arthrogryposis

Gynecology and Obstetrics Gynecology and Obstetrics

What anomalies do we miss? 11-14 WEEK SONOGRAM SUGGESTED GUIDELINES

• Crown-rump length • Abdominal CI • Heart rate • Stomach • Nuchal translucency • Bladder • BPD level • Sag/ coronal spine • Profile • Four extremities • TRV chest at heart • Hands • TRV abdomen • Feet

Gynecology and Obstetrics Gynecology and Obstetrics

The future… FUTURE DIRECTIONS

• Integrating first trimester screening and cfDNA in aneuploidy screening strategies • First trimester preeclampsia screening

Gynecology and Obstetrics Gynecology and Obstetrics

CELL FREE DNA CELL FREE DNA TERMINOLOGY

• NIDT – noninvasive DNA testing • NIPD – noninvasive prenatal diagnosis (Y chromosome specific sequences, RHD) • NIPT – noninvasive prenatal testing • NIPS – noninvasive prenatal screening

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SOURCES OF FETAL DNA CELL FREE DNA IN MATERNAL BLOOD

• Fetal cells • Released through apoptosis – 1 in 1 billion of total cell population – Fetal cfDNA likely arises from – Require isolation via mechanical cytotrophoblast cells of placenta and/or biochemical means • Released into bloodstream as small • Cell free DNA (cfDNA) DNA fragments (140-200 bp) – Maternal blood contains both • Reliably detected after 7 weeks of maternal and fetal cfDNA gestation – 2-20% of total cfDNA is fetal • Undetectable within hours postpartum Gynecology and Obstetrics Gynecology and Obstetrics

TEST COMPARISON TEST COMPARISON SENSITIVITY verifi® Harmony MaterniT21 NIPT Verinata Ariosa Sequenom Natera Result • Aneuploidy Detected Risk score • Positive Risk score Types • Aneuploidy Suspected incorporating • Negative incorporating • No Aneuploidy maternal, gestational maternal, gestational Detected age age T21 T18 T13 Assay <0.7% 4.6 – 4.9% 1% 5.9 – 12.6% Failure Rate Ariosa >99 >98 80 Sample 1 tube maternal blood 2 tubes maternal blood 2 tubes maternal 2-4 tubes maternal Natera >99 >99 >99 blood blood (best with paternal sample) Sequenom 99.1 >99.9 91.7 Egg Donors Yes (with data) No Yes No Verinata >99.9 97.4 87.5 Test Menu T21, T18, T13 T21, T18, T13 T21, T18, T13 T21, T18, T13 Optional sex Y chromosome Mandatory sex Sex chromosome chromosome (optional)(not chromosome aneuploidies (only aneuploidies (Published published) aneuploidies (not MX published) data) published) Published Large-scale, blinded Large-scale, blinded Large-scale, Small, blinded *From website Clinical clinical validation clinical validation blinded clinical clinical validation Speciﬁcities >99% ValidationGynecology and Obstetrics validation Gynecology and Obstetrics

POSITIVE SCREENING TEST POSITIVE SCREENING TEST FETAL KARYOTPE FETAL KARYOTPE

Not Detectable by NIPT Mosaicism 186 (6.2) Detectable by NIPT Other trisomy 92 (3.1) Trisomy 21 1592 (53.2) Insertion/Deletion 88 (2.9) Trisomy 18 511 (17.1) Structural abnormality 100 (3.3) Trisomy 13 139 (4.6) Balanced rearrangement 97 (3.2) Sex chromosome aneuploidy 247 (8.3) Unbalanced rearrangement 3 (0.1) Total 2489 (83.2) Triploidy 29 (1) Marker 9 (0.3) Total 504 (16.8)

Norton SMFM 2014 Gynecology and Obstetrics Gynecology and Obstetrics Norton SMFM 2014

FTS AND cfDNA CONTINGENT cfDNA ON SCREENING STRATEGIES COMBINED FTS IN THE UK

• Initial combined FTS • High risk result (≥ 1:100) offered CVS, cfDNA, or no further testing • Intermediate risk result (1:101-1:2500) offered cf DNA or no further testing • Low risk result (< 1:2500) not offered additional testing

Singapore Med J 2015;56:1 Gynecology and Obstetrics Gynecology and Obstetrics Ultrasound Obstet Gynecol 2016;47:45

CONTINGENT cfDNA ON CONTINGENT cfDNA ON COMBINED FTS IN THE UK COMBINED FTS IN THE UK • Overall detection rates – 91.5% trisomy 21 • 43% reduction in rate of invasive testing – 100% trisomy 18 • 74.4% trisomy 21 termination rate • FTS detection rate (FPR 3.4%) – 92.6% who chose invasive testing – 87% trisomy 21 – 35.7% who chose cfDNA – 93% trisomy 18 • 31.9% trisomy 21 live birth rate • cfDNA detection rate (FPR 0.25%) • Prenatal detection of trisomies depends – 98% trisomy 21 upon test performance and patient choice – 82% trisomy 18 Gynecology and Obstetrics Gynecology and Obstetrics Ultrasound Obstet Gynecol 2016;47:45 Ultrasound Obstet Gynecol 2016;47:45

FIRST TRIMESTER PREECLAMPSIA SCREENING

THANK YOU!

Gynecology and Obstetrics Womens Health 2016;12:199