IN THE NAME OF GOD

1. IN THE NAME OF GOD

2. CRITICALLY APPRAISED TOPIC • If there is a Non-invasive prenatal testing for aneuploidies with low FPR at first trimester? If we can predict some adverse obstetrics outcomes like diabetes,macrosomia,preterm delivery at first trimester?

3. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies M. M. Gil, M. S. Quezada, B. Bregant, M. Ferraro, K. H. Nicolaides Volume 42, Issue 1, Date: July 2013, pages 34–40

4. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Objective To explore the feasibility of routine maternal blood cfDNA testing in screening for trisomies 21, 18 and 13 at 10 weeks’ gestation.

5. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Patients and Methods • Prospective observational study • Singleton pregnancy and live fetus with CRL 32–45 mm • Women attending The Fetal Medicine Centre, London, between October 2012 and April 2013, were screened for trisomies 21, 18 and 13 by cfDNA testing at 10 wks and the combined test at 12 wks

6. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 • Clinical visit at 10 weeks: • CRL • Maternal blood sample • Clinical visit at 12 weeks: • Ultrasound scan:CRL,NT,NB,TR,DV,major abnormalities Pretest counseling

7. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Patients and Methods cfDNA test result for risk for trisomies 21, 18 and 13 High risk CVS at 12 weeks Further management Low risk Anomaly scan at 20 weeks for all Growth scan at 32 weeks for all Additional scan at 16 wks if: Fetal NT >3.5 mm TR, abnormal DV a-wave All cases No result NT>3.5 mm or major defects High risk on combined test Additional scan at 28 wks if: PAPP-A <0.3 MoM Protocol for pregnancy management according to results of maternal blood cfDNA testing and the combined test

8. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Results Presentation at 10 weeks (n=1111) Median maternal age of 37 (range 20-49) years; 98% had results within 14 days Appropriate (n=941; 84.7%) Inappropriate (n=170; 15.3%) CRL <32 mm (n=64; 5.8%) cfDNAtesting (n=1005) CRL >45 mm (n=50; 4.5%) Result (n=775; 95.2%) No result (n=48; 4.8%) Miscarriage (n=46; 4.1%) n=64 No trisomy (n=940) Twins (n=6; 0.9%) Repeat blood draw (n=40) Trisomy 21 (n=11) No result (n=13; 32.5%) Result (n=27; 67.5%) Trisomy 18 (n=5) No trisomy (n=27) Trisomy 13 (n=1)

9. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Results Findings/outcomes in the 17 pregnancies classified by cfDNAtesting as being at high risk for aneuploidy

10. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Discussion • Study demonstrates the feasibility of implementing cfDNA testing in early pregnancy screening for trisomies in singleton pregnancies • Blood sampling at 10 weeks and USS at both 10 and 12 weeks retains the advantage of 1st trimester diagnosis as for the combined test • It is necessary to confirm +ve results of cfDNA testing by fetal karyotyping, as one of the cases of suspected trisomy 18 had a normal karyotype • In this population (median maternal age, 36.7 yrs), the screen-positive rate on cfDNA testing was 1.7% vs5.0% for the combined test (risk cut-off 1:100)

11. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Discussion • The main advantages of cfDNA testing, compared with the combined test, are: • Substantial reduction in FPR • Reporting of results as very high or very low risk, which makes it easier for parents to decide in favour of or against invasive testing • cfDNA testing has substantially reduced the rate of invasive testing but some women still desire a diagnostic test to provide certainty of exclusion of not only the common trisomies but all other aneuploidies

12. Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies Gil et al., UOG 2013 Conclusions • This study has shown that routine screening for trisomies by cfDNA testing at 10 weeks is feasible, allowing diagnosis of aneuploidies and the option of pregnancy termination within the first trimester • Advantages of cfDNA testing: • Substantial reduction in FPR • Clear separation of high and low risk results • Disadvantages of cfDNA testing: • Need to investigate abnormal results by invasive testing

13. THANKS FOR YOUR ATTENTION

14. CRITICALLY APPRAISED TOPIC • CLINIAL SCENARIO: • A 40 y women G2P1, GA=10w referred for screening tests. She had a history of preterm delivery and GDM in previous pregnancy .If NIPT (cf DNA) is a sensitive test for early screening of trisomies? If we can predict adverse obstetric out comes like preterm delivery at first trimester?

15. SEARCH STRATEGY: • Patient/Client Group: Pregnant women between 11 week and 13 weeks and 6 days. • Intervention (or Assessment): If screen tests and placental perfusion tests predict adverse obstetric out comes at first trimester? • Outcome(s): 1) Predict adverse obstetric out comes • 2) Early screening for aneuploidies with lower false positive rate.

16. Level of evidence: • Implementation of maternal blood cell-free DNA testing in early screening for aneuploidies. 2a(2013). • First-Trimester Prediction of Macrosomia. 2a (2010). • Prediction of spontaneous preterm delivery from maternal factors, obstetric history and placental perfusion and function at 11–13 weeks. 2a (2011). • Prediction of gestational diabetes mellitus by maternal factors and biomarkers at 11 to 13 weeks.2b (2011).

17. Summary/Conclusion • According to this finding: • We can use cfDNA test with low FPR for early screening of aneuploidies. • At first trimester combining of maternal characteristics and biochemical testing predict GDM and macrosamia in pregnancy. • Placental perfection testes at 11-13 weeks are not altered in pregnancies resulting in spontaneous early delivery but the risk of preterm delivery is provided by maternal factors and obstetric history.