Non-invasive Prenatal Diagnostic Testing Research Articles

Non-invasive prenatal testing: ethical issues explored

This paper explores the ethical implications of introducing non-invasive prenatal diagnostic tests (NIPD tests) in prenatal screening for foetal abnormalities. NIPD tests are easy and safe and can be performed early in pregnancy. Precisely because of these features, it is feared that informed consent may become more difficult, that both testing and selective abortion will become 'normalized', and that there will be a trend towards accepting testing for minor abnormalities and non-medical traits as well. In our view, however, the real moral challenge of NIPD testing consists in the possibility of linking up a technique with these features (easy, safe and early) with new genomic technologies that allow prenatal diagnostic testing for a much broader range of abnormalities than is the case in current procedures. An increase in uptake and more selective abortions need not in itself be taken to signal a thoughtless acceptance of these procedures. However, combining this with considerably enlarging the scope of NIPD testing will indeed make informed consent more difficult and challenge the notion of prenatal screening as serving reproductive autonomy. If broad NIPD testing includes later-onset diseases, the 'right not to know' of the future child will become a new issue in the debate about prenatal screening. With regard to the controversial issue of selective abortion, it may make a morally relevant difference that after NIPD testing, abortion can be done early. A lower moral status may be attributed to the foetus at that moment, given the dominant opinion that the moral status of the foetus progressively increases with its development.

Will the introduction of non-invasive prenatal diagnostic testing erode informed choices? An experimental study of health care professionals

Objective Informed choice is a fundamental concept within prenatal care. The present study assessed the extent to which the introduction of non-invasive prenatal diagnosis (NIPD) of Down's syndrome may undermine the process of making informed choices to undergo prenatal testing or screening for Down's syndrome by altering the quality and quantity of pre-test counselling. Methods 231 obstetricians and midwives were randomly allocated one of three vignettes, each describing a different type of test: (a) invasive prenatal diagnosis (IPD), (b) non-invasive prenatal diagnosis (NIPD) or (c) Down's syndrome screening (DSS). Participants were then asked to complete a questionnaire assessing (1) the information considered important to communicate to women, (2) whether test offer and uptake should take place on different days, and (3) whether signed consent forms should be obtained prior to testing. Results Across the three test types, five out of the seven presented topics were considered equally important to communicate, including the information that testing is the woman's choice. Compared with participants receiving the IPD vignette, those receiving the NIPD and DSS vignettes were less likely to report that counselling and testing should occur on different days (IPD 94.7% versus 74.1% and 73.9% for NIPD and DSS respectively, p = .001) and that written consent was a necessity (IPD 96.1% versus 68.3% and 75.4% for NIPD and DSS respectively, p < .001). Conclusion This study provides the first empirical evidence to demonstrate that practitioners may view the consent process for NIPD differently to IPD. There is potential for the introduction of NIPD to undermine women making informed choices in the context of prenatal diagnostic testing for conditions like DS. Practice implications Given the importance of informed choice in reproductive decision-making, implementation of any programme based on NIPD should be designed to facilitate this.

Non-invasive fetal sex determination: Impact on clinical practice

Prenatal fetal sex determination is undertaken in women at high risk of serious genetic disorders affecting a specific sex. Traditionally, this is undertaken by invasive testing, usually chorionic villus sampling, which carries a risk of miscarriage of around 1%. The identification of cell-free fetal DNA in the maternal circulation has allowed the development of 'non-invasive prenatal diagnostic tests', which permit fetal sex determination without risk to the pregnancy.

C21ORF105, A chromosome 21‐encoded mRNA, is not a discriminative marker gene for prediction of Down syndrome in maternal plasma

The presence and detectability of placental mRNA in maternal plasma opens possibilities for the development of non-invasive prenatal diagnostic tests. In this study, we tested C21orf105, a chromosome 21-encoded, placentally expressed gene, in maternal plasma of women carrying a fetus with or without trisomy 21. Using real-time RT-PCR, we determined transcript levels of target (C21orf105) and reference (hPL) genes in first-trimester plasma samples. Plasma was obtained from first-trimester EDTA blood after two sequential centrifugation steps and stored at -70 degrees C. After RNA extraction, quantitative RT-PCR was performed using Taqman probes. From the 51 samples, 43 samples were conclusive. Comparison of transcript levels of C21orf105 in both groups showed no significant differences. When expressed as ratios of hPL/C21orf105, the differences between trisomy 21 and normal pregnancies remained non-significant. The amount of C21orf105 mRNA in maternal plasma, although situated in the Down syndrome critical region on chromosome 21 and up regulated in trisomy 21 placentas, is not higher in women carrying a fetus with trisomy 21.

Quantification of fetal nucleated cells in maternal blood of pregnant women with a male trisomy 21 fetus using molecular cytogenetic techniques

Prenatal diagnosis of trisomy 21 is based on fetal karyotyping generally obtained using invasive methods. During pregnancy, the circulating fetal cells in maternal blood constitute a potential source for development of a noninvasive prenatal diagnosis. The objective of this study was the identification and quantification of all fetal nucleated cells per unit volume of peripheral blood of pregnant women carrying male fetuses with trisomy 21 using molecular cytogenetic techniques. Peripheral blood samples were obtained from 16 women carrying male fetuses with trisomy 21. We used a simple and rapid method of harvesting blood without recourse to any enrichment procedures or cell-separation techniques. To evaluate the potential of this method, 16 specimens were analyzed by molecular cytogenetic techniques such as fluorescence in situ hybridization (FISH) and primed in situ labeling (PRINS) using specific probes to chromosomes X, Y and 21. The number of fetal cells varied between 6 and 32 per mL of maternal blood. This number is 3-5 times higher than that from normal pregnancies. Our current results are in agreement with the results previously reported by other groups showing that the number of fetal cells in maternal blood in trisomic 21 pregnancies is higher than in normal pregnancies. This high number of fetal cells is regarded as an advantage for the development of a noninvasive prenatal diagnostic test.

Methods to Increase the Percentage of Free Fetal DNA Recovered From the Maternal Circulation

Present invasive methods for detecting fetal chromosomal abnormalities, although quite reliable, carry a risk of pregnancy loss. Many candidates for such testing reject it for this reason. An alternative is to recover fetal cells and fetal DNA from the maternal circulation, as has been done to determine fetal gender. In the hope of increasing the recovery of free fetal DNA, the investigators determined whether inhibiting cell lysis at all stages with formaldehyde would increase the proportion of free fetal DNA in maternal blood samples. Initially, 2 blood samples were taken from each of 10 pregnant women to compare the percentage of free fetal DNA in treated and untreated samples. Treated samples were exposed to 4% weight per volume of formaldehyde. In a second phase, free fetal DNA was measured in 69 formaldehyde-treated maternal blood samples collected from 27 clinical sites in 16 states. In the initial phase of the study, untreated and formaldehyde-treated maternal blood samples contained a mean of 7.7% and 20.2%, respectively, of free fetal DNA. In several untreated samples, DNA levels were substantially below the median. In the second phase, a median of 25% free fetal DNA was detected in the treated maternal blood samples. Only 16% of samples contained less than 10% fetal DNA, whereas 27.5% had 50% or more. Inhibiting cell lysis by treating maternal blood samples with formaldehyde clearly increases the relative percentage of free fetal DNA recovered. Hopefully this work will help in developing a noninvasive prenatal diagnostic test for detecting fetal chromosomal abnormalities.

Methods to increase the percentage of free fetal DNA recovered from the maternal circulation.

Noninvasive prenatal diagnostic tests using free fetal DNA provide an alternative to invasive tests and their attendant risks; however, free fetal DNA exists in the maternal circulation at low percentages, which has hindered development of noninvasive tests. To test the hypothesis that using formaldehyde to reduce cell lysis could increase the relative percentage of free fetal DNA in samples of maternal blood. The first phase of the study was conducted from January through February 2002 at a single US clinical site; 2 samples of blood were collected from each of 10 pregnant women, and the percentage of free fetal DNA in formaldehyde-treated and untreated samples was determined. The second phase of the study was conducted from March 2002 through May 2003, and measured the percentage of free fetal DNA in 69 formaldehyde-treated samples of maternal blood obtained from a network of 27 US clinical sites in 16 states. Percentage of free fetal DNA in samples of maternal blood. In the first phase of the study, the mean percentage of free fetal DNA in the untreated samples was 7.7% (range, 0.32%-40%), while the mean percentage of free fetal DNA in the formaldehyde-treated samples was 20.2% (range, 1.6%-40%) (P =.02 for difference). In the second phase, a median of 25% (range, 3.1% to >50%) free fetal DNA was obtained for the 69 formaldehyde-treated maternal blood samples. Approximately 59% of the samples in this study had 25% or greater fetal DNA, and only 16% of the samples had less than 10% fetal DNA. In addition, 27.5% of the samples in this study had 50% or greater fetal DNA. Addition of formaldehyde to maternal blood samples, coupled with careful processing protocols, increases the relative percentage of free fetal DNA, providing a foundation for development of noninvasive prenatal diagnostic tests to distinguish fetal DNA from maternal DNA in the maternal circulation.

Recent advances in prenatal screening and diagnosis of genetic disorders.

In any pregnancy, there is an approximate 3% to 5% chance that a fetal complication will occur. The most familiar prenatal diagnostics cannot be performed until the fetus is well into gestation, and most involve invasive procedures along with their inherent risks. In light of these facts, many noninvasive prenatal screening and diagnostic tests have been developed, the newest using recombinant deoxyribonucleic acid (DNA) technology in the examination of fetal cells. Through these procedures, genetic coding errors and chromosomal disruptions may be detected. This article discusses the currently available prenatal and screening diagnostic tests for genetic disorders with a focus on the latest technology.

Smith-Lemli-Opitz Syndrome

Smith-Lemli-Opitz syndrome (SLOS) is a genetic condition characterized by dysmorphic facies, mental retardation and multiple malformations. A specific defect in cholesterol metabolism, 7-dehydrocholesterol-Δ7 reductase (DHCR7) deficiency due to mutation of theDHCR7gene is the underlying cause of this syndrome. DHCR7 is a microsomal enzyme that catalyzes the conversion of 7-dehydrocholesterol (7DHC) to cholesterol. Hence, affected individuals exhibit low plasma cholesterol and high 7DHC levels. The phenotype most likely results from the combination of cholesterol deficiency and 7DHC accumulation. Diagnosis is based on clinical findings with confirmation by plasma sterol analysis. Prenatal diagnosis may be performed by sterol analysis of amniotic fluid/amniocytes or chorionic villi, or enzyme assay of chorionic villi. Maternal serum estriol and urine sterol analyses provide the opportunity for noninvasive prenatal diagnostic testing. Preliminary evidence from animal and human studies shows that dietary cholesterol supplementation may be beneficial for SLOS patients, but issues including prenatal onset of damage plus poor transport of cholesterol across the blood-brain barrier may limit treatment efficacy. The incidence of SLOS has been estimated to be one in 20,000 to one in 60,000 making it one of the most common autosomal recessive disorders. Recent studies suggest that the carrier frequency is much higher than the disease incidence would suggest.▪ The Endocrinologist 2000; 10: 300-313

Investigation of maternal blood enriched for fetal cells: role in screening and diagnosis of fetal trisomies.

Prenatal diagnosis of chromosomal abnormalities relies on assessment of risk followed by invasive testing in the group with highest risk. Assessment of risk by a combination of maternal age and fetal nuchal translucency and invasive testing in the 5% of the population with the highest risk would identify about 80% of trisomy 21 pregnancies. Preliminary reports suggest that chromosomal abnormalities can also be diagnosed by fluorescent in situ hybridization (FISH) in maternal blood enriched for fetal cells. This study examines the potential role of this method on the prenatal diagnosis of fetal trisomies. Maternal blood was obtained before invasive testing in 230 pregnancies at 10-14 weeks of gestation. After enrichment for fetal cells, by triple density centrifugation and anti-CD71 magnetic cell sorting, FISH was performed and the proportion of cells with positive signals in the chromosomally normal and abnormal groups was determined. Fetal karyotype was normal in 150 cases and abnormal in 80 cases, including 36 with trisomy 21. Using a 21 chromosome-specific probe, three-signal nuclei were present in at least 5% of the enriched cells from 61% of the trisomy 21 pregnancies and in none of the normal pregnancies. For a cut-off of 3% of three-signal nuclei the sensitivity for trisomy 21 was 97% for a false positive rate of 13%. Similar values were obtained in trisomies 18 and 13 using the appropriate chromosome-specific probe. Examination of fetal cells from maternal blood may provide a noninvasive prenatal diagnostic test for trisomy 21 with the potential of identifying about 60% of affected pregnancies. Alternatively, this technique can be combined with maternal age and fetal nuchal translucency as a method of selecting the high-risk group for invasive testing. Potentially, 80% of trisomy 21 pregnancies could be identified after invasive testing in less than 1% of the pregnant population.

The use ofin vitro expanded erythroid cells in a model system for the isolation of fetal cells from maternal blood

The development of a non-invasive prenatal diagnostic test using fetal nucleated red blood cells (NRBCs) isolated from the maternal circulation is hampered by the low frequency of these cells in maternal blood, requiring extensive enrichment procedures before any analytical procedure can be performed. In order to improve and simplify these procedures, we have used in vitro expanded erythroid cells derived from male umbilical cord blood in a model system for the isolation of fetal NRBCs from maternal blood. Erythroblast cells were expanded in vitro to high cell numbers and were immunophenotypically identical to fetal NRBCs isolated from maternal blood. Magnetic activated cell sorting (MACS) isolation procedures were optimized using in vitro expanded male NRBCs diluted up to 1 in 400,000 with female peripheral blood mononucleated cells. The number of recovered male cells was determined using two-colour fluorescence in situ hybridization with X and Y chromosomal probes. Using this model system, an NRBC isolation technique is described. It is based on a one-step MACS enrichment protocol for CD71 positive cells, which showed a significant (Wilcoxon signed ranks test, p<0.05) two-fold higher yield of male NRBCs than previously described MACS methodologies, in which CD71 positive cells were enriched after depletion of other cell types. Application of these isolation strategies to maternal blood samples resulted in a similar improved enrichment of male fetal cells after the direct enrichment of CD71 positive cells.

The use of in vitro expanded erythroid cells in a model system for the isolation of fetal cells from maternal blood

The development of a non-invasive prenatal diagnostic test using fetal nucleated red blood cells (NRBCs) isolated from the maternal circulation is hampered by the low frequency of these cells in maternal blood, requiring extensive enrichment procedures before any analytical procedure can be performed. In order to improve and simplify these procedures, we have used in vitro expanded erythroid cells derived from male umbilical cord blood in a model system for the isolation of fetal NRBCs from maternal blood. Erythroblast cells were expanded in vitro to high cell numbers and were immunophenotypically identical to fetal NRBCs isolated from maternal blood. Magnetic activated cell sorting (MACS) isolation procedures were optimized using in vitro expanded male NRBCs diluted up to 1 in 400 000 with female peripheral blood mononucleated cells. The number of recovered male cells was determined using two-colour fluorescence in situ hybridization with X and Y chromosomal probes. Using this model system, an NRBC isolation technique is described. It is based on a one-step MACS enrichment protocol for CD71 positive cells, which showed a significant (Wilcoxon signed ranks test, p<0·05) two-fold higher yield of male NRBCs than previously described MACS methodologies, in which CD71 positive cells were enriched after depletion of other cell types. Application of these isolation strategies to maternal blood samples resulted in a similar improved enrichment of male fetal cells after the direct enrichment of CD71 positive cells. Copyright © 1999 John Wiley & Sons, Ltd.