1. By Dr. Shumaila Zia Assistant Professor
PRENATAL DIAGNOSIS By
Dr. Shumaila Zia
Assistant Professor

2. Prenatal Diagnosis
Over the last 4 decades, the genetic basis of an increasing number of diseases is becoming understood. At the same time, safe and effective fetal diagnostic techniques are being developed.

3. Fetal medicine
Only in the past few decades has the fetus been considered a patient and become the subject of extensive scientific study and attempts at treatment. Fetal medicine is a complex multidisciplinary undertaking with a team
Fetal diagnosis
Fetal Therapy

4. Prenatal Diagnosis of fetal Abnormalities
Benefits:
Malformation incompatible with life may be terminated.
Certain abnormalities may be correctible in-utero.
-Provides opportunity to arrange corrective measures before hand.
- offer a chance to be delivered at a place where the required facilities are available.
4. Parents decision to continue pregnancy/ mentally prepare to have a handicapped child.

5. Classification of Congenital Abnormalities
Chromosomal Abnormalities: Trisomy 21 (D.S)
- Trisomy 18 (E.S)
- Trisomy 13 (P.S)
Structural Abnormalities: CNS
CVS
GIT
Bone
Renal system
Genetic Disorders: Inborn error of metabolism
- Haemoglobinopathies

6. What Should We Do?
Every pregnancy should be evaluated with the most definite test.
Practically & economically not feasible because
expensive
Invasive
Worldwide practice is to carry out
-Screening procedures
-Definite (diagnostic)tests for screening
positive cases

7. Screening Procedures
These are: - Simple - Cheap - Least invasive - safe - Easily repeatable

8. Screening Procedures --- Cont.
History:
- Increasing maternal age
- Congenital anomalies in previous children
- F/Hx.
. Still birth
. Recurrent 1st trimester abortion
. Cousin marriage

9. Screening Procedures ---Cont.
2. Features of current pregnancy: - Drug intake(antiepileptics e.g. warfarin, alcohol, smoking) - Radiation exposure - Maternal ch. diseases e.g.DM, cardiac, renal - Uterine fundas large/ small for date - Decrease fetal movements - Fetal malpresentation - Viral infection in early pregnancy

10. Screening Procedures --- Cont.
3. Ultrasonography: - Screening tool in all trimesters - At weeks if fetal nuchal translucency - > 2.5 mm- chromosomal anomalies association - At weeks 75% fetal abnormalities can be diagnose

11. 1st Trimester Ultrasound
NT Ultrasound

12. Cleft lip and palate

13. Ventriculomegaly

14. Posterior Urethral Valve

15. Multicystic Dysplastic kidney

16. Multicystic Dysplastic kidney

17. Screening Procedures ---Cont.
4. Maternal blood tests: - Maternal Serum alpha fetoproteins: . Produced by . Fetus &enter in maternal circulation. . Yolk sac in first trimester . Liver in second and third trimester . Normally increase from weeks . Abnormally raise on fetal capillaries exposure to amniotic fluid e.g. in NTD.

18. Maternal S. alpha fetoproteins --cont.
- Raised level in neural tube defect(NTD). - Screen for NTD at weeks if +ve confirm with detailed USG. - Also raised in following conditions: . Miscalculated dates . Multiple pregnancies . Threatened abortion . IUD . Teratoma . Congenital nephrosis . Ant. Abdominal wall defects

20. MSAFP

21. Triple Test - Used for Down Synd. Screening. It comprises . AFP . hCG
. uE3 (unconjugated oestriol )
- Best carried at weeks. In DS AFP & uE3 are low while hCG is raised
- Triple test+ maternal age diagnose 60% DS
- In trisomy 18 all above components are low

22. Quadruple test Triple test+ Inhibin A estimation
This test + maternal age detects 76% DS

23. Double Test
Low pregnancy associated plasma proteins-A (PAPP-A) level and raised serum Beta-hCG during 1st trimester
Double test+ maternal age diagnose 60% DS.

27. DIAGNOSTIC TESTS For high risk women on basis of screening tests
An ideal test should be :
- Least invasive
- diagnose c. abnormality in early pregnancy.
- Minimally interfering developing pregnancy
Diagnostic tests are also not risk free.

28. Counselling Organize an appointment Couple should be present Explain:
- Risk of occurance of c. abnormality
- All tests available, their procedure, cost, diagnostic ability and benefits, possible risks
- Possible management plain
If termination of pregnancy is unacceptable diagnostic tests would be fruitless.

29. NON INVASIVE TESTS Ultrasonography:
Diagnostic USG is different from screening USG,
- It takes longer time
- Dx. Wide range of c. anomalies
- Non invasive and diagnosis at spot possible
- But possible only at large gestational age
Colour doppler further enhance the capability especially for cardiac malformations and renal agenesis.

30. Other Soft Signs short ears cerebellar hypoplasia cholecystomegaly
Mild cerebral ventriculomegaly
Hypoplasia of middle phalanx of 5th digit
Increased Iliac angle
Short frontal lobe

31. What are the 2T soft signs?
Increased nuchal thickness
short femur or humerus
Pylectasis
echogenic foci in heart
Echogenic Bowel
choroid plexus cysts

32. INVASIVE TESTS AMNIOCENTESIS:
Aspiration of amniotic fluid which contain fetal cells
Fluid can be used for estimation of
- bilirubin level (for fetal haemolytic disease).
- AFP
-Acetyl cholinesterase
Cells used for karyotyping (Chromosomal dis.)
Fetal cells-cultured for 3 weeks- karyotyping.
New technique-PCR, FISH-give result in 48 h.
Preferred time of test 16weeks of pregnancy.

33. AMNIOCENTESIS---Cont.
Procedure:
Preliminary USG to confirm-duration of gestation, -placental site,- adequacy of liqour ( ml)
Sterilize the abdomen
22 G spinal needle is used.
About 20 cc amniotic fluid is withdrawn.
Give Anti- D to all Rh-ve mothers.
Ask rest for 30 min.& restrict movements for 48h

34. Amniocentesis

35. AMNIOCENTESIS---Cont.
Limitations (difficulties)of procedure: if
- Anteriorly placed placenta
- Multiple pregnancy.
- Maternal obesity
- Oligohydramnios
Risks:
- Pregnancy loss 1 % Bleeding , Infection,
- Rupture of membrane - Preterm labour&IUD
- Leaking of Amniotic fluid
- Increase risk of RDS in newborn

36. CHORIONIC VILLUS SAMPLING
Collection of fragments of placental tissue (chorionic villi)- cells are examined for Dx. of C.Anomalies.
Cytotrophoblastic (rapidly dividing) cells are used for direct karyotyping- result available within h.
Chorionic villi are best source of DNA
CVS can be performed at 10 weeks gestation.
Indications:
1-DNA analysis for SCD,thallasemias, CF. hemophillias
2-Chromosomal abnormalities
3-Inborn error of metabolism

37. CHORIONIC VILLUS SAMPLING
Procedure:
Trans-abdominal approach preferred –under USG guidance in supine position
Trans-cervical approach is easy.
In lithotomy position, sterilize area & Aspiration catheter and biopsy forceps.
Introduce through Cx. under USG into placental tissue avoiding membrane rupture
Risks: Pregnancy loss 2-6%
Before 10 weeks- associated with limb deformities, micrognathia, microglassia

40. FETAL BLOOD SAMPLING (FBS)
Fetal blood- lymphocyte are rapidly cultured, results within hours.
Indications: 1- Prenatal Dx. DNA available for Cytogenetic studies In failed amniocentesis, and mosaicism in chorion or amniotic fluid.
2-Fetal assessment: for red cell alloimmunization, (Hb;Hc,TrF) Hydrops fetalis, viral infection, platelets alloimmunization
Unfortunately Associated with highest rate of fetal loss.
Currently used for blood transfusion in-utero in fetal A.

41. FETAL BLOOD SAMPLING (FBS)
Procedure : (cordocentesis):
The sites for FBS are placental insertion of umbilical cord, abdominal insertion of cord, intrahepatic fetal vein and fetal heart.
Suitable time is weeks
Risks:
- Bleeding from site of puncture
- Cord haematoma
- Fetal bradycardia
- Fetal death

42. EMBRYOSCOPY & FETOSCOPY
Direct visualization of embryo and fetus.
Limited field of vision.
Provide information only about external fetal structures .

43. NEW MOLECULAR ANALYTIC TECHNIQUES
Fetal cell obtained by CVS and Amniocentesis can be used for prenatal Dx. For congenital anomalies by following new techniques
1- Southern blotting:
Cleavage of chromosomal DNA at specific
sites and used for tests
2- PCR
3- FISH

44. Polymerase chain reaction (PCR)
Amplify specific DNA and RNA fragments
Once nucleotide sequence of a region of DNA strand is known, complimentary oligonucleotides & polymerase are added to single strand DNA
Repeat process 30 times to get adequate DNA
PCR identify specific DNA sequence for gene mutation & prenatal Dx. at an earlier stage before an embryo transfer in IVF cycle.

45. FLOURESCENT IN SITU HYBRIDIZATION
FISH allows detection & localization of specific DNA sequence in interphase or metaphase.
Advantage – results available in h.
Disadvantage – fail to detect big structural rearrangements
Identify 80% clinically relevant abnormalities, helpful for early decision about further management of affected pregnancies.

46. MANAGEMENT OF FETAL C. ANOMALIES
It is a tedious task, requires skillful, sympathetic & professional approach.
Management options
- Termination of pregnancy
- In- utero management if possible
- Conservative management

47. POSTPARTUM MANAGEMENT OF C.A.
For better understanding of congenital anomalies
and its impact on future reproductive performance of
couple, following procedures are carried out on
affected babies/ abortusses:
Physical examination /postmortem
Fetal tissue(blood, skin, placenta) for karyotyping
Placenta and membrane for histopathology
Placental & baby swab for microbiology & virology.
Baby gram (x-rays of whole baby)
Baby photograph

48. THANKS