Medicine:Noninvasive prenatal testing

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Short description: Medical procedure
Noninvasive prenatal testing
Other namesNIPT
SpecialtyMedical diagnosis, obstetrics and gynaecology

Noninvasive prenatal testing (NIPT) is a method used to determine the risk for the fetus being born with certain chromosomal abnormalities, such as trisomy 21, trisomy 18 and trisomy 13.[1][2][3] This testing analyzes small DNA fragments that circulate in the blood of a pregnant woman.[4] Unlike most DNA found in the nucleus of a cell, these fragments are not found within the cells, instead they are free-floating, and so are called cell free fetal DNA (cffDNA). These fragments usually contain less than 200 DNA building blocks (base pairs) and arise when cells die, and their contents, including DNA, are released into the bloodstream. CffDNA derives from placental cells and is usually identical to fetal DNA. Analysis of cffDNA from placenta provides the opportunity for early detection of certain chromosomal abnormalities without harming the fetus.[5]

Background

Non-Invasive Prenatal Testing, or NIPT, is a simple blood draw that screens for chromosomal abnormalities of a fetus while still in utero. When this screening was first performed it was used to determine the sex of a fetus, now it is also used to find aneuploidies in fetal DNA.[6] Aneuploidies are disorders in which a fetus has the incorrect number of chromosomes, either too many or not enough.[7] The use of ultrasound and biochemical markers to detect aneuploidies is usually done in the first and / or second trimester of pregnancy.[8] Aneuploidies is when a fetus retains an abnormal amount of haploid cells from their parents. However, both of these approaches have a high rate of false positive results of 2–7%.[9] If these tests indicate an increased risk of aneuploidy, then invasive diagnostic testing is used, such as amniocentesis or chorionic villus sampling. Many women, however, feel uncomfortable with the invasive testing, because of the risk associated with miscarriage, which is around 0.5%.[10] Noninvasive prenatal testing is an intermediate step between prenatal screening and invasive diagnostic testing. The only physical risk associated with the procedure is the blood draw and there is no risk of miscarriage.[11]

NIPT works by sampling cffDNA, which are small fragments of fetal blood DNA that comes from the placenta of the mother and flows in her blood vessels. Circulating cffDNA can be detected in maternal blood between the 5th and the 7th week of gestational age,[12] however more fetal DNA is available for analysis usually after 10 weeks, because the amount of fetal DNA increases over time.[13] cffDNA, RNA and intact fetal cells can all be used to assess the genetic status of the fetus non-invasively. Recent advances in DNA sequencing, such as massive parallel sequencing (MPS) and digital polymerase chain reaction (PCR), are currently under exploration for the detection of chromosomal aneuploidies via NIPT/NIPS.[14][15][16][17]

Since 2014, noninvasive testing has identified aneuploidies in chromosomes 13, 16, 18, 21, 22, X and Y, including Down syndrome (caused by trisomy 21), Edwards syndrome (caused by trisomy 18), Patau syndrome (caused by trisomy 13), as well as sex chromosome aneuploidies, such as Turner syndrome (45, X) and Klinefelter syndrome (47, XXY).[18][19][20] NIPT can also detect congenital heart disease such as atrioventricular septal defect, which can also be a side effect in the aforementioned chromosomal conditions.[21] These methods of cffDNA sequencing have sensitivity and specificity rates greater than 99% in identifying Trisomy 21. Sensitivity and specificity rates are lower for other aneuploidies, such as trisomy 18 (97–99% and > 99%, respectively), trisomy 13 (87–99% and > 99%, respectively), and 45, X (92–95% and 99%, respectively). The low false positive rate (1–3%) is one of the advantages of NIPT which allows pregnant women to avoid invasive procedures.[22] In the UK the Advertising Standards Authority has stated that one should not quote "Detection Rate" figures unless the figures are accompanied by (i.e. alongside) a robust "Positive Predictive Value" figure; and a clear explanations about what both figures mean.[23]

NIPT can determine paternity and may be able to determine fetal sex earlier in gestation than previous tests such as ultrasounds. It is recommended that the test be performed towards the end of the first trimester to the beginning of the second trimester, when there is enough cffDNA circulating in the mother's bloodstream to be detectable.[24] If the test is performed too early the test is more likely to yield a false negative result because there is not enough cffDNA in the sample. False negative results for NIPT would indicate that the fetus does not have a genetic abnormality when it actually does.[25][26] It is also used to determine fetal Rhesus D, which can prevent mothers who are Rhesus D negative from undergoing unnecessary prophylactic treatment.[27][28] Finally, it is used to detect genetic mutations, such as duplications or microdeletions, including 1p, 5p, 15q, 22q, 11q, 8q, and 4p. The sensitivity and specificity of these tests, however, for most have not yet been validated.[11]

The Natera SMART study however has shown that most cases of 22q11.2 deletion can be detected using SNP-based NIPT/NIPS (Panorama) including smaller nested deletions whilst still maintaining a low false positive rate.[29] Single nucleotide polymorphism (SNP) NIPT can also detect Triploidy and can differentiate between maternal and "fetal" DNA which reduces the redraw rate and allows determination of gender for each fetus in twin pregnancies and can be done from 9 weeks of pregnancy.[30][31]

For micro deletions such as DiGeorge syndrome, 1p36 deletion, Cri-du-chat syndrome, Wolf-Hirschhorn syndrome, Prader-Willi and Angelman syndromes, positive results can be incorrect as much as 85% of the time, according to a New York Times investigation.[32]

There is some ethical debate surrounding NIPT and eugenics, because the results of this test can lead to parents opting for abortion if the fetus tests positive for a genetic disorder.[33]

References

  1. ↑ Dondorp, Wybo; de Wert, Guido; Bombard, Yvonne; Bianchi, Diana W.; Bergmann, Carsten; Borry, Pascal; Chitty, Lyn S.; Fellmann, Florence et al. (2015). "Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening" (in en). European Journal of Human Genetics 23 (11): 1438–1450. doi:10.1038/ejhg.2015.57. ISSN 1476-5438. PMID 25782669. 
  2. ↑ Goldwaser, Tamar; Klugman, Susan (2018). "Cell-free DNA for the detection of fetal aneuploidy". Fertility and Sterility 109 (2): 195–200. doi:10.1016/j.fertnstert.2017.12.019. ISSN 0015-0282. PMID 29447662. 
  3. ↑ Rose, Nancy C.; Kaimal, Anjali J.; Dugoff, Lorraine; Norton, Mary E.; Medicin, American College of Obstetricians and Gynecologists' Committee on Practice Bulletins-ObstetricsCommittee on GeneticsSociety for Maternal-Fetal (2020). "Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226" (in en-US). Obstetrics & Gynecology 136 (4): e48–e69. doi:10.1097/AOG.0000000000004084. ISSN 0029-7844. PMID 32804883. 
  4. ↑ Skrzypek, Hannah; Hui, Lisa (2017-07-01). "Noninvasive prenatal testing for fetal aneuploidy and single gene disorders" (in en). Best Practice & Research Clinical Obstetrics & Gynaecology 42: 26–38. doi:10.1016/j.bpobgyn.2017.02.007. ISSN 1521-6934. PMID 28342726. https://www.sciencedirect.com/science/article/abs/pii/S1521693417300329. 
  5. ↑ "What is noninvasive prenatal testing (NIPT) and what disorders can it screen for?: MedlinePlus Genetics" (in en). https://medlineplus.gov/genetics/understanding/testing/nipt/. 
  6. ↑ Horton, Rachel Helen; Wellesley, Diana Gay (January 2019). "Extending non-invasive prenatal testing to non-invasive prenatal diagnosis" (in en). Archives of Disease in Childhood - Fetal and Neonatal Edition 104 (1): F6–F7. doi:10.1136/archdischild-2018-314845. ISSN 1359-2998. https://fn.bmj.com/lookup/doi/10.1136/archdischild-2018-314845. 
  7. ↑ Jayashankar, Siva Shantini; Nasaruddin, Muhammad Luqman; Hassan, Muhammad Faiz; Dasrilsyah, Rima Anggrena; Shafiee, Mohamad Nasir; Ismail, Noor Akmal Shareela; Alias, Ekram (2023-08-02). "Non-Invasive Prenatal Testing (NIPT): Reliability, Challenges, and Future Directions" (in en). Diagnostics 13 (15): 2570. doi:10.3390/diagnostics13152570. ISSN 2075-4418. PMID 37568933. 
  8. ↑ Jayashankar, Siva Shantini; Nasaruddin, Muhammad Luqman; Hassan, Muhammad Faiz; Dasrilsyah, Rima Anggrena; Shafiee, Mohamad Nasir; Ismail, Noor Akmal Shareela; Alias, Ekram (2023-08-02). "Non-Invasive Prenatal Testing (NIPT): Reliability, Challenges, and Future Directions" (in en). Diagnostics 13 (15): 2570. doi:10.3390/diagnostics13152570. ISSN 2075-4418. PMID 37568933. 
  9. ↑ Shamshirsaz, Alireza A.; Benn, Peter; Egan, James F.X. (2010-09-01). "The Role of Second-Trimester Serum Screening in the Post–First-Trimester Screening Era" (in en). Clinics in Laboratory Medicine 30 (3): 667–676. doi:10.1016/j.cll.2010.04.013. ISSN 0272-2712. PMID 20638580. https://www.sciencedirect.com/science/article/abs/pii/S0272271210000454. 
  10. ↑ Amniocentesis and Chorionic Villus Sampling (Green-top Guideline No. 8) rcog.org.uk 25 October 2021 Retrieved 30 March 2023
  11. ↑ 11.0 11.1 Allyse, Megan; Minear, Mollie A.; Berson, Elisa; Sridhar, Shilpa; Rote, Margaret; Hung, Anthony; Chandrasekharan, Subhashini (2015-01-16). "Non-invasive prenatal testing: a review of international implementation and challenges". International Journal of Women's Health 7: 113–126. doi:10.2147/IJWH.S67124. PMID 25653560. 
  12. ↑ Wright, Caroline F.; Burton, Hilary (2009). "The use of cell-free fetal nucleic acids in maternal blood for non-invasive prenatal diagnosis". Human Reproduction Update 15 (1): 139–151. doi:10.1093/humupd/dmn047. ISSN 1460-2369. PMID 18945714. 
  13. ↑ Chiu, Rossa W. K.; Lo, Y. M. Dennis (2011-04-01). "Non-invasive prenatal diagnosis by fetal nucleic acid analysis in maternal plasma: the coming of age" (in English). Seminars in Fetal and Neonatal Medicine 16 (2): 88–93. doi:10.1016/j.siny.2010.10.003. ISSN 1744-165X. PMID 21075065. https://www.sfnmjournal.com/article/S1744-165X(10)00090-9/abstract. 
  14. ↑ Sayres, Lauren C.; Cho, Mildred K. (2011). "Cell-Free Fetal Nucleic Acid Testing: A Review of the Technology and Its Applications" (in en-US). Obstetrical & Gynecological Survey 66 (7): 431–442. doi:10.1097/OGX.0b013e31822dfbe2. ISSN 0029-7828. PMID 21944155. 
  15. ↑ Hall, A.; Bostanci, A.; Wright, C. F. (2010). "Non-Invasive Prenatal Diagnosis Using Cell-Free Fetal DNA Technology: Applications and Implications" (in english). Public Health Genomics 13 (4): 246–255. doi:10.1159/000279626. ISSN 1662-4246. PMID 20395693. https://www.karger.com/Article/FullText/279626. 
  16. ↑ Hung, E. C. W.; Chiu, R. W. K.; Lo, Y. M. D. (2009-04-01). "Detection of circulating fetal nucleic acids: a review of methods and applications" (in en). Journal of Clinical Pathology 62 (4): 308–313. doi:10.1136/jcp.2007.048470. ISSN 0021-9746. PMID 19329710. https://jcp.bmj.com/content/62/4/308. 
  17. ↑ Lo, Y. M. D. (2009). "Noninvasive prenatal detection of fetal chromosomal aneuploidies by maternal plasma nucleic acid analysis: a review of the current state of the art" (in en). BJOG: An International Journal of Obstetrics & Gynaecology 116 (2): 152–157. doi:10.1111/j.1471-0528.2008.02010.x. ISSN 1471-0528. PMID 19076946. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/j.1471-0528.2008.02010.x. 
  18. ↑ Nicolaides, Kypros H.; Syngelaki, Argyro; Ashoor, Ghalia; Birdir, Cahit; Touzet, Gisele (2012-11-01). "Noninvasive prenatal testing for fetal trisomies in a routinely screened first-trimester population" (in English). American Journal of Obstetrics & Gynecology 207 (5): 374.e1–374.e6. doi:10.1016/j.ajog.2012.08.033. ISSN 0002-9378. PMID 23107079. https://www.ajog.org/article/S0002-9378(12)00913-1/abstract. 
  19. ↑ Zimmermann, Bernhard; Hill, Matthew; Gemelos, George; Demko, Zachary; Banjevic, Milena; Baner, Johan; Ryan, Allison; Sigurjonsson, Styrmir et al. (2012). "Noninvasive prenatal aneuploidy testing of chromosomes 13, 18, 21, X, and Y, using targeted sequencing of polymorphic loci" (in en). Prenatal Diagnosis 32 (13): 1233–1241. doi:10.1002/pd.3993. ISSN 1097-0223. PMID 23108718. 
  20. ↑ Palomaki, Glenn E.; Deciu, Cosmin; Kloza, Edward M.; Lambert-Messerlian, Geralyn M.; Haddow, James E.; Neveux, Louis M.; Ehrich, Mathias; van den Boom, Dirk et al. (2012). "DNA sequencing of maternal plasma reliably identifies trisomy 18 and trisomy 13 as well as Down syndrome: an international collaborative study" (in en). Genetics in Medicine 14 (3): 296–305. doi:10.1038/gim.2011.73. ISSN 1530-0366. PMID 22281937. 
  21. ↑ Pierpont, Mary Ella; Brueckner, Martina; Chung, Wendy K.; Garg, Vidu; Lacro, Ronald V.; McGuire, Amy L.; Mital, Seema; Priest, James R. et al. (2018-11-20). "Genetic Basis for Congenital Heart Disease: Revisited: A Scientific Statement From the American Heart Association" (in en). Circulation 138 (21). doi:10.1161/CIR.0000000000000606. ISSN 0009-7322. PMC 6555769. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000606. 
  22. ↑ Dickens, Bernard M. (2014). "Ethical and legal aspects of noninvasive prenatal genetic diagnosis" (in en). International Journal of Gynecology & Obstetrics 124 (2): 181–184. doi:10.1016/j.ijgo.2013.11.001. ISSN 1879-3479. PMID 24299974. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1016/j.ijgo.2013.11.001. 
  23. ↑ "Enforcement Notice - Advertising Non-invasive Prenatal Testing". https://www.asa.org.uk/resource/enforcement-notice-nipt.html. 
  24. ↑ Pan, Ci; Li, Zilong; Cheng, Guomei; Luo, Xiaohua; Nie, Fufang; Gao, Jing; Yang, Peifeng (2023-09-01). "Association between chromosome abnormities and prenatal diagnosis indicators screening in the second trimester of pregnancy". Medicine 102 (35). doi:10.1097/md.0000000000034762. ISSN 0025-7974. 
  25. ↑ Devaney, Stephanie A.; Palomaki, Glenn E.; Scott, Joan A.; Bianchi, Diana W. (2011-08-10). "Noninvasive Fetal Sex Determination Using Cell-Free Fetal DNA: A Systematic Review and Meta-analysis". JAMA 306 (6): 627–636. doi:10.1001/jama.2011.1114. ISSN 0098-7484. PMID 21828326. 
  26. ↑ Devaney, Stephanie A.; Palomaki, Glenn E.; Scott, Joan A.; Bianchi, Diana W. (2011-08-10). "Noninvasive Fetal Sex Determination Using Cell-Free Fetal DNA: A Systematic Review and Meta-analysis". JAMA 306 (6): 627–636. doi:10.1001/jama.2011.1114. ISSN 0098-7484. PMID 21828326. 
  27. ↑ Goodspeed, Taylor A.; Allyse, Megan; Sayres, Lauren C.; Norton, Mary E.; Cho, Mildred K. (2013-01-01). "Translating cell-free fetal DNA technology: structural lessons from non-invasive RhD blood typing" (in English). Trends in Biotechnology 31 (1): 7–9. doi:10.1016/j.tibtech.2012.09.001. ISSN 0167-7799. PMID 23040170. 
  28. ↑ Clausen, Frederik Banch (2014). "Integration of noninvasive prenatal prediction of fetal blood group into clinical prenatal care" (in en). Prenatal Diagnosis 34 (5): 409–415. doi:10.1002/pd.4326. ISSN 1097-0223. PMID 24431264. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/pd.4326. 
  29. ↑ <https://www.natera.com/resource-library/publications/smart-22q-1-2022-fully-published
  30. ↑ Dar, P.; Jacobsson, B.; MacPherson, C.; Egbert, M.; Malone, F.; Wapner, R. J.; Roman, A. S.; Khalil, A. et al. (2022). "Cell-free DNA screening for trisomies 21, 18, and 13 in pregnancies at low and high risk for aneuploidy with genetic confirmation". American Journal of Obstetrics and Gynecology 227 (2): 259.e1–259.e14. doi:10.1016/j.ajog.2022.01.019. PMID 35085538. https://www.ajog.org/article/S0002-9378(22)00041-2/fulltext. 
  31. ↑ "Panorama Overview V4". https://www.natera.com/womens-health/panorama-nipt-prenatal-screening. 
  32. ↑ Kliff, Sarah; Bhatia, Aatish (January 1, 2022). "When They Warn of Rare Disorders, These Prenatal Tests Are Usually Wrong". The New York Times. https://www.nytimes.com/2022/01/01/upshot/pregnancy-birth-genetic-testing.html. 
  33. ↑ on behalf of the European Society of Human Genetics (ESHG) and the American Society of Human Genetics (ASHG); Dondorp, Wybo; de Wert, Guido; Bombard, Yvonne; Bianchi, Diana W; Bergmann, Carsten; Borry, Pascal; Chitty, Lyn S et al. (October 2015). "Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening" (in en). European Journal of Human Genetics 23 (11): 1438–1450. doi:10.1038/ejhg.2015.57. ISSN 1018-4813. PMC 4613463. https://www.nature.com/articles/ejhg201557. 



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