Chinese Medical Journal 2013;126 (11)

2007

Original article
Genetic counseling, prenatal screening and diagnosis of Down
syndrome in the second trimester in women of advanced maternal
age: a prospective study
QI Qing-wei, JIANG Yu-lin, ZHOU Xi-ya, LIU Jun-tao, YIN Jie and BIAN Xu-ming
Keywords: genetic counseling; advanced maternal age; Down syndrome; prenatal screening; genetic amniocentesis; second
trimester
Background The incidence of autosomal trisomy in livebirths is strongly dependent on maternal age. Special
consideration is given to the provision of prenatal screening and cytogenetic testing to women of advanced maternal age
(AMA). The aim of this study was to evaluate the effectiveness of second trimester prenatal screening and amniocentesis
for Down syndrome (DS) and compare the trends of choice of screening and amniocentesis among AMA women.
Methods A total of 5404 AMA patients with natural singleton pregnancy were recruited for this prospective study from
January 2008 to December 2010. The gestational weeks were from 15 weeks to 20+6 weeks. The patients referred were
grouped into a screening group (2107 cases) and an amniocentesis group (3297 cases) by their own decision. The
prevalence of DS was compared between the two groups by chi-square test. Choice rates for each maternal age with
trends were compared by regression analysis.
Results There were 18 cases of fetal DS detected in the screening group with a prevalence of 8.54 (18/2107). Twentyfive cases of fetal DS were diagnosed in the amniocentesis group with a prevalence of 7.58 (25/3297). No statistical
difference was observed in the prevalence of DS between the screening and amniocentesis group (P=0.928). The invasive
testing rate for DS in the amniocentesis group was 5.54 times higher than that of the screening group (1/131.88 vs.
1/23.78). With the increase of the maternal age, the choice of amniocentesis increased while the choice of the screening
showed an opposite trend. The choice of the AMA women between the screening and amniocentesis was significantly age
relevant (P=0.012).
Conclusions The second trimester serum screening in combination with maternal age was more effective than maternal
age alone to screen for DS. We suggest educating the patients by recommending AMA women be informed of both
screening and amniocentesis options.
Chin Med J 2013;126 (11): 2007-2010

own syndrome (DS) is the most common chromosomal

aneuploidy diagnosed in neonates, affecting
approximately one child in 800. 1 Advanced maternal
age (AMA), usually defined as greater than 35 years old
at delivery, has remained the most common indication for
genetic amniocentesis in many countries since the early
1970s. However, this strategy has become suspect in the past
decade.2-5 In China, the age alone is still recommended as the
single risk parameter to offer the second trimester genetic
amniocentesis based on the health law of the government.

on the maternal age is being debated in China. It is very

important for the physician to provide appropriate genetic
counseling to AMA women to help them to choose the
option that best supports their choice. The data about the
efficacy of screening in AMA women was very limited in
China.11 Based on this background, this prospective study
was undertaken to evaluate and compare the efficacy of
second trimester maternal serum screening and genetic
amniocentesis in the Peking Union Medical College
Hospital (PUMCH).

Prenatal screening for aneuploidy has evolved and

advanced significantly over the last decade.6-8 In China,
non-invasive screening for aneuploidy has been offered to
women less than 35 years of age in the second trimester.9
The recent American College of Obstetrics and Gynecology
(ACOG) Practice Bulletin recommended that screening
and invasive diagnostic testing for aneuploidy should be
available to all women who present for prenatal care before
20 weeks of gestation regardless of maternal age. Women
should be counseled regarding the differences between
screening and invasive diagnostic testing.10

METHODS

Implementing invasive prenatal procedures based solely

Study population
This prospective study was carried out from January 2008
DOI: 10.3760/cma.j.issn.0366-6999.20122345
Department of Obstetrics and Gynecology, Chinese Academy of
Medical Science, Peking Union Medical College, Peking Union
Medical College Hospital, Beijing 100730, China (Qi QW, Jiang
YL, Zhou XY, Liu JT, Yin J and Bian XM)
Correspondence to: Dr. LIU Jun-tao, Department of Obstetrics and
Gynecology, Chinese Academy of Medical Science, Peking Union
Medical College, Peking Union Medical College Hospital, Beijing
100730, China (Tel: 86-10-69156228. Email: tao_aus@hotmail.
com)

Chin Med J 2013;126 (11)

2008

to December 2010. Only those women age 35 or greater

at the time of delivery age with a live singleton fetus were
eligible. The gestational weeks were from 15 weeks to 20+6
weeks and the gestational age was estimated by ultrasound
dating of the fetus. The gestational age at amniocentesis
was 17 weeks 0 day through 20+6 weeks. Women with
an abnormal ultrasound result, a family history of a
chromosomal abnormality, genetic disorder, or congenital
malformation were excluded. Likewise, pregnancies that
resulted from assisted reproductive technologies (ART)
were also excluded.
Study design
Genetic counseling was offered to all the patients by
genetic counselors. This included a discussion of the
referral indication and the age-related risk for DS and other
chromosomal abnormalities, as well as the baseline risk
for other birth defects. Genetic counselors discussed the
associated risks, benefits and limitations of the maternal
serum screening and the genetic amniocentesis. Informed
consent was signed by the women who received the
maternal serum screening or genetic amniocentesis. Thus
the women were divided into two groups, the screening
group and the amniocentesis group.
All the ID-marked serum samples were separated within
24 hours of collection. Alpha-fetoprotein (AFP) and
free -subunit of human chorionic gonadotrophin (free
-hCG) and unconjugated estriol (uE3) were measured
using the AutoDELFIA analyzer platform (PerkinElmer
Inc., Turku, Finland). These platforms are based on timeresolved fluoroimmunoassay (TRFIA). The individualized
risk for fetal DS was generated by LifeCycle software.
(LifeCycle, PerkinElmer Inc. USA). The screen
positive cut-off was set at 1/270 for follow up genetic
counseling and the option of amniocentesis. If an affected
pregnancy was confirmed by amniocentesis, termination
of the pregnancy was offered and performed based on
the womans decision. For women continuing with their
pregnancies, all newborn outcomes were recorded and
confirmed at the time of delivery by the pediatricians. The
data on pregnancy and pediatric outcomes of all the women
included in the study were obtained.
Amniocytes were cultured in Amniomax media (GIBCO,
Invitrogen Corporation, USA) under 5% CO2 at 37 for 5
to 7 days. After adding colcemid, the cells were harvested
after an additional one h of culture, treated in hypotonic
KCl, fixed in methanol/acetic acid fixative (3:1), and
deposited on glass slides. After the glass slides were air
dried, G-banding was performed. Chromosomal mosaicism
of the amniocytes was analyzed using the guidelines
proposed by Hsu and Benn.12
Statistical analysis
The statistical significance of difference between the
prevalence of DS in the screening group and amniocentesis
group was determined using a Chi-square test. The
statistical difference between the trend of the choice of the

screening group and amniocentesis group was determined

using regression analysis. All data were analyzed by SPSS
11.0 software (SPSS Inc., USA). A value of P<0.05 was
considered statistically significant.
RESULTS
General outcome
There were 5688 cases involved in the 3-year investigation
and the pregnancy outcomes were obtained for 5404 cases,
and 5404 cases were included in this study. The median
maternal age of AMA women was 37.22 years old (3548
years). There were 3297 cases in the amniocentesis group,
with the median age of 37.42 years old (3548 years), and
2107 cases in the screening group with the median age of
36.90 years old (3547 years).
In the screening group, 428 cases were positive, all these
patients received genetic amniocentesis, among which
18 cases of DS were detected and the pregnancy was
terminated. No procedure-related spontaneous fetal loss
occurred in the 428 patients having amniocentesis. No
DS was found in the 1679 cases that screened negative.
The overall prevalence of DS in this study population was
8.54 (18/2107). The cut-off value was 1/270, the false
positive rate (FPR) was 19.63%, false negative rate (FNR)
was 0%, and the positive predictive value was 4.2%. This
result was consistent with our previous report.11
In the amniocentesis group, there were 25 cases of DS
diagnosed prenatally, with the prevalence as 7.58
(25/3297). There were five cases of spontaneous fetal
loss within two weeks after the amniocentesis, and the
karyotype of these five fetuses were normal, with a
procedure-related fetal loss rate of 1/659.
The age distribution of the patients and DS diagnosed of
each group are shown in Figure 1A. There was no statistical
significance between the prevalence of DS in the screening
group and amniocentesis group (P=0.928) by Chi-square
test.
Trends of choice of screening and amniocentesis in
AMA women
About 39% of the AMA women chose the maternal
serum screening and 71% of the AMA women chose the
amniocentesis. In the subgroup of women 35 years old, the
choice between the screening group and the amniocentesis
group was almost half and half (49.2% vs. 50.8%). When
the data were analyzed by maternal age, the preference
for amniocentesis increased with increasing maternal age,
while the screening choice showed the opposite trend of
amniocentesis (Figure 1B). The regression analysis showed
that there was a statistical difference between the trend
of the choice of the screening and the amniocentesis with
increasing maternal age, The choice of the AMA women
between the maternal serum screening and the genetic
amniocentesis was significantly age relevant (P=0.012).

Chinese Medical Journal 2013;126 (11)

2009

group. The result of our study also confirmed that secondtrimester serum screening in combination with maternal
age was more effective than maternal age alone to screen
for DS. The procedure-related fetal loss rate in the
amniocentesis group of this study was 1/659, which is
consistent with previous reports,13 while there was no fetal
loss in the screening group.
The prevalence of the DS in our study was lower than that
of the previous report.15 A useful database for evaluating the
prevalence of second trimester chromosomal abnormalities
is the European collaborative study involving 52965
amniocenteses performed on women 35 years old and
older.15 In that report, the incidence of DS was 11.6,
which was higher than in our study. One of the reasons is
that the maternal age in our data was the age at the time of
delivery, while the age in the European report was the age
at the time of amniocentesis, so our population was a little
bit younger than the European population. And in our study,
we excluded those women with an abnormal ultrasound
result, and in this group many of them likely had a fetus
with DS.
Figure 1. The age distribution of amniocentesis and screening
group (A). Comparison of choice of amniocentesis and
screening for each age group (B).

DISCUSSION
The incidence of autosomal trisomy in livebirths is strongly
dependent on maternal age. Age alone has been regarded
as the single indication to offer a second trimester genetic
amniocentesis according to the health laws of the Chinese
government. The genetic amniocentesis will cause a
0.2%0.3% chance of procedure-related spontaneous fetal
loss.13 As childbearing is increasingly delayed, choosing
an effective prenatal screening and prenatal diagnosis
strategy is a practical social problem for China. One
feasible solution is to offer the screening to AMA women
in an attempt to decrease the numbers undergoing genetic
amniocentesis.
When maternal serum screening is provided to AMA
women, both the detection rate and the false-positive rate
are increased, but overall, the screening is more effective
with a higher positive predictive value compared to that
received for younger women.14 Consistent with theoretical
expectations for this screening, we observed a 19.63%
false-positive rate, 0 false-negative rate, and 4.2% positive
predictive value.
In the screening group with 2107 AMA cases, there were
18 cases of DS diagnosed among the 428 screening positive
cases, with the invasive testing rate for fetal DS of 1/23.78
(18/428). This meant that there was an average of one fetal
DS diagnosed for every 23.78 cases of amniocentesis.
While in the amniocentesis group, 25 cases of fetal DS
were found among 3297 cases of AMA women, with the
invasive testing rate for fetal DS of1/131.88 (25/3297),
which was 5.54 times higher than that of the screening

When we reviewed the patients decisions for further

testing after genetic counseling, about half of the 35year
old women chose prenatal screening, but along with the
increasing maternal age, the choice of the amniocentesis
increased while the choice of the screening showed an
opposite trend. The regression analysis showed that the
choice of the AMA women between the maternal serum
screening and the genetic amniocentesis was significantly
age relevant (P=0.012).
Benn et al 3 examined the impact of second trimester
maternal serum screening in choice of invasive testing
and reported a decline in the number of amniotic fluid and
villi samples referred to their laboratory for AMA alone.
They further reported an increase in the proportion of
AMA women receiving second trimester maternal serum
screening from 1991 to 2003.16 The decline in invasive
testing was attributed to improved serum screening and
second trimester ultrasound that provided better risk
assessment and resulted in more effective use of invasive
testing. Nakata et al17 also evaluated the trends in choice of
amniocentesis and CVS for prenatal diagnosis compared
with choice of first and second trimester prenatal serum
screening for Down syndrome among patients referred for
genetic counseling for AMA. They found that improved
prenatal screening tests and increased availability of
screening for AMA patients led to a steady decline in
choice of invasive testing from 2001 through 2007.
The results of our study were consistent with these studies.
We propose that these trends are partly attributed to: (1)
the 2007 ACOG Practice Bulletin that recommended that
screening and invasive testing be available to all women,
regardless of maternal age, (2) about 39% (2107/5404)
of the AMA women wanted to avoid the possibility of
procedure-related fetal loss from amniocentesis and
received the maternal serum screening, we observed

Chin Med J 2013;126 (11)

2010

this among the younger AMA, i.e., 35 and 36 years old

women, (3) The women who decline the screening wanted
the assurance provided by a diagnostic test rather than
proceeding with screening that provided a refined risk
assessment, we observed this among the older AMA, i.e.,
40years old women. This rationale would account for the
trend of the choice of screening and amniocentesis among
these AMA women.
With the largest population of pregnant women in the
world and the increasing AMA population, how to establish
a practical and effective strategy to control the birth
defect rate is very important to the health administration
in China. In the developed Western countries, the
molecular cytogenetic techniques, such as fluorescence
in situ hybridization (FISH), quantitative fluorescence
PCR, and more recently, multiplex ligation-dependent
probe amplification (MLPA) for the rapid detection of
aneuploidies for chromosomes 13, 18, 21 and the sex
chromosomes have been applied. 18,19 New technology,
such as prenatal BACs-on-Beads have been suggested for
AMA women or those with increased risk after maternal
screening. 20 However, these successful experiences in
western countries might not be suitable for current use
in China. According to the ACOG Committee Opinion,
conventional karyotyping is still the gold standard for
invasive prenatal diagnosis.21 In China, the first trimester
prenatal screening is not available and second trimester
karyotyping is still the main technique to detect all the
aneuploidies and large chromosome rearrangements, which
are the most frequent abnormalities identified in prenatal
diagnosis.
Our study supports the ACOG Bulletin regarding prenatal
screening. To those who are solely AMA women and
without the other additional indications for prenatal
cytogenetic diagnosis, we suggest an alternative approach
for prenatal testing to give them an option as to the further
testing they might choose. We suggest that in our daily
practice we should respect the AMA patients choice by
informing and counseling with all the necessary information
about both screening and diagnostic testing options. It will
significantly decrease the cases of genetic amniocentesis
and the procedure-related pregnancy loss in AMA women.
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(Received October 12, 2012)

Edited by CHEN Li-min