MATERNAL SERUM ALPHA-FETOPROTEIN (MSAFP):

INTRODUCTION:
Maternal serum alpha-fetoprotein (MSAFP): Many changes occur in woman’s
body during pregnancy. These changes although most apparent in the
reproductive organs, involve other body systems as well. Weeks may pass before
the family realizes she has become pregnant or she may learn upon a visit to a
doctor for other reasons

Confirmation her pregnancy is most important for the health & welfare of herself
& the baby. In this lesson, we will cover the tests used to determine pregnancy
Alpha-fetoprotein is manufactured principally in the fetus's liver and
gastrointestinal (GI) tract besides the yolk sac, a structure temporarily present
during embryonic development.

The alpha-fetoprotein level is typically high in the fetus's blood. It decreases in

the baby's blood after birth. And by one year of age, it is virtually undetectable.

During pregnancy, alpha-fetoprotein crosses the placenta from the fetal

circulation and appears in the mother's blood. The alpha-fetoprotein level in the
mother's blood (the maternal serum alpha-fetoprotein) provides a screening test
for several disorders including:

Open neural tube defects (anencephaly and spina bifida); and

Down syndrome (and other chromosome abnormalities).

The maternal serum alpha-fetoprotein (MSAFP) tends to be:

High with open neural tube defects such as anencephaly and spina bifida
(meningomyelocele); and

Low with Down syndrome (trisomy 21, an extra chromosome number 21).

Alpha-fetoprotein production is essentially zero after a year of age. However, it

increases again under the stimulus of some liver diseases. It may, for example, be
produced by viral hepatitis and cirrhosis of the liver. Alpha-fetoprotein is also
made by primary liver tumors (hepatomas) and by germ cell tumors
(teratocarcinoma and embryonal cell carcinomas). A person's serum alpha-
fetoprotein level can therefore be used to help detect these conditions and monitor
their cirrhosis of the liver. Alpha-fetoprotein is also made by primary liver tumors
(hepatomas) and by germ cell tumors (teratocarcinoma and embryonal cell
carcinomas). A person's serum alpha-fetoprotein level can therefore be used to
help detect these conditions and monitor their treatment.
DEFINITION:
The presence of alpha-fetoprotein (AFP) , a plasma protein normally produced by
the fetus, in the mother's blood. MSAFP serves as the basis for some valuable
tests.

OR

Alpha-fetoprotein (AFP) is a plasma protein that is normally produced by the

fetus. It serves as the basis for some valuable tests.

OR

AFP is the major serum protein of fetus synthesized by the fetal yolk sac & fetal
liver

OR

An MSAFP screen involves a simple blood draw from the mother’s vein. Results
are usually available in one to two weeks.

OR

Alpha-fetoprotein (AFP) , a plasma protein normally produced by the fetus, in

the mother's blood. MSAFP serves as the basis for some valuable tests.

OR

Maternal serum alpha fetoprotein (MSAFP) is a screening test that examines the
level of alpha fetoprotein (AFP) in a pregnant woman. AFP is produced by both
the yolk sac and foetal liver during pregnancy.

RISK APPROACH SCREENING

• Blood testing
• Excessive weight gain of the mother due to fluid retention. Falling weight also
poses risk as there can be intrauterine growth retardation.
• Pre-existing hypertension or PIH
• Excess amount or decreased amount of amniotic fluid is another risk factor.
• Other approaches, which should be followed for high-risk cases, are: non-
invasive & invasive methods are used
NON-INVASIVE METHODS:

• Examination of the woman’s uterus from outside the baby.

• Listening to the fetal heart sound
• External fetal monitoring

It includes:

 Ultrasonography,
 Cardiotocography,
 Non- stress test,
 Contraction stress test,
 amniotic fluid index
 Invasive methods:
 Chorionic villus sampling
 Amniocentesis
 Fetoscopy
 MSAFP: maternal serum alpha feto protein.
 Others includes Cordocenthesis, Amnioscopy.

OBJECTIVE OF INVASIVE & NONINVASIVE DIAGNOSIS:

 To reduce maternal and fetal mortality rate.
 To check fetal growth and development.
 To enable timely medical or surgical treatment of a condition before
or after birth,
 To give the parents the chance to abort a fetus with the diagnosed
condition,
 To give parents the chance to "prepare" psychologically, socially,
financially, and medically for a baby with a health problem or
disability, or for the likelihood of a stillbirth.

Common indicators of invasive & noninvasive diagnosis:-

 1) ULTRASONOGRAPHY
 2) CARDIOTOCOGRAPHY
 3) NON STRESS TEST
 4) CONTRACTION STRESS TEST
 5) AMNIOTIC FLUID INDEX (AFI)
INVASIVE METHODS:
 MATERNAL ALPHA-FETOPROTEIN
 AMNIOCENTESIS
 CHORIONIC VILLUS SAMPLING (CVS)
 CORDOCENTHESIS OR PERCUTANEOUS UMBLICAL CORD
BLOOD SAMPLING (PUBS)
 FETOSCOPY
 AMNIOSCOPY

Maternal alpha-fetoprotein screening (MAFP)-

• A blood test that measures the level of alpha- fetoprotein in the mothers' blood
during pregnancy.

• AFP is a fetal protein normally produced by the fetal liver and is present in the
fluid surrounding the fetus (amniotic fluid), and crosses the placenta into the
mother's blood. • The AFP blood test is also called MSAFP (maternal serum AFP

Abnormal levels of AFP may signal the following MSAFP level high indicates:-

 Open neural tube defects (ONTD) such as spina bifida

 Other chromosomal abnormalities lead to IUFD
 Defects in the abdominal wall of the fetus
 Twins more than one fetus is making the protein
 A miscalculated due date
 Renal anomalies. MSAFP level low indicates
 Down’s syndrome
 Gestational trophoblastic disease

INDICATION:
 All pregnant women are usually offered the AFP test. But, the doctor
may recommend the test, especially if :
 Mother is 35 or older
 Have a family history of birth defects
 Have diabetes
 Have taken certain drugs or medication during pregnancy
Time of performing test:-
15-18 weeks
AIMS:-
 To ensure satisfactory growth and well being of the fetus throughout
pregnancy.
 To screen out the high risk factors that affects the growth of the fetus.

PURPOSE:-
 Advanced maternal age.
 Previous child with a chromosome abnormality
 Women who are pregnant with multiples (twins or more)
 Family history of single gene disorder.
 Family history of neural tube defect.
 Family history of other congenital structural abnormalities.
 Abnormalities identified in pregnancy.
 Women who have previously had miscarriages .
 Other high risk factors (consguinity ,poor obst. ,maternal illness).

PREPARATION OF THE PATIENT:-

 Explain that the AFP tests helps in monitoring fetal development, screens
for a need for further testing, helps detect possible congenital defects in the
fetus, and monitors the patient’s response to therapy by measuring a
specific blood protein, as appropriate.

 Inform the patient that she need not restrict food, fluids, or medications.

 Tell the patient that the test requires a blood sample. Explain who will
perform the venipuncture and when.

 Explain to the patient that she may experience slight discomfort from the
tourniquet and needle puncture.
 PROCEDURES:

1. Introduce yourself to the patient and confirm the patient's name and date of
birth.
2. Explain procedure to the patient, warning patient of possible discomfort
from the needle prick.
3. Position patient appropriately, exposing the upper arm.
4. Follow hand washing and basic universal precautions.
5. Tie the tourniquet around the upper arm.
6. Identify a prominent vein and clean with an alcohol swab.
7. Introduce the needle attached to a vacutainer.
8. Remove tourniquet and remove needle after obtaining a sample.
9. Apply cotton ball to needle site with pressure to stop bleeding. 
10.Label sample bottles appropriately.
11.Send a sample for AFP assay.

Pregnant maternal serum AFP levels elevated:

 Neural tube defects (e.g., spina bifida, anencephaly)

 Omphalocele
 Gastroschisis
 Pregnant maternal serum AFP low levels:
 Down syndrome

Non-pregnant female or male adult AFP elevated:

 Hepatocellular cancer
 Metastatic liver cancer
 Liver cirrhosis
 Hepatitis
 Germ cell tumors
 Yolk sac tumor
 Ataxia telangiectasia
1.ALPHA FETO PROTEIN:

In 1956,Bergstrand & czar described a protein in fetal serum,located in the α1

region on electrophoresis[subsequently labelled as α1- Feto Protein[AFP] that
was not present in maternal serum.

 It is this unique protein that serves as a marker for leakage of fetal serum
into the amniotic fluid & which is therefore helpful in diagnosing open
fetal lesions.
 AFP is the major serum protein of fetus synthesized by the fetal yolk sac &
fetal liver
 Gene located on chromosome 4,is also part of a family of genes that also
encodes for albumin & vitamin D- binding protein. .The protein is
composed of carbohydrate & a single polypeptide chain containing 591
amino acids.
 The molecular weight and structure of AFP is similar to that of
albumin[about 69kd],but antibodies rised against AFP have virtual no cross
reactivity.
 This characteristic was critical in allowing the development of a veriety of
antibody based assays for reliably measuring AFP in amniotic fluid &
maternal serum.
 The protein is very stable @room temperature in serum as long as a week.
  Maximum concncentration of AFP in fetal serum~3,000,000ng/ml reaches
by 9 wk gestation decreases to 20,000ng/ml @ term.
 Maternal serum AFP first detectable [~5ng/ml] at about 10 wk gestation.
 The concentration increases at a rate of 15% per week to a peak at about
~180ng/ml 25 wk gestation,decline slowly till term.
 After birth MSAFPdecreases to less than 2ng/ml. In infant,serum AFP
level decreases exponentially to reach adult level by 10th month of life

MULTIPLES OF MEDIAN [MOM]

•To simplify interpretation of the result , each patient AFP result expressed as a
Multiples of Median[MOM].

•Screening programmes should determine the AFP medians for each week of
gestation from 14 to 20 weeks using at least 100 patients at each week.

METHODS FOR DETERMINING α-Feto Protein:

 TRADITIONALLY MEASURED BY RADIO IMMUNO ASSAY [RIA]

 NEWER METHODS USE IMMUNO ENZYMATIC ASSAYS [IEMA]

•Because of it’s lower detection limits , better precision , speed, avoidance of

radiation & ease of automation.

The FDA has licenced three immuno assay AFP kits for use in maternal serum
screening for neural tube defects,

1. A monoclonal bead assay

2. A microparticles immuno assay
3. A polyclonal bead assay

•Each assay uses a sandwich design

•A solid phase antibody captures the AFP present in serum, then, after washing a
second enzyme labelled antibody is added. After a second wash that removes
unbound labelled antibody, substrate is added to produce a coloured product.

Relative concentration of AFP in maternal serum & amniotic fluid

•MSAFP a cut off point of 2.5 MOM & values below 0.5 MOM are abnormal for
Elevated & lowered values.
•AFAFP a cut off point of 2.0 MOM is used to identify elevated AFAFP & 1.0
MOM for lowered values.
1. MILD - 2.0 to 4.9 MOM
2. MODERATE - 5.0 to 9.9 MOM
3. VERY HIGH - > or Equal to 10.0 MOM

CLINICAL SIGNIFICANCE OF AFP:

Predicting the risk of open NTD’s. Managing certain neoplasms. Normal Results

INTERPRETATION:-
NORMAL RESULTS:-

 When testing by immunoassay, AFP values are less than 15 ng/ml (SI, <15
mg/l) in male patients and nonpregnant female patients.
 Values in maternal serum normally are less 25 ng/ml (SI, 25 ug/L). At 15
to 18 weeks gestation, values range from 10 to 150 ng/ml (SI, 10 to 150
ug/L).

ABNORMAL RESULTS:-
  Elevated maternal serum AFP level may suggest neural tube defect or other
tube anomalies.
 Definitive diagnosis requires ultrasonography and amniocentesis.
 High AFP levels may indicate intrauterine death, or high levels indicate
other anomalies, such as duodenal atresia, omphalocele, tetralogy of fallot,
and Tuner’s syndrome.
 Elevated serum AFP levels occur in 70% of nonpregnant patients with
hepatocellular carcinoma.
 Elevated levels are also related to germ cell tumor of gonadal,
retroperitoneal, or mediastinal origin.
 Transient modest elevations can occur in nonneoplastic hepatocellular
disease, such as alcoholic cirrhosis and acute or chronic hepatitis.
 Elevation of AFP levels after remission suggests tumor recurrence.

PRECAUTIONS

Handle the sample gently to prevent hemolysis.

INTERFERING FACTORS-

 Hemolysis from rough handling of the sample.

 Multiple pregnancies that may cause false positive result.

COMPLICATIONS-

Hematoma at the venipuncture site.