Importance of the 11-13 weeks scan
Dr. Muresan M. B1., Dr. Muresan Cezara2, Dr. Moldovan S1., Conf. Dr. Hrubaru N2
1 - Centrul Medical Dr. Muresan, Timisoara - FMF Center 9955
2 - Clinica Universitara Obstetrica Ginecologie "Bega", Timisoara
The 11-13 weeks scan provides the most effective method of early screening for trisomy 21 and other major chromosomal abnormalities. Screening by nuchal translucency can detect about 80% of affected fetuses for a false positive rate of 5%. The combination of nuchal translucency and maternal serum free β-hCG and PAPP-A improves the detection to 90%. There is now evidence that the detection rate can increase to about 95% and the false positive rate can be reduced to 2.5% by also examining the nasal bone, facial angle, ductus venosus flow and tricuspid flow. This method of screening is superior to the alternative methods of maternal age or maternal serum biochemistry at 15-20 weeks because the respective detection rates are about 30% and 55-70% for a false positive rate of 5%. Other benefits of the 11-13 weeks scan include: accurate dating of the pregnancy, early diagnosis of many major fetal defects, diagnosis of multiple pregnancies and early screening for severe preeclampsia.
In the late 1980s, a new method of screening was introduced that takes into account not only maternal age but also the concentration of various fetoplacental products in the maternal circulation. At 16 weeks of gestation the median maternal serum concentrations
of a-fetoprotein (AFP), uconjugated estriol (uE3), human chorionic gonadotropin (hCG) (total and free-b) and inhibin-A in trisomy 21 pregnancies are sufficiently different from normal to allow the use of combinations of some or all of these substances to select a 'high-risk' group. This method of screening is more effective than maternal age alone and, for the same rate of invasive testing (about 5%), it can identify about 50-70%
of the fetuses with trisomy 21.
In the 1990s, screening by a combination of maternal age and fetal NT thickness at 11-13+6 weeks of gestation was introduced. This method has now been shown to identify about 75% of affected fetuses for a screen-positive rate of about 5%.
Subsequently, maternal age was combined with fetal NT and maternal serum biochemistry (free b-hCG and PAPP-A) in the first-trimester to identify about 85-90% of affected fetuses. Furthermore, the development of new methods of biochemical testing, within 30 min of taking a blood sample, made it possible to introduce One-Stop Clinics for Assessment of Risk (Figure 3). In 2001, it was found that in 60-70% of fetuses with trisomy 21 the nasal bone is not visible by ultrasound at 11-13+6 weeks and preliminary results suggest that this finding can increase the detection rate of the first trimester scan and serum biochemistry to more than 95%.
Table 1. Comparison of the detection rates (DR), for a false positive rate of 5%, of different methods of
screening for trisomy 21. In prenatal screening, the term screen positive rate is used interchangeably with the invasive rate, because most women with a positive screening test undergo an invasive test, and with false positive rate (FPR) because the vast majority of fetuses in this group are normal.
Method of screening DR (%)
Maternal age (MA) 30
MA and maternal serum biochemistry at 15-18 weeks 50-70
MA and fetal nuchal translucency (NT) at 11-13+6 wks 70-80
MA and fetal NT and maternal serum free b-hCG and 85-90
PAPP-A at 11-13+6 wks
MA and fetal NT and fetal nasal bone (NB) at 11-13+6 wks 90
MA and fetal NT and NB and maternal serum free b-hCG and 95
PAPP-A at 11-13+6 wks
hCG human chorionic gonadotropin, PAPP-A: pregnancy-associated plasma protein A.
Every woman has a risk that her fetus/baby has a chromosomal defect.
The background or a priori risk depends on maternal age and gestation.
The individual patient-specific risk is calculated by multiplying the a priori risk with a series of likelihood ratios, which depend on the results of a series of screening tests carried out during the course of the pregnancy.
Every time a test is carried out the a priori risk is multiplied by the likelihood ratio of the test to calculate a new risk, which then becomes the a priori risk for the next test.
Effect of maternal age and gestation on risk:
The risk for trisomies increases with maternal age.
The risk for Turner syndrome and triploidy does not change
with maternal age.
The earlier the gestation, the higher the risk for chromosomal
The rates of fetal death in trisomy 21 between 12 weeks
(when NT screening is carried out) and 40 weeks is about
30% and between 16 weeks (when second trimester maternal
serum biochemical testing is carried out) and 40 weeks is
In trisomies 18 and 13 and Turner syndrome, the rate of fetal
D eath between 12 and 40 weeks is about 80%.
Recurrence of chromosomal defects
If a woman has had a previous fetus or baby with a trisomy,
the risk in the current pregnancy is 0.75% higher than her a
Recurrence is chromosome-specific.
Fetal nuchal translucency
Fetal NT normally increases with gestation (crown-rumplength). In a fetus with a given crown-rump length, every NT measurement represents a likelihood ratio which is multiplied by the a priori maternal and gestational age-related risk to calculate a new risk.
Table 2. Multicentre study coordinated by the Fetal Medicine Foundation. Number of pregnancies with nuchal translucency (NT) thickness above the 95th centile and an estimated risk for trisomy 21, based on maternal age and fetal nuchal translucency and crown-rump length, of 1 in 300 or more (Snijders et al 1998).
Nasal bone and other first-trimester sonographic markers
At 11-13+6 weeks the nasal bone is not visible by ultrasonography in about 60-70% of fetuses with trisomy 21 and in about 2% of chromosomally normal fetuses. Abnormalities in the flow velocity waveform from the ductus venosus are observed in about 80% of fetuses with trisomy 21 and in 5% of chromosomally normal fetuses. Similarly, the prevalence of other sonographic markers, such as exomphalos, megacystis and single umbilical artery, are higherin certain chromosomal abnormalities than in chromosomally normal fetuses. Each of these sonographic markers is associated with a likelihood ratio, which can be multiplied by the a priori risk to calculate a new risk.
Maternal serum biochemistry in the first-trimester
The level of free b-hCG in maternal blood normally decreases with gestation. In trisomy 21 pregnancies free b-hCG is increased. The level of PAPP-A in maternal blood normally increases with gestation and in trisomy 21 pregnancies the level is decreased. For a given gestation, each b-hCG and PAPP-A level represents a likelihood ratio that is multiplied by the a priori risk to calculate the new risk. The higher the level of b-hCG and the lower the level of PAPP-A the higher the risk for trisomy 21.
Trisomic pregnancies are associated with altered maternal serum concentrations of various feto-placental products, including AFP, free b-hCG, uE3, inhibin A and PAPP-A. Screening in the second trimester by maternal age and various combinations of
free b-hCG, AFP, uE3 and Inhibin A can identify 50-75% of trisomy 21 pregnancies for a false positive rate of 5%. Screening in the first trimester by a combination of maternal age and serum free b-hCG and PAPP-A identifies about 60% of affected pregnancies for a false positive rate of 5%. However, an essential component of biochemical screening is accurate dating of the pregnancy by ultrasound, otherwise the detection rate is reduced
by about 10%.
Fetal NT and maternal serum testing in the first-trimester
In trisomy 21 pregnancies at 12 weeks, the maternal serum concentration of free b-hCG (about 2 MoM) is higher than in chromosomally normal fetuses whereas PAPP-A is lower (about 0.5 MoM). The difference in maternal serum free b-hCG between normal and trisomy 21 pregnancies increases with advancing gestation and the difference in PAPP-A decreases with gestation. These temporal variations in marker levels, their interrelation and their association with maternal weight should be taken into account when developing risk algorithms in order to produce accurate patient-specific risks. There is no significant association between fetal NT and maternal serum free b-hCG or PAPP-A in either trisomy 21 or chromosomally normal pregnancies and therefore the ultrasononographic
and biochemical markers can be combined to provide more effective screening than either method individually (Spencer et al 1999). Six prospective screening studies have confirmed the feasibility and effectiveness of combining fetal NT and maternal serum free b-hCG and PAPP-A. In the combined data on a total of 38,804 pregnancies, including 182 with trisomy 21, the detection rate for trisomy 21 at a 5% false positive rate was 86% (Nicolaides 2004).
In trisomies 18 and 13 maternal serum free b-hCG and PAPP-A are decreased. In cases of sex chromosomal anomalies maternal serum free b-hCG is normal and PAPP-A is low. In paternally derived triploidy maternal serum free b-hCG is greatly increased, whereas PAPP-A is mildly decreased. Maternally derived triploidy is associated with markedly decreased maternal serum free b-hCG and PAPP-A. Screening by a combination of fetal NT and maternal serum PAPP-A and free b-hCG can identify about 90% of all these chromosomal abnormalities for a screen positive rate of 1%, in addition to the 5% necessary in screening for trisomy 21.
An important development in biochemical analysis is the introduction of a new technique (random access immunoassay analyzer using time-resolved-amplified-cryptate-emission), which provides automated, precise and reproducible measurements within 30 minutes of obtaining a blood sample. This has made it possible to combine biochemical and ultrasonographic testing as well as to counsel in one-stop clinics for early assessment of fetal risk (OSCAR) (Bindra et al 2002, Spencer et al 2003b).
Fetal NT and maternal serum testing in the second-trimester
In women having second-trimester biochemical testing following first-trimester NT screening the a priori risk needs to be adjusted to take into account the first-trimester screening results. Prospective studies of screening by a combination of fetal NT in
the first trimester and maternal serum biochemistry in the second trimester reported that for a false positive rate of 5% the detection rate of trisomy 21 (85-90%) is similar to combined screening in the first trimester (Nicolaides 2004).
Integration of first and second trimester testing
A statistical model combining first-trimester fetal NT and maternal serum PAPP-A with second-trimester free b-hCG, uE3 and inhibin A, estimated that for a false positive rate of 5% the detection rate of trisomy 21 could be 94% (Wald et al 1999). This test assumes complete compliance by the pregnant women in firstly, participating in a two stage process separated by one month, secondly, in having an ultrasound scan without receiving information as to whether the fetus looks normal or not, and thirdly, accepting second rather than first trimester diagnosis and termination. It is therefore likely that even if the estimates of this hypothetical test are found to be true in prospective studies, it
will not gain widespread clinical acceptability. Some of the logistical problems in the implementation of an integrated test are highlighted by the results of a multicentre
observational study (SURUSS) investigating first and second trimester screening for trisomy 21 (Wald et al 2003a). The aim was to obtain a measurement of fetal NT in the first trimester and collect maternal serum and urine samples in the first and second trimesters. Intervention was based on the second trimester serum results and all other data were analyzed retrospectively. However, of the 47,053 women that were recruited, only 60% completed all components of the protocol. In this study there were 101 fetuses
with trisomy 21 and satisfactory NT images were obtained only from 75 of the cases. The data were used to derive a statistical model suggesting that for a 5% false positive rate, 93% of trisomy 21 fetuses could be detected by the integrated test. However, it is
likely that this model is inaccurate. For example, the predicted detection rates, for a 5% false positive rate, were 71% for the double test, 77% for the triple test and 83% for the quadruple test, which are substantially higher than the respective rates of 61%, 66% and 75% reported by the same authors in their prospective screening studies (Wald et al 2003b).
A similar study in the USA (FASTER trial), reported its findings in the subgroup of 33,557 pregnancies with complete first and second trimester data, including 84 cases of trisomy 21 (Malone et al 2004). It was estimated that, for a 5.4% false positive rate, 90% of trisomy 21 fetuses could be detected. Prospective studies have demonstrated that such results are achievable by screening with fetal NT and maternal serum free b-hCG and PAPP-A in the first-trimester (Bindra et al 2002, Spencer et al 2003b). It is therefore essential that, in screening, attention is paid to the provision of high quality sonographic
and biochemical services for early diagnosis of chromosomal defects, rather than the development of theoretical models which would delay diagnosis until the second trimester and are, in any case, unlikely to be implemented in clinical practice.
Screening by nuchal translucency and serum biochemistry
In trisomy 21 pregnancies at 11-13+6 weeks, the maternal
serum concentration of free b-hCG is higher (about 2 MoM)
and PAPP-A is lower (about 0.5 MoM) than in chromosomally
There is no significant association between fetal NT and
maternal serum free b-hCG or PAPP-A in either trisomy 21 or
chromosomally normal pregnancies. The ultrasononographic
and biochemical markers can be combined to provide more
effective screening than either method individually.
Prospective studies, in more than 50,000 pregnancies, including
more than 250 fetuses with trisomy 21, have demonstrated
that screening by a combination of fetal NT and either
first or second trimester maternal serum biochemistry can
identify 85-90% of fetuses with trisomy 21 for a false positive
rate of 5%.
In trisomies 18 and 13 maternal serum free b-hCG and
PAPP-A are decreased.
In sex chromosomal anomalies maternalserum free b-hCG is normal and PAPP-A is low. In paternally derived triploidy maternal serum free b-hCG is greatly
increased, whereas PAPP-A is mildly decreased. Maternally
derived triploidy is associated with markedly decreased
maternal serum free b-hCG and PAPP-A.
Screening by a combination of fetal NT and maternal serum PAPP-A and
free b-hCG can identify about 90% of all these chromosomal abnormalities for a screen positive rate of 1%, in addition to the 5% in screening for trisomy 21.
WOMENS' ATTITUDES TO 1ST VERSUS 2ND TRIMESTER SCREENING
Studies investigating the preference of pregnant women in terms of the methods of screening, have reported that the vast majority prefer this to be carried out in the first rather than in the second trimester. A criticism of NT screening has been that some women with increased fetal NT will face unnecessary decisions regarding invasive testing and ultimately pregnancy termination in an affected pregnancy that would otherwise have ended in spontaneous miscarriage. In a survey of women's preferences, about 70% stated that they would still choose NT screening even if all the Down's syndrome pregnancies identified by this method miscarried before the second trimester (Mulvey and Wallace
2000). The women wanted to know if their fetus had had Down's syndrome regardless of the pregnancy outcome and they also valued the knowledge of an underlying reason for a miscarriage if it occurred.
Clinical importance of respect for autonomy
Respect for autonomy is a central principle in medical ethics and law. This ethical principle obliges the physician to elicit and implement the patient's preferences. The relevance of respect for autonomy to first trimester screening is two-fold. Firstly, early
diagnosis of fetal abnormality and the option of early termination of pregnancy are important to many women. Secondly, most first trimester screening tests provide reassurance for many women who would prefer not to have an invasive procedure if the
risk is low. Consequently, the provision of a high-quality first trimester screening service significantly enhances the autonomy of pregnant women (Chasen et al 2001).
The vast majority of pregnant women prefer screening and diagnosis to be performed in the first, rather than in the second trimester.
This is a FMF material
Bindra R, Heath V, Liao A, Spencer K, Nicolaides KH. One stop clinic for assessment of risk for trisomy 21 at 11-14 weeks: A prospective study of 15,030 pregnancies. Ultrasound Obstet Gynecol 2002;20:219-25.
Chasen ST, Skupski DW, McCullough LB, Chervenak FA. Prenatal informed consent for sonogram: the time for first-trimester nuchal translucency has come. J Ultrasound Med 2001;20:1147-52.
Crossley JA, Aitken DA, Cameron AD, McBride E, Connor JM. Combined ultrasound and biochemical screening for Down's syndrome in the first trimester: a Scottish multicentre study. BJOG 2002;109:667-76.
Down LJ. Observations on an ethnic classification of idiots. Clin Lectures and Reports, London Hospital 1866;3:259-62.
Hecht CA, Hook EB. The imprecision in rates of Down syndrome by 1-year maternal age intervals: a critical analysis of rates used in biochemical screening. Prenat Diagn 1994;14:729-38.
Kornman LH, Morssink LP, Beekhuis JR, DeWolf BTHM, Heringa MP, Mantingh A. Nuchal translucency cannot be used as a screening test for chromosomal abnormalities in the first trimester of pregnancy in a routine ultrasound practice. Prenat Diagn 1996;16:797-805.
Malone FD, Wald NJ, Canick JA, Ball RH, Nyberg DA, Comstock CH, Bukowski R, et al. First- and second-trimester evaluation of risk (FASTER) trial: principal results of the NICHD multicenter Down syndrome screening study. SMFM 2004, Abstract 1.
Mulvey S, Wallace EM. Women's knowledge of and attitudes to first and second trimester screening for Down's syndrome. BJOG 2000;107:1302-5.
Nicolaides KH, Azar G, Byrne D, Mansur C, Marks K. Fetal nuchal translucency: ultrasound screening for chromosomal defects in first trimester of pregnancy. BMJ 1992;304:867-89.
Nicolaides KH, Brizot ML, Snijders RJM. Fetal nuchal translucency: ultrasound screening for fetal trisomy in the first trimester of pregnancy. BJOG 1994;101:782-6.
Nicolaides KH. Nuchal translucency and other first-trimester sonographic markers of chromosomal abnormalities. Am J Obstet Gynecol 2004;191:45-67.
Pandya PP, Snijders RJM, Johnson SJ, Brizot M, Nicolaides KH. Screening for fetal trisomies by maternal age and fetal nuchal translucency thickness at 10 to 14 weeks of gestation. BJOG 1995;102:957-62.
Roberts LJ, Bewley S, Mackinson AM, Rodeck CH. First trimester fetal nuchal translucency: Problems with screening the general population 1. BJOG 1995;102:381-5. FMF-Chapter1.pmd 9/17/04, 5:33 PM 43
Snijders RJM, Sebire NJ, Cuckle H, Nicolaides KH. Maternal age and gestational age-specific risks for chromosomal defects. Fetal Diag Ther 1995;10:356-67.
Snijders RJM, Nicolaides KH. Sequential screening. In: Nicolaides KH, editor. Ultrasound markers for fetal chromosomal defects. Carnforth, UK: Parthenon Publishing, 1996, pp109-13.
Snijders RJM, Noble P, Sebire N, Souka A, Nicolaides KH. UK multicentre project on assessment of risk of trisomy 21 by maternal age and fetal nuchal translucency thickness at 10-14 weeks of gestation. Lancet 1998;351:343-6.
Snijders RJM, Sundberg K, Holzgreve W, Henry G, Nicolaides KH. Maternal age and gestation-specific risk for trisomy 21. Ultrasound Obstet Gynecol 1999;13:167-70.
Spencer K, Souter V, Tul N, Snijders R, Nicolaides KH. A screening program for trisomy 21 at 10-14 weeks using fetal nuchal translucency, maternal serum free b-human chorionic gonadotropin and pregnancy-associated plasma protein-A. Ultrasound Obstet Gynecol 1999;13:231-7.
Spencer K, Bindra R, Nix ABJ, Heath V, Nicolaides KH. Delta- NT or NT MoM: which is the most appropriate method for calculating accurate patient-specific risks for trisomy 21 in the first trimester? Ultrasound Obstet GynecoI 2003a;22:142-8.
Spencer K, Spencer CE, Power M, Dawson C, Nicolaides KH. Screening for chromosomal abnormalities in the first trimester using ultrasound and maternal serum biochemistry in a one stop clinic: A review of three years prospective experience. BJOG 2003b;110:281-6.
Tabor A, Philip J, Madsen M, Bang J, Obel EB, Norgaard-Pedersen B. Randomised controlled trial of genetic amniocentesis in 4,606 low-risk women. Lancet 1986;1:1287-93.
Wald NJ, Watt HC, Hackshaw AK. Integrated screening for Down's syndrome on the basis of tests performed during the first and second trimesters. N Engl J Med 1999;341:461-7.
Wald NJ, Rodeck C, Hackshaw AK, Walters J, Chitty L, Mackinson AM; SURUSS Research Group. First and second trimester antenatal screening for Down's syndrome: the results of the Serum, Urine and Ultrasound Screening Study (SURUSS). Health Technol Assess 2003a;7:1-77.
Wald NJ, Huttly WJ, Hackshaw AK. Antenatal screening for Down's syndrome with the quadruple test. Lancet 2003b;361:835-6.