Genetic Testing

Question 1

What happens in a normal pregnancy

Answer 1

Positive pregnancy test ( no longer confirmed at GP)
Book into antenatal care ( see midwife) at hospital where you will deliver

Nuchal scan - 10-14 weeks gestation Different tests dependent upon NHS Trust e.g. nuchal translucency, combined test etc.

Mid-trimester anomaly scan

Ultrasound examination is the main method for prenatal diagnosis of foetal abnormalities. All pregnant women should be offered routine ultrasound scans at 11-14 weeks and again at 20-22 weeks.

Question 2

What also happens at the nuchal scan to identify risk

Answer 2

At nuchal scan, bloods are done to check hormone levels, maternal age is taken into account , sonographer looks at nuchal fold which is the back of the babys neck
Come up from a risk figure.

Risk of 1 in 150 or higher is considered high risk

Question 3

Aims of 12 weeks scan

Answer 3

To date the pregnancy accurately.

To diagnose multiple pregnancy.

To diagnose major foetal abnormalities. 

To diagnose early miscarriage. 

To assess the risks of Down Syndrome and other chromosomal abnormalities. 

Taking into account the maternal age, blood hormone levels, nuchal translucency thickness*, nasal bone, blood flow through the fetal heart and fetal abnormalities.

Question 4

If there is an increased thickness at the back of the feral neck during the nuchal scan ( >3mm) this can indicate :

Answer 4

Chromosome abnormalities 
		(e.g. Downs, Edwards, Patau, Turners)
		NT + maternal age detects up to 75% of Down syndrome with 5% false positive rate
	Birth defects: 
		Cardiac anomalies
		Pulmonary defects (diaphragmatic hernia)
		Renal defects
		Abdominal wall defects
	Skeletal dysplasias

Question 5

When is prenatal testing arranged

Answer 5

Following abnormal findings at nuchal scan or mid-trimester scan

Following results of combined test which give an increased risk of Down Syndrome

If previous pregnancy affected with a condition e.g. DS, CF

If parent(s) carrier of chromosome rearrangement/abnormality or genetic condition, e.g. t(13;14), DMD, HD.

Family history of genetic condition

Question 6

Aims of prenatal testing

Answer 6

To inform and prepare parents for the birth of an affected baby/To be prepared for complications at or after birth

To allow in utero treatment 

Manage the remainder of the pregnancy

To allow termination of an affected fetus

Question 7

What other prenatal scans can be carried out in addition to nuchal scan

Answer 7

Feral MRI and cardiac scan ( usually at around 20 weeks)

Question 8

Non invasive prenatal tests

Answer 8

Maternal blood test and Cell free feral DNA

Question 9

Invasive prenatal tests

Answer 9

Chorionic villus sampling ( CVS) - takes a bit of tissue from placenta
Amniocentesis - takes fluid from around the developing baby

Question 10

Cell free fetal DNA ( cffDNA)

Answer 10

Non-invasive prenatal diagnosis (NIPD) works by analysing the DNA fragments present in the maternal plasma during pregnancy (cell-free DNA).

Most of this DNA comes from the mother
10%-20% of it comes from the placenta, which is representative of the unborn baby (cell-free fetal DNA).

Cell-free fetal DNA (cffDNA) is first detectable from about 4 -5 weeks’ gestation, but cannot accurately be detected on testing until around 9 weeks

Question 11

Why does cffDNA work

Answer 11

DNA from baby is shed from the placenta into mothers blood and so that is why a very small portion is found in the plasma of the mother

Eg. In trisomy 21 the amount of cfDNA for chromosome 21 is higher than in normal pregnancies

Question 12

NIPD maternal blood test for which diseases

Answer 12

• Achondroplasia - testing is free
  
  • Thanatophoric dysplasia ( can often be seen due to shorter limbs ) - testing is free
  • Apert syndrome- testing is free

Question 13

Find out the sex of the baby

Answer 13

Currently offered when there is a X-linked condition in the family e.g. DMD
Test detects SRY gene on Y chromosome, enabling us to determine if male or female fetus
If male -go on to prenatal test
If female - no invasive test required

Question 14

NIPD offered privately visa NHS

Answer 14

Autosomal dominant single gene disorders inherited from the father or arisede novo
NF1
NIPD is also possible to alter management of pregnancies at risk of recessive conditions when the mother and father carry different altered genes.

- If the paternal alterationhas been inherited by the foetus, invasive prenatal testing can be offered to find the maternal gene
   - Cystic fibrosis – haplotyping (RHDO) can test for both maternal and paternal mutation

Question 15

cffDNA testing for Aneuploidy ( NIPT)

Answer 15

Offered privately (Harmony) or via research studies
Harmony currently test for T13, T18, T21 and this identifies:
99% of fetuses with trisomy 21
97% of fetuses with trisomy 18
92% of fetuses with trisomy 13.

But not 100% accurate . May then need an invasive test to confirm

Question 16

Limitations of NIPT and NIPD

Answer 16

Multiple pregnancies - It is not possible to tell which fetus the DNA is from when carrying twins/triplets etc. - so only used with singleton pregnancies

The relative proportion of cell-free fetal DNA is reduced in women with a high BMI as they have more of their own cell-free DNA. 

Although it is just a blood test, it has the same implications as an invasive test. 
	Women may prepare themselves more for the implications of an invasive test result
	Women must consider the consequences of the results. Do they want this information?

An invasive test may still be required to confirm an abnormal result.

Question 17

Benefits of NIPT and NIPD

Answer 17

The number of invasive tests carried out is likely to reduce as a result

There is no increased risk of miscarriage.

Less expertise is required to perform a blood test than an invasive test.

In many cases we can offer NIPD /NIPT earlier than traditional invasive testing, thereby getting a result much earlier.

Question 18

CVS

Answer 18

11-14 weeks

1-2% risk of miscarriage (lower in specialist centres e.g. UCH, Chelsea and Westminster appx 1 in ) - risk is higher because the foetus is smaller

Transabdominal or transvaginal

Takes sample of chorionic villi – part of developing placenta – same DNA as fetus

Allows patient to have an earlier result than amnio  - important for many patients re. TOP decision (termination of pregnancy)

Question 19

Amniocentisis

Answer 19

From 16 weeks

	Takes sample of amniotic fluid which contains fetal cell

Risks
Up to 1% risk of miscarriage

Infection

Rh sensitisation

Question 20

What test are done with the DNA sample

Answer 20

Test for the genetic disorder in question
Timing for results dependent upon condition

Karyotype if chromosomal abnormality in family
Results 2 weeks (dependent upon the cells growing)

QF-PCR for all:
We send samples to Guy’s Hospital laboratory
Looks for t13, 18 & 21 (plus sex chromosomes if sex chromosome disorder suspected)
Result within 24-48 hours

Question 21

CGH array - comparative genomics hybridisation

Answer 21

If there are concerns on 20 week scan the gold standard is to offer CGH array

Looks for small/large imbalances in chromosomes (picks up microdeletions and duplications)

If something found on array we standardly test parents to see if either is a carrier. This can help with interpretation

Neurosusceptibility loci: 1q21.1 dup, 16.11.2 dup, 15q11.2 del etc etc. Uncertainty regarding penetrance. Be wary about discussing PND/PGD

Question 22

What is the process of comparative genomics hybridisation

Answer 22

1) extract genomic DNA from a test and a reference sample and label one with a red fluorescent dye and the other one with a green fluorescent dye
2) mix and hybridise to a microarray printed with thousands of oligonucleotide probes then wash
3) detect red and green signals using a fluorescence scanner
4) compute and report gains or losses in the test DNA using software

Question 23

Trio exonerated sequence

Answer 23

Consider where fetus in previous pregnancy had significant anomalies e.g. heart, brain, skeletal or where baby has been born with developmental delay, dysmorphic features (and array normal)

Exome is the coding region of the genome. Take DNA from fetus/baby and parents

Trio refers to the parents and the baby

Good pick up (40%+) where referrals are appropriate

Started with Deciphering Developmental Disorders (DDD) study

Question 24

Reproductive options when there is a known reproductive risk

Answer 24

Conceive naturally, no prenatal testing

Conceive naturally, have prenatal testing

Use of egg and/or sperm donors

Adoption

Choose not to have children

Pre-implantation genetic diagnosis (PGD)

Question 25

Egg and sperm donation

Answer 25

No longer anonymous, children conceived have the right to contact donor when 18

Best to go through a UK HFEA licensed fertility centre – conform to strict medical, ethical and legal standards

Can privately find own donor

Some couples may consider going abroad

Question 26

Adoption process

Answer 26

Two stages:
1. Registration and checks
Registering interest with adoption agency
Medical and criminal background checks; three written references
Usually takes ~2 months

1. Assessment and approval
Home visits by social worker
Compilation of ‘prospective adopters report’, taken to adoption panel
Panel review information and make a decision whether a couple is suitable to adopt
Takes ~4 months

Question 27

PGD

Answer 27

Uses IVF with an additional step to genetically test the embryo before implantation

PGD is particularly used by people who do not want TOP

PGD not always an easy option:
Emotional and physical implications

Can be lengthy process

Success rates ~30% per cycle; ~40% per embryo transfer

Our patients use PGD for many genetic disorders
Translocation carriers
HD
DMD – can only implant female embryos (where mutation in family is unknown)
CF
BRCA1/2

PGD is now nationally funded

A licence is required from the HFEA for each genetic condition or indication

Question 28

Process of PGD

Answer 28

1. Stimulation of the ovaries
2, Egg collection 
3. Insemination 
4. Fertilisation 
5. Embryo biopsy
6. Embryo testing 
7. Embryo transfer
8. Pregnancy test

Follow hyper simulation of the ovaries, many eggs are hopefully removed. Each egg is surrounded by sperm to allow fertilisation .

ICSI - Intracytoplasmic Sperm Injection

• single sperm injected into the centre of each egg
• used for conditions caused by a single faulty gene to reduce the amount of non- embryo DNA ( including sperm DNA) which could make the risk of a wrong diagnosis higher

Question 29

When is the cell removed from the development to genetically test for the genetic condition in the family

Answer 29

Day 5- cell is removed from the blastocyst and tested for genetic condition

Question 30

Eligibility criteria for PGD

Answer 30

Female partner is suitable age, BMI and hormone levels
Female partner is under age 39
Female partner has a BMI of 19-30
Female partner has hormone levels that suggest she will respond to treatment

The couple are non-smokers in an appropriate situation (stable and no concerns)
Both partners are non-smokers
Couple are living together in a stable relationship
No welfare concerns for the unborn child

No other unaffected children
No living unaffected children from the relationship

Genetic problems (accurate test with at least 10% risk of serious condition)
Known risk of having a child affected by a ‘serious’ genetic condition (at least 10%)
An accurate genetic test is available

Licence
A licence is required from the HFEA for each genetic condition or indication

Eligible couples are usually funded for three rounds of PGD.

Question 31

What is the role of a GC in prenatal testing

Answer 31

Arrange & explain CVS, amniocentesis, PGD, cffDNA

Facilitate decision-making

Give results

See patients in clinic following a diagnosis in utero

Arrange termination if necessary

Discuss recurrence risks and plans for future pregnancies