Noninvasive Prenatal Testing and Incidental Detection of Occult Maternal Malignancies.

IMPORTANCE: Understanding the relationship between aneuploidy detection on noninvasive prenatal testing (NIPT) and occult maternal malignancies may explain results that are discordant with the fetal karyotype and improve maternal clinical care. OBJECTIVE: To evaluate massively parallel sequencing data for patterns of copy-number variations that might prospectively identify occult maternal malignancies. DESIGN, SETTING, AND PARTICIPANTS: Case series identified from 125,426 samples submitted between February 15, 2012, and September 30, 2014, from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening. Analyses were conducted in a clinical laboratory that performs DNA sequencing. Among the clinical samples, abnormal results were detected in 3757 (3%); these were reported to the ordering physician with recommendations for further evaluation. EXPOSURES: NIPT for fetal aneuploidy screening (chromosomes 13, 18, 21, X, and Y). MAIN OUTCOMES AND MEASURES: Detailed genome-wide bioinformatics analysis was performed on available sequencing data from 8 of 10 women with known cancers. Genome-wide copy-number changes in the original NIPT samples and in subsequent serial samples from individual patients when available are reported. Copy-number changes detected in NIPT sequencing data in the known cancer cases were compared with the types of aneuploidies detected in the overall cohort. RESULTS: From a cohort of 125,426 NIPT results, 3757 (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. From this set of 3757 samples, 10 cases of maternal cancer were identified. Detailed clinical and sequencing data were obtained in 8. Maternal cancers most frequently occurred with the rare NIPT finding of more than 1 aneuploidy detected (7 known cancers among 39 cases of multiple aneuploidies by NIPT, 18% [95% CI, 7.5%-33.5%]). All 8 cases that underwent further bioinformatics analysis showed unique patterns of nonspecific copy-number gains and losses across multiple chromosomes. In 1 case, blood was sampled after completion of treatment for colorectal cancer and the abnormal pattern was no longer evident. CONCLUSIONS AND RELEVANCE: In this preliminary study, a small number of cases of occult malignancy were subsequently diagnosed among pregnant women whose noninvasive prenatal testing results showed discordance with the fetal karyotype. The clinical importance of these findings will require further research.

Small bowel obstruction and internal hernias during pregnancy after gastric bypass surgery.

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB. In both patients a Petersen's type IH was found. We reviewed the cases reported in the literature of SBO during pregnancy after RYGB. IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.

Recurrent spontaneous abortion and skewed X-inactivation: is there an association?

OBJECTIVE: The purpose of this study was to determine whether there is an association between skewed X-inactivation and recurrent spontaneous abortion in a large, well-defined sample of women with recurrent loss. STUDY DESIGN: X-chromosome inactivation patterns were compared in 5 groups of women. Group 1 (recurrent spontaneous abortion) consisted of 357 women with 2 or more spontaneous losses. In group 2 (infertility), there were 349 subjects from infertility practices recruited at the time of a positive serum beta-human chorionic gonadotropin. Group 3 (spontaneous abortion) women (n = 81) were recruited at the time of an ultrasound diagnosis of an embryonic demise or an anembryonic gestation. Groups 4 (primiparous) and 5 (multiparous) were healthy pregnant subjects previously enrolled in another study to determine the incidence and cause of pregnancy complications, such as preeclampsia and intrauterine growth restriction. The Primiparous group included 114 women in their first pregnancy, whereas the Multiparous group consisted of 79 women with 2 or more pregnancies but without pregnancy loss. RESULTS: The rate of extreme skewing (90% or greater) in the recurrent spontaneous abortion population was 8.6%, and not statistically different from any of the other groups, except the Primiparous group (1.0%, P < .01). The incidence of X-inactivation skewing of 90% or greater was no different whether there had been at least 1 live birth (9.9%), or no previous live births and at least 3 losses (5.6%, P > .05). When age and skewing of 90% or greater are compared, subjects with extreme skewing have a mean age of 2 years older than those without extreme skewing (P < .05). CONCLUSION: Skewed X-inactivation is not associated with recurrent spontaneous abortion but is associated with increasing maternal age.

Fetal aneuploidy screening with cell-free DNA in late gestation.

OBJECTIVE: The aim of this study was to evaluate clinical use of NIPT at gestational ages of 23 weeks and above. METHODS: A cohort of 5579 clinical patients with singleton gestations of 23 weeks or greater submitting a blood sample for NIPT in an 18-month period were selected for this study. Clinical outcomes were requested for samples with NIPT results indicating fetal aneuploidy and compared with NIPT findings to confirm concordance or discordance. RESULTS: A review of clinical indications revealed that a significantly (p < 0.0001) larger proportion of late-gestation samples indicated abnormal ultrasound findings with or without other indications, 6.2% and 42.1%, compared with early-gestation samples, 1.8% and 6.0%, respectively. Of 5372 reported late-gestation samples, 151 (2.8%) were reported as aneuploidy detected or suspected. In late-gestation samples, the overall observed positive predictive value (PPV) for NIPT was 64.7%, with an observed PPV of 100% in the subset of cases with multiple clinical indications including abnormal ultrasound findings. CONCLUSIONS: NIPT is a highly accurate prenatal screening option for women after 23 weeks of gestation. Women who presented for NIPT in the latter stages of pregnancy more frequently specified clinical indications of abnormal ultrasound findings than women who entered screening earlier in pregnancy.

Multiple-marker screening in human immunodeficiency virus-positive pregnant women: Screen positivity rates with the triple and quad screens.

OBJECTIVE: The study was undertaken to determine the screen-positive rates of multiple-marker screening tests in pregnant women who are positive for human immunodeficiency virus (HIV) at our institution for open neural tube defects and aneuploidy, for both triple (alpha-fetoprotein, human chorionic gonadotropin [hCG], unconjugated estriol) and quad (alpha-fetoprotein, hCG, unconjugated estriol, inhibin A) screens, and to compare these rates with a matched control group. STUDY DESIGN: A 1:1 matched case-control study was performed comparing multiple marker screening test results in 34 HIV-positive women with age- and race-matched HIV-negative controls. Individual serum markers and screen positive rates for both the triple and quad screens were compared among the cases and controls. RESULTS: In each group, there were 19 women with triple screens and 15 with quad screens. Serum hCG multiples of the median were significantly higher in the HIV-positive compared with the HIV-negative women (P=.033). There was no difference in screen positive rates between the cases and controls using the triple screen, but there was a significantly higher overall screen positive rate in the HIV-positive group when the quad screen was used (33% vs 7%, P=.046). CONCLUSION: There is a significantly higher rate of overall quad screen positivity on multiple-marker screening among HIV-positive women compared with a matched control group.