Implementation of high-throughput non-invasive prenatal testing for fetal RHD genotype testing in England: Results of a cross-sectional survey of maternity units and expert interviews

Healthcare professionals' perspectives on and experiences with non-invasive prenatal testing: a systematic review

BACKGROUND

The increasing integration of non-invasive prenatal testing (NIPT) into antenatal practice and public healthcare systems globally raises both significant challenges in standardising service delivery and important ethical questions around routinisation and reproductive autonomy. This systematic review aims to synthesise existing primary empirical research on healthcare professionals' views on and experiences with NIPT.

METHODS

A systematic search was conducted across four major databases in September 2023 and repeated in December 2024. Studies that reported findings from primary empirical research, including quantitative, qualitative and mixed methods research were included.

RESULTS

Searches returned 65 eligible articles, spanning 38 countries and 1 special administrative region and at least 12 professions. Views on who NIPT should have access to and which conditions should be screened for were influenced by perceived clinical utility. While healthcare professionals acknowledged NIPT as beneficial for supporting reproductive autonomy, concerns were raised about the amount and complexity of information to be conveyed during prenatal counseling and potential pressure to test. Cost was also identified as a significant barrier. Challenges reported during post-test counseling included communicating test failures and gaining information from laboratories. Views on the implications of NIPT for decision-making around abortion and for people with disabilities varied.

CONCLUSIONS

Healthcare professionals play a critical role in facilitating the access to and decisions by pregnant people around prenatal genetic testing. Addressing barriers in clinical practice and increasing consistency across and access to clinical guidelines and education resources may support healthcare professionals in supporting reproductive autonomy.

Antenatal RHD screening to guide antenatal anti-D immunoprophylaxis in non-immunized D- pregnant women

In pregnancy, D- pregnant women may be at risk of becoming immunized against D when carrying a D+ fetus, which may eventually lead to hemolytic disease of the fetus and newborn. Administrating antenatal and postnatal anti-D immunoglobulin prophylaxis decreases the risk of immunization substantially. Noninvasive fetal RHD genotyping, based on testing cell-free DNA extracted from maternal plasma, offers a reliable tool to predict the fetal RhD phenotype during pregnancy. Used as a screening program, antenatal RHD screening can guide the administration of antenatal prophylaxis in non-immunized D- pregnant women so that unnecessary prophylaxis is avoided in those women who carry a D- fetus. In Europe, antenatal RHD screening programs have been running since 2009, demonstrating high test accuracies and program feasibility. In this review, an overview is provided of current state-of-the-art antenatal RHD screening, which includes discussions on the rationale for its implementation, methodology, detection strategies, and test performance. The performance of antenatal RHD screening in a routine setting is characterized by high accuracy, with a high diagnostic sensitivity of ≥99.9 percent. The result of using antenatal RHD screening is that 97-99 percent of the women who carry a D- fetus avoid unnecessary prophylaxis. As such, this activity contributes to avoiding unnecessary treatment and saves valuable anti-D immunoglobulin, which has a shortage worldwide. The main challenges for a reliable noninvasive fetal RHD genotyping assay are low cell-free DNA levels, the genetics of the Rh blood group system, and choosing an appropriate detection strategy for an admixed population. In many parts of the world, however, the main challenge is to improve the basic care for D- pregnant women.

Implementation of high-throughput non-invasive prenatal testing for fetal RHD genotype testing in England: Results of a cross-sectional survey of maternity units and expert interviews

Background

Previously, routine antenatal anti‐D prophylaxis (RAADP) was administered to all RhD‐negative mothers to reduce the risk of sensitisation in the UK's National Health Service (NHS). If the baby is RhD‐negative, RAADP is not required. In 2016, the UK National Institute for Health and Care Excellence (NICE) recommended non‐invasive prenatal testing (NIPT) for fetal RHD genotype as a cost‐effective option to guide RAADP.

Objectives

To evaluate the implementation of high‐throughput NIPT for fetal RHD genotype in maternity units in England by addressing research recommendations from the NICE. These were to reduce uncertainty around the resource use and cost of staff training, management of samples and results and record‐keeping, as well as resultant changes to antenatal or post‐partum care and performance of NIPT.

Methods

A cross‐sectional survey was developed and sent to clinicians at 39 English NHS Trusts in May 2018. Qualitative interviews with seven individuals were conducted to explore missing or contraindicatory data. Qualitative findings were supplemented with NIPT test results (April 2017 to February 2019) from English hospitals.

Results

Staff reported that training took up to 30 minutes. There were no extra costs associated with sample management or additional appointments. Extra time required for record‐keeping and management of test results was balanced later in the patient pathway. The antenatal pathway was not changed in the Trusts surveyed. The survey revealed that four post‐partum scenarios were being used within English NHS Trusts. The frequency of inconclusive NIPT results was 4.3%.

Conclusion

NIPT for fetal RHD genotype can be implemented without consuming substantial extra resources through incorporation into an existing patient pathway.