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Becking EC, Scheffer PG, Henrichs J, Bax CJ, Crombag NMTH, Weiss MM, Macville MVE, Van Opstal D, Boon EMJ, Sistermans EA, Henneman L, Schuit E, Bekker MN. Fetal fraction of cell-free DNA in noninvasive prenatal testing and adverse pregnancy outcomes: a nationwide retrospective cohort study of 56,110 pregnant women. Am J Obstet Gynecol 2023:S0002-9378(23)02128-2. [PMID: 38097030 DOI: 10.1016/j.ajog.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Noninvasive prenatal testing by cell-free DNA analysis is offered to pregnant women worldwide to screen for fetal aneuploidies. In noninvasive prenatal testing, the fetal fraction of cell-free DNA in the maternal circulation is measured as a quality control parameter. Given that fetal cell-free DNA originates from the placenta, the fetal fraction might also reflect placental health and maternal pregnancy adaptation. OBJECTIVE This study aimed to assess the association between the fetal fraction and adverse pregnancy outcomes. STUDY DESIGN We performed a retrospective cohort study of women with singleton pregnancies opting for noninvasive prenatal testing between June 2018 and June 2019 within the Dutch nationwide implementation study (Trial by Dutch Laboratories for Evaluation of Non-Invasive Prenatal Testing [TRIDENT]-2). Multivariable logistic regression analysis was used to assess associations between fetal fraction and adverse pregnancy outcomes. Fetal fraction was assessed as a continuous variable and as <10th percentile, corresponding to a fetal fraction <2.5%. RESULTS The cohort comprised 56,110 pregnancies. In the analysis of fetal fraction as a continuous variable, a decrease in fetal fraction was associated with increased risk of hypertensive disorders of pregnancy (adjusted odds ratio, 2.27 [95% confidence interval, 1.89-2.78]), small for gestational age neonates <10th percentile (adjusted odds ratio, 1.37 [1.28-1.45]) and <2.3rd percentile (adjusted odds ratio, 2.63 [1.96-3.57]), and spontaneous preterm birth from 24 to 37 weeks of gestation (adjusted odds ratio, 1.02 [1.01-1.03]). No association was found for fetal congenital anomalies (adjusted odds ratio, 1.02 [1.00-1.04]), stillbirth (adjusted odds ratio, 1.02 [0.96-1.08]), or neonatal death (adjusted odds ratio, 1.02 [0.96-1.08]). Similar associations were found for adverse pregnancy outcomes when fetal fraction was <10th percentile. CONCLUSION In early pregnancy, a low fetal fraction is associated with increased risk of adverse pregnancy outcomes. These findings can be used to expand the potential of noninvasive prenatal testing in the future, enabling the prediction of pregnancy complications and facilitating tailored pregnancy management through intensified monitoring or preventive measures.
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Affiliation(s)
- Ellis C Becking
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter G Scheffer
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jens Henrichs
- Department of Midwifery Science, VU University Medical Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Caroline J Bax
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Neeltje M T H Crombag
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marjan M Weiss
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merryn V E Macville
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Diane Van Opstal
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Elles M J Boon
- Department of Human Genetics, VU University Medical Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Erik A Sistermans
- Amsterdam Reproduction and Development research institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of Human Genetics, VU University Medical Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Lidewij Henneman
- Amsterdam Reproduction and Development research institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of Human Genetics, VU University Medical Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mireille N Bekker
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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van den Heuvel JFM, Teunis CJ, Franx A, Crombag NMTH, Bekker MN. Home-based telemonitoring versus hospital admission in high risk pregnancies: a qualitative study on women's experiences. BMC Pregnancy Childbirth 2020; 20:77. [PMID: 32019499 PMCID: PMC7001237 DOI: 10.1186/s12884-020-2779-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/29/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Hospital admission during pregnancy complications is considered to be an event of significant impact. Besides conventional in-clinic maternal and fetal monitoring, recent technologies enable home-based telemonitoring with self-measurements in high risk pregnancy. This study is part of a feasibility pilot to explore the usability and acceptability of telemonitoring and aims to gain insight in the experiences and preferences of high risk pregnant women concerning the novel strategy of telemonitoring, opposed to women who were hospitalized in pregnancy. METHODS Using secured Facebook Groups, we conducted four online focus groups: two focus groups with women who were admitted during pregnancy (n = 11) and two with women who received home telemonitoring in the pilot phase (n = 11). The qualitative data were analyzed thematically. RESULTS Four major themes emerged from both participant groups: [1] care experience, [2] emotions regarding pregnancy, [3] privacy and [4] impact on daily life. Different views were reported on all four themes, resulting in a direct comparison of experiences during hospitalization and telemonitoring. Most admitted patients reported a growing sense of boredom and anxiety during their clinical admission. Lack of privacy on ward was a great concern, as it affected their contact with hospital staff and family. This issue was not reported amongst telemonitored women. These participants still felt like a patient at times but responded that the comfort of their own home and bed was pleasant. Only a minority of telemonitored participants reported being anxious at times at home, while not having a physician or nurse nearby. Being at home resulted in less travel time for partners or family for hospital visits, which had its positive effects on family life. CONCLUSIONS Telemonitoring of a high-risk pregnancy provides an innovative manner to monitor fetal and maternal condition from home. Compared to the experiences of hospital admission in high risk pregnancy, it allows women to be in a comforting and private environment during an anxious time in their lives. As future studies should further investigate the safety and cost effectiveness of this novel strategy, women's views on the preference of telemonitoring need to be taken into consideration.
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Affiliation(s)
- J F M van den Heuvel
- Department of Obstetrics, University Medical Center Utrecht, Utrecht University, Ref: KE 04.123.1 Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - C J Teunis
- Department of Obstetrics, University Medical Center Utrecht, Utrecht University, Ref: KE 04.123.1 Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - A Franx
- Department of Obstetrics, University Medical Center Utrecht, Utrecht University, Ref: KE 04.123.1 Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - N M T H Crombag
- Department of Obstetrics, University Medical Center Utrecht, Utrecht University, Ref: KE 04.123.1 Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.,Department of Development and Regeneration, Leuven, KU, Belgium
| | - M N Bekker
- Department of Obstetrics, University Medical Center Utrecht, Utrecht University, Ref: KE 04.123.1 Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
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Crombag NMTH, Lamain-de Ruiter M, Kwee A, Schielen PCJI, Bensing JM, Visser GHA, Franx A, Koster MPH. Perspectives, preferences and needs regarding early prediction of preeclampsia in Dutch pregnant women: a qualitative study. BMC Pregnancy Childbirth 2017; 17:12. [PMID: 28061818 PMCID: PMC5219667 DOI: 10.1186/s12884-016-1195-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/13/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND To improve early risk-identification in pregnancy, research on prediction models for common pregnancy complications is ongoing. Therefore, it was the aim of this study to explore pregnant women's perceptions, preferences and needs regarding prediction models for first trimester screening for common pregnancy complications, such as preeclampsia, to support future implementation. METHOD Ten focus groups (of which five with primiparous and five with multiparous women) were conducted (n = 45). Six focus groups were conducted in urban regions and four in rural regions. All focus group discussions were audio taped and NVIVO was used in order to facilitate the thematic analysis conducted by the researchers. RESULTS Women in this study had a positive attitude towards first trimester screening for preeclampsia using prediction models. Reassurance when determined as low-risk was a major need for using the test. Self-monitoring, early recognition and intensive monitoring were considered benefits of using prediction models in case of a high-risk. Women acknowledged that high-risk determination could cause (unnecessary) anxiety, but it was expected that personal and professional interventions would level out this anxiety. CONCLUSION Women in this study had positive attitudes towards preeclampsia screening. Self-monitoring, together with increased alertness of healthcare professionals, would enable them to take active actions to improve pregnancy outcomes. This attitude enhances the opportunities for prevention, early recognition and treatment of preeclampsia and probably other adverse pregnancy outcomes.
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Affiliation(s)
- Neeltje M T H Crombag
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands.
| | - Marije Lamain-de Ruiter
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands
| | - Anneke Kwee
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands
| | - Peter C J I Schielen
- Centre for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Jozien M Bensing
- Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands.,The Netherlands Institute for Health Services Research Utrecht, Utrecht, The Netherlands
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands
| | - Arie Franx
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands
| | - Maria P H Koster
- Department of Obstetrics, University Medical Center Utrecht, Room KE04.123.1, P.O. Box 85090, 3508AB, Utrecht, The Netherlands.,Department of obstetrics and gynaecology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Crombag NMTH, Boeije H, Iedema-Kuiper R, Schielen PCJI, Visser GHA, Bensing JM. Reasons for accepting or declining Down syndrome screening in Dutch prospective mothers within the context of national policy and healthcare system characteristics: a qualitative study. BMC Pregnancy Childbirth 2016; 16:121. [PMID: 27229318 PMCID: PMC4880977 DOI: 10.1186/s12884-016-0910-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 05/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uptake rates for Down syndrome screening in the Netherlands are low compared to other European countries. To investigate the low uptake, we explored women's reasons for participation and possible influences of national healthcare system characteristics. Dutch prenatal care is characterised by an approach aimed at a low degree of medicalisation, with pregnant women initially considered to be at low risk. Prenatal screening for Down syndrome is offered to all women, with a 'right not to know' for women who do not want to be informed on this screening. At the time this study was performed, the test was not reimbursed for women aged 35 and younger. METHODS We conducted a qualitative study to explore reasons for participation and possible influences of healthcare system characteristics. Data were collected via ten semi-structured focus groups with women declining or accepting the offer of Down syndrome screening (n = 46). All focus groups were audio- and videotaped, transcribed verbatim, coded and content analysed. RESULTS Women declining Down syndrome screening did not consider Down syndrome a condition severe enough to justify termination of pregnancy. Young women declining felt supported in their decision by perceived confirmation of their obstetric caregiver and reassured by system characteristics (costs and age restriction). Women accepting Down syndrome screening mainly wanted to be reassured or be prepared to care for a child with Down syndrome. By weighing up the pros and cons of testing, obstetric caregivers supported young women who accepted in the decision-making process. This was helpful, although some felt the need to defend their decision to accept the test offer due to their young age. For some young women accepting testing, costs were considered a disincentive to participate. CONCLUSIONS Presentation of prenatal screening affects how the offer is attended to, perceived and utilised. By offering screening with age restriction and additional costs, declining is considered the preferred choice, which might account for low Dutch uptake rates. Autonomous and informed decision-making in Down syndrome screening should be based on the personal interest in knowing the individual risk of having a child with Down syndrome and system characteristics should not influence participation.
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Affiliation(s)
- Neeltje M T H Crombag
- Department of Obstetrics, University Medical Center Utrecht, P.O. Box 85090, Room KE04.123.1, 3508AB, Utrecht, The Netherlands.
| | - Hennie Boeije
- The Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Rita Iedema-Kuiper
- Department of Obstetrics, University Medical Center Utrecht, P.O. Box 85090, Room KE04.123.1, 3508AB, Utrecht, The Netherlands
| | - Peter C J I Schielen
- Centre for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center Utrecht, P.O. Box 85090, Room KE04.123.1, 3508AB, Utrecht, The Netherlands
| | - Jozien M Bensing
- The Netherlands Institute for Health Services Research, Utrecht, The Netherlands.,Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
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Crombag NMTH, van Schendel RV, Schielen PCJI, Bensing JM, Henneman L. Present to future: what the reasons for declining first-trimester combined testing tell us about accepting or declining cell-free DNA testing. Prenat Diagn 2016; 36:587-90. [PMID: 27061402 DOI: 10.1002/pd.4824] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/29/2016] [Accepted: 04/06/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Neeltje M T H Crombag
- Department of Obstetrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rachel V van Schendel
- Department of Clinical Genetics, section Community Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter C J I Schielen
- Centre for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Jozien M Bensing
- The Netherlands Institute for Health Services Research, Utrecht, The Netherlands.,Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics, section Community Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Crombag NMTH, Schielen PCJI, Hukkelhoven CW, Iedema R, Bensing JM, Visser GHA, Stoutenbeek P, Koster MPH. Determinants of first trimester combined test participation within the central region of the Netherlands. Prenat Diagn 2016; 35:486-92. [PMID: 25613681 DOI: 10.1002/pd.4564] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/15/2015] [Accepted: 01/18/2015] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Our objective is to study the association between potentially influential determinants and first-trimester combined test (FCT) uptake rates in the central region of the Netherlands. METHODS Data were extracted from the national prenatal screening database Peridos and the Netherlands Perinatal Registry and compared at the level of the health care provider. Univariable and multivariable linear regression analysis was used to determine the effect of determinants (maternal age, parity, socio-economic status (SES), mode of conception, ethnicity and urbanisation) on uptake. RESULTS Prenatal screening data were available for 24 657 women and overall uptake rate was 25.7%. The strongest association with FCT uptake was found for advanced maternal age (β 2.2; 95% CI [1.7, 2.8]). Grand multiparity had a significantly negative association with FCT uptake (β -4.3; 95% CI [-5.9, -2.7]). Positive associations were found for very high urbanisation (β 0.3; 95% CI [0.1, 0.4]) and high SES (β 0.2; 95% CI [0.0, 0.3]). CONCLUSION Advanced maternal age is strongly associated with participation in prenatal testing. The role of age related risk perception should be incorporated in future policy making to support women in informed and autonomous decision making. The negative association of grand multiparity and FCT might be religion based but requires further research. © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Neeltje M T H Crombag
- Department of Obstetrics, University Medical Center Utrecht, Utrecht, The Netherlands
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