Genetic counseling for fetal sex prediction by NIPT: Challenges and opportunities

Non-invasive prenatal testing (NIPT) has grown in ubiquity in the last decade and is now endorsed by Society for Maternal Fetal Medicine and American College of Obstetricians and Gynecologists as a screening tool for aneuploidy in all patients. Past studies have demonstrated a tendency among obstetrics patients to focus on the ability of NIPT to predict fetal sex chromosomes; however, data on the experiences of genetic counselors (GCs) counseling on NIPT and fetal sex prediction are limited. This mixed-methods study aimed to explore how GCs counsel about NIPT and fetal sex prediction, as well as the use of gender-inclusive language in this setting. A 36-item survey with multiple choice, Likert scale, and open-ended questions was distributed to GCs who currently offer NIPT to patients. Quantitative data were analyzed using R and qualitative data were manually analyzed and coded via inductive content analysis. A total of 147 individuals completed at least some portion of the survey. A majority of participants (68.5%) reported frequent interchangeable use of the terms 'sex' and 'gender' by patients. A majority (72.9%) of participants reported that they rarely or never discuss the difference between these terms in sessions (Spearman's rho = 0.17, p = 0.052). Seventy-five respondents (59.5%) indicated that they had taken continuing education courses on inclusive clinical practices for trans and gender-diverse (TGD) patients. Several themes arose from free responses; the most frequently identified themes were the need for thorough pretest counseling that properly describes the scope of NIPT and the challenge of discrepant pretest counseling by other healthcare providers. Results from our research identified challenges and misconceptions GCs face when offering NIPT and various tactics implemented to mitigate these. Our study highlighted the need for the standardization of pretest counseling regarding NIPT, additional guidance from professional organizations, and continuing education focused on gender-inclusive language and clinical practices.

Postnatal genetic testing on cord blood for prenatally identified high-probability cases

OBJECTIVE

To evaluate the utility of postnatal genetic testing on umbilical cord blood (CB) for prenatally identified high-probability fetuses.

METHOD

CB for genetic testing was offered to individuals who met one of the following criteria: (i) fetal anomaly, (ii) positive non-invasive prenatal screening by cfDNA or biochemical analysis, or (iii) family history. Individuals with diagnostic testing, but not microarray, were also included when recommended by society guidelines. CB was collected at Brigham and Women's and Emerson Hospitals between 2016 and 2021.

RESULTS

448 individuals consented for cord blood testing (370 (82.6%) for fetal anomalies, 51 (11.4%) for high-probability cfDNA, and 27 (6.0%) for family history) and a total of 393 (87.7%) samples were analyzed. Genetic testing yielded a diagnosis in 92 (23.4%) neonates by karyotype (n = 37), chromosomal microarray (CMA) (n = 32), and other molecular analysis (n = 23). Testing averaged 10.3 days (range 1-118 days). 68 (73.9%) diagnoses potentially impacted neonatal management. MCC could not be definitively excluded in only 1.4% (6/418) of samples.

CONCLUSION

Prenatal identification of high-probability fetuses and genetic testing on CB facilitates timely genetic diagnoses and neonatal management. Testing provides reassurance and reduces a postnatal diagnostic odyssey for high-probability neonates.

Chromosomal Microarray Analysis in Pregnancy Loss: Is it Time for a Consensus Approach?

OBJECTIVE

To investigate the efficacy and outcomes of chromosomal microarray (CMA) in cytogenomic evaluation of products of conception (POC).

METHOD

Over a 42-month period, 323 POC samples were tested by CMA. Results were assessed using variables including phenotype, gestational age, results from orthogonal testing, and follow-up parental analysis.

RESULTS

CMA identified cytogenetic abnormalities in 47.4% of first trimester losses and 10.9% of second and third trimester losses. CMA specifically of five- to seven-week losses showed similar rates of abnormalities (45.6%) compared to that of all first trimester losses combined. CMA and karyotype results were discordant in 20.0% of cases, most likely due to maternal cell overgrowth in culture. The most prevalent abnormalities identified in all losses were autosomal trisomies followed by triploidy. In 43/323 cases, the observed abnormality suggested a parental aberration that prompted follow-up studies; two of these cases indeed identified an inherited aberration.

CONCLUSION

Our finding of specific types of genetic abnormalities and the respective frequencies by gestational age closely align with those of published karyotype studies, supporting the use of routine CMA testing for POCs. CMA outperforms karyotype analysis because it does not require viable, sterile cultures free of maternal admixture or admixture due to multiple gestations. Finally, CMA results can play an important role in identifying increased recurrence risks for some couples. This article is protected by copyright. All rights reserved.

Rare disease patient matchmaking: development and outcomes of an internet case-finding strategy in the Undiagnosed Diseases Network

Background

Although clinician, researcher, and patient resources for matchmaking exist, finding similar patients remains an obstacle for rare disease diagnosis. The goals of this study were to develop and test the effectiveness of an Internet case-finding strategy and identify factors associated with increased matching within a rare disease population.

Methods

Public web pages were created for consented participants. Matches made, time to each inquiry and match, and outcomes were recorded and analyzed using descriptive statistics. A Poisson regression model was run to identify characteristics associated with matches.

Results

385 participants were referred to the project and 158 had pages posted. 579 inquiries were received; 89.0% were from the general public and 24.7% resulted in a match. 81.6% of pages received at least one inquiry and 15.0% had at least one patient match. Primary symptom category of neurology, diagnosis, gene page, and photo were associated with increased matches (p ≤ 0.05).

Conclusions

This Internet case-finding strategy was of interest to patients, families, and clinicians, and similar patients were identified using this approach. Extending matchmaking efforts to the general public resulted in matches and suggests including this population in matchmaking activities can improve identification of similar patients.

Supplementary information

The online version contains supplementary material available at 10.1186/s13023-021-01825-1.

High-Risk HPV Genotypes Identified in Northern Honduras: Evidence for Prevention

Background: Cervical cancer is one of the most prevalent cancers in Honduran women. Lacking national or population-based registries, we rely on hospital registries to establish incidence: San Felipe General Hospital in 2012 diagnosed 38% of 998 women and The League against Cancer Hospital (LCC) in 2016 diagnosed 54.4% of 695 women with cervical cancer CC. According to PAHO's Honduras Profile 2013, screening coverage with Pap was 48.1%. Bruni in 2010 reported a prevalence of high risk HPV (hrHPV) infection for Central America of 13%, identifying genotypes 16, 18, 52, 31 and 58 as most frequent. Information about pathogenesis of hrHPV to induce cervical lesions is based on models of genotypes 16 and 18 only. Aim: Inform evidence of hrHPV genotypes collected in Honduras from an urban and a rural population, generate discussion and subsequent improvement of cervical cancer control strategies in our country. Methods: In 2016, 2 clinical studies funded by Norris Cotton Cancer Center at Dartmouth College and the LCC accrued 913 women: 401 in Locomapa Valley (rural), 111 in La Mosquitia (remote rural), and 401 in a textile factory in San Pedro Sula (urban). Women were consented, to obtain 3 cervical samples, during a cervical cancer screening brigade. One sample for conventional cytology, and 2 for hrHPV by PCR genotyping. One local with our customized PCR device and the second at Dartmouth. An educational component and survey were included. Positive patients identified with hrHPV, pre or invasive cancer were referred to LCC for treatment and follow-up. Results: In Locomapa and the factory (rural and urban sites) 13% of participants were positive for hrHPV. Only 15% had HPV 16. The following common genotypes varied by location: urban factory HPV 59, 12% in rural location HPV 58, 10%; HPV 31, 9%; HPV 39 8%; HPV 35 and 66, 7%; HPV 45 and 51, 6%; HPV 18 and 56, 3%; HPV 33 and 52, 1%. 17% of women had multiple hrHPV coinfection. 7.7% had abnormal Pap tests. In La Mosquitia (remote rural), 24% of women were positive for hrHPV: HPV 52, 29%; HPV 16, 23%; HPV 39, 10%; HPV 68, 6%; HPV 58, 6%; HPV 45, 6%; HPV 51 and HPV 31, 18, 66, 59 and 35, 3% each. 1.8% had abnormal Pap tests; all participants identified with hrHPV were referred for follow-up. The average age was 40.3 years, parity, 3 children, education 6.0 years; and 15% were first-time users of a cervical screening program. Conclusion: Associate the burden of disease, with risk factors, will help us to generate models of prevention and care that are reproducible and effective to reduce morbi-mortality. Brigade-type screening models, with trained providers working at a community location over a single day, can offer improved access for women at risk and facilitate educational activities for health promotion. Introducing tests as hrHPV DNA detection, effectively reduces the volume of women to follow. Strengthening the capacity of primary care with novel screening techniques and ensure diligent follow-up is essential.

Rural distribution of human papilloma virus in low- and middle-income countries

Cervical cancer rates in low- and middle-income countries (LMICs) are higher than in developed countries and account for 80% of an estimated 500,000 new cases annually. Factors that contribute to this are that diagnostic and prevention strategies designed for developed countries suffer from the combination of low vaccination rates and limitations due to lack of consistent access to both healthcare and supplies. Here we: 1) improve upon our LMIC deployable HPV test and 2) determine both the high and low-risk HPV genotype prevalence in an isolated Honduran population. We found an unexpected HPV distribution with an abundance of HPV 52 and HPV 72 infections. In this context, molecular testing using a LMIC deployable approach for the detection of HPV can aid in both the triage of HPV positive cytology-based follow up and provide information regarding HPV genotype distribution in support of vaccination strategies.