Aetna considers multiple serum marker testing (dimeric inhibin A, human chorionic gonadotropin (hCG) with maternal serum alpha-fetoprotein (MSAFP), and unconjugated estriol) medically necessary for pregnant women who have been adequately counseled and who desire information on their risk of having a Down syndrome fetus.
According to recommendations of the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, women aged 35 and older who desire information of their risk of having a Down syndrome fetus should have chorionic villus sampling (CVS) or amniocentesis for detection. Multiple serum marker testing is considered medically necessary for women who decline these more invasive procedures.
Aetna considers the use of the following serum markers experimental and investigational for second trimester serum marker screening for Down syndrome because the clinical use of these markers is under investigation:
Aetna considers the use of serum markers A Disintegrin And Metalloprotease 12 (ADAM 12) and placental protein 13 (PP13) experimental and investigational for first trimester screening for Down syndrome because their clinical use is under investigation.
Aetna considers measurement of cell-free fetal nucleic acids in maternal blood (e.g., MaterniT21, MaterniT21 PLUS, Verifi Prenatal Test, Harmony Prenatal Test, Panorama Prenatal Test, QNatal Advanced) medically necessary for testing for fetal aneuploidy (trisomy 13, 18 and 21) in pregnant women with single gestations who meet any of the following indications:
Aetna considers the use of maternal serum anti-Mullerian hormone level for first or second trimester screening for Down syndrome experimental and investigational because its effectiveness has not been established.
Maternal Serum Screening for Fetal Aneuploidy
Levels of human chorionic gonadotropin (hCG), maternal serum alpha-fetoprotein (MSAFP), and unconjugated estriol have been associated with maternal risk of Down syndrome, a chromosomal abnormality associated with mental retardation, congenital heart defects, and physical anomalies. Measurement of these serum markers has been proposed as a means of identifying pregnant women of all ages who are likely to have a Down syndrome fetus.
All pregnant women should be counseled about the risk of having a Down syndrome fetus. Multiple serum marker testing, in conjunction with adequate counseling, should be offered to pregnant women under age 35 who desire information on their risk of having a Down syndrome fetus. Women found to be at high-risk would be candidates for amniocentesis or chorionic villus sampling (CVS), with karyotyping of the tissue obtained to confirm the diagnosis. Multiple serum markers testing and counseling should also be offered to women age 35 or older who wish to avoid the risks of amniocentesis or CVS but desire information on their risk of having a Down syndrome fetus.
High maternal serum levels of hCG with low levels of MSAFP and/or unconjugated estriol in pregnant women has been associated with an increased risk of carrying a Down syndrome fetus. Measurement of multiple serum markers offers a means of identifying young women who are at high-risk of having a Down syndrome fetus; women found to be at high-risk would be offered confirmatory testing by karyotyping tissue obtained by amniocentesis or CVS. Multiple marker testing may also allow pregnant women at high-risk (such as pregnant women age 35 and older) an alternative means of determining the likelihood of having a Down syndrome fetus if they wish to avoid the risk of fetal harm and death associated with amniocentesis and CVS.
Dimeric inhibin A is now used by some commercial laboratories in combination with the 3 traditional analytes. With a screen-positive rate of 5 % or less, this new 4-analyte combination appears to detect 67 % to 76 % of Down syndrome cases in women younger than 35 years (ACOG, 2001).
Efforts to improve biochemical screening have centered on the investigation of screening in the first trimester and on the search for better markers. Two potential serum markers that can be measured during the first trimester are the free beta subunit of hCG and pregnancy-associated protein A. Serum concentrations of the free beta subunit of hCG are higher than average, and pregnancy-associated protein A concentrations are lower, in the presence of a fetus with Down syndrome. The combination of free beta-hCG, PAPP-A, and maternal age appears to yield detection and false-positive rates comparable to second-trimester serum screening (63 % and 5.5 %, respectively) (ACOG, 2001). Unfortunately, free beta-hCG may not be higher in Down syndrome pregnancies until 12 weeks of gestation, and PAPP-A seems to lose its discrimination value after 13 weeks of gestation, making accurate assessment of gestational age and careful timing of the screening test essential. The American College of Obstetricians and Gynecologists (2001) states, however, that “preliminary data [regarding these analytes] remains controversial and testing is not yet standard of care.” Many other screening analytes, including urinary beta-core and human placental lactogen, are currently being investigated for use in the first and second trimesters to determine whether they alone or in combination, will increase detection to a rate greater than the current 60 %.
Maternal serum screening for Down syndrome in the first trimester, rather than second, is not widespread because: (i) CVS and early amniocentesis are not as widely available as amniocentesis during the second trimester, and they may be less safe; (ii) maternal serum screening for Down syndrome in the first trimester, followed by screening for open neural-tube defects during the second, is likely to be less cost effective than performing all the screening at the same time; (iii) because serum concentrations of pregnancy-associated protein A change rapidly during the first trimester, gestational age needs to be established by ultrasonography in order for the sensitivity of first-trimester screening to be equivalent to second-trimester screening; and (iv) assays for serum pregnancy-associated protein A and the free beta subunit of hCG are not licensed for clinical use in the United States.
The National Institutes of Health sponsored a multi-center prospective study (the First and Second Trimester Evaluation of Aneuploidy Risk or 'FASTER' trial) that compared first- and second-trimester non-invasive methods of screening for fetal aneuploidies with second trimester multiple marker maternal serum screening that is the current standard of care (NICHD, 2001). The results of the FASTER trial are described in CPB 282 - Noninvasive Down Syndrome Screening. First-trimester screening, taken together with maternal age, involves an ultrasound measurement of fetal nuchal translucency thickness at 10 to 14 gestational weeks, as well as serum levels of pregnancy-associated protein A and free beta-hCG. Second-trimester screening is based on the serum “triple screen,” which consists of measurement of levels of AFP, unconjugated estriol (uE3), and hCG, performed at 15 to 18 gestational weeks, taken together with maternal age and serum inhibin-A levels (so called “quad test”).
In October 1999, the ACOG issued a position statement that first trimester screening is investigational and should not be used in routine clinical practice. The ACOG statement concluded that “[f]irst-trimester screening for fetal chromosome, cardiac, and other abnormalities using the nuchal translucency marker alone or in combination with serum markers appears promising but remains investigational.”
Based on the results of the FASTER trial, which found that first-trimester screening is as good as or better than second-trimester screening, ACOG (2004) stated that first-trimester screening using nuchal translucency, free beta-hCG, and pregnancy-associated plasma protein-A has comparable detection rates and positive screening rates for Down syndrome as second-trimester screening using 4 serum markers (AFP, beta-hCG, uE3, and inhibin-A). The American College of Obstetricians and Gynecologists stated that, although first-trimester screening for Down syndrome and trisomy 18 is an option, it should be offered only if certain criteria can be met.
Wright et al (2010) provided estimates and confidence intervals for the performance (detection and false-positive rates) of screening for Down's syndrome using repeated measures of biochemical markers from first and second trimester maternal serum samples taken from the same woman. Stored serum on Down's syndrome cases and controls was used to provide independent test data for the assessment of screening performance of published risk algorithms and for the development and testing of new risk assessment algorithms. A total of 78 women with pregnancy affected by Down's syndrome and 390 matched unaffected controls, with maternal blood samples obtained at 11 to 13 and 15 to 18 weeks' gestation, and women who received integrated prenatal screening at North York General Hospital at 2 time intervals: between December 1, 1999 and October 31, 2003, and between October 1, 2006 and November 23, 2007 were include in this analysis. Repeated measurements (first and second trimester) of maternal serum levels of hCG, uE3 and PAPP-A together with AFP in the second trimester were carried out. Main outcome measures were detection and false-positive rates for screening with a threshold risk of 1 in 200 at term, and the detection rate achieved for a false-positive rate of 2 %. Published distributional models for Down's syndrome were inconsistent with the test data. When these test data were classified using these models, screening performance deteriorated substantially through the addition of repeated measures. This contradicts the very optimistic results obtained from predictive modeling of performance. Simplified distributional assumptions showed some evidence of benefit from the use of repeated measures of PAPP-A but not for repeated measures of uE3 or hCG. Each of the 2 test data sets was used to create new parameter estimates against which screening test performance was assessed using the other data set. The results were equivocal but there was evidence suggesting improvement in screening performance through the use of repeated measures of PAPP-A when the first trimester sample was collected before 13 weeks' gestation. A Bayesian analysis of the combined data from the 2 test data sets showed that adding a second trimester repeated measurement of PAPP-A to the base test increased detection rates and reduced false-positive rates. The benefit decreased with increasing gestational age at the time of the first sample. There was no evidence of any benefit from repeated measures of hCG or uE3. The authors concluded that If realized, a reduction of 1 % in false-positive rate with no loss in detection rate would give important benefits in terms of health service provision and the large number of invasive tests avoided. The Bayesian analysis, which shows evidence of benefit, is based on strong distributional assumptions and should not be regarded as confirmatory. The evidence of potential benefit suggests the need for a prospective study of repeated measurements of PAPP-A with samples from early in the first trimester. A formal clinical effectiveness and cost-effectiveness analysis should be undertaken. This study has shown that the established modeling methodology for assessing screening performance may be optimistically biased and should be interpreted with caution.
Wright and Burton (2009) stated that cell-free fetal nucleic acids (cffNA) can be detected in the maternal circulation during pregnancy, potentially offering an excellent method for early non-invasive prenatal diagnosis (NIPD) of the genetic status of a fetus. Using molecular techniques, fetal DNA and RNA can be detected from 5 weeks gestation and are rapidly cleared from the circulation following birth. These investigators searched PubMed systematically using keywords free fetal DNA and NIPD. Reference lists from relevant papers were also searched to ensure comprehensive coverage of the area. Cell-free fetal DNA comprises only 3 % to 6 % of the total circulating cell-free DNA, thus diagnoses are primarily limited to those caused by paternally inherited sequences as well as conditions that can be inferred by the unique gene expression patterns in the fetus and placenta. Broadly, the potential applications of this technology fall into 2 categories: (i) high genetic risk families with inheritable monogenic diseases, including sex determination in cases at risk of X-linked diseases and detection of specific paternally inherited single gene disorders; and (ii) routine antenatal care offered to all pregnant women, including prenatal screening/diagnosis for aneuploidy, particularly DS, and diagnosis of Rhesus factor status in RhD negative women. Already sex determination and Rhesus factor diagnosis are nearing translation into clinical practice for high-risk individuals. The authors concluded that the analysis of cffNA may allow NIPD for a variety of genetic conditions and may in future form part of national antenatal screening programs for DS and other common genetic disorders.
The American College of Obstetricians and Gynecologists (2012) stated that non-invasive prenatal testing that uses cell free fetal DNA from the plasma of pregnant women offers tremendous potential as a screening tool for fetal aneuploidy. The ACOG Committee Opinion concluded that measurement of cell-free DNA may be considered for the following indications: maternal age 35 years or older at delivery; fetal ultrasonographic findings predicting an increased risk of fetal aneuploidy; history of a prior pregnancy with an aneuploidy; positive screening test for an aneuploidy, including first trimester, sequential, or integrated screen, or a positive quadruple screen; parental balanced robertsonian translocation with increased risk for fetal trisomy 13 or trisomy 21. The ACOG Committee Opinion stated that cell free fetal DNA testing should be an informed patient choice after pre-test counseling and should not be part of routine prenatal laboratory assessment. The ACOG Committee Opinion stated that cell free fetal DNA testing should not be offered to low-risk women or women with multiple gestations because it has not been sufficiently evaluated in these groups. A negative cell free fetal DNA test result does not ensure an unaffected pregnancy. The Committee Opinion stated that a patient with a positive test result should be referred for genetic counseling and should be offered invasive prenatal diagnosis for confirmation of test results.
Currently available cell-free DNA tests are laboratory developed tests, and there is no requirement for premarket approval by the U.S. Food and Drug Administration. Such laboratory developed tests are regulated by the Centers for Medicare & Medicaid Services as part of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). However, CLIA regulations are restricted to certifying internal procedures and qualifications of laboratories rather than the safety and efficacy of laboratory developed tests specifically. CLIA regulations of genetic tests are designed to ensure procedural compliance at laboratory level and do not extend to validation of specific tests.
Ehrich and colleagues (2011) evaluated a multi-plexed massively parallel shotgun sequencing assay for non-invasive trisomy 21 detection using circulating cell-free fetal DNA. Sample multi-plexing and cost-optimized reagents were evaluated as improvements to a non-invasive fetal trisomy 21 detection assay. A total of 480 plasma samples from high-risk pregnant women were employed. In all, 480 prospectively collected samples were obtained from third-party storage site; 13 of these were removed due to insufficient quantity or quality. Eighteen samples failed pre-specified assay quality control parameters. In all, 449 samples remained: 39 trisomy 21 samples were correctly classified; 1 sample was mis-classified as trisomy 21. The overall classification showed 100 % sensitivity (95 % confidence interval [CI]: 89 to 100 %) and 99.7 % specificity (95 % CI: 98.5 to 99.9 %). The authors concluded that extending the scope of previous reports, this study demonstrated that plasma DNA sequencing is a viable method for non-invasive detection of fetal trisomy 21 and warrants clinical validation in a larger multi-center study.
Sehnert et al (2011) reported on a cross sectional study of the use of cell free DNA to detect fetal aneuploidy. Blood samples from 119 adult pregnant women underwent massively parallel DNA sequencing. Fifty-three sequenced samples came from women with an abnormal fetal karyotype. To minimize the intra- and interrun sequencing variation, the investigators developed an optimized algorithm by using normalized chromosome values (NCVs) from the sequencing data on a training set of 71 samples with 26 abnormal karyotypes. The classification process was then evaluated on an independent test set of 48 samples with 27 abnormal karyotypes. The authors reported that sequencing of the independent test set led to 100% correct classification of T21 (13 of 13) and T18 (8 of 8) samples. The authors noted that other chromosomal abnormalities were also identified.
Palomaki et al (2011) reported on a nested case-control study of the use of massively parallel DNA sequencing to detect fetal aneuploidy. The investigators used blood samples that were collected in a prospective, blinded study from 4664 pregnancies at high risk for Down syndrome by maternal age, family history, or positive screening test. Fetal karyotyping results from amniocentesis or chorionic villus sampling were compared to cell free DNA sequencing in 212 Down syndrome and 1484 matched euploid pregnancies. Down syndrome detection rate was 98.6% (209/212), the false-positive rate was 0.20% (3/1471), and the testing failed in 13 pregnancies (0.8%); all were euploid.
In a subsequent report, Palomaki et al (2012) selected 62 pregnancies with trisomy 18 and 12 with trisomy 13 from the cohort of 4,664 pregnancies along with matched euploid controls (including 212 additional Down syndrome and matched controls already reported in Palomaki, et al., 2011), and their samples tested by massively parallel DNA sequencing. Among the 99.1% of samples interpreted (1,971/1,988), observed trisomy 18 detection rates was 100% (59/59), with a false positive rate of 0.28%. Observed trisomy 13 detection rate was 91.7% (11/12) with a false-positive rates of 0.97%l however, this estimate was based upon only 12 cases. Among the 17 samples without an interpretation, three were trisomy 18. The authors stated that, if z-score cutoffs for trisomy 18 and 13 were raised slightly, the overall false-positive rates for the three aneuploidies could be as low as 0.1% (2/1,688) at an overall detection rate of 98.9% (280/283) for common aneuploidies.
Bianchi et al (2012) reported on a nested case-control study of the use of massively parallel DNA sequencing to detect fetal aneuploidy. The investigators used blood samples that were collected in a prospective, blinded study from 2,882 high-risk women scheduled to undergo amniocentesis or chorionic villus sampling procedures at 60 U.S. sites. An independent biostatistician selected from these blood samples all singleton pregnancies with any abnormal karyotype, and for comparison, selected a balanced number of randomly selected pregnancies with euploid karyotypes. Chromosome classifications were made for each sample by massively parallel sequencing and compared with fetal karyotype determined by amniocentesis or chorionic villus sampling. The authors had 532 samples, 221 of which had abnormal karyotypes. The authors reported that 89 of 89 trisomy 21 cases were classified correctly (sensitivity 100%, 95% confidence interval [CI] 95.9 to 100), 35 of 36 trisomy 18 cases were classified correctly (sensitivity 97.2%, 95% CI 85.5 to -99.9), 11 of 14 trisomy 13 cases (sensitivity 78.6%, 95% CI 49.2 to 99.9), and 15 of 16 monosomy X cases (sensitivity 93.8%, 95% CI 69.8 to 99.8). The authors reported that there were no false-positive results for autosomal aneuploidies (100% specificity, 95% CI more than 98.5 to 100). In addition, fetuses with mosaicism for trisomy 21 (3/3), trisomy 18 (1/1), and monosomy X (2/7), three cases of translocation trisomy, two cases of other autosomal trisomies (20 and 16), and other sex chromosome aneuploidies (XXX, XXY, and XYY) were classified correctly. Because this was a nested case control study, and therefore it did not reflect true population prevalence of the fetal aneuploidies, positive and negative predictive values cannot be calculated. Specificities were estimated based upon a relatively small number of controls; further studies involving a larger number of unaffected controls would estimate the specificity with greater precision.
Regarding the evidence for cell-free DNA tests for fetal aneuploidy, Allyse et al (2012) has commented that companies offering such tests have limited themselves to publishing the results of clinical and analytic validation studies. However, more contextual, but no less important, issues of consistent and systematic validation, timing, risk and scope of cell-free DNA testing still need to be resolved. The authors stated that, at present, however, cell-free DNA tests have not achieved sufficient specificity and sensitivity to replace existing invasive tests as a diagnostic tool. The authors stated that demonstrated detection rates with cell-free DNA show a significant improvement over existing noninvasive integrated screening regimes. Nevertheless, they do not match the near-perfect diagnostic capabilities of invasive tests. Furthermore, existing clinical validation trials have taken place only in high-risk populations. The authors stated that it is unclear whether acceptable positive and negative predictive values can be attained in lower risk populations.
In addition to its noninvasive nature, another commonly espoused feature of non-invasive tests using cell-free DNA is its potential to detect fetal DNA beginning at 10 weeks of gestation (Allyse et al, 2012). Some women may want cell-free DNA testing to enable them to terminate a non-viable pregnancy as early as possible to avoid physical and emotional discomfort. However, a majority of pregnancies with trisomy 13, 18 and 21 spontaneously abort during the first trimester. Conducting early testing to recognize a trisomic pregnancy could require women to make wrenching decisions about termination and generate considerable guilt and stress that might have been avoided had the fetus spontaneously aborted. In addition to the psychosocial effects, this process would also entail spending considerable medical resources on prenatal care for non-viable pregnancies (Allyse, et al., 2012).
The Society for Maternal-Fetal Medicine (2015) has stated that cell-free DNA (cfDNA) screening has been largely recommended in patients at higher risk for aneuploidy, given more limited evidence regarding effectiveness in lower risk populations.
The ACOG guideline’s on “Noninvasive Prenatal Testing for Fetal Aneuploidy” (2012) stated that cell Cell free fetal DNA testing should not be offered to low-risk women or women with multiple gestations because it has not been sufficiently evaluated in these groups. The guideline explained that preliminary data available on twins demonstrated accuracy in a very small cohort, but more information is needed before use of this test can be recommended in multiple gestations.
The UK National Health Service Fetal Anomaly Screening Programme has stated that cell-free DNA testing "is very much in the early stages of development" and more research is needed to make sure cell-free DNA is a better test than those currently offered to women wanting information on the health of their baby (Delbarre, 2012). As such, non-invasive prenatal diagnosis using cell-free DNA to test for genetic conditions is unlikely to be available on the UK National Health Service for at least five years. The UK National Health Service would not currently consider using these tests to replace any of the tests currently offered as part of the Fetal Anomaly Ultrasound and Down’s syndrome Screening Programme.
Mersy and associates (2013) noted that research on NIPT of fetal trisomy 21 is developing fast. Commercial tests have become available. These investigators provided an up-to-date overview of NIPT of trisomy 21 by evaluating methodological quality and outcomes of diagnostic accuracy studies. These researchers undertook a systematic review of the literature published between 1997 and 2012 after searching PubMed, using MeSH terms “RNA”, “DNA” and “Down Syndrome” in combination with “cell-free fetal (cff) RNA”, “cffDNA”, “trisomy 21” and “noninvasive prenatal diagnosis” and searching reference lists of reported literature. From 79 abstracts, 16 studies were included as they evaluated the diagnostic accuracy of a molecular technique for NIPT of trisomy 21, and the test sensitivity and specificity were reported. Meta-analysis could not be performed due to the use of 6 different molecular techniques and different cut-off points. Diagnostic parameters were derived or calculated, and possible bias and applicability were evaluated utilizing the revised tool for Quality Assessment of Diagnostic Accuracy (QUADAS-2). Seven of the included studies were recently published in large cohort studies that examined massively parallel sequencing (MPS), with or without pre-selection of chromosomes, and reported sensitivities between 98.58 % [95 % CI: 95.9 to 99.5 %] and 100 % (95 % CI: 96 to 100 %) and specificities between 97.95 % (95 % CI: 94.1 to 99.3 %) and 100 % (95 % CI: 99.1 to 100 %). None of these 7 large studies had an overall low-risk of bias and low concerns regarding applicability. Massively parallel sequencing with or without pre-selection of chromosomes exhibits an excellent negative predictive value (100 %) in conditions with disease odds from 1:1,500 to 1:200. However, positive predictive values were lower, even in high-risk pregnancies (19.7 to 100 %). The other 9 cohort studies were too small to give precise estimates (number of trisomy 21 cases: less than or equal to25) and were not included in the discussion. The authors concluded that NIPT of trisomy 21 by MPS with or without pre-selection of chromosomes is promising and likely to replace the prenatal serum screening test that is currently combined with NT measurement in the first trimester of pregnancy. Moreover, they stated that before NIPT can be introduced as a screening test in a social insurance health-care system, more evidence is needed from large prospective diagnostic accuracy studies in first trimester pregnancies. Furthermore, they believed further assessment, of whether NIPT can be provided in a cost-effective, timely and equitable manner for every pregnant woman, is needed.
Norton and colleagues (2013) stated that the recent introduction of clinical tests to detect fetal aneuploidy by analysis of cell-free DNA in maternal plasma represents a tremendous advance in prenatal diagnosis and the culmination of many years of effort by researchers in the field. The development of NIPT for clinical application by commercial industry has allowed much faster introduction into clinical care, yet also presents some challenges regarding education of patients and health care providers struggling to keep up with developments in this rapidly evolving area. It is important that health care providers recognize that the test is not diagnostic; rather, it represents a highly sensitive and specific screening test that should be expected to result in some false-positive and false-negative diagnoses. Although currently being integrated in some settings as a primary screening test for women at high-risk of fetal aneuploidy, from a population perspective, a better option for NIPT may be as a second-tier test for those patients who screen positive by conventional aneuploidy screening. The authors concluded that how NIPT will ultimately fit with the current prenatal testing algorithms remains to be determined. They stated that true cost-utility analyses are needed to determine the actual clinical effectiveness of this approach in the general prenatal population.
Lutgendorf et al (2014) stated that the clinical use of NIPT to screen high-risk patients for fetal aneuploidy is becoming increasingly common. Initial studies have demonstrated high sensitivity and specificity, and there is hope that these tests will result in a reduction of invasive diagnostic procedures as well as their associated risks. Guidelines on the use of this testing in clinical practice have been published; however, data on actual test performance in a clinical setting are lacking, and there are no guidelines on quality control and assurance. The different NIPT employ complex methodologies, which may be challenging for health-care providers to understand and utilize in counseling patients, particularly as the field continues to evolve. The authors concluded that how these new tests should be integrated into current screening programs and their effect on health-care costs remain uncertain.
Moise (2012) reviewed the evidence for the use of cell-free fetal DNA to determine the fetal RHD gene. The feasibility of using cell-free fetal DNA circulating in maternal serum to determine fetal RHD gene and guide administration of prophylaxis has been shown in several studies (Rouillac-Le Sciellour et al, 2004; Finning et al, 2008; Muller et al, 2008; Van der School et a., 2006; Clausen et al, 2012). In the largest of these studies (n = 2,312 Rh(D)-negative women), fetal RHD gene detection sensitivity was 99.9 % at 25 weeks of gestation using an automated system that targeted 2 RHD exons (Clausen et al, 2012). Six fetuses were falsely identified as RHD-positive and 74 results were inconclusive due to methodologic issues or variant D types; all of these women received antenatal Rh(D) prophylaxis. Prophylaxis was unnecessary and avoided in 862 true-negative cases (37.3 %), unnecessary antenatal prophylaxis was administered to 39 women who had a positive or inconclusive result antenatally but delivered a Rh(D)-negative newborn (1.7 %). In 2 pregnancies (0.087 %), a Rh(D)-positive fetus was not detected antenatally so antenatal prophylaxis was not given; however, the women received post-natal prophylaxis.
An assessment by the Swedish Council on Technology Assessment in Health Care (SBU, 2011) found that there is moderately strong scientific evidence that fetal RHD determination by non-invasive fetal diagnostic tests has a sensitivity and specificity of nearly 99 %. The assessment stated that these results are largely based on studies of RhD-negative pregnant women who are not RhD-immunized. The report stated that those studies that also included pregnant women who have been immunized against RhD showed similar results. The report concluded that screening for fetal blood group using non-invasive fetal diagnostic tests, in combination with specific prenatal preventive measures (targeted RhD prophylaxis), could result in fewer RhD-negative pregnant women developing antibodies to RhD. The report concluded that the organizational and health economic consequences of introducing this type of screening have not been established.
In some European countries, fetal RHD gene determination is performed clinically in Rh(D)-negative women and administration of antenatal anti-D is avoided in the case of a RHD-negative fetus. An opinion by the Royal College of Obstetricians and Gynaecologists (Chitty and Crolla, 2009) stated that obstetricians have used non-invasive prenatal diagnosis to guide management of women who are RhD-negative and at risk of hemolytic disease of the newborn for years and guidelines should be revised to reflect this change in practice.
The American College of Obstetricians and Gynecologists (2012) has no recommendation for use of fetal cell-free DNA in preventing RHD alloimmunization.
Moise and Argoti (2012) evaluated the application of new technologies to the management of the red cell alloimmunized pregnancy. These investigators searched 3 computerized databases for studies that described treatment or prevention of alloimmunization in pregnancy (MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials [1990 to July 2012]). The text words and MeSH included Rhesus alloimmunization, Rhesus isoimmunization, Rhesus prophylaxis, Rhesus disease, red cell alloimmunization, red cell isoimmunization, and intrauterine transfusion. Of the 2,264 studies initially identified, 246 were chosen after limiting the review to those articles published in English and cross-referencing to eliminate duplication. Both authors independently reviewed the articles to eliminate publications involving less than 6 patients. Special emphasis was given to publications that have appeared since 2008. Quantitative polymerase chain reaction can be used instead of serology to more accurately determine the paternal RHD zygosity. In the case of unknown or a heterozygous paternal RHD genotype, new DNA techniques now make it possible to diagnose the fetal blood type through cell-free fetal DNA in maternal plasma. Serial Doppler assessment of the peak systolic velocity in the middle cerebral artery is now the standard to detect fetal anemia and determine the need for the first intrauterine transfusion. Assessment of the peak systolic velocity in the middle cerebral artery can be used to time the second transfusion, but its use to decide when to perform subsequent procedures awaits further study. New data suggested normal neurologic outcome in 94 % of cases after intrauterine transfusion, although severe hydrops fetalis may be associated with a higher risk of impairment. Recombinant Rh immune globulin is on the horizon. The authors stated that cell-free fetal DNA for fetal RHD genotyping may be used in the future to decide which patients should receive antenatal Rh immune globulin.
Sonographic Markers of Fetal Aneuploidy
Raniga et al (2006) stated that chromosomal abnormalities occur in 0.1 % to 0.2 % of live births, and the most common clinically significant aneuploidy among live-born infants is DS (trisomy 21). Other sonographically detectable aneuploidies include trisomy 13, 18, monosomy X, and triploidy. Second-trimester ultrasound scan detects 2 types of sonographic markers suggestive of aneuploidy. Markers for major fetal structural abnormalities comprise the first type; the second type of markers are known as "soft markers" of aneuploidy. These latter markers are non-specific, often transient, and can be readily detected during the 2nd-trimester ultrasound. The most commonly studied soft markers of aneuploidy include absent or hypoplastic nasal bone, choroid plexus cyst, echogenic bowel, and echogenic intracardiac focus, mild fetal pyelectasis, and rhizomelic limb shortening. There is a great deal of interest in the ultrasound detection of aneuploidy, as evidenced by the large number of publications in the literature on this topic. Unfortunately, studies evaluating the significance of the soft markers of aneuploidy varied widely and showed contradictory results. These investigators reviewed the most common ultrasonographic soft markers used to screen aneuploidy and discussed ultrasonographic technique and measurement criteria for the detection of soft markers. They also reviewed the clinical relevance of soft markers to aneuploidy risk assessment and evidence-based strategies for the management of affected pregnancies with each of these markers in light of current literature. The authors concluded that the detection of any abnormal finding on ultrasound should prompt an immediate detailed ultrasound evaluation of the fetus by an experienced sonographer. If there is more than 1 abnormal finding on ultrasound, if the patient is older than 35 years of age, or if the multiple marker screen is abnormal, an amniocentesis should be recommended to rule out aneuploidy.
Coco and Jeanty (2005) examined if isolated pyelectasis is a risk factor for trisomy 21. A total of 12,672 unselected singleton fetuses were examined by prenatal ultrasound during the 2nd trimester at a single institution. The sensitivity, specificity, positive- predictive value (PPV), negative-predictive value (NPV), and likelihood ratio of pyelectasis (either isolated or in association with other soft markers/structural anomalies) to detect trisomy 21 were calculated. Pyelectasis (antero-posterior pelvic diameter greater than or equal to 4 mm) was detected in 2.9 % (366/12,672) of the fetuses. Among these, 83.3 % (305/366) were isolated, and 16.7 % (61/366) were associated with other markers/structural anomalies. The prevalence of trisomy 21 was 0.087 % (11/12,672) and, among these fetuses, 2 (18.1 %) had pyelectasis, 1 isolated, and 1 associated with other markers/structural anomalies. The presence of isolated pyelectasis had 9.09 % sensitivity, 97.6 % specificity, 0.33 % PPV, and 99.9 % NPV to detect fetuses with trisomy 21. The likelihood ratio of trisomy 21 in this group of fetuses was 3.79 (95 % CI: 0.582 to 24.616). Among fetuses with pyelectasis and other associated markers/structural anomalies, the sensitivity, specificity, PPV, NPV, and likelihood ratio for trisomy 21 were 9.09 %, 99.5 %, 1.64 %, 99.9 %, and 19.2 (95 % CI: 2.91 to 126.44). The authors concluded that in the absence of other findings, isolated pyelectasis is not a justification for the performance of an amniocentesis.
Smith-Bindman et al (2007) examined the association between 2nd trimester ultrasound findings (genetic sonogram) and the risk of DS. This was a prospective population-based cohort study of women who were at increased risk of chromosome abnormality based on serum screening. Overall, 9,244 women with singleton pregnancies were included, including 245 whose fetuses had DS. Overall, 15.3 % of the women had an abnormal genetic sonogram, including 14.2 % of pregnancies with normal fetuses and 53.1 % of those with DS. If the genetic sonogram were normal, the risk that a woman had a fetus with DS was reduced (likelihood ratio 0.55 [95 % CI: 0.49, 0.62]). However, if the normal genetic sonogram were used to counsel these high-risk women that they could avoid amniocentesis, approximately 50 % of the cases of DS (115 of 245) would have been missed. The isolated ultrasound soft markers were the most commonly observed abnormality. These were seen in a high proportion of DS fetuses (13.9 %) and normal fetuses (9.3 %). In the absence of a structural anomaly, the isolated ultrasound soft markers of choroid plexus cyst, echogenic bowel, clenched hands, clinodactyly, renal pyelectasis, short femur, short humerus, and 2-vessel umbilical cord were not associated with DS. Nuchal fold thickening was a notable exception, as a thick nuchal fold raised the risk of DS even when it was seen without an associated structural anomaly. The authors concluded that the accuracy of the genetic sonogram is less than previously reported. The genetic sonogram should not be used as a sequential test following serum biochemistry, as this would substantially reduce the prenatal diagnosis of DS cases. Moreover, they stated that in contrast to prior reports, most isolated soft markers were not associated with DS.
Cho and associates (2009) described ultrasound findings in fetuses with trisomy 18. These investigators performed a prospective population-based cohort study of 2nd trimester ultrasound among Californian women who were at increased risk of chromosome abnormality based on serum screening between November 1999 and April 2001. Structural anomalies plus the following soft markers were assessed: choroid plexus cyst (CPC), clenched hands, clinodactyly, echogenic bowel, echogenic intracardiac focus, nuchal fold thickening, renal pyelectasis, short femur, short humerus and a single umbilical artery (SUA). Overall, 8,763 women underwent ultrasound evaluation, including 56 whose fetuses had trisomy 18. Ultrasound anomalies were seen in 89 % of trisomy 18 fetuses, as compared with 14 % of normal fetuses. If the genetic sonogram was normal (no structural anomaly and no soft marker), the risk was reduced by approximately 90 %. The ultrasound soft markers were typically seen in conjunction with structural anomalies in affected fetuses and in the absence of a structural anomaly, most isolated ultrasound soft markers were not associated with trisomy 18. The only exception was an isolated CPC, seen as the only finding in 11 % of fetuses with trisomy 18. The authors concluded that if the genetic sonogram is used as a sequential test following serum biochemistry, a normal ultrasound study reduces the likelihood of trisomy 18 substantially even if a woman has abnormal serum biochemistry. The presence of an isolated CPC raised the risk, but not high enough to prompt invasive testing.
Ting and colleagues (2011) examined the significance of isolated absent or hypoplastic nasal bone in the 2nd trimester ultrasound scan. All cases of absent or hypoplastic nasal bone (length less than 5th percentile) encountered during 2007 to 2009 were retrieved from database and all the ultrasound findings including structural abnormalities and soft markers for DS and fetal karyotype were reviewed. The cases were categorized into a study group with isolated absent or hypoplastic nasal bone and a comparison group with additional ultrasound findings. The incidence of DS confirmed by karyotyping was compared between the 2 groups. Among 14 fetuses with absent or hypoplastic nasal bone identified, 6 (42.9 %) had DS and 8 (57.1 %) were normal. All (100 %) of the 6 fetuses with isolated absent or hypoplastic nasal bone (Study Group) had normal karyotype, while 6 (75 %) of the other 8 fetuses with additional ultrasound findings (Comparison Group) had DS (p = 0.010). The authors concluded that the use of isolated absent or hypoplastic nasal bone in the 2nd trimester ultrasound scan for DS screening may not be effective. Amniocentesis, however, is indicated for fetuses with structural abnormality or additional soft markers, which should be carefully searched by an experienced ultrasonographer.
Ameratunga et al (2012) described the association between fetal echogenic bowel (FEB) diagnosed during the 2nd trimester and adverse perinatal outcomes in an Australian antenatal population. A retrospective analysis of ultrasound scans was performed between March 1, 2004 and March 1, 2009 at The Royal Women's Hospital, Melbourne, Vic., Australia. Cases reported as having FEB on 2nd trimester ultrasound were included. Medical records of each case were reviewed and information concerning additional investigations and perinatal outcomes were extracted. A total of 66 cases were identified in the database. Three patients (5 %) were excluded from further analysis as they were lost to follow-up, leaving 63 (95 %) cases in this series. Thirty-two fetuses (52 %) underwent karyotyping via amniocentesis, 5 (16 %) of which were found to have chromosomal defects. Maternal serology for cytomegalovirus (CMV) was performed in 49 (78 %) cases. Investigations indicated a total of 5 women who had CMV infection during their pregnancy. Thirty-three pregnancies (53 %) were tested for cystic fibrosis (CF) and 1 baby was confirmed to have CF post-natally. Among the 50 live-born infants, 3 cases of fetal growth restriction were apparent. Overall, 42 of the 50 live-born infants (84 %) and 67 % of the entire cohort of 63 patients with a mid-trimester diagnosis of FEB had a normal short-term neonatal outcome. The authors concluded that the findings of this study reiterated the increased prevalence of aneuploidy, CMV, CF and fetal growth restriction in pregnancies complicated by the mid-trimester sonographic finding of FEB. However, reassuringly, 67 % of cases with ultrasound-detected echogenic bowel in the 2nd trimester had a normal short-term neonatal outcome in this multi-ethnic Australian population.
Buiter et al (2013) determined the outcome of infants who presented with FEB and identified additional sonographic findings that might have clinical relevance for the prognosis. These investigators reviewed all pregnancies in which the diagnosis FEB was made in the authors’ Fetal Medicine Unit during 2009 to 2010 (n = 121). They divided all cases into 5 groups according to additional sonographic findings. Group 1 consisted of cases of isolated FEB, group 2 of FEB associated with dilated bowels, group 3 of FEB with 1 or 2 other soft markers, group 4 of FEB with major congenital anomalies or 3 or more other soft markers, and group 5 consisted of FEB with isolated intra-uterine growth restriction (IUGR). Of 121 cases, 5 were lost to follow-up. Of the remaining 116 cases, 48 (41.4 %) were assigned to group 1, 15 (12.9 %) to group 2, 15 (12.9 %) to group 3, 27 (23.2 %) to group 4, and 11 (9.5 %) to group 5. The outcome for group 1 was uneventful. In group 2 and 3, 2 anomalies, anorectal malformation and cystic fibrosis, were detected post-natally (6.7 %). In group 4, mortality and morbidity were high (78 % and 22 %, respectively). Group 5 also had high mortality (82 %) and major morbidity (18 %). The authors concluded that if FEB occurs in isolation, it is a benign condition carrying a favorable prognosis. If multiple additional anomalies or early IUGR are observed, the prognosis tends to be less favorable to extremely poor.
Laigaard and colleagues (2006) stated that maternal serum A Disintegrin And Metalloprotease 12 (ADAM 12) is reduced, on average, in early first trimester Down and Edwards' syndrome pregnancies; however the extent of reduction declines with gestation. These investigators examined the levels of ADAM 12 at 9 to 12 weeks when the marker might be used concurrently with other established markers. Samples from 16 Down and 2 Edwards' syndrome cases were retrieved from storage and tested together with 313 unaffected singleton pregnancies using a semi-automated time-resolved immuno-fluorometric assay. Results were expressed in multiples of the gestation-specific median (MoM) based on regression. The median in Down syndrome was 0.94 MoM with a 10th to 90th percentile range of 0.22 to 1.63 MoM compared with 1.00 and 0.33 to 2.24 MoM in unaffected controls (p = 0.21, one-side Wilcoxon Rank Sum Test). The 2 Edwards' syndrome cases had values 0.31 and 2.17 MoM. The authors concluded that ADAM12 can not be used concurrently with other markers in the late first trimester. However, it does have the potential to be used earlier in pregnancy either concurrently with other early markers or in a sequential or contingent protocol. The authors stated that more research is needed to reliably predict the performance of either approach. Furthermore, the ACOG practice bulletin on screening for fetal chromosomal abnormalities (2007) does not mention ADAM 12 as a serum marker for screening Down syndrome.
Christiansen et al (2007) examined the potential of ADAM 12 as a second-trimester maternal serum marker of Down syndrome (DS). The concentration of ADAM 12 was determined in gestational week 14 to 19 in 88 DS pregnancies and 341 matched control pregnancies. Medians of normal pregnancies were established by polynomial regression and the distribution of log(10) MoM ADAM 12 values in DS pregnancies and controls determined. Correlations with alpha-fetoprotein (AFP) and free beta-hCG were established and used to model the performance of maternal serum screening with ADAM 12 in combination with other second-trimester serum markers. The ADAM 12 maternal serum concentration was significantly increased with a median MoM of 1.85 and a mean log(10) MoM (SD) of 0.268 (0.2678) compared to a mean log(10) MoM (SD) of 0.013 (0.4318) in controls. ADAM 12 correlated with maternal weight and ethnicity (with the serum concentration increased in Afro-Caribbeans), but neither with maternal age nor gestational age, and only marginally with AFP (r(DS) = 0.078, r(controls) = 0.093) and free beta-hCG (r(DS) = 0.073, r(controls) = 0.144. The increase in detection rate -- for a false positive rate of 5 % -- by adding ADAM 12 to the double test (AFP + free beta-hCG) was 4 %, similar to that of adding unconjugated estriol to the double test. The authors concluded that ADAM 12 is an efficient second-trimester marker for DS. Moreover, they stated that further studies should be conducted to determine whether it may be a useful additional or alternative marker to those currently used in the second-trimester.
Koster and co-workers (2010) ascertained the distributions of pregnancy-associated plasma protein A (PAPP-A), fbeta-hCG, ADAM12 and PP13 in first trimester twin pregnancies. Serum marker concentrations were measured in monochorionic and dichorionic twin pregnancies and singleton controls to study differences in MoMs. Median PAPP-A and fbeta-hCG MoMs were 2.03 and 1.87 for monochorionic twins (n = 116) and 2.18 and 1.89 for dichorionic twins (n = 650). Furthermore, ADAM12 and PP13 MoMs were 1.66 and 1.56 for monochorionic twins (n = 51) and 1.64 and 1.53 for dichorionic twins (n = 249). No statistically significant differences between monochorionic and dichorionic twin pregnancies were found. Correlations between markers in these pregnancies did not differ from singletons. The authors concluded that for first-trimester screening, different parameters for monochorionic and dichorionic twin pregnancies is not necessary. Furthermore, if ADAM12 and PP13 will be adopted as screening markers, the presented median MoM values, standard deviations and correlation coefficients for twin pregnancies may contribute to a proper twin risk estimation.
In a case control study, Torring and colleagues (2010) examined if ADAM12-S is a useful serum marker for fetal trisomy 21 using the mixture model. These researchers measured ADAM12-S by KRYPTOR ADAM12-S immunoassay in maternal serum from gestational weeks 8 to 11 in 46 samples of fetal trisomy 21 and in 645 controls. Comparison of sensitivity and specificity of first trimester screening for fetal trisomy 21 with or without ADAM12-S was included in the risk assessment using the mixture model. The concentration of ADAM12-S increased from week 8 to 11 and was negatively correlated with maternal weight. Log MoM ADAM12-S was positively correlated with log MoM PAPP-A (r = 0.39, p < 0.001), and with log MoM free beta hCG (r = 0.21, p < 0.001). The median ADAM12-S MoM in cases of fetal trisomy 21 in gestational week 8 was 0.66 increasing to about 0.9 MoM in weeks 9 and 10. The use of ADAM12-S along with biochemical markers from the combined test (PAPP-A, free beta-hCG) with or without nuchal translucency measurement did not affect the detection rate or false positive rate of fetal aneuploidy as compared to routine screening using PAPP-A and free beta-hCG with or without nuchal translucency. The authors concluded that these findings showed moderately decreased levels of ADAM12-S in cases of fetal aneuploidy in gestational weeks 8 to 11. However, including ADAM12-S in the routine risk does not improve the performance of first trimester screening for fetal trisomy 21.
Cowans et al (2010) examined the stability of ADAM-12 with time and at different temperatures. Maternal serum and whole blood pools were stored at 30 degrees C, room temperature and refrigerator temperature or subjected to repeated freeze-thaw cycles. ADAM-12 was measured at set time points using an automated DELFIA research assay. Using a 10 % change in concentration as a limit of stability, ADAM-12 is stable in serum for less than 15 hrs at 30 degrees C, less than 20 hrs at room temperature and for 51 hrs at refrigerator temperature. ADAM-12 levels are not altered following 3 -20 degrees C to room temperature freeze-thaw cycles. The stability of ADAM-12 in whole blood appears similar to that in serum. The authors concluded that these findings suggested that ADAM-12 may be unstable under many routine laboratory conditions, and the marker's instability may also be partly responsible for the discrepancies in the literature.
Other Markers of Fetal Aneuploidy
Koster and colleagues (2009) examined if placental protein 13 (PP13) could be an additional marker in first trimester screening for aneuploidies. These researchers assessed differences in multiples of the gestation-specific normal median (MoMs), PP13 concentrations were measured in serum samples from DS, trisomy 18 and 13 affected pregnancies and euploid singleton pregnancies (4 for each case matched for duration of storage, maternal weight and age). The PP13 MoM in DS cases (n = 153) was 0.91 [not statistically significant from controls (n = 853); p = 0.06; Wilcoxon rank sum test, 2-tail]. Placental protein 13 MoMs were decreased in trisomy 18 (n = 38- median MoM 0.64; p < 0.0001) and trisomy 13 cases (n = 23-median MoM 0.46; p < 0.0001). There was a slight upward trend in MoM values of the DS cases with gestational weeks. The PP13 MoM was significantly correlated with the pregnancy associated plasma protein-A MoM and the free beta-subunit of hCG (fbeta-hCG) MoM. The authors concluded that PP13 does not seem to be a good marker for DS.
Li et al (2010) compared the difference in maternal serum anti-Mullerian hormone (AMH) level between DS pregnancies and unaffected pregnancies, and evaluated its performance as a screening marker for DS pregnancy. A total of 145 pregnancies affected by fetal DS and 290 unaffected controls matched with maternal age and gestational age were selected, and their archived first or second trimester serum retrieved for AMH assay. There was no significant difference in maternal serum AMH level between pregnancies affected and unaffected by fetal DS. First trimester serum samples had higher AMH level compared to second trimester samples. The authors concluded that maternal serum AMH level, as a marker of ovarian age, is not superior to chronological age in predicting DS pregnancies. They stated that despite the cross-sectional nature of the study, the variation of maternal serum AMH concentration with gestational age warrants further investigation.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|81507||Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy|
|81508 - 81509||Fetal congenital abnormalities, biochemical assays two or three proteins (PAPP-A, hCG [any form], or DIA), utilizing maternal serum, algorithm reported as a risk score|
|81510 - 81512||Fetal congenital abnormalities, biochemical assays analytes (AFP, uE3, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk score|
|82105||Alpha-fetoprotein (AFP); serum|
|84702||Gonadotropin, chorionic (hCG); quantitative|
|84704||free beta chain|
|CPT codes not covered for indications listed in the CPB:|
|83516||Immunoassay for analyte other than infectious agent antibody or infections agent antigen; qualitative or semiquantitative, multiple step method [not covered for anti-Mullerian hormone level for first or second trimester screening for Down syndrom]|
|83520||Immuoassay, analyte, quantitative; not otherwise specified [not covered for anti-Mullerian hormone level for first or second trimester screening for Down syndrome]|
|83632||Lactogen, human placental (HPL) human chorionic somatomammotropin|
|84163||Pregnancy-associated plasma protein-A (PAPPA-A)|
|CELL-FREE DNA testing of maternal blood:|
|CPT codes covered if selection criteria are met:|
|0009M||Fetal aneuploidy (trisomy 21, and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy|
|81420||Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21|
|81507||Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy|
|ICD-10 codes covered if selection criteria are met:|
|G91.2||(Idiopathic) normal pressure hydrocephalus [Ventriculomegaly]|
|O09.291 - O09.299||Supervision of pregnancy with other poor reproductive or obstetric history [prior pregnancy with an aneuploidy]|
|O09.511 - O09.529||Supervision of elderly primigravida and multigravida [high-risk]|
|O09.521 - O09.529||Supervision of elderly multigravida|
|O28.5||Abnormal chromosomal and genetic finding on antenatal screening of mother [fetal ultrasonographic findings predicting an increased risk of fetal aneuploidy or positive screening test for an aneuploidy]|
|O35.0XX0 - O35.0XX9||Maternal care for (suspected) central nervous system malformation in fetus|
|O35.1XX0 - O35.1XX9||Maternal care for (suspected) chromosomal abnormality in fetus [aneuploidy in mother, fetal aneuploidy|
|Q90.0 - Q91.7||Down syndrome, Patau's syndrome [Trisomy 13], Edward's syndrome [Trisomy 18]|
|Q92.0 - Q92.9||Other trisomies and partial trisomies of the autosomes, not elsewhere classified [aneuploidy in mother, fetal aneuploidy]|
|Q95.0 - Q95.9||Balanced translocation and insertion in normal individual [Robertsonian translocation]|
|Z13.71 - Z13.79||Encounter for screening for genetic and chromosomal anomalies|
|ICD-10 codes not covered for indications listed in the CPB:|
|O30.001 - O30.93||Multiple gestations|
|Z34.80 - Z34.93||Encounter for supervision of normal pregnancy [low risk women]|