Official reprint from UpToDate®
www.uptodate.com ©2015 UpToDate®

First trimester combined test and integrated tests for screening for Down syndrome and trisomy 18

Geralyn M Messerlian, PhD
Antonio Farina, MD
Glenn E Palomaki, PhD
Section Editor
Louise Wilkins-Haug, MD, PhD
Deputy Editor
Vanessa A Barss, MD, FACOG


First trimester and integrated screening tests for Down syndrome and trisomy 18 will be reviewed here. Other aspects of Down syndrome screening are discussed separately:

(See "Down syndrome: Overview of prenatal screening".)

(See "Second trimester maternal serum screening for Down syndrome".)

(See "Laboratory issues related to maternal serum screening for Down syndrome".)

(See "Sonographic findings associated with fetal aneuploidy".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Apr 2015. | This topic last updated: Oct 30, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2015 UpToDate, Inc.
  1. Reddy UM, Mennuti MT. Incorporating first-trimester Down syndrome studies into prenatal screening: executive summary of the National Institute of Child Health and Human Development workshop. Obstet Gynecol 2006; 107:167.
  2. Canick JA, Kellner LH. First trimester screening for aneuploidy: serum biochemical markers. Semin Perinatol 1999; 23:359.
  3. Wald NJ, Hackshaw AK. Combining ultrasound and biochemistry in first-trimester screening for Down's syndrome. Prenat Diagn 1997; 17:821.
  4. Spencer K, Macri JN, Aitken DA, Connor JM. Free beta-hCG as first-trimester marker for fetal trisomy. Lancet 1992; 339:1480.
  5. Haddow JE, Palomaki GE, Knight GJ, et al. Screening of maternal serum for fetal Down's syndrome in the first trimester. N Engl J Med 1998; 338:955.
  6. Wald NJ, George L, Smith D, et al. Serum screening for Down's syndrome between 8 and 14 weeks of pregnancy. International Prenatal Screening Research Group. Br J Obstet Gynaecol 1996; 103:407.
  7. Canick JA, Lambert-Messerlian GM, Palomaki GE, et al. Comparison of serum markers in first-trimester down syndrome screening. Obstet Gynecol 2006; 108:1192.
  8. Palomaki GE, Lambert-Messerlian GM, Canick JA. A summary analysis of Down syndrome markers in the late first trimester. Adv Clin Chem 2007; 43:177.
  9. Nicolaides KH. Nuchal translucency and other first-trimester sonographic markers of chromosomal abnormalities. Am J Obstet Gynecol 2004; 191:45.
  10. Crossley JA, Aitken DA, Cameron AD, et al. Combined ultrasound and biochemical screening for Down's syndrome in the first trimester: a Scottish multicentre study. BJOG 2002; 109:667.
  11. Krantz DA, Hallahan TW, Orlandi F, et al. First-trimester Down syndrome screening using dried blood biochemistry and nuchal translucency. Obstet Gynecol 2000; 96:207.
  12. Wapner R, Thom E, Simpson JL, et al. First-trimester screening for trisomies 21 and 18. N Engl J Med 2003; 349:1405.
  13. Spencer K, Spencer CE, Power M, et al. One stop clinic for assessment of risk for fetal anomalies: a report of the first year of prospective screening for chromosomal anomalies in the first trimester. BJOG 2000; 107:1271.
  14. Muller F, Benattar C, Audibert F, et al. First-trimester screening for Down syndrome in France combining fetal nuchal translucency measurement and biochemical markers. Prenat Diagn 2003; 23:833.
  15. Bindra R, Heath V, Liao A, et al. One-stop clinic for assessment of risk for trisomy 21 at 11-14 weeks: a prospective study of 15 030 pregnancies. Ultrasound Obstet Gynecol 2002; 20:219.
  16. Avgidou K, Papageorghiou A, Bindra R, et al. Prospective first-trimester screening for trisomy 21 in 30,564 pregnancies. Am J Obstet Gynecol 2005; 192:1761.
  17. Wald NJ, Rodeck C, Hackshaw AK, et al. First and second trimester antenatal screening for Down's syndrome: the results of the Serum, Urine and Ultrasound Screening Study (SURUSS). Health Technol Assess 2003; 7:1.
  18. Malone FD, Canick JA, Ball RH, et al. First-trimester or second-trimester screening, or both, for Down's syndrome. N Engl J Med 2005; 353:2001.
  19. Cusick W, Buchanan P, Hallahan TW, et al. Combined first-trimester versus second-trimester serum screening for Down syndrome: a cost analysis. Am J Obstet Gynecol 2003; 188:745.
  20. Gekas J, Durand A, Bujold E, et al. Cost-effectiveness and accuracy of prenatal Down syndrome screening strategies: should the combined test continue to be widely used? Am J Obstet Gynecol 2011; 204:175.e1.
  21. Evans MI, Krantz DA, Hallahan TW, Galen RS. Meta-analysis of first trimester Down syndrome screening studies: free beta-human chorionic gonadotropin significantly outperforms intact human chorionic gonadotropin in a multimarker protocol. Am J Obstet Gynecol 2007; 196:198.
  22. Spencer K, Crossley JA, Aitken DA, et al. Temporal changes in maternal serum biochemical markers of trisomy 21 across the first and second trimester of pregnancy. Ann Clin Biochem 2002; 39:567.
  23. Szabó J, Gellén J. Nuchal fluid accumulation in trisomy-21 detected by vaginosonography in first trimester. Lancet 1990; 336:1133.
  24. Nicolaides KH, Azar G, Byrne D, et al. Fetal nuchal translucency: ultrasound screening for chromosomal defects in first trimester of pregnancy. BMJ 1992; 304:867.
  25. Wald NJ, Rodeck C, Hackshaw AK, Rudnicka A. SURUSS in perspective. BJOG 2004; 111:521.
  26. Spencer K, Bindra R, Nix AB, et al. Delta-NT or NT MoM: which is the most appropriate method for calculating accurate patient-specific risks for trisomy 21 in the first trimester? Ultrasound Obstet Gynecol 2003; 22:142.
  27. Kornman LH, Morssink LP, Beekhuis JR, et al. Nuchal translucency cannot be used as a screening test for chromosomal abnormalities in the first trimester of pregnancy in a routine ultrasound practice. Prenat Diagn 1996; 16:797.
  28. Mol BW, Lijmer JG, van der Meulen J, et al. Effect of study design on the association between nuchal translucency measurement and Down syndrome. Obstet Gynecol 1999; 94:864.
  29. Schielen PC, van Leeuwen-Spruijt M, Belmouden I, et al. Multi-centre first-trimester screening for Down syndrome in the Netherlands in routine clinical practice. Prenat Diagn 2006; 26:711.
  30. Hermann M, Fries N, Mangione R, et al. Nuchal translucency measurement: are qualitative and quantitative quality control processes related? Prenat Diagn 2013; 33:770.
  31. Lambert-Messerlian, GM, Palomaki, GE, Knight, et al. Dimeric inhibin-A as a marker for Down syndrome in the first trimester. Am Coll Med Genet, 2004 Ann Clin Genet Mtg, Mar 4-7, Orlando, FL, Abstr No 63.
  32. Wald NJ, Watt HC, Hackshaw AK. Integrated screening for Down's syndrome on the basis of tests performed during the first and second trimesters. N Engl J Med 1999; 341:461.
  33. Rausch DN, Lambert-Messerlian GM, Canick JA. Participation in maternal serum screening following screen positive results in a previous pregnancy. J Med Screen 2000; 7:4.
  34. Palomaki GE, Steinort K, Knight GJ, Haddow JE. Comparing three screening strategies for combining first- and second-trimester Down syndrome markers. Obstet Gynecol 2006; 107:367.
  35. Platt LD, Greene N, Johnson A, et al. Sequential pathways of testing after first-trimester screening for trisomy 21. Obstet Gynecol 2004; 104:661.
  36. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities. Obstet Gynecol 2007; 109:217.
  37. Wright D, Bradbury I, Benn P, et al. Contingent screening for Down syndrome is an efficient alternative to non-disclosure sequential screening. Prenat Diagn 2004; 24:762.
  38. ACOG Committee Opinion #296: first-trimester screening for fetal aneuploidy. Obstet Gynecol 2004; 104:215.
  39. Wald NJ, Rudnicka AR, Bestwick JP. Sequential and contingent prenatal screening for Down syndrome. Prenat Diagn 2006; 26:769.
  40. Ball RH, Caughey AB, Malone FD, et al. First- and second-trimester evaluation of risk for Down syndrome. Obstet Gynecol 2007; 110:10.
  41. Cuckle HS, Malone FD, Wright D, et al. Contingent screening for Down syndrome--results from the FaSTER trial. Prenat Diagn 2008; 28:89.
  42. Gekas J, Gagné G, Bujold E, et al. Comparison of different strategies in prenatal screening for Down's syndrome: cost effectiveness analysis of computer simulation. BMJ 2009; 338:b138.
  43. Tul N, Spencer K, Noble P, et al. Screening for trisomy 18 by fetal nuchal translucency and maternal serum free beta-hCG and PAPP-A at 10-14 weeks of gestation. Prenat Diagn 1999; 19:1035.
  44. Lambert-Messerlian, G, Canick, J, Malone, F, Porter, F, et al. First trimester levels of maternal serum hCG and inhibin A in pregnancies affected by fetal trisomy 18: A FASTER Trial study. Annual Meeting of the American College of Medical Genetics, Orlando, FL, March 4-7, 2004.
  45. Breathnach FM, Malone FD, Lambert-Messerlian G, et al. First- and second-trimester screening: detection of aneuploidies other than Down syndrome. Obstet Gynecol 2007; 110:651.
  46. Palomaki GE, Neveux LM, Knight GJ, Haddow JE. Maternal serum-integrated screening for trisomy 18 using both first- and second-trimester markers. Prenat Diagn 2003; 23:243.
  47. Kagan KO, Wright D, Valencia C, et al. Screening for trisomies 21, 18 and 13 by maternal age, fetal nuchal translucency, fetal heart rate, free beta-hCG and pregnancy-associated plasma protein-A. Hum Reprod 2008; 23:1968.
  48. Kagan KO, Avgidou K, Molina FS, et al. Relation between increased fetal nuchal translucency thickness and chromosomal defects. Obstet Gynecol 2006; 107:6.