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Prenatal screening for Down syndrome using cell-free DNA

Glenn E Palomaki, PhD
Geralyn M Messerlian, PhD
Jacquelyn V Halliday, MS
Section Editor
Louise Wilkins-Haug, MD, PhD
Deputy Editor
Vanessa A Barss, MD, FACOG


Prenatal screening for trisomy 21 (Down syndrome), trisomy 18, trisomy 13, and sex chromosome aneuploidies can be performed using next-generation sequencing of cell-free DNA (cfDNA) in the maternal circulation. Circulating cfDNA is derived from both the mother and the fetus, although most "fetal" DNA is thought to be derived from the placenta [1-3] and cleared from the maternal circulation soon after delivery [4]. Although this approach is often called "noninvasive prenatal screening" or "noninvasive prenatal testing," these terms are nonspecific, as conventional serum screening is also noninvasive.

The cfDNA test provides excellent performance – 98 to 99 percent of Down syndrome pregnancies are identified prenatally with less than 1 percent of women called screen-positive – but it is considered a screening test due to infrequent false-positive and false-negative results. An invasive procedure (eg, amniocentesis or chorionic villus sampling) to determine the fetal karyotype is considered the gold standard diagnostic test and is recommended for women who screen positive by cfDNA testing, particularly those who are considering pregnancy termination.

This topic will discuss prenatal aneuploidy screening via sequencing of cfDNA. Other issues related to prenatal screening for Down syndrome and other aneuploidies are reviewed separately:

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

(See "First trimester combined test and integrated tests for screening for Down syndrome and trisomy 18".)


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Literature review current through: Oct 2015. | This topic last updated: Oct 19, 2015.
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  1. Sekizawa A, Samura O, Zhen DK, et al. Apoptosis in fetal nucleated erythrocytes circulating in maternal blood. Prenat Diagn 2000; 20:886.
  2. Tjoa ML, Cindrova-Davies T, Spasic-Boskovic O, et al. Trophoblastic oxidative stress and the release of cell-free feto-placental DNA. Am J Pathol 2006; 169:400.
  3. Lui YY, Chik KW, Chiu RW, et al. Predominant hematopoietic origin of cell-free DNA in plasma and serum after sex-mismatched bone marrow transplantation. Clin Chem 2002; 48:421.
  4. Lo YM, Corbetta N, Chamberlain PF, et al. Presence of fetal DNA in maternal plasma and serum. Lancet 1997; 350:485.
  5. Lo YM, Lo ES, Watson N, et al. Two-way cell traffic between mother and fetus: biologic and clinical implications. Blood 1996; 88:4390.
  6. Zhong XY, Holzgreve W, Hahn S. Cell-free fetal DNA in the maternal circulation does not stem from the transplacental passage of fetal erythroblasts. Mol Hum Reprod 2002; 8:864.
  7. Chan KC, Zhang J, Hui AB, et al. Size distributions of maternal and fetal DNA in maternal plasma. Clin Chem 2004; 50:88.
  8. Guibert J, Benachi A, Grebille AG, et al. Kinetics of SRY gene appearance in maternal serum: detection by real time PCR in early pregnancy after assisted reproductive technique. Hum Reprod 2003; 18:1733.
  9. Wang E, Batey A, Struble C, et al. Gestational age and maternal weight effects on fetal cell-free DNA in maternal plasma. Prenat Diagn 2013; 33:662.
  10. Chiu RW, Akolekar R, Zheng YW, et al. Non-invasive prenatal assessment of trisomy 21 by multiplexed maternal plasma DNA sequencing: large scale validity study. BMJ 2011; 342:c7401.
  11. Palomaki GE, Kloza EM, Lambert-Messerlian GM, et al. DNA sequencing of maternal plasma to detect Down syndrome: an international clinical validation study. Genet Med 2011; 13:913.
  12. Nygren AO, Dean J, Jensen TJ, et al. Quantification of fetal DNA by use of methylation-based DNA discrimination. Clin Chem 2010; 56:1627.
  13. Lo YM, Tein MS, Lau TK, et al. Quantitative analysis of fetal DNA in maternal plasma and serum: implications for noninvasive prenatal diagnosis. Am J Hum Genet 1998; 62:768.
  14. Canick JA, Palomaki GE, Kloza EM, et al. The impact of maternal plasma DNA fetal fraction on next generation sequencing tests for common fetal aneuploidies. Prenat Diagn 2013; 33:667.
  15. Ashoor G, Poon L, Syngelaki A, et al. Fetal fraction in maternal plasma cell-free DNA at 11-13 weeks' gestation: effect of maternal and fetal factors. Fetal Diagn Ther 2012; 31:237.
  16. Nicolaides KH, Syngelaki A, del Mar Gil M, et al. Prenatal detection of fetal triploidy from cell-free DNA testing in maternal blood. Fetal Diagn Ther 2014; 35:212.
  17. Palomaki GE, Kloza EM, Lambert-Messerlian GM, et al. Circulating cell free DNA testing: are some test failures informative? Prenat Diagn 2015; 35:289.
  18. Lo YM, Zhang J, Leung TN, et al. Rapid clearance of fetal DNA from maternal plasma. Am J Hum Genet 1999; 64:218.
  19. Yu SC, Lee SW, Jiang P, et al. High-resolution profiling of fetal DNA clearance from maternal plasma by massively parallel sequencing. Clin Chem 2013; 59:1228.
  20. Gil MM, Quezada MS, Revello R, et al. Analysis of cell-free DNA in maternal blood in screening for fetal aneuploidies: updated meta-analysis. Ultrasound Obstet Gynecol 2015; 45:249.
  21. Mazloom AR, Džakula Ž, Oeth P, et al. Noninvasive prenatal detection of sex chromosomal aneuploidies by sequencing circulating cell-free DNA from maternal plasma. Prenat Diagn 2013; 33:591.
  22. Samango-Sprouse C, Banjevic M, Ryan A, et al. SNP-based non-invasive prenatal testing detects sex chromosome aneuploidies with high accuracy. Prenat Diagn 2013; 33:643.
  23. Hooks J, Wolfberg AJ, Wang ET, et al. Non-invasive risk assessment of fetal sex chromosome aneuploidy through directed analysis and incorporation of fetal fraction. Prenat Diagn 2014; 34:496.
  24. Malvestiti F, Agrati C, Grimi B, et al. Interpreting mosaicism in chorionic villi: results of a monocentric series of 1001 mosaics in chorionic villi with follow-up amniocentesis. Prenat Diagn 2015; 35:1117.
  25. Kalousek DK, Vekemans M. Confined placental mosaicism. J Med Genet 1996; 33:529.
  26. Schreck RR, Falik-Borenstein Z, Hirata G. Chromosomal mosaicism in chorionic villus sampling. Clin Perinatol 1990; 17:867.
  27. Kalousek DK, Howard-Peebles PN, Olson SB, et al. Confirmation of CVS mosaicism in term placentae and high frequency of intrauterine growth retardation association with confined placental mosaicism. Prenat Diagn 1991; 11:743.
  28. Curnow KJ, Wilkins-Haug L, Ryan A, et al. Detection of triploid, molar, and vanishing twin pregnancies by a single-nucleotide polymorphism-based noninvasive prenatal test. Am J Obstet Gynecol 2015; 212:79.e1.
  29. Wang Y, Chen Y, Tian F, et al. Maternal mosaicism is a significant contributor to discordant sex chromosomal aneuploidies associated with noninvasive prenatal testing. Clin Chem 2014; 60:251.
  30. Yao H, Zhang L, Zhang H, et al. Noninvasive prenatal genetic testing for fetal aneuploidy detects maternal trisomy X. Prenat Diagn 2012; 32:1114.
  31. Stone JF, Sandberg AA. Sex chromosome aneuploidy and aging. Mutat Res 1995; 338:107.
  32. Bianchi DW, Chudova D, Sehnert AJ, et al. Noninvasive Prenatal Testing and Incidental Detection of Occult Maternal Malignancies. JAMA 2015; 314:162.
  33. Amant F, Verheecke M, Wlodarska I, et al. Presymptomatic Identification of Cancers in Pregnant Women During Noninvasive Prenatal Testing. JAMA Oncol 2015; 1:814.
  34. Snyder MW, Simmons LE, Kitzman JO, et al. Copy-number variation and false positive prenatal aneuploidy screening results. N Engl J Med 2015; 372:1639.
  35. Bianchi DW, Parsa S, Bhatt S, et al. Fetal sex chromosome testing by maternal plasma DNA sequencing: clinical laboratory experience and biology. Obstet Gynecol 2015; 125:375.
  36. Kalousek DK, Barrett IJ, McGillivray BC. Placental mosaicism and intrauterine survival of trisomies 13 and 18. Am J Hum Genet 1989; 44:338.
  37. Mennuti MT, Cherry AM, Morrissette JJ, Dugoff L. Is it time to sound an alarm about false-positive cell-free DNA testing for fetal aneuploidy? Am J Obstet Gynecol 2013; 209:415.
  38. American College of Obstetricians and Gynecologists Committee on Genetics. Committee Opinion No. 545: Noninvasive prenatal testing for fetal aneuploidy. Obstet Gynecol 2012; 120:1532.
  39. Sachs A, Blanchard L, Buchanan A, et al. Recommended pre-test counseling points for noninvasive prenatal testing using cell-free DNA: a 2015 perspective. Prenat Diagn 2015; 35:968.
  40. Grati FR, Bajaj K, Malvestiti F, et al. The type of feto-placental aneuploidy detected by cfDNA testing may influence the choice of confirmatory diagnostic procedure. Prenat Diagn 2015; 35:994.
  41. Committee Opinion No. 640: Cell-Free DNA Screening For Fetal Aneuploidy. Obstet Gynecol 2015; 126:e31.
  42. Benn P, Borell A, Chiu R, et al. Position statement from the Aneuploidy Screening Committee on behalf of the Board of the International Society for Prenatal Diagnosis. Prenat Diagn 2013; 33:622.
  43. Devers PL, Cronister A, Ormond KE, et al. Noninvasive prenatal testing/noninvasive prenatal diagnosis: the position of the National Society of Genetic Counselors. J Genet Couns 2013; 22:291.
  44. Gregg AR, Gross SJ, Best RG, et al. ACMG statement on noninvasive prenatal screening for fetal aneuploidy. Genet Med 2013; 15:395.
  45. Langlois S, Brock JA, Genetics Committee, et al. Current status in non-invasive prenatal detection of Down syndrome, trisomy 18, and trisomy 13 using cell-free DNA in maternal plasma. J Obstet Gynaecol Can 2013; 35:177.
  46. Dondorp W, de Wert G, Bombard Y, et al. Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening. Eur J Hum Genet 2015; 23:1438.
  47. Society for Maternal-Fetal Medicine (SMFM) Publications Committee. Electronic address: pubs@smfm.org. #36: Prenatal aneuploidy screening using cell-free DNA. Am J Obstet Gynecol 2015; 212:711.
  48. Michaelson-Cohen R, Gershoni-Baruch R, Sharoni R, et al. Israeli Society of Medical Genetics NIPT Committee Opinion 072013: Non-invasive prenatal testing of cell-free DNA in maternal plasma for detection of fetal aneuploidy. Fetal Diagn Ther 2014; 36:242.