DiscussionOur fetal medicine unit is part of the obstetrics and Gynecology Department at King Hussein Medical Centre. We have around 12000 deliveries per year at our hospital. We get referrals from all peripheral hospitals and the private sector. The caesarian section rate at our hospital is around 40%. This is the first audit done at the center regarding the indication, results and the outcome of invasive procedures. A total number of 943 women were involved in the study over a period of 5 years with an average of 188 procedures done a year ( around 62 procedures per operator) which is in excess to the standard set by the expert committee of the Royal College of Obstetricians and Gynecologists 7. The most common procedure done by far with a 3 fold prevalence is amniocentesis as compared to CVS which accounts for 25.
2 percent of the procedures done over the five years interval. All our patients were insured at our hospital and all tests were done at our hospital for free. The maximum number of procedures was done in 2016 where the number of cases was 211, on the other hand the lowest number of procedures was in 2017 reaching 166 cases as shown in Chart 1. All tests were analyzed at our cytogenetic Lab. Chart 2 shows the number of abnormal cytology detected at our unit, showing the highest at 25 cases in 2014 and the lowest at 8 cases in 2013. The total number of abnormal results were reported in 72 cases out of 942 invasive procedure giving a rate of 7.
6% of picking abnormal results which is consistent with what is reported by many studies. 8,9. Fig 1 shows the type of abnormalities detected over 5 years period.
As shown above, the majority of abnormalities were Trisomy 21, 18 and 13 making 76% of all abnormalities detected. The rest of the abnormalities included few cases of Turners, Triploidy and Klinefelter. These findings are in agreement with what is reported by other studies. 10,11. There were also few cases of reciprocal translocations and deletions. All samples had an early results using quantitative fluorescence polymerase chain reaction for the rapid testing for chromosome 13, 18, 21, X and Y chromosome within 24-48 hours and then a complete culture of all chromosomes within 2 weeks. The advantage of having CVS for our patients is to have an early result. Termination of pregnancy is not allowed in Jordan but we have FATAWAS from religious leaders which allows it, if the fetus has severe abnormality and the baby has not exceeded 120 days.
Few patients opted for termination of pregnancy in cases of severe abnormalities. Amniocentesis is technically easer but the results are later compared to CVS. 12. We had 8 cases of culture failure, 5 after CVS and 3 after AC. This is consistent with what has been reported in a number of studies. 13,14 Figure 2 shows indications of procedures annually between 2013 and 2017, showing AMA as the leading indication followed by family history of abnormal offspring.
Ultrasound indication, on the other hand, rose significantly in 2017 reaching 62 cases compared to the number of cases in previous years and to other indications. There is a drop in AMA as an indication in 2017 as more numbers of patients started to do first trimester screening test which led to a reduce in unnecessary procedures as illustrated in figure one. Ultrasound indication, on the other hand, rose significantly in 2017 reaching 62 cases compared to number of cases in previous years and to other indications. This can be explained by the introduction of top of the range new U/S machine at our unit by the end of 2016. Few cases were done because of high risk on biochemical screening which was done privately. The majority of our invasive procedures were Amniocentesis, constituting 74.
7% of all procedures. The rest of the procedures were done by CVS. (Table1) This is probably because Amniocentesis needs less training and most of our patients are referred late to our fetal medicine unit. 15.16The rate of miscarriage rates for both procedures is constant over the 5 years period. The pregnancy loss in our study was 0.28% for Amniocentesis and 1.265 for CVS as shown in Table 2.
These results are consistent with what is reported in the literature. 17,18 We usually council our patients and tell them that the rate of miscarriage for both procedures at our unit is 1% but after these results, we should tell our patients that the risk of miscarriage from CVS is less than Amniocentesis. There are many studies on Amniocentesis, the most prominent is by Tobaretal, 1986 which reported a 1% rate of fetal loss after amniocentesis 18.
More recent studies were by Seeds 15 and Mujezinovicet.al 16 concluded that pregnancy loss after amniocentesis was 0.6%.
Philip et.al in 2004 reported a miscarriage rate of less than 0.5% 19.
Several factors lead to increase the rate of miscarriage post invasive diagnostic procedures such as the operator’s experience (the experienced operator has a lower rate of loss) 20. Other important factors that increase the rate of miscarriage are increase PAPP-A and increased NT 21. Our miscarriage rates for both procedures are acceptable.Table 3 shows the frequency of the abnormalities detected in relation to the indication of procedure. The highest number of abnormalities were detected after scanning the mother due to advanced maternal age where the number of detected cases was 27 (37.5%). This is followed by abnormal US findings with a number of 20 cases (28%).
The least number of detection occurred with the history of abnormal offspring standing at 17%. At the end, our fetal medicine unit at King Hussein Medical Centre is busy, our doctors are experienced. We perform a large number of invasive procedures annually. Our complication rates are consistent with what is reported in other studies as shown earlier.Conclusion At King Hussein Medical Centre, the most common method of invasive procedure is amniocentesis followed by CVS. Advanced maternal age is the most common indication for invasive prenatal procedures, however, this indication is on the decline due to the introduction of biochemical testing and NIPND. Miscarriage rates are consistent with what is reported in the