Background: Chorionic villus sampling (CVS) and amniocentesis are two invasive methods of diagnostic approaches for prenatal diagnosis. The indication, adverse effects and final outcome of these two methods are&nbsp;different. The goal of this study was to compare indication, complications and outcomes of CVS and amniocentesis in pregnant women underwent prenatal screening program.Methods: Medical records of 1464 women who underwent CVS, or amniocentesis were reviewed in two tertiary hospitals (imam and women hospitals, affiliated hospitals of Tehran University of Medical Sciences).Results: For 1073 patients amniocentesis was performed while for 391 cases CVS was one. Mean maternal age, gestational age, and age at birth of the neonates were significantly lower in CVS group than the other&nbsp;group. Mean needle time was significantly higher in CVS group. Mean needle time was significantly higher in CVS Group (1.3 vs. 1.5, P &lt; 0.001). The most finding of CVS result was minor Thalassemia while trisomy 21&nbsp;was the most finding in amniocentesis group. Rupture of membranes was the most side effects in amniocentesis group and intrauterine fetal death was the most complication in CVS group.Conclusions: Indication, results and complications of CVS and amniocentesis are different

Ghajarzadeh, Mahsa

Mohseni, Mona

Shirazi, Mahboobeh

English

Academic Journal of Surgery (AJS - Tehran University of Medical Sciences)

Acad J Surg, Vol. 2, No. 1-2 (2015) O RI GI NAL R E P O R TCorr esp ondi ng  Aut hor : Mona Mohseni Department of Obstetrics and Gynecology, Women’s Hospital, North Villa St., Karimkhan Zand, Tehran, Iran. Tel: +98 21 88533663, E-mail: monamohseni62@gmail.com Co mpl i c at io ns , I ndic a ti o ns  and Re s ul ts  o f  Tw o  Scr e e ni ng  Me t ho ds :  Amni o c e nt e sis  a nd Cho r io ni c  Vil l us  Sampl i ng M ahbo ob eh S hi ra zi 1 ,  M ona M ohse ni 1 ,  M ahsa G haj arz a de h 21 Dep a rt men t of  Ob ste t ri c s an d Gyn e co lo gy , Wo men ’s Ho sp ita l , Teh ran  Un iv e rsit y of  M ed ic al  S ci en c e s,  Teh ran ,  Ira n  2 B ra in  an d Sp ina l  In ju ry  Re sea rch  C en te r,  Te h ran  Uni ve rsit y of  M ed i cal  S ci en c e s,  Teh ra n,  Ira n  Received: 7 Jul. 2014; Received in revised form: 10 Aug. 2014; Accepted: 22 Sep. 2014 A bst r a c t B ac kg ro un d : Chorioni c villus sampling (CVS) and amniocentesis are two invasive methods of diagnostic approaches for prenatal diagnosis. The indication, adverse effects and final outcome of these two methods are different. The goal of this study was to compare indication, complications and outcomes of CVS and amniocentesis in pregnant women underwent prenatal screening program. M et hods: Medica l records of 1464 women who underwent CVS, or amniocentesis were reviewed in two tertiary hospitals (imam and women hospitals, affiliated hospitals of Tehran University of Medical Sciences). Resul t s : Fo r 1073 patients amniocentesis was performed while for 391 cases CVS was one. Mean maternal age, gestational age, and age at birth of the neonates were significantly lower in CVS group than the other group. Mean needle time was significantly higher in CVS group. Mean needle time was significantly higher in CVS Group (1.3 vs. 1.5, P < 0.001). The most finding of CVS result was minor Thalassemia while trisomy 21 was the most finding in amniocentesis group. Rupture of membranes was the most side effects in amniocentesis group and intrauterine fetal death was the most complication in CVS group. Conclusions: Indication, results and complications of CVS and amniocentesis are different. © 2015 Tehran University of Medical Sciences. All rights reserved. Citation : Shirazi M, Mohseni M, Ghajarzadeh M. Complications, Indications and Results of Two Screening Methods: Amniocentesis and Chorionic Villus Sampling. Acad J Surg, 2015; 2(1-2): 23-6. K e yw o r ds : Amniocentesis , Chorionic villi sampling, Pregnant women, Prenatal diagnosis, Indication, Complications I n trod u cti on  Chorionic villus sampling (CVS) is an ambulatory procedure conducted prior to 12 weeks of gestation for prenatal diagnosis (1). CVS is performed in pregnancies with advanced maternal age, first trimester screening for Down’s syndrome, and in high risk groups according to US preventive services task force and the society of obstetricians and gynecologists Canada, in conjunction with the Canadian College of Medical Geneticists (2). It is a safe procedure with reported fetal loss between 0.5% and 1.5% (3). Miscarriage, infection, rhesus sensitization are complications of CVS.  Amniocentesis is another invasive diagnostic method for prenatal diagnosis which is invasive and provides information regarding chromosomal abnormalities (4). Although, it is an invasive method, fetal loss rate reported in 0.06% and 1% of performed procedures (5,6). Procedure-related complications after amniocentesis include miscarriage, infection, club foot, and puncture of the placenta. Different factors such as trans-placental needle insertion, angle of puncture, numerous punctures, fetal abnormalities and experience of the operator are related with fetal loss following amniocentesis (7-10). Previous studies showed that different diameters of the needle are important in the occurrence of adverse effects (5,8,11). We designed this study to find out indications, complications and outcomes of CVS and amniocentesis in pregnant women underwent prenatal screening programs. Materi al s  an d  Meth od s  In this retrospective study, medical records of 1464 women who underwent CVS, or amniocentesis were reviewed in two tertiary hospitals (Imam and Women hospitals, affiliated hospitals of Tehran University of Medical Sciences). The procedures were conducted during 10 years, using 22 gauze needles.  A structured questionnaire applied to collect information regarding (age, gravidity, live birth, gestational age, placenta location, indication of procedure, alpha-fetoprotein level, procedure complications, final outcome (abortion, live birth, intrauterine fetal death [IUFD]), number of needling, human chorionic gonadotropin level, and age at birth. Statistical analyses performed with SPSS (version 18; SPSS Inc., Chicago, IL, USA). Results are presented as mean ± standard deviations, and frequencies. The χ² test with Fisher’s exact test was applied for comparing categorical variables and ANOVA test used to compare continuous variables. P < 0.050 was considered statistically significant.  Res u l ts  Medical records of 1464 patients reviewed. For 1073 patients amniocentesis was performed while for 391 cases CVS was one. Table 1 shows basic characteristics of patients in both groups. Mean needle time was significantly higher in CVS group (Table 2). The mean number of needle time according to placenta location was not significantly different in both groups (Table 3). The most finding of CVS result was minor  thalassemia while trisomy 21 was the most finding in amniocentesis group (Table 4). Rupture of membranes was the most side effects in amniocentesis group, and IUFD was the most complication in CVS group (Table 5). Di s cu s s i on The result of the current study showed that mean maternal age, gestational age, and age at birth of the neonates were significantly lower in CVS group than the other group (Table 6). The results also showed that in both groups, the placenta was located mainly at the anterior position and mean number of needle time in two groups according to the location of the placenta was not significantly different. In CVS group, the previous history of the problem was the most reason for doing the procedure while in amniocentesis group the main reason was abnormal biomarkers. Daniilidis et al. reviewed medical records of patients attended to their clinic for amniocentesis during 4 years (12). In their study, amniocentesis result was normal in 93% and Down syndrome was detected in 4%. Tabl e 1 .  Basic characteristics of patients in both groups Cha ract eri st i cs  A mni oce nt esi s  CVS  P  val ue  Maternal age 33.6 ± 6.1 28 ± 6.6 < 0.001 Gravidity 2.5 ± 1.4 2.2 ± 1.4 < 0.001 Live birth 1 ± 0.9 0.7 ± 1 < 0.001 Gestational age 18.6 ± 4.3 12.5 ± 2.4 < 0.001 Age at birth 36.5 ± 5.4 33.1 ± 9.9 < 0.001 Placenta location Anterior 540 192 0.007 Posterior 380 163 Fundal 117 20 Previa 13 5 Lateral 23 11 CVS: Chorionic villus sampling Tabl e 2 .  Procedure related factors in both groups F act or s  A mni oce nt esi s  CVS  P  val ue  AFP 1 ± 0.8 0.9 ± 0.6 0.500 hCG 2 ± 2.3 2 ± 1 0.900 Needle time 1.3 ± 0.6 1.5 ± 0.7 < 0.001 Indication of procedure Maternal age 491 53 < 0.001 According to sonography findings 73 16 0.100 According to biomarkers 777 25 < 0.001 Maternal request 55 4 < 0.001 Previous history of problem in children 158 342 CVS: Chorionic villus sampling; AFP: Alpha-fetoprotein, hCG: Human chorionic gonadotropin Tabl e 3 .  Mean number of needle time in two groups according to location of the placenta Gro u ps  Ant eri or  P ost eri o r  F un dal  P revi a  Lat er al  P  val ue  Amniocentesis 1.3 ± 0.6 1.2 ± 0.5 1.2 ± 0.6 1.1 ± 0.3 1.5 ± 0.7 0.080 CVS 1.5 ± 0.7 1.5 ± 0.7 1.7 ± 0.9 1.2 ± 0.4 1.1 ± 0.4 0.200 CVS: Chorionic villus sampling 24    Acad J Surg, Vol. 2, No. 1-2 (2015)Amniocenthesis and Chorionic Villus Sampling for Prenatal DiagnosisTabl e 4 .  Results of two procedures Resul t s  A mni oce nt esi s ( %)  CVS  ( %)  P-value Normal 950 (88.5) 169 (43.2) < 0.001 Trisomy 21 57 (5.3) 12 (3) Trisomy 18 15 (1.3) 3 (0.7) NTD 4 (0.3) 0 Major thalassemia 1 (0.09) 69 (17.6) Minor thalassemia 1 (0.09) 117 (29.9) Hemophilia 2 (0.18) 7 (1.7) Others 43 (4) 14 (3.4) NTD: Neural tube deficit; CVS: Chorionic villus sampling Tabl e 5 .  Side-effects of the procedures S i de- ef f ect s  A mni oce nt esi s  CVS  P - val u eAbortion 1 2 0.040 Bleeding 0 2 ROM 3 1 IUFD 2 3 Chorioamnionitis 2 0 ROM: Rupture of membranes; CVS: Chorionic villus sampling; IUFD: Intrauterine fetal death Tabl e 6 .  Final outcome Gro u ps  Li ve bi rt h ( %)  Abortion or termination (%) IUFD (%) P-value Amniocentesis 965 (89.9) 79 (7.3) 29 (2.7) < 0.001 CVS 316 (80.8) 66 (16.8) 9 (2.3) CVS: Chorionic villus sampling; IUFD: Intrauterine fetal death The outcome of pregnancy was live births in 89%, stillbirths in 3% (2/73), miscarriages in 1% and terminations in 7%. In our study, down syndrome detected in 5% of cases who underwent amniocentesis and abortion or termination done in 7%. Brambati et al. performed CVS on 1,844 women at weeks 13-20 of gestational age in whom the indication of the procedure was chromosomal anomalies in 85% (13). Tchirikov et al. evaluated 311 patients who underwent amniocentesis. They reported that the indication for amniocentesis was mostly advanced maternal age, followed by positive family anamnesis (4). The most karyotype in their study was trisomy 21, followed by trisomy 18 which is consistent with our finding. They reported no procedure complication in their cases while we detected 8 complications related to the amniocentesis. The mean rate of complications of amniocentesis such as miscarriage, amniotic fluid loss, bleeding, pyrexia, etc.) reported between 1% and 2% in previous studies (5,6,14,15). In a single center 16 years experience, Odibo et al. reported a total fetal loss in 0.4% of patients underwent amniocentesis and 0.26% in the group without this procedure (10). In CVS group, abortion occurred in 2 (0.5%) which is lower than the rate reported by Choudry et al. (1.5%) (3). Since-mid 1960, when chromosome analysis after amniocentesis introduced by Steele and Breg (16), screening for chrosomal abnormalities before birth becomes possible. Amniocentesis is an invasive method which is the most common prenatal diagnosticprocedure. The aim of amniocentesis is obtaining fetal cells derived from skin, mucous membranes, amnion, and umbilical cord for karyotyping or DNA analysis (12). It is usually performed between 15 and 20 weeks of gestational age and performing the procedure before 14 weeks of gestational age is related to the higher rate of miscarriage (12). Literature showed that procedure related complications could be controlled by the size of the needle used for the procedure (5,11,17). In most centers, it is performed by means of a 22-gauze spinal needle transabdominally under ultrasound guidance. The needle size which was used for both procedures in our cases was 22 gauge. In a previous study, Tchirikov et al. used 29 gauge needle for amniocentesis for 316 patients and reported no procedure-related fetal loss. No other complications were observed (4). However, the 29 gauge needle has its limitations such as higher risk of bending and it needs more attention for obese cases (4). The cost of the needle in our center is 1$ but the cost is near 25$ in other countries. CVS is a diagnostic test for inherited disorders which involves removing some chorionic villi cells from the placenta before 14th weeks of gestational age (3). The most indication for CVS is an increased risk of fetal aneuploidies due to advanced maternal age, family history or abnormal screening tests (3). CVS is related with fetal limb reduction defects, pre-eclampsia, focal placental hemorrhage and inflammation (18). We found none of these complications in this study. Acad J Surg, Vol. 2, No. 1-2 (2015)   25S hi razi  M ,  et  al . Con cl u s i on Indication, results and complications of CVS and amniocentesis are different. So, the proper method should be considered for a specific patient. Ref eren ces  1. Cederholm M, Haglund B, Axelsson O. Maternalcomplications following amniocentesis and chorionicvillus sampling for prenatal karyotyping. BJOG. 2003;110(4): 392-9.2. Lau KT, Leung YT, Fung YT, Chan LW, Sahota DS,Leung NT. Outcome of 1,355 consecutivetransabdominal chorionic villus samplings in 1,351patients. Chin Med J (Engl). 2005; 118(20): 1675-81.3. Choudry A, Masood S, Ahmed S. Feasibility and safetyof transabdominal chorionic villus sampling. J Ayub MedColl Abbottabad. 2012; 24(1): 38-43.4. Tchirikov M, Arnold C, Oshovskyy V, Heinrich UR,Thale V. Three years' experience of using a 29-gaugeatraumatic needle for amniocentesis. J Perinat Med.2012; 40(4): 413-7.5. Eddleman K, Berkowitz R, Kharbutli R, Malone F,Vidaver J, Porter TF, et al. Pregnancy loss rates aftermidtrimester amniocentesis: the faster trial. Am J ofGynecol Obstet. 2003; 189(6): S111.6. Tabor A, Philip J, Bang J, Madsen M, Obel EB,Norgaard-Pedersen B. Needle size and risk of miscarriageafter amniocentesis. Lancet. 1988; 1(8578): 183-4.7. Bravo RR, Shulman LP, Phillips OP, Grevengood C,Martens PR. Transplacental needle passage in earlyamniocentesis and pregnancy loss. Obstet Gynecol. 1995;86(3): 437-40.8. Devlieger R, Gratacos E, Ardon H, Vanstraelen S,Deprest J. Factors influencing the flow rate through asurgical defect in human fetal membranes. Prenat Diagn.2002; 22(3): 201-5. 9. Mujezinovic F, Alfirevic Z. Procedure-relatedcomplications of amniocentesis and chorionic villoussampling: a systematic review. Obstet Gynecol. 2007;110(3): 687-94.10. Odibo AO, Gray DL, Dicke JM, Stamilio DM, MaconesGA, Crane JP. Revisiting the fetal loss rate after second-trimester genetic amniocentesis: a single center's 16-yearexperience. Obstet Gynecol. 2008; 111(3): 589-95.11. Li DZ. Which is preferred: 20G or 22G needle atamniocentesis? Prenat Diagn. 2009; 29(8): 822.12. Daniilidis A, Karydas H, Zournatzi V, Tantanasis T,Giannoulis C, Tzafettas J. A four-year retrospective studyof amniocentesis: one centre experience. Hippokratia.2008; 12(2): 113-5.13. Brambati B, Tului L, Camurri L, Guercilena S. Earlysecond trimester (13 to 20 weeks) transabdominalchorionic villus sampling (TA-CVS): a safe andalternative method for both high and low riskpopulations. Prenat Diagn. 2002; 22(10): 907-13.14. Athanasiadis AP, Pantazis K, Goulis DG, ChatzigeorgiouK, Vaitsi V, Assimakopoulos E, et al. Comparisonbetween 20G and 22G needle for second trimesteramniocentesis in terms of technical aspects and short-term complications. Prenat Diagn. 2009; 29(8): 761-5.15. Scott F, Peters H, Boogert T, Robertson R, Anderson J,McLennan A, et al. The loss rates for invasive prenataltesting in a specialised obstetric ultrasound practice. AustN Z J Obstet Gynaecol. 2002; 42(1): 55-8.16. Steele MW, Breg WR. Chromosome analysis of humanamniotic-fluid cells. Lancet. 1966; 1(7434): 383-5.17. Uludag S, Aydin Y, Ibrahimova F, Madazli R, Sen C.Comparison of complications in second trimesteramniocentesis performed with 20G, 21G and 22Gneedles. J Perinat Med. 2010; 38(6): 597-600.18. Khalil A, Akolekar R, Syngelaki A, Penco JM,Nicolaides KH. Effect of chorionic villus sampling onuterine artery Doppler. Fetal Diagn Ther. 2010; 28(1):9-13.26    Acad J Surg, Vol. 2, No. 1-2 (2015)Amniocenthesis and Chorionic Villus Sampling for Prenatal Diagnosis

Complications, Indications and Results of Two Screening Methods: Amniocentesis and Chorionic Villus Sampling

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Complications, Indications and Results of Two Screening Methods: Amniocentesis and Chorionic Villus Sampling

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