MoonDragon's Women's Health Procedures Information
ALPHA-FETOPROTEIN ASSESSMENT (AFP)
Triple Screen Test
Human Chorionic Gonadotropin Test
Unconjugated Estriol Test)
For "Informational Use Only".
For more detailed information, contact your health care provider
about options that may be available for your specific situation.
AFP Description Reasons For AFP Procedure AFP Possible Risks AFP Procedure Description AFP Expected Outcome AFP Test Result Values AFP Possible Complications Post Procedure Treatment Medication Activity Restrictions & Recommendations Diet & Nutrition Notify Health Care Provider Pregnancy-Related Supplements & Products
Alpha-Fetoprotein Assessment (AFP), also known as Triple Screen Test when combined with testing for human chorionic gonadotropin and unconjugated estriol, is a relatively common screening of a blood sample taken from the mother usually during the 15th to 20th week of pregnancy. Many women find this prenatal testing useful with 40 percent of pregnant women having the test each year. The primary measurement on the triple screen is for maternal serum alpha-fetoprotein (MSAFP or AFP), a protein produced by the liver cells of every fetus and is present in both the amniotic fluid and the mother's blood. Testing for human chorionic gonadotropin (hCG) and unconjugated estriol (uE3) is combined with the AFP test to help improve the accuracy of the results for genetic problems.
Generally speaking, any combination of the testing will identify 60 percent of the babies with Down Syndrome and 80 to 90 percent of the babies with neural tube defects.
Outside pregnancy, the AFP test is used to detect liver disease, certain cancerous tumors, and to monitor the progress of cancer treatment. AFP testing is performed when certain types of cancer tumors are suspected. See below under "Reasons For Procedure" for more information about Cancer Tumor Markers.
REASONS FOR PROCEDURE
This test is used to help rule out possible fetal abnormalities. The triple test is for screening purposes only and further testing is always necessary for accurate diagnosis of any problem.
The controversy in these tests lies in many places. One of which is the accuracy of the screenings. While some claim that they have only a 5 percent "false positive" rate, most research finds that there are 80-plus percent rate of positive tests while the baby is unaffected. The false positive rates depend on many factors, including appropriate gestational age, maternal age, weight and the presence of diabetes.
False positives may not seem like a problem, however, there are follow up tests that are done that do carry risks, like Amniocentesis, which does carry a 1 to 2 percent rate of fetal loss. The standard is usually to repeat the AFP or triple screen. Another positive screen will then go to the Level II Ultrasound. Ultrasound can even be used to detect some of the anomalies associated with Downs Syndrome. If the ultrasound does not find a mix up in gestational age, or a multiple pregnancy, an amniocentesis is generally the next step.
There is a possible benefit of identifying neural tube defects before birth, because that can alter care. Such as the mode of delivery. It is generally considered safer for a baby with spina bifida to have a cesarean delivery. Although this can also be identified by ultrasound alone.
Abnormally high AFP may indicate that the fetus has an increased risk of a neural tube defect, the most common and severe type of disorder associated with increased AFP. These types of defects include spinal column defects (spina bifida) and anencephaly (a severe and usually fatal brain abnormality). If the tube that becomes the brain and spinal cord does not close correctly during fetal development, AFP may leak through this abnormal opening and enter the amniotic fluid. This leakage creates abnormally high levels of AFP in amniotic fluid and in maternal blood.
It has been estimated that every positive screening will cost approximately $106,000 or more. Of the positive test results, 90 percent of these babies will not have any anomalies. There may be other benign reasons for the elevated or low levels of the hormones, specifically the gestational age, or multiple pregnancies. The AFP test is generally done between the 16th and 18th weeks of pregnancy, while the triple screen can be done a bit earlier. The gestational age is very important, because the amount of hormone in your blood will vary with gestational age.
Other fetal conditions that can raise AFP levels above normal include:
- Cysts at the end of the spine.
- Blockage in the esophagus or intestines.
- Liver disease causing liver cells to die.
- Defects in the abdominal wall.
- Kidney or urinary tract defects or disease.
- Brittle bone disease.
Levels may also be high if there is too little amniotic fluid in the amniotic sac around the fetus, more than one developing fetus, or a pregnancy that is farther along than estimated.
For unknown reasons, abnormally low AFP may indicate that the fetus has an increased risk of Down syndrome. Down syndrome is a condition that includes mental retardation and a distinctive physical appearance linked to an abnormality of chromosome 21 (called trisomy 21). If the screening test indicates an abnormally low AFP, amniocentesis is used to diagnose the problem. Abnormally low levels of AFP can also occur when the fetus has died or when the mother is overweight.
In 2004, a new study showed that the risk of an infant's death from sudden infant death syndrome (SIDS) increased if levels of AFP were higher during the second trimester of the mother's pregnancy.
Although AFP in human blood gradually disappears after birth, it never disappears entirely. It may reappear in liver disease, or tumors of the liver, ovaries, or testicles. The AFP test is used to screen people at high risk for these conditions. After a cancerous tumor is removed, an AFP test can monitor the progress of treatment. Continued high AFP levels suggest the cancer is growing.
The American College of Obstetricians and Gynecologists have stated that they believe this test should be offered to all pregnant women, regardless of maternal age. However, many women are made to believe the testing is mandatory. Many who refuse are asked to sign waivers in order to not take the test. While others are finding that their insurance coverage has a part to play in the whole scenario.
The test results are generally given as either positive / negative or a risk ranking, such as: 1/47 chance of having a baby with X anomaly. As well as low/high rankings. It is important to remember that being at an increased risk does not mean your baby has the defect. You should also ask that your health care practitioner or midwife explain the results in detail to you.
Physician-researchers at Boston's Brigham and Women's Hospital, after studying 87,584 pregnancies, reported that an elevated AFP [alpha-feto-protein] level in conjunction with a normal ultrasound scan implies a less than 0.1 percent chance that the baby will have one of the four most common birth defects. In light of the finding that amniocentesis itself carries a 0.5 to 1.5 percent chance of terminating a pregnancy (Robin J.R. Blatt, Prenatal Tests), the researchers have concluded that "many women may choose not to have an amniocentesis when informed that the risk of pregnancy loss is substantially greater than the likelihood of finding an anomaly". (New England Journal of Medicine 323, No. 9, Aug 30, 1990)
Whether or not to have the test is a very hard decision and a very personal one. Some women feel that no matter what is wrong that they would not terminate the pregnancy, and therefore do not want the test. While others are very happy to have the normal results, even knowing that there are no guarantees.
OTHER USES FOR THE AFP TEST: AFP CANCER TUMOR MARKERS
Also known as: AFP, Total AFP, AFP-L3%
Formal name: Alpha-fetoprotein, Alpha-fetoprotein-L3%
Related tests: CEA, hCG, Tumor markers
THE TEST FOR TUMOR DETECTION
AFP is used to detect tumors that mark cancers of the liver, testes, and ovaries. Patients with chronic liver diseases such as cirrhosis or chronic hepatitis B must be monitored at regular intervals because they have a lifetime risk of developing liver cancer. A health care provider may order an AFP test, along with imaging studies, to try to detect liver cancer when it is in its earliest, and most treatable, stages. An AFP-L3% test may be ordered by some health care providers to help further evaluate the risk of patients with chronic liver disease developing hepatocellular carcinoma in the near future. If a patient has been diagnosed with hepatocellular carcinoma or another form of cancer, an AFP test may be ordered periodically to help monitor a patient's response to therapy.
Your health care provider may order an AFP blood test when he/she:
An AFP-L3% may be ordered to help evaluate the risk of hepatocellular carcinoma when a patient has chronic liver disease. This new test, however, is not widely used and its ultimate clinical utility has yet to be established.
- Suspects that a patient has liver cancer or certain cancers of the testes or ovaries.
- Is monitoring a patient with chronic liver disease for the emergence of hepatocellular carcinoma or another type of liver cancer.
- Is monitoring the effectiveness of treatment in a patient who has been diagnosed with and treated for a cancer of the liver, testes, or ovaries.
TEST RESULTS CANCER TUMOR TESTING
Note: A standard reference range is not available for this test. Because reference values are dependent on many factors, including patient age, gender, sample population, and test method, numeric test results have different meanings in different labs. Your lab report should include the specific reference range for your test. Lab Tests Online strongly recommends that you discuss your test results with your health care provider.
Increased AFP levels can mean liver cancer, cancer of the ovary, germ cell tumor of the testes, cirrhosis, hepatitis, or other cancers (stomach, colon, lung, breast, lymphoma). With an AFP-L3%, the health care provider receives both a total AFP result and the percentage of AFP that is L3. If a patient has chronic liver disease and their AFP and L3% are significantly elevated, then the patient has an increased risk of having or developing hepatocellular carcinoma in the next year or two. Both AFP and AFP-L3% concentrations can be elevated, and fluctuate, in patients with chronic hepatitis and cirrhosis.In these patients, a significant increase in AFP is more important than the actual numerical value of the test result.
In general, the higher the AFP level in patients with cancer, the bigger the tumor. AFP decreases when your body responds to anti-cancer therapy. If AFP does not return to normal within about one month after cancer therapy, some of the tumor may still be present. Not every patient with increased AFP and AFP-L3% test results has cancer or will develop liver cancer. The AFP and AFP-L3% tests are not diagnostic; they are indicators. They must be used in conjunction with imaging studies to look for malignant tumors when monitoring the patient, or when a health care provider suspects that a cancer is present. The tests can provide useful information, but they are not as specific or sensitive as health care providers would wish. They should not be used to screen the general population for cancer.
Note that AFP is not always a tumor marker. Because AFP is produced by the fetus, levels are normally higher in pregnant women and in their newborns.
POSSIBLE AFP ASSESSMENT TEST RISKS
No expected risks with the blood test itself. The blood is drawn from the mother, not the fetus.
AFP PROCEDURE DESCRIPTION
The test is most sensitive between 15 and 17 weeks (some resources say up to 20 weeks) of gestation. Accurate dating and assurance of the number of babies is very important. Both of these factors can throw the results off. Falsely high values may result if the mother has diabetes or is pregnant with twins. Keep in mind, this is only a screening test and it is not perfect. False high and low levels do occur. It may need to be followed up by an ultrasound and amniocentesis.
Blood is usually drawn by needle from the upper arm or a vein, usually on the inside of the elbow (sometimes from the finger, heel or earlobe). The sample is then sent to a laboratory for testing. Results are available in a few days to about a week. AFP can also be measured in the sample of amniotic fluid taken at the time of amniocentesis.
The test results are usually given in percentages. Example: Risk of Neural Tube Defect 1 in 500.
EXPECTED TESTING OUTCOME
The majority of time (over 95 percent of women tested), the test results fall with in the normal range.
About 3 to 5 percent of women tested will have AFP levels outside the normal range the first time and 3 percent of these women will still have abnormal levels on a repeat blood test. Those women will be offered genetic counseling which may lead to further testing such as amniocentesis, ultrasound or other prenatal tests to help verify if a problem exists.
Higher concentration of AFP levels may indicate:
- A neural tube defect such as spina bifida failure of the spinal column to close completely).
- Other rarer abnormalities.
- Twins (or triplets) are expected.
- Abruptio placentae.
- The pregnancy is inaccurately dated. Fetal gestational age may need to be reassessed.
AFP levels can be abnormally low which may indicate:
- The pregnancy is inaccurately dated. Fetal gestational age may need to be reassessed.
- Trisomy-21 (Down syndrome).
AFP TEST RESULT VALUES
When you receive the results of your AFP, or triple screen, they are likely to tell you that you had high or low results. Here is what we know when placing these generic statements into the disorders detected.
Disorder AFP uE3 hCG Down Syndrome (Trisomy 21) Low Low High Trisomy 13 Normal No Data Low Trisomy 18 Low Low Low Open Neural Tube Defects High Normal Normal IUGR, preterm birth, stillbirth High No Data No Data Multiple Gestation High High High
Alpha-fetoprotein is measured in nanograms per milliliter (ng/mL) and is expressed as a probability. The probability (1:100, for example) translates into the chance that the fetus has a defect (a one in 100 chance, for example).
When testing for cancer or liver diseases, AFP results are reported as nanograms per milliliter. An AFP level less than or equal to 50 ng/mL is considered normal. In tumor or liver disease testing, an AFP level greater than 50 ng/mL is considered abnormal.
INCIDENCE OF DOWN SYNDROME WITH INCREASING MATERNAL AGE
Maternal Age At Delivery Risk at Term 32 1/725 33 1/592 34 1/465 35 1/365 36 1/287 37 1/255 38 1/177 39 1/139 40 1/109 41 1/85 42 1/67 43 1/53 44 1/41 45 1/32 46 1/25 47 1/20 48 1/16 49 1/12
OB/GYN Secrets by Helen L. Frederickson, M.D. & Louise Wilkins-Haug, M.D. Ph.D.
MoonDragon's Pediatric Information: Down Syndrome
MoonDragon's Pediatric Information: Edwards Syndrome (Trisomy 18)
MoonDragon's Pregnancy Information: Spina Bifida
MoonDragon's Pregnancy Information: Twins
MoonDragon's ObGyn Procedures: Ultrasound
MoonDragon's ObGyn Procedures: CVS (Chorionic Villus Sampling)
MoonDragon's ObGyn Procedures: Amniocentesis
MoonDragon's ObGyn Procedures: Amniocentesis, How To
MoonDragon's ObGyn Procedures: Genetic Screening
Some discoloration (bruising), soreness or swelling (blood accumulating under the puncture site, called a hematoma) may develop at the puncture site. Use warm compresses if blood collects under the puncture site or if the area becomes tender, red or painful.
False-positive results of the test which may cause anxiety and worry for the parents-to-be.
CONVENTIONAL MEDICAL TREATMENT
TO TEST OR NOT TO TEST, THAT IS THE QUESTION!
ONE EXPECTANT PARENTS' DECISION:
Just recently, my husband and I came around to that time again - AFP testing. A test we avoided during the first pregnancy, the old issues were revisited at 18 weeks. Should we or should we not have the alpha-fetoprotein (AFP) test? This is a simple blood test that can give insight into the health of the unborn baby. Once blood is drawn, the protein is measured and this is then compared to a standard range for the current length of pregnancy. A low level of AFP could be an indicator that the unborn fetus has Down's syndrome, and a high level could indicate a neural tube disorder such as spina bifida or anencephaly.
But are the results accurate? Dating of pregnancy could influence the results, as could the presence of twins. Of the one in thirty women who have a high level of AFP in their blood, the vast majority has a normal healthy baby. And it can happen that a woman who receives a normal result on this screening test can still have a child with a genetic abnormality.
To decide whether or not we would have this test, we had to look beyond the results. If my results suggested a problem with the baby, would I move to a riskier test such as amniocentesis? This test uses a long needle to extract amniotic fluid surrounding the fetus, and that fluid contains genetic material. An analysis of this genetic material will reveal with accuracy whether there is a genetic defect with the fetus. But, 1 to 2 percent of women who have an amniocentesis will spontaneously abort the fetus, and that number varies depending on the skill level of the health care provider or technician performing the procedure.
Then, if the amniocentesis showed a genetic abnormality, would I ever be able to consider the choices that would be offered? Am I willing to terminate the pregnancy if the results showed a genetic abnormality? I knew in my heart that the answer was a strong 'No'. After feeling the baby since 14 weeks, and my husband could feel movement at 18 weeks, there was a strong attachment, a clear bond that was solid. I firmly decided that amniocentesis was not an option. Any such procedure was far too invasive into the baby's secure world.
That decided I once again had to assess my own personality. If I opted for the test and the results were questionable, would I stress and obsess and worry and pace trails in the floors until the baby was born? Knowing myself, I was certain that any news that was not positive would be on my mind constantly - even with the knowledge that chances are the baby is 100 percent fine. The fetus undoubtedly feels this level of stress and worry on the part of the mother-to-be, even though the effects of chronic stress are unclear.
For me and my husband, this was more of a spiritual question than a medical one. Every pregnancy is a gift and should be looked upon as such. But above all, it is a very personal decision that each pregnant couple has to address on their own.
AFP TESTING IS EXPENSIVE, NOW LARGELY OBSOLETE
OB/GYN News, March 15, 2006
By Damian McNamara, MIAMI BEACH
Maternal serum [alpha]-fetoprotein is no longer an effective or cost-effective second-trimester screen for neural tube defects in an era when women routinely undergo first-trimester Down syndrome screening and subsequent ultrasound, Dr. Todd J. Rosen said at the annual meeting of the Society for Maternal-Fetal Medicine.
Before ultrasound was commonplace - back in the 1970s and 1980s - women got an [alpha]-fetoprotein (AFP) test for spina bifida and anencephaly. "Now more and more women are screening for Down syndrome in the first trimester, and it is routine for women to do an ultrasound screen as well," said Dr. Rosen of the division of maternal-fetal medicine, Columbia University, New York. Dr. Rosen and his associates assessed clinical and cost effectiveness of AFP testing for U.S. women who had a first-trimester Down syndrome risk assessment and second-trimester ultrasound examination. They used a decision analysis model that assumed ultrasound provides 100 percent detection of anencephaly and 92 percent detection of spina bifida (the lowest percentage reported in the literature). To put AFP testing in the most favorable light, the model assumed a 92 percent detection rate for spina bifida (the highest in the literature) with a 3 percent false-positive rate.
The model predicted an estimated 4,000 neural tube defects among the approximate 4 million births in the United States in 2003. Screening of all these women with ultrasound would detect 2,208 of the 2,400 cases of spina bifida. AFP testing would yield 120,000 positive results and detect 176 of the 192 cases of spina bifida missed by ultrasound.
"The AFP test induces anxiety - for every 10,000 women who screen positive, only 3 will have a baby with spina bifida," Dr. Rosen said. AFP screening in women who undergo first- and second-trimester ultrasound examinations has a poor predictive value and causes more pregnancy losses from amniocentesis than cases of spina bifida it detects, he added. In addition, "by continuing to do AFP, we are spending all this money," Dr. Rosen said. For example, universal screening in the study cohort would cost $184 million. Because about 40 percent of women terminate a pregnancy because of spina bifida (in this model, 70 of 176 women), the cost becomes $2.6 million for each case prevented. With the assumption that 50 percent of women with an elevated AFP result have amniocentesis, and the procedure's loss rate is 1 fetus per 250, 245 women would lose their pregnancies, he estimated.
"As doctors we are really caught. We want to do what is right for patients, but we have a high risk of malpractice [suits]," he said. "Because we are so wary of missing anything, we err on the side of overtesting and this can do more harm than good."
Maryland Family Health Administration: AFP Testing for Improved Pregnancy Outcomes Epinions: Should You Take the AFP/Triple Screen Test? NIH: Commentary: What Can We Do To Prepare Patients For Test Results During Pregnancy?
Medicine is usually not necessary.
ACTIVITY RESTRICTIONS & RECOMMENDATIONS
DIET & NUTRITION
No special diet. Continue to follow your pregnancy dietary plan. Make sure you are consuming sufficient Folic Acid (a deficiency has been linked to neural tube defects). Take a quality Prenatal Ssupplement, if needed, as recommended by your midwife or health care provider. For more information about nutrition and pregnancy, see MoonDragon's Nutrition Guidelines and Recommendations
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NOTIFY YOUR HEALTH CARE PROVIDER
Following the test, you have any unusual pain or reaction at the puncture site. You need further information about the testing or test results.
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