Non Invasive Prenatal Testing (NIPT) Harmony™ Patient Information The vast majority of babies are normal. However, all women, irrespective of their age, have a small chance of delivering a baby with a physical and/or learning disability. In some cases this disability is caused by a chromosomal abnormality. The most common chromosome abnormalities are trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome) and trisomy 13 (Patau syndrome). The Portland Hospital has introduced a new approach to provide the most accurate way of estimating the risk of the fetus having these conditions by offering a simple non invasive blood test that analyses cell-free DNA in the mothers blood. About the test: DNA is the genetic material found in each and every cell in our body. The pattern of DNA makes up the genes that code for our characteristics, such as hair and eye colour, and any genetic conditions we may have or carry Fetal genetic material can be found in the maternal circulation, raising the possibility of using maternal blood to diagnose fetal disease. Intact fetal cells can be identified in maternal blood, but are not a reliable source of fetal genetic material because these cells are extremely rare and may persist for years after prior pregnancies . By comparison, fetal "cell-free" nucleic acids (DNA and RNA) are more plentiful in the maternal circulation and are unique to the current pregnancy. DNA from the fetus circulates in the mother’s blood. Cell-free DNA (cfDNA) results from the natural breakdown of fetal cells (presumed to be mostly placental) and clears from the maternal system within hours of giving birth. During a pregnancy, cfDNA can be tested to give the most accurate screening approach in estimating the risk of a fetus having a common chromosome condition sometimes called a trisomy. What is a Trisomy ? Humans have 23 pairs of chromosomes, which are strands of DNA and proteins that carry genetic information. A trisomy is a chromosomal condition that occurs when there are three copies of a

particular chromosome instead of the expected two. The risk of having a baby with a trisomy increases with maternal age. Trisomy 21 is due to an extra chromosome 21 and is the most common trisomy at the time of birth. Trisomy 21, also called Down Syndrome, is associated with mild to severe intellectual disabilities and may also lead to digestive disease and congenital heart defects. It is estimated that trisomy 21 is present in 1 out of every 700 newborns.(1) Trisomy 18 is due to an extra chromosome 18. Trisomy 18, also called Edwards Syndrome, is associated with a high rate of miscarriage. Infants born with trisomy 18 often have congenital heart defects as well as various other medical conditions, shortening their lifespan. It is estimated that trisomy 18 is present in approximately 1 out of every 5,000 newborns.(2) Trisomy 13 is due to an extra chromosome 13. Trisomy 13, also called Patau Syndrome, is associated with a high rate of miscarriage. Infants born with trisomy 13 usually have severe congenital heart defects and other medical conditions. Survival beyond the first year is rare. It is estimated that trisomy 13 is present in approximately 1 out of every 16,000 newborns.(3) How are trisomies diagnosed? The only way to know for sure whether or not a baby has a chromosomal abnormality is to have an invasive test such as Chorionic Villus Sampling (CVS) or Amniocentesis. Chorionic villi sampling (CVS) is a procedure that takes a small amount of tissue from the developing placenta. The tissue is then sent to a laboratory to test the chromosomes. CVS is typically performed between 11 and 14 weeks of pregnancy. CVS is associated with a small risk of miscarriage. 1-2% Amniocentesis is a procedure that withdraws a small amount of fluid that surrounds the fetus. The fluid is then sent to the laboratory to test the chromosomes. An amniocentesis is usually performed around or after the 15 weeks of pregnancy. Amniocentesis is associated with a small risk of miscarriage. 1% Risk of having the test: The NIPT is a simple safe blood test undertaken by the mother with absolutely no risk to mother or baby. How accurate is the NIPT? Detection rate for Down syndrome (trisomy 21) At least 99% of all pregnancies with trisomy 21 can be detected using this test. However, up to 1 in 100 pregnancies with trisomy 21 will have a normal result and be missed on screening. The falsepositive rate is approximately 0.2%, meaning 1 in about 500 unaffected pregnancies are reported as ‘positive ‘or consistent with’ trisomy 21. For that reason, it is recommended that CVS or amniocentesis be considered after an abnormal result to confirm the presence of a chromosome abnormality.

Detection rate for Edwards syndrome (trisomy 18) The detection rate for trisomy 18 may be similar to that for trisomy 21; approximately 98% of pregnancies with trisomy 18 will be detected by NIPT. About 2 in 100 pregnancies with trisomy 18 will be missed on screening. The false-positive rate is also similar to trisomy 21. About 1 in 500 pregnancies unaffected with trisomy 18 will have an abnormal, or positive, result, so confirmatory testing is recommended. Detection of Patau syndrome ( trisomy 13) There is less confidence in NIPT as a screen for trisomy 13 due to technical issues and the infrequency of the condition. Detection rates of 80% have been reported, meaning 20 out of 100 pregnancies with affected fetuses will be missed. The false-positive rate may be about 1%, so 1 out of 100 unaffected pregnancies may be positive for trisomy 13, so confirmatory testing is recommended. Traditional Down Syndrome screening tests have a detection rate of 75-95% for a false positive rate of 3-5%. This means that between 5 to 25 pregnancies with trisomy 21 will be missed on screening and that between 3-5 out of 100 unaffected pregnancies may be positive for trisomy 21. This means that this novel screening test will detect a greater proportion of babies affected by chromosomal abnormalities, and women will be less likely to require an invasive test (which carries a 1-2% chance of causing a miscarriage) following screening. When and who can have the NIPT? The test can be performed in women carrying a single baby at or after 10 completed weeks of pregnancy. This test is not for use in multiple pregnancies (such as twins) or for egg-donor pregnancies where the egg-donor is unrelated to the woman carrying the baby. The Combined Test can still be offered in these situations. What is the process? If you are less than 11 weeks: You will have two visits to the Portland Hospital: The first visit will be between 10+0 weeks to 10 weeks and 6 days of your pregnancy. During this visit, we will explain the test to you and answer any questions you may have. You will then have an ultrasound scan to confirm that you have singleton pregnancy (one baby), that the baby is alive and that the size of the baby agrees with the number of weeks pregnant you are. We will also take a sample of blood from you that will be used for the NIPT. The second visit will be two weeks later, at 12 weeks. At this visit we will discuss the results of the NIPT and will also carry out an early abnormality scan. The Early Anomaly Scan is an ultrasound scan involving a detailed examination of the baby’s anatomy. This includes examination of the baby’s major organs, including the brain, heart, abdomen, stomach, bladder and limbs.

On the basis of the NIPT and the early anomaly scan you will be supported to decide whether you wish to have invasive testing or not. If you are 11-14+1 weeks: You will have one visit to The Portland Hospital During this visit, we will explain the test to you and answer any questions you may have. You will then have an ultrasound examination; this will comprise an early anomaly scan and the ultrasound component of the Combined test. We will also take a sample of blood from you that will be used for the NIPT and to measure two hormones in the blood that are produced by the placenta. On the basis of the NIPT, the early anomaly scan and the Combined test results you will be supported to decide whether you wish to have invasive testing. If you are more than 14+1 weeks: You may have already had Down syndrome screening and an anomaly scan at 18-20 weeks. The NIPT for prediction of trisomies is still available to you. We would be happy to see you at The Portland Hospital to review the results of any previous examinations / tests in conjunction with one of our Fetal Medicine consultants who we will perform a detailed ultrasound examination to examine the baby’s anatomy and growth. We will then take a blood sample from you that will be used for the NIPT. On the basis of the NIPT you will be supported to decide whether you wish to have invasive testing. Who carries out the analysis of the Non Invasive Prenatal Testing? We will send your blood sample along with your personal information (including name, date of birth, gestational age) to The Doctors Laboratory based in London, UK, which has an arrangement with a company called Ariosa Diagnostics Inc, based in San Jose, USA. Ariosa will perform their NIPT test called Harmony™ Prenatal Test on the DNA extracted from your blood sample. There will be no further clinical testing on this blood and your blood sample will be discarded once we have confirmed the results with you. Ariosa Diagnostics Inc. will not use your blood sample or the extracted DNA samples for any other purpose

When can I expect to get my results? The results from the NIPT will generally be available within two weeks and we will either give them to you at the time of the second visit to The Portland Hospital at 12 weeks or contact you by telephone and letter. There needs to be enough fetal DNA in the maternal blood to be able to provide a result. If there is insufficient fetal DNA in the sample , another blood sample from the mother may be required and this occurs in 3 to 5 % of cases. This will be processed in the laboratory at no extra charge.

How will my test results be presented? Your test result will be reported as low risk or high risk of a fetal trisomy. If the Harmony™Prenatal Test shows that there is a high risk that the baby has trisomy 21 or 18 or 13, it does not mean that the baby definitely has one of these conditions. You will be offered an invasive test (CVS or amniocentesis) which is the only way to know for sure whether or not an unborn baby has a chromosomal abnormality. If the Harmony™ Prenatal Test shows that there is a low risk that the baby has trisomy 21 or 18 or 13, it is highly unlikely that the baby has one of these conditions. The test identifies more than 99%, but not all, of the babies with trisomy 21, 98% of babies with trisomy 18 and 80% of babies with trisomy 13.

Do I need to have any other tests? The NIPT prenatal test does not provide information on other rare chromosomal abnormalities. If the ultrasound scan shows a high nuchal translucency or other major physical defects such as brain abnormalities, heart abnormalities, the risk for some rare chromosomal defects may be high. In such cases, you may choose to have a CVS or an amniocentesis. The NIPT prenatal test does not provide information on other physical defects such spina bifida, or information on fetal growth. It is therefore advisable that you have all the usual ultrasound scans during your pregnancy In addition to the Early Anomaly Scan and the NIPT we recommend that you have ultrasound scans at 20-22 weeks to examine the baby’s anatomy and at 30-34 weeks to examine the baby’s growth. Transfer of your information outside the European Union For the purposes of carrying out the Harmony Prenatal Test, your personal information will be transferred outside of the European Union, to the USA. Please be aware that the laws applicable to your personal data in the USA are different from those operating in the UK, where The Portland Hospital and The Doctors Laboratory is established.

Who do I contact if I would like more information about the NIPT? If you have any questions about the NIPT, please do not hesitate to contact a member of staff from the Ultrasound department at the Portland Hospital: 0207 390 6351 or email Dean Meredith, Sonography & Fetal Medicine Lead at [email protected]. References 1- http://ghr.nlm.nih.gov/condition/down-syndrome 2 - http://ghr.nlm.nih.gov/condition/trisomy-18 3- http://ghr.nlm.nih.gov/condition/trisomy-13