Determinants of altered anxiety after abnormal maternal serum alpha-fetoprotein screening.

With maternal serum alpha-fetoprotein testing, large numbers of previously "low-risk" patients are now considered high risk and are offered genetic testing. Anecdotally, these patients have been perceived as more highly anxious than other second-trimester patients referred for genetic testing because of advanced maternal age. Thus we have studied patient demographics, true genetic risks, the perceptions of risk, and state (situational) and trait (constitutional) anxiety for these patients and their partners. Significantly increased state anxiety was noted for mothers as compared with fathers both in the group of women referred for testing because of maternal serum alpha-fetoprotein levels and in those referred due to advanced maternal age. State anxiety was increased in the women referred for maternal serum alpha-fetoprotein levels as compared with women referred for advanced maternal age. True genetic risks were comparable between the groups. Some critics have argued that maternal serum alpha-fetoprotein screening engenders unnecessary anxiety. Our data show that patients undergoing genetic testing due to maternal serum alpha-fetoprotein levels have higher state anxiety than women undergoing testing because of advanced maternal age, but that indication is much less a factor than are partner differences. Therefore, increased anxiety after abnormal maternal serum alpha-fetoprotein testing results cannot be reasonably used as an argument against such testing.

Wide variation in maternal serum alpha-fetoprotein reports in one metropolitan area: concerns for the quality of prenatal testing.

The variation in reported laboratory values, medians, and confounding variables used in the interpretation of alpha-fetoprotein (AFP) values from 14 laboratories servicing the Detroit-Metropolitan area was assessed by reviewing the laboratory report forms. The wide variation found in reported values, medians, and use of correction factors makes interpretation of results difficult and inaccurate. The need for large data bases for continuous correction of medians, uniform use of correction factors, and clinical decision making is emphasized.

Amniotic fluid acetylcholinesterase: implications of an inconclusive result.

The implications of an "inconclusive" acetylcholinesterase test (a faint but true band) in amniotic fluid were studied over a 2 1/2-year period in our laboratory. One thousand one hundred fifty-four amniotic fluid samples were tested for acetylcholinesterase and alpha-fetoprotein; the rate of an inconclusive acetylcholinesterase result was 3.3% (38 of 1154). Fourteen such results were found in patients with a high amniotic fluid alpha-fetoprotein level (23.3%), and 24 results were associated with normal amniotic fluid alpha-fetoprotein levels (2.19%). The rates of congenital fetal malformation associated with an inconclusive acetylcholinesterase result in the two groups were 57.14% and 37.5%, respectively. In amniotic fluid samples obtained before 15 weeks' gestation, there was a higher rate of inconclusive acetylcholinesterase tests (9.29%), but a lower percentage of malformed fetuses were found compared with later in pregnancy (2.46% and 56%, respectively). Thus we suggest the terminology "equivocal" for early specimens and "suspicious" for later specimens. If obtained in early second trimester and the ultrasound scan is normal, such findings implicate the need for a careful search for fetal malformations. A positive pregnancy outcome may be expected in most cases.

Establishment of a collaborative university-commercial maternal serum alpha-fetoprotein screening program: a model for tertiary center outreach.

Expansion of the availability of tertiary level services beyond major medical centers has proved to be a major problem in health care delivery. Routine maternal serum alpha-fetoprotein screening for neural tube defects, and now also for aneuploidy, is a classic example in which there has been a schism between the clinical expertise to manage such a program within a tertiary level reproductive genetics center and the ability to reach patients in regions that are not routinely accessible to the tertiary center. To address this problem we have established a collaborative university-commercial laboratory statewide maternal serum alpha-fetoprotein program that we believe can serve as a model for others. In the first 4 months since its implementation, the program volume has increased tenfold. The detection frequency of neural tube defects has been consistent with that of other programs (1/1690). Three aneuploid karyotypes were found in amniotic fluid of 118 women less than 30 years old who underwent genetic amniocentesis because of a low maternal serum alpha-fetoprotein value. Thus we conclude that: the establishment of a joint university-commercial maternal serum alpha-fetoprotein program may provide a successful model for efficient tertiary center outreach, assessment of our data suggests that a population at high risk for abnormal fetuses can be identified among patients not generally considered at high risk, low maternal serum alpha-fetoprotein values may likely be a more important public health measure than high ones.

Confidence in contraception.

PIP: The extended use effectiveness of precoital contraceptives (pills, injections, mechanical devices, and sterilization) and postcoital methods (pills, abortion, and menstrual aspiration) are evaluated in terms of the effectiveness of the method in preventing pregnancy and the qualities which encourage continuation over an extended period. 2 new forms of the IUD, the copper IUD which improves antifertility effects and reduces expulsion, and the progesterone IUD which acts topically feeding the uterus with progesterone, are under study. A postcoital pill of antihormones to deplete the body's store of the sex hormones necessary to maintain pregnancy is seen as a future development. Biochemical methods inhibiting sperm function, egg production, or implantation will not be realized for 8-10 years. Prostaglandins produce unbearable side effects and have not turned out to be safe, self-administrable abortifacients. Reversible sterilization would make this form of contraception more palatable. Several methods are under study but whether potency could be restored is a major question. Motivation is stressed as the key to successful contraception.^ieng