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Maternal serum screening ofPalestinian women in the West Bank


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824 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005

Short communication

Maternal serum screening of

Palestinian women in the West Bank

A. Husseini1 and M. Akkawi2

1Institute of Community and Public Health, Birzeit University, Birzeit, Palestine (Correspondence to Abdullatif Husseini: abdullatif@birzeit.edu).

2Department of Biology, Al-Quds University, Jersusalem.

ABSTRACT An audit was made of laboratory records of triple test results from 943 Palestinian women residing in the West Bank from 2000–03. The mean expected age at delivery of the subjects was 25.5 years;

12% were 35 years old or above. Age was the main factor associated with an abnormal calculated risk score.

The frequency of elevated serum alpha-fetoprotein was 1.3%, abnormal human choriogonic gonadotropin (elevated or reduced) was 1.9% and reduced unconjugated estriol was 0.3%.

Dépistage sérologique maternel chez des Palestiniennes en Cisjordanie

RÉSUMÉ On a procédé à un audit des dossiers de laboratoire pour les résultats du triple test de 943 Pales- tiniennes résidentes en Cisjordanie durant la période 2000-2003. L’âge moyen des sujets prévu à la date de l’accouchement était de 25,5 ans ; 12 % étaient âgés de 35 ans ou plus. L’âge était le principal facteur associé à un score de risque calculé anormal. La fréquence du taux élevé de l’alpha-foeto-protéine sérique était de 1,3 % ; pour la gonadotropine choriogonique humaine anormale (élévation ou diminution), la fréquence était de 1,9 %, et pour le taux diminué de l’estriol non conjugué de 0,3 %.

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Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 825


Maternal screening of pregnant women uti- lizing the serum triple test and other newly introduced investigations has become a common tool for the detection of certain syndromes and defects in utero [1–3].

These include Down syndrome, trisomy 18, neural tube defects and other defects [1,3]. The mid-trimester triple test can also be used to predict early onset pre- eclampsia [4].

Down syndrome is caused by the pres- ence of an extra copy of chromosome 21, which leads to mental retardation, birth de- fects and some physical features that can be identified at birth [1,6]. In general, Down syndrome is the most common dis- order of the autosomal chromosomes, with an incidence of 1:800 live births [5]. The risk of Down syndrome increases with maternal age [7]. The incidence of Down syndrome in a study conducted on 3000 consecutive neonates in Egypt was 1.33 per 1000 [8]. In Bahrain, the incidence of Down syndrome was reported to be 1.14 per 1000 compared with an international estimated incidence of 1.40 per 1000 [9].

In Israel the incidence of Down syndrome was 1.00 per 1000 for Jews and 1.20 per 1000 for non-Jews (mostly Arabs)[7].

Neural tube defects usually occur in 1/

500 births. They can be anencephaly (in- complete closure of the brain) or spina bifi- da (incomplete closure of the spine).

Neural tube defects are usually marked by elevated levels of maternal serum alpha- fetoprotein [10].

The triple test is usually performed be- tween the 14th and the 20th weeks of preg- nancy, preferably between the 16th and 18th weeks. Three different substances are measured in the medical laboratory, namely alpha-fetoprotein (AFP), unconjugated es- triol (uE3), and human chorionic gonadot- ropin (hCG). High levels of AFP are

suggestive of neural tube defects while low levels of AFP may indicate Down syn- drome. Abnormal levels of hCG and estriol are indicators for chromosome abnormali- ties. The values of the 3 tests are factored together with information about the preg- nant woman including maternal age, gesta- tional age, weight and race to give a summary risk value. An additional risk val- ue based on the age risk may be included in some reports [5].

The importance of maternal screening is well established. This is the first study to describe the results of such tests among Palestinian women and to describe the characteristics of Palestinian women un- dergoing the triple test. It also aimed to ex- plore the risks for Down syndrome and neural tube defects estimated in the study subjects.


A record audit was made of triple test re- sults from 943 Palestinian women collected in the period 2000–03. The women were living in different areas of the West Bank, mainly East Jerusalem. The following vari- ables were noted from the records: age at expected date of delivery, weight in kilo- grams, gestational age in weeks, history of in vitro fertilization and twins status. Blood samples were collected from women at- tending laboratories or clinics and sent to the medical laboratory for analysis.

All triple tests were performed in Zer Laboratories, Jerusalem, utilizing standard- ized techniques for analysis. The cut-off values [expressed as multiple of median (MOM)] were as follows: elevated AFP >

2.50 MOM, elevated hCG > 3.00 MOM, reduced hCG < 0.20, reduced uE3 < 0.15 MOM.

Basic descriptive statistics including means, medians, modes, standard deviation

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826 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005

and frequencies were calculated. Cross- tabulations and chi-squared tests were used to explore the relation between different variables. Wald tests were used for risk cal- culation according to age and according to age and triple test. The cut-off point uti- lized in this analysis was 1:270.


Characteristics of the subjects The mean (standard error) expected age at delivery of the 943 women was 25.5 (SE 0.2) years; 12% of the participants were 35 years old or above. The mean weight at the time of testing was 64.9 (SE 0.4) kg. The range of gestational age when the test was performed was 15 to 21 weeks, with a mean of 17.2 weeks (SE 0.03).

Triple test results

The mean (SE) serum concentration of AFP was 41.53 (0.88) IU/mL, hCG was 27.93 (0.61) IU/mL and uE3 was 1.28 (0.03) IU/mL.

The frequency of elevated AFP was 1.3%, abnormal hCG (elevated or reduced) was 1.9% and reduced uE3 was 0.3% (Ta- ble 1).

Age plays an important role as a risk factor for chromosomal diseases, especial- ly Down syndrome. The calculated risk for Down syndrome varied widely between the age groups. Table 1 shows the data for the women divided into 3 age groups (15–24, 25–34 and > 35 years). The calculated risk ranged from 1.2% in the lowest age group up to 16.2% in the highest. The total calcu- lated risk for all subjects was 2.8%. This may be due to the young mean age of the subjects.

Cross-tabulation of a binary variable of calculated risk (age- and triple-test) cate- gorized as high-risk and low-risk with age categorized into 2 age groups (≤ 34 and

> 35 years) yielded a 10-fold statistically significant relationship between age and calculated risk as estimated by chi-squared tests.

Nine (9) pregnancies were twins and 6 pregnancies were from in vitro fertilization but the numbers were too small for further analysis.


Maternal AFP is a very important and effec- tive indicator of neural tube defects, detect-

Table 1 Triple test results for 943 Palestinian women and calculated risk by age group

Age % of women Calculated

(years) Elevated Elevated Reduced Reduced riska

AFP hCG hCG uE3 %

15–24 1.8 2.2 0.4 0.2 1.2

25–34 0.8 0.8 0.3 0.3 2.2

> 35 0.0 1.4 0.0 1.4 16.2

Total 1.3 1.6 0.3 0.3 2.8

AFP = alpha-fetoprotein.

hCG = human chorionic gonadotropin.

uE3 = unconjugated estriol.

aBy age and triple test.

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Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 827

ing up to 90% of cases. Although the inci- dence of neural tube defects is usually about 1/500, it increases greatly to 2%

when a previous child of the same parents had neural tube defects [5]. The AFP re- sults show that only 1.3% of the tested subjects had high concentrations. Usually, in screening for neural tube defects about 3% of patients will have a high AFP [5].

This may reflect a lower incidence of neu- ral tube defects in the offspring of tested subjects.

Using the originally proposed cut-off value of 1:190 would classify about 5% of the women as having abnormal results in Down syndrome screening. This should detect about 60% of Down syndrome and 60% of Edwards syndrome cases [5]. In

this study the calculated risk for Down syndrome was about 13-fold higher in women aged 35 and above compared with younger women aged 15–24 years. At age 35 years, the risk at birth is 1:385 and in- creases dramatically at age 40 to 1:105.

Usually 1 in every 50 women with abnor- mal triple test results will be found to have a fetus with Down syndrome [5].

In conclusion, the generally low calcu- lated risk of Down syndrome among Pales- tinian women tested is probably due to the young age of the subjects. In addition to its clinical benefits, the introduction of the tri- ple test has helped to raise awareness about Down syndrome, neural tube defect and chromosomal diseases in general among Palestinian women.

References 1. Benn PA. Advances in prenatal screen-

ing for Down syndrome: I general prin- ciples and second trimester testing.

Clinica chimica acta, 2002, 323:1–16.

2. Benn PA. Advances in prenatal screen- ing for Down syndrome: II first trimester testing, integrated testing, and future di- rections. Clinica chimica acta, 2002, 324:1–11.

3. Rose NC, Mennuti MT. Maternal screen- ing for neural tube defects and fetal chro- mosome abnormalities. Western journal of medicine, 1993, 159:312–7.

4. Shenhav S et al. Mid-trimester triple test levels in early and late onset severe pre- eclampsia. Prenatal diagnosis, 2002, 22:579–82.

5. Burtis C, Ashwood E, eds. Teitz textbook of clinical chemistry, 3rd ed. Philadel- phia, WB Saunders, 1999:1744–57.

6. El-Hazmi M. Spectrum of genetic disor- ders and the impact on health care delivery: an introduction. Eastern Medi- terranean health journal, 1999, 5:1104–


7. Merrick J. Down syndrome in Israel.

Down syndrome research and practice, 2001, 6:128–30.

8. Temtamy SA et al. A genetic epidemio- logical study of malformation at birth in Egypt. Eastern Mediterranean health journal, 1998, 4:252–9.

9. Al Arrayed SS. Epidemiology of congeni- tal abnormalities in Bahrain. Eastern Mediterranean health journal, 1995, 1:248–52.

10. Ross HL, Elias S. Maternal serum screening for fetal genetic disorders. Ob- stetrics and gynecology clinics of North America, 1997, 24:33–47.

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