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MSAFP is quite sensitive but not very specific. There was concern that women
would be frightened into aborting fetuses on the basis of the preliminary screening
test. This led to specific standards of practice that stress the importance of the
entire process of counseling and testing:
The successful implementation of a screening program for MSAFP should
include patient education, accurate and prompt laboratory testing,
competent counseling and support services, access to consultants for
sonography, and complex prenatal diagnosis, as well as available options
for pregnancy termination. Success is further dependent on the proper
coordination of these components, all of which must function within a
relatively short time span from screening to decision- making. Missing
components or malfunctions could result in unnecessary anxiety for the
patients, as well as improper diagnoses that could lead to unnecessary
termination of pregnancy or other serious errors in judgment. [ACOG
Technical Bulletin 154. Prenatal Detection of Neural Tube Defects. April
1991.]
The coordination of the various components is critical because it is recommended
that the test not be performed until 16 weeks of gestation. If the test indicates a
sufficiently increased level of MSAFP, the patient should be offered a second test a
week or two later, if time permits. Otherwise ultrasound should be used to correct
the gestational age, check for multiple gestation, and, if possible, identify a neural
tube defect. Among patients with two high MSAFP levels (or one low one) slightly
over half will have a singleton fetus at the appropriate gestational age without an
apparent anomaly. These patients should be offered amniocentesis. Of the patients
undergoing amniocentesis, one to two will have significantly increased amniotic
fluid AFP that indicates a high probability of a fetus with a serious abnormality.
[ACOG Technical Bulletin 154. Prenatal Detection of Neural Tube Defects. April
1991.]
At this point further tests can be done to identify the specific defect, but this will be
impossible in some cases. If a defect is confirmed, the patient must decide whether
she wants an abortion. Many patients choose to abort the fetus. Some may be
willing to accept a child with spina bifida but be unwilling to carry a fetus with
anencephaly. The woman with an elevated amnionic AFP but no identifiable defect
has the more difficult decision. She should be given full information and an
opportunity to seek in- depth counseling before making her decision. Once the
process of recommending the initial test begins, every following step must be
planned carefully and executed. It is critical that the patient be carefully tracked to
ensure that there are no delays that can push the abortion into the third trimester,
with the attendant medical and legal complications.
b) MSAFP and Down Syndrome
The first widely available postconception test was for Down syndrome. This
condition becomes more common with increasing age of the pregnant woman,
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