title: Routine measurement of amniotic fluid alpha-fetoprotein and acetylcholinesterase: the need for a reevaluation.
abstract: OBJECTIVE
  The objective of the study was to evaluate whether the current screening regimen of measuring amniotic fluid alpha-fetoprotein (AF-AFP) at the time of amniocentesis and reflex acetylcholinesterase testing vs ultrasound alone to detect neural tube and ventral wall defects offers improved diagnostic accuracy and cost benefit.
  
  
  METHODS
  A retrospective chart review on all patients who had amniocentesis performed at 1 center over the past 11 years was performed. Those with an elevated AF-AFP were compared with those whose AF-AFP was within normal limits. Ultrasound findings and outcomes were reviewed in all cases to assess whether neural tube defects (NTDs) or ventral wall defects (VWDs) were missed by AF-AFP or ultrasound screening. A cost-benefit analysis was then performed.
  
  
  RESULTS
  Of 6232 women who underwent amniocentesis between January 2002 and December 2012, 81 had an elevated AF-AFP with or without a positive acetylcholinesterase (AChE). Of these 81 women, 13 had NTDs and 5 had VWDs. The sensitivity of the detailed ultrasound was 100% in detecting NTDs and VWDs, whereas that of the AF-AFP ranged from 22% to 77%, with the inclusion of AChE. The total expenditure for AF-AFP in our sample set (n = 6232 amniocentesis at $76.00 per AF-AFP) was $473,632, and all NTDs and VWDs were detected by ultrasound. Translated to a national laboratory (>42,447 samples/year), the cost savings in 2011 alone would be $3,225,972.
  
  
  CONCLUSIONS
  Given the accuracy of high-resolution ultrasound in the detection of both NTDs and VWDs, measuring AF-AFP and AChE as a reflex-screening test is not a cost-effective approach.
authors: Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, CA.
authors: Amy
authors: A
authors: Flick
authors: Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, CA; Department of Human Genetics and Orthopedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA; Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA.
authors: Deborah
authors: D
authors: Krakow
authors: Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA.
authors: Anahit
authors: A
authors: Martirosian
authors: Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, CA; Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA.
authors: Neil
authors: N
authors: Silverman
authors: Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, CA; Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA. Electronic address: ldplatt@gmail.com.
authors: Lawrence D
authors: LD
authors: Platt
mesh_terms: D000009:Abdominal Muscles / Q000002:abnormalities / Q000000981:diagnostic imaging; D000110:Acetylcholinesterase / Q000378:metabolism*; D000293:Adolescent; D000328:Adult; D000649:Amniocentesis / Q000191:economics; D000653:Amniotic Fluid / Q000378:metabolism*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008875:Middle Aged; D009436:Neural Tube Defects / Q000175:diagnosis; D011247:Pregnancy; D012189:Retrospective Studies; D016216:Ultrasonography, Prenatal; D055815:Young Adult; D000509:alpha-Fetoproteins / Q000378:metabolism*
chemical_list: D000509:alpha-Fetoproteins; D000110:Acetylcholinesterase
keywords: amniocentesis; amniotic alpha-fetoprotein; neural tube defects; ultrasound; ventral wall defects