First-trimester or second-trimester screening, or both, for Down's syndrome

N Engl J Med. 2005 Nov 10;353(19):2001-11. doi: 10.1056/NEJMoa043693.


Background: It is uncertain how best to screen pregnant women for the presence of fetal Down's syndrome: to perform first-trimester screening, to perform second-trimester screening, or to use strategies incorporating measurements in both trimesters.

Methods: Women with singleton pregnancies underwent first-trimester combined screening (measurement of nuchal translucency, pregnancy-associated plasma protein A [PAPP-A], and the free beta subunit of human chorionic gonadotropin at 10 weeks 3 days through 13 weeks 6 days of gestation) and second-trimester quadruple screening (measurement of alpha-fetoprotein, total human chorionic gonadotropin, unconjugated estriol, and inhibin A at 15 through 18 weeks of gestation). We compared the results of stepwise sequential screening (risk results provided after each test), fully integrated screening (single risk result provided), and serum integrated screening (identical to fully integrated screening, but without nuchal translucency).

Results: First-trimester screening was performed in 38,167 patients; 117 had a fetus with Down's syndrome. At a 5 percent false positive rate, the rates of detection of Down's syndrome were as follows: with first-trimester combined screening, 87 percent, 85 percent, and 82 percent for measurements performed at 11, 12, and 13 weeks, respectively; with second-trimester quadruple screening, 81 percent; with stepwise sequential screening, 95 percent; with serum integrated screening, 88 percent; and with fully integrated screening with first-trimester measurements performed at 11 weeks, 96 percent. Paired comparisons found significant differences between the tests, except for the comparison between serum integrated screening and combined screening.

Conclusions: First-trimester combined screening at 11 weeks of gestation is better than second-trimester quadruple screening but at 13 weeks has results similar to second-trimester quadruple screening. Both stepwise sequential screening and fully integrated screening have high rates of detection of Down's syndrome, with low false positive rates.

Publication types

  • Clinical Trial
  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Chorionic Gonadotropin / blood
  • Chorionic Gonadotropin, beta Subunit, Human / blood*
  • Down Syndrome / diagnosis*
  • Estriol / blood
  • False Positive Reactions
  • Female
  • Humans
  • Inhibins / blood
  • Lymphangioma, Cystic / diagnosis
  • Nuchal Translucency Measurement*
  • Pregnancy
  • Pregnancy Trimester, First / blood
  • Pregnancy Trimester, Second / blood
  • Pregnancy-Associated Plasma Protein-A / analysis*
  • Prenatal Diagnosis / methods*
  • Prospective Studies
  • Risk
  • alpha-Fetoproteins / analysis


  • Chorionic Gonadotropin
  • Chorionic Gonadotropin, beta Subunit, Human
  • alpha-Fetoproteins
  • inhibin A
  • Inhibins
  • Pregnancy-Associated Plasma Protein-A
  • Estriol