Can cell-free DNA (cfDNA) testing alleviate psychological distress in early miscarriage? A commentary

Abstract

Background

Psychological, emotional, and mental distress affects many patients who experience early pregnancy loss (EPL). A common concern is that the patient’s actions or choices caused the loss. Understanding the cause of EPL may improve the distress of EPL patients and their partners. Chromosomal abnormalities leading to a significant portion of EPL. Cell-free DNA (cfDNA) testing, a non-invasive test providing high quality information about the chromosomal makeup of a fetus, may offer assurance that a fetal abnormality caused the loss, and provide more certainty or closure in processing EPL. CfDNA may be a useful adjunct to patient-centered care in the setting of EPL. This commentary explores the possibility of cfDNA testing in lessening the emotional distress that often accompanies EPL.

Methods

The peer reviewed literature was explored for manuscripts addressing (1) the potential for cfDNA serum testing for patients experiencing EPL and screening products of conception to determine the cause of EPL; and/or (2) the impact that information might have on the psychological morbidity of EPL for patients and their partners. Themes generated from extracted data were used to generate key questions for future research.

Results

Preliminary findings suggest fetal fraction values are instrumental in the success of cfDNA testing, and a successful cfDNA testing experience can have a positive impact on patients.

Conclusions

Ultimately, we conclude cfDNA testing could have a positive impact in patient care and improve the well-being of patients undergoing the emotional toll of EPL by reducing feelings of guilt and providing closure to those who learn the loss was associated with chromosomal abnormality. Further trials and studies that explore the intersection of mental health of EPL on patients should explore the efficacy of cfDNA testing as an adjunct to patient-centered care in these cases.

Introduction

Early pregnancy loss (EPL) is a common phenomenon, occurring in up to 10–25% of pregnant patients. Chromosomal abnormalities are responsible for a significant portion of first trimester loss, estimated at up to 50% [1–3]. In addition to physical consequences, patients and their partners suffer a host of mental health issues such as clinical levels of anxiety and depression and may simultaneously meet criteria for PTSD [4]. A patient’s beliefs that they somehow caused the EPL through exercise, diet, or some other behavior may exacerbate untoward psychological effects of EPL. Research suggests that providing patients with greater understanding of the etiology of the EPL may reduce negative psychological impacts [5].

Cell-free DNA testing is commonly used as noninvasive screening of pregnant patients, detecting fetal chromosomal abnormalities in maternal blood samples. This could provide an effective tool for patients who miscarry at home and present for care when no products of conception are available for direct genetic testing of products of conception. While not standard of care for universal prenatal testing, cfDNA testing can be conducted using a maternal blood sample offering information about fetal chromosomal status with high sensitivity and specificity as early as 7 weeks of pregnancy [6]. If cfDNA interpretation is reliable in early pregnancy loss (EPL), using this tool could provide some patients who miscarry an explanation as to the cause. It is possible that more information about the chromosomal status of a pregnancy could mitigate some of the emotional burdens of miscarriage on patients and their partners, who may also experience negative emotions associated with EPL. This commentary will explore the existing literature on the use of cfDNA testing and its potential relationship to psychosocial concerns of patients experiencing EPL.

Four studies directly explored cfDNA on patients who experienced early pregnancy loss (EPL). Table A provides a summary of all included studies.

Table 1.

Table A

Study	Origin	Type	Aims	Eligibility/Inclusion Criteria	Sample	Study Design	Data Collection Tool(s)	Relevant Findings
cfDNA studies
Colley et al., 2020 [7]	UK	Quantitative	To investigate the use of cfDNA from maternal blood to identify chromosomal abnormalities in miscarriage	Maternal age over 16 years and a gestational age of <12 weeks confirmed by ultrasound scan at the time of miscarriage diagnosis with pregnancy tissue remaining in situ	102 blood samples from women who was experiencing EPL with 57 samples with cytogenetic results	Prospective cohort study	Blood samples were taken for cfDNA analysis and to access βhCG levels	- Half of the miscarriages are due to chromosomal abnormalities. In this research, scientists investigated how cfDNA could be applied to detect chromosomal abnormalities in miscarriages and compare that to POC testing.- cfDNA can be used to detect chromosomal abnormalities in miscarriages where the ‘fetal fraction’ is high enough;- Chromosomal abnormalities were identified in 47% (27/57) of POC analyses, and cfDNA analysis correctly identified 59% (16/27) of these
Clark-Ganheart et al. 2015 [2]	USA	Quantitative	To estimate whether cell-free DNA is present in nonviable pregnancies and thus can be used in diagnostic evaluation in this setting	- Women with nonviable singleton pregnancy at less than 20 weeks of gestation and intrauterine fetal demises- Able to consent in English, at least 18 years of age, and had products of conception in utero at the time of blood sampling	50 samples from nonviable pregnancies with average gestational age of 16.9 weeks	Prospective cohort study	Maternal blood was collected in cfDNA BCT tubes before uterine evacuation	- 76% (38/50) of samples yielded cell-free DNA results (had fetal fractions within the detectable range of 3.7-65%). Among the 38, 76% (29) were classified as euploid, 21% (8) as trisomies, and 3% (1) as microdeletion. A cell-free DNA result was obtained more frequently at ultrasonographic gestational ages of 8 weeks or greater compared with less than 8 weeks.- cfDNA present in the maternal plasma with fetal fractions greater than 3.7% in more than ¾ of the cases after gestational age of 8 weeks
Yaron et al. 2020 [8]	Israel	Quantitative	To understand whether cell-free DNA can detect chromosomal anomalies in EPL and RPL	- Consenting patients >18 years of age- Undergoing EPL or RPL at sonographic gestational age  < 14 weeks- Available cfDNA results- Non-mosaic cytogenetic results from STC and/or LTC	109 consenting patients participated in the study with 86 samples with cytogenetic results (non-mosaic)	Prospective diagnostic test study	-Blood samples undergone Verifi® Plus prenatal aneuploidy screening test- Cytogenetic analysis by chorionic villus sampling (CVS)	- Chromosomal anomaly was detected in 64% (55/86)- Rate of chromosomal anomalies increased with maternal age- With standard LLR thresholds used for noninvasive prenatal screening, the sensitivity of cfDNA in detecting aneuploidy was 55% (30/55) and with a specificity of 100% (31/31).- Using pregnancy loss-specific LLR thresholds, the sensitivity of cfDNA in detecting aneuploidy was 82% (45/55), with a specificity of 90% (28/31). The positive and negative likelihood ratios were 8.46 and 0.20, respectively.
Yaron et al. 2019 [9]	Israel	Quantitative	To assess whether chromosomal anomalies causingEPL and RPL can be detected by genome-wide analysis of cfDNA present in maternalserum.	- Patients experiencing pregnancy loss before 14 weeks- Patients to undergo parental karyotyping, uterine cavity assessment, and testing for endocrine and autoimmune factors	102 patients experiencing pregnancy loss before 14 weeks	Prospective diagnostic test study	- Blood samples were drawn for genome-wide cfDNA testing- Chorionic villus sampling for karyotyping.- Quantitative fluorescent PCR for some chromosomes.	- A chromosomal anomaly was detected in 67% of cases (68/102). CfDNA-based testing had a sensitivity of 69% (47/68) and specificity of 88% (30/34). The sensitivity increased to 83% (45/54) in cases with a single autosomal trisomy or monosomy X. Of 14 cases with complex abnormalities, monosomy, triploidy, or a mosaic karyotype, only two were detected.

Efficacy of CFDNA in detecting chromosomal abnormalities

Two studies conducted by Yaron et al. in different time frames examined the general ability of cfDNA in detecting chromosomal abnormalities in patients experiencing EPL. They compared aneuploidy detection achieved by cfDNA testing versus that achieved by cytogenetic testing of pregnancy loss samples.

Yaron’s 2019 study tested 102 patients experiencing pregnancy loss before 14 weeks. In 68 cases, cfDNA detected a chromosomal abnormality, which represented 67% of cases; the sensitivity was found to be approximately 69%, but varied with the type of aneuploidy detected in the sample. The sensitivity rate increased to 83% in detection of relatively simpler aneuploidies, such as single autosomal trisomy or monosomy X. Of these cases, cfDNA testing detected only 2 of 14 cases with complex abnormalities, such as monosomy, triploidy, or mosaic karyotype. Ultimately, this study concluded that cfDNA has the potential to detect fetal chromosomal anomalies in patients who experience early miscarriages [9].

The second study by Yaron et al. 2020, further assessed the efficacy of cfDNA testing. In this study of 109 participants who had miscarried, 55 chromosomal abnormalities were detected by cfDNA. The fetal fraction rate was 5%. With standard log-likelihood ratio (LLR) thresholds used for noninvasive prenatal screening, the sensitivity was 55% with a specificity of 100%. With pregnancy loss-specific LLR thresholds, the sensitivity of cfDNA in detecting aneuploidy was 82% with a specificity of 90%. Fetal sex was assigned correctly in all cases [8].

Role of fetal fraction in cfDNA interpretation

Two prospective cohort studies investigated the role of fetal fraction in cfDNA interpretation. Colley et al. investigated the use of cfDNA from maternal blood to identify chromosomal abnormalities in miscarriage. They examined 102 blood samples from women experiencing a first trimester miscarriage, with the mean gestational age of 7.1 weeks. Chromosomal abnormalities were identified in 47% of the products of conception (POC) analyses, and cfDNA analysis correctly identified 59% of these from maternal blood. In total, 75% of results were correctly identified. The average cfDNA fetal fraction in maternal serum specimens was 6%. The researchers concluded that cfDNA could detect chromosomal abnormalities in miscarriages in cases with sufficient fetal fraction, although caution that sufficient fetal fraction is not always present [7].

Clark-Ganheart and colleagues analyzed 50 samples from nonviable pregnancies with an average clinical gestational age of 16.9 weeks. Seventy-six percent of samples yielded cell-free DNA results and had fetal fractions within the detectable range of 3.7–65%. Among the 38 samples yielding cfDNA results, 76% were classified as euploid, 21% as trisomies, and 3% as microdeletion. The authors found that fetal fraction increased proportionally to gestational age, as a cell-free DNA result was obtained 87.9% of the time at ultrasonographic gestational ages 8 weeks or greater compared with 52.9% of the time at ages less than 8 weeks of gestation [6]. The later gestational age of the patients in this study likely accounts for the higher proportion of euploid cfDNA results than the roughly half of pregnancies experiencing EPL anticipated to have abnormal chromosomes.

Potential impact of cfDNA on emotional toll of miscarriage

Only the 2019 Yaron study briefly touched upon the potential for cfDNA to address the emotional toll of miscarriage. This study highlighted the potential for cfDNA to reduce psychological distress; even though it would not change the clinical management of miscarriage, the authors suggest it may have a positive influence on psychological adjustment [9]. However, the psychological impact of miscarriage can vary among patients, and for patients whose cfDNA result is normal, the additional testing does not provide more information or closure regarding the etiology of the loss. For this reason, careful study must explore the association between emotional reaction to EPL and the additional clinical information cfDNA testing would provide before it should be widely recommended.

Discussion and conclusion

In summary, genome-wide cfDNA-based screening provides a noninvasive approach for determining whether fetal aneuploidy is responsible for EPL. As prenatal technologies continue to evolve, research must explore the impact of this information, and the challenges that arise with interpreting it in taxing circumstances. It is not yet known how this information influences the experiences of patients and their partners, both in terms of the outcomes of their pregnancies and how they approach future pregnancies. Studies that empirically examine whether cfDNA testing done at the time of EPL reduces the emotional distress associated with EPL are needed to clarify whether this tool should be proposed as an adjunct to care for patients experiencing EPL. Prior research on the depression and anxiety correlated to EPL suggests that information on the cause of EPL may mitigate some of the anxiety and guilt experienced by patients, as many miscarrying patients and their partners wonder if the loss was related to something they did or did not do [10].

Based on research showing that patients and partners suffering EPL wonder whether their actions or choices caused EPL, it is likely that integrating cfDNA testing into their care could lessen anxiety and guilt and contribute to improved mental health. However, the psychological impact of miscarriage varies from patient to patient, so there may be further nuances related to the impact of cfDNA on patients’ mental health. The sensitivity and specificity of cfDNA for detecting chromosomal abnormalities are relatively high, but cfDNA is not “foolproof” in detecting fetal abnormalities in samples that are less than 8 weeks because of inconsistent fetal fraction in samples.

This further demonstrates the need for trials, studies, and research exploring the range of possible effects of cfDNA on the psychological effects of miscarriage in patients, particular in cases where testing is not conclusive or does not reveal aneuploidy. Another consideration is the cost/benefit of cfDNA testing in the management of EPL. Peng et al. examined the costs of three testing pathways: (1) current American Society for Reproductive Medicine (ASRM) RPL workup; (2) microarray or karyotyping analysis of products of conception (POCs) and RPL workup only for euploid cases; and (3) cfDNA testing and RPL workup only for euploid cases. Results found a 1% failure rate for cfDNA compared to a 5% for POC microarray and 32% for POC karyotyping. In terms of costs, though the cfDNA averaged $777 compared to $2361 for D&C and $1160 for clinical management [11].

The actual costs of cfDNA testing, both financial and in terms of additional patients time, should be explored in future studies that directly measure the impact of cfDNA testing on the patient experience [12]. Improving the efficacy, sensitivity, and accuracy of cfDNA is likely to improve patients’ experience, as counseling based on uncertain information is limited in the emotionally charged setting of EPL. In addition, it would be beneficial to conduct and examine studies directly comparing other forms of understanding causes of EPL (such as cytogenetic testing of the products of misconception, which is not always available).

Based on current understanding of cfDNA and the way that it might provide useful answers for patients and partners experiencing EPL, these future avenues of research should be explored. Weighing cost and technical considerations against the potential for increased certainty and decreased guilt related to EPL in studies [13] examining this evolving technology can lead to more clarity regarding the usefulness of cfDNA in patient-centered care of EPL.

Declarations

Conflict of interest

The authors declare no competing interests.