Maternal Serum Screening and Prenatal Diagnosis Requisition Form
Maternal Serum Screening CPT Codes
Maternal Serum Screening and Amniotic Fluid Assays *
Why is the Quadruple Screen important?
This blood test is recommended for screening in all pregnancies and is important because it enables:
- Detection of a high proportion of certain birth defects such as:
- Neural tube defects — detects 95-100% of anencephaly and 80-90% of spina bifida [AFP test only]
- Down syndrome — detects over 80% [combined AFP, hCG, inhibin, estriol]
- Identification of some pregnancies now known previously to be at increased risk of certain serious complications
- Early recognition of 30-40% of twin (or multiple) pregnancies
What is a Neural Tube Defect?
Defects in the development of the brain (called anencephaly) or the spinal cord (called spina bifida) are collectively described as neural tube defects (NTDs). Almost all babies with anencephaly die within hours or days of birth. Those born with spina bifida often survive, but because of damage to the spinal cord the vast majority develop handicaps varying from total paralysis from the waist down (associated with lack of bladder and bowel control) to some cases with only mild impairment of walking. Hydrocephalus (an accumulation of fluid in the brain) occurs in 80-90% of these children. Affected children with spina bifida require continuous medical and surgical care and often have a shorter life span. Mental retardation is a frequent complication.
What is Down Syndrome?
Humans have 46 chromosomes in each cell. During analysis they are arranged in 23 pairs, each pair being numbered. About 95% of children born with Down syndrome have an extra chromosome present in each cell which belongs to the number 21 group. Individuals with Down syndrome are always mentally retarded, have characteristic facial features and frequently have other birth defects. All individuals with Down syndrome require care throughout their lives.
Maternal serum must be obtained in a Red or Tiger Top tube, minimum 5cc.
In order for the quad calculations to be done and accurately reported the following information must be clearly provided on the accompanying requisition:
- Patient Name
- Patient (or Egg Donor) DOB
- Date Specimen obtained
- Patient LMP or
- Ultrasound DATE & Gestational Age at the time of US
- Evidence of Diabetes
- Singleton, twins or multiple pregnancy
- RACE of mother
- Maternal WEIGHT at the time specimen obtained
If you have any questions please call the Maternal Serum Coordinator at 617-492-7083.
Please note that Adobe Acrobat Reader is necessary in order to view the Requisition Form, which can be completed on-line and then printed for a signature. The latest version of the Reader may be downloaded for free by clicking on the image below.