{"id":9220,"date":"2020-04-23T04:31:44","date_gmt":"2020-04-23T01:31:44","guid":{"rendered":"https:\/\/www.synevo.ro\/product\/dublu-test-screening-prenatal-trim-i\/"},"modified":"2026-02-18T23:24:03","modified_gmt":"2026-02-18T21:24:03","slug":"dublu-test-screening-prenatal-trim-i","status":"publish","type":"product","link":"https:\/\/old.synevo.md\/ru\/shop\/dublu-test-screening-prenatal-trim-i\/","title":{"rendered":"\u0414\u0432\u043e\u0439\u043d\u043e\u0439 \u0442\u0435\u0441\u0442 (\u043f\u0440\u0435\u043d\u0430\u0442\u0430\u043b\u044c\u043d\u044b\u0439 \u0441\u043a\u0440\u0438\u043d\u0438\u043d\u0433 1 \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430)"},"content":{"rendered":"<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>\u041e\u0431\u0449\u0430\u044f \u0438\u043d\u0444\u043e\u0440\u043c\u0430\u0446\u0438\u044f <\/em><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In ultimii 30 ani numeroase cercetari s-au concentrat pe dezvoltarea unor investiga\u0163ii neinvazive care sa evalueze riscul unei femei gravide de a da na\u015ftere unui copil cu anomalii. Riscul de sindrom Down a fost cel mai mult studiat; ini\u0163ial screening-ul prenatal a fost recomandat numai in cazul unei varste materne \u226535 ani, insa in ultimii ani speciali\u015ftii in medicina materno-fetala sus\u0163in faptul ca aceasta op\u0163iune de screening trebuie oferita, printr-o informare corecta, tuturor femeilor gravide.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Screening-ul prenatal in trimestrul II de sarcina se bazeaza pe faptul ca in aceasta perioada se pot efectua cele mai sigure investiga\u0163ii invazive (amniocenteza). Totu\u015fi exista un beneficiu mai mare, atat pentru medici cat \u015fi pentru paciente, daca se pot ob\u0163ine informa\u0163ii despre sanatatea produsului de concep\u0163ie cat mai devreme in sarcina. Depistarea unor markeri serici ce pot fi determina\u0163i in primul trimestru \u015fi care au utilitate in estimarea riscului de abera\u0163ii cromozomiale ale fatului a condus la dezvoltarea investiga\u0163iei denumite <strong>dublu test<\/strong><sup>1;3<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Dublul test include:<\/span><\/p>\n<ul>\n<li style=\"text-align: justify;\"><span style=\"font-size: medium;\">determinarea markerilor serici PAPP-A \u015fi free beta-HCG;<\/span><\/li>\n<li style=\"text-align: justify;\">calculul MoM (multiplu de mediana) pentru fiecare marker (se imparte valoarea ob\u0163inuta la mediana corespunzatoare varstei gesta\u0163ionale);<\/li>\n<li style=\"text-align: justify;\">corectarea MoM in func\u0163ie de covariabilele materne;<\/li>\n<li style=\"text-align: justify;\">riscul biochimic de sindrom Down la na\u015ftere (calculat pe baza MoM corectat pentru fiecare din cei doi markeri \u015fi a varstei materne la na\u015ftere);<\/li>\n<li style=\"text-align: justify;\">riscul de trisomie 18 la na\u015ftere (calculat pe baza MoM corectat pentru fiecare din cei doi markeri \u015fi a varstei materne la na\u015ftere);<\/li>\n<li style=\"text-align: justify;\">riscul de trisomie 13 la na\u015ftere (calculat pe baza MoM corectat pentru fiecare din cei doi markeri \u015fi a varstei materne la na\u015ftere);<\/li>\n<li style=\"text-align: justify;\">calculul MoM pentru translucen\u0163a nucala (in cazul in care medicul trimi\u0163ator furnizeaza laboratorului marimea translucen\u0163ei nucale \u015fi lungimea cranio-caudala \u2013 CRL, estimate ecografic);<\/li>\n<li style=\"text-align: justify;\">vizualizarea sau non-vizualizarea osului nazal la examenul ecografic este de asemenea inclusa in algoritmul de calcul de risc prenatal;<\/li>\n<li style=\"text-align: justify;\">riscul combinat de sindrom Down\u00a0 (risc biochimic + parametri ecografici);<\/li>\n<li style=\"text-align: justify;\">risc pentru alte aneuploidii fetale (sindrom Turner, triploidie) in cazul in care medicul trimi\u0163ator\/pacienta informeaza laboratorul despre existen\u0163a unei sarcini anterioare cu un anumit tip de anomalie cromozomiala;<\/li>\n<li style=\"text-align: justify;\">calcularea MoM corectata pentru fiecare parametru seric \u015fi a riscurilor de aneuploidii fetale la na\u015ftere este efectuata de programul <b style=\"font-size: medium;\">LifeCycle versiunea 3.2<\/b><sup>5<\/sup><span style=\"font-size: medium;\">.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Markerii serici<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>PAPP-A (proteina plasmatica asociata sarcinii) <\/strong>este o glicoproteina derivata din placenta. In timpul sarcinii este produsa in cantitate mare de catre trofoblast \u015fi eliberata in circula\u0163ia materna. Nivelurile serice ale acestei proteine cresc odata cu varsta gesta\u0163ionala, cel mai pregnant in ultima parte a sarcinii. Studii recente au demonstrat ca scaderea concentra\u0163iei PAPP-A in cursul sarcinii este asociata cu anomalii cromozomiale ale fatului: trisomie 21, 18, 13, sindrom Turner, triploidie de origine paterna (scadere u\u015foara), triploidie de origine materna (scadere marcata).<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>Free beta-HCG<\/strong> \u2013 subunitatea beta libera a HCG \u2013 este considerat a fi un marker mai relevant decat molecula de HCG intact in trimestrul I de sarcina. In sarcinile asociate cu sindrom Down, nivelurile de free beta-HCG sunt &gt;2 MoM. Valorile sunt de asemenea mult crescute in triploidia de origine paterna. In sindromul Turner nivelul de free beta-HCG este normal. In prezen\u0163a trisomiei 18 sau 13 precum \u015fi a triploidiei de origine materna concentra\u0163iile de free beta-HCG sunt considerabil scazute.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Pentru a ob\u0163ine o standardizare atat pentru varsta gesta\u0163ionala cat \u015fi pentru diferen\u0163ele sistematice intre popula\u0163ii, laboratoare \u015fi metode de lucru, valorile ob\u0163inute la markerii serici vor fi exprimate ca MoMs (multipli de mediana). MoM pentru un marker se ob\u0163ine prin impar\u0163irea valorii masurate la mediana corespunzatoare varstei gesta\u0163ionale la care s-a efectuat determinarea, mediana ce este specifica popula\u0163iei din care face parte persoana testata \u015fi metodei de lucru utilizata in laborator<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Estimarea varstei gesta\u0163ionale<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Este efectuata de catre programul LifeCycle pe baza valorii CRL \u015fi este exprimata in saptamani + zile; data ultimei menstrua\u0163ii este introdusa de asemenea in program, insa in cazul unei discrepan\u0163e intre varsta gesta\u0163ionala calculata pe baza CRL \u015fi cea determinata pe baza ultimei menstrua\u0163ii (ca urmare a unui ciclu menstrual neregulat) este luata in considerare cea stabilita pe baza masuratorii ecografice<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Datele materne<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>Varsta materna <\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Riscul pentru trisomiile fetale (13, 18, 21) cre\u015fte odata cu varsta mamei. <em>Riscul ini\u0163ial<\/em> (\u201eprior risk\u201d sau \u201eage risk\u201d) pentru o anomalie fetala se refera la prevalen\u0163a la na\u015ftere a defectului respectiv, specifica unei anumite varste materne; riscul este calculat pe baza unei formule ce ia in considerare prevalen\u0163ele specifice varstei in diferite popula\u0163ii. De men\u0163ionat ca riscul de sindrom Turner \u015fi triploidie nu se modifica odata cu varsta mamei.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>Sarcini anterioare afectate de aneuploidii fetale<\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Riscul pentru trisomii al unei femei care a avut in antecedente un fat sau un copil cu trisomie este mai mare decat riscul de varsta.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Daca anomalia detectata la o sarcina anterioara a aparut <em>de novo<\/em> (ca urmare a unei non-disjunc\u0163ii meiotice), riscul de varsta este ajustat cu un factor aditiv configurabil. Pentru sindromul Down factorul este pre-configurat in programul LifeCycle \u015fi este derivat din meta-analiza unor date combinate provenite de la 3983 sarcini, dintre care 28 au fost asociate cu sindrom Down (<em>Cuckle, Arbuzova 2001<\/em>).<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Riscul este mult mai mare in cazul in care anomalia fetala a fost mo\u015ftenita; deoarece riscul este strans corelat cu modul de transmitere, programul LifeCycle nu poate furniza o estimare a riscului in acest caz<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Covariabile materne<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Fiecare MoM va fi corectat pentru fiecare din covariabilele prezentate mai jos, atunci cand sunt furnizate informa\u0163ii despre acestea. Valoarea MoM va fi impar\u0163ita la un factor egal cu mediana MoM pentru sarcinile neafectate asociata cu covariabila respectiva. Aceste ajustari presupun ca efectul covariabilei asupra nivelului marker-ului nu este diferit in sarcinile afectate comparativ cu cele neafectate.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium; text-decoration: underline;\">Greutatea materna <\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Concentra\u0163ia markerilor serici este influen\u0163ata de greutatea materna. Femeile cu greutate mai mare au un volum sanguin crescut, care dilueaza concentra\u0163ia anali\u0163ilor. Greutatea materna este folosita pentru a ajusta matematic concentra\u0163ia markerilor la diferen\u0163ele in volumul sanguin.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Presupunerea ca varia\u0163ia MoM cu greutatea este propor\u0163ional similara atat in sarcinile afectate cat \u015fi in cele neafectate este sus\u0163inuta de un studiu efectuat de Wald \u015fi Cuckle (1987) care a inclus 51 sarcini cu sindrom Down \u015fi 3000 sarcini normale. Valoarea MoM pentru o greutate data deriva printr-o analiza de regresie a femeilor care se prezinta pentru invetiga\u0163ii de rutina. Factorul de corec\u0163ie este specific unei anumite popula\u0163ii deoarece depinde de distribu\u0163ia greuta\u0163ii intr-o popula\u0163ie.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium; text-decoration: underline;\">Diabetul zaharat insulino-dependent<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Influen\u0163eaza valorile markerilor serici, de aceea programul face o ajustare corespunzatoare a MoM.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium; text-decoration: underline;\">\u043a\u0443\u0440\u0435\u043d\u0438\u0435<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Influen\u0163eaza concentra\u0163ia markerilor serici (cel mai mult reduce nivelul PAPP-A) \u015fi poate afecta performan\u0163a screening-ului. Din acest motiv, programul ajusteaza MoM in func\u0163ie de statusul fumatoare\/nefumatoare.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium; text-decoration: underline;\">Originea etnica (rasa)<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Exista varia\u0163ii ale medianelor pentru \u00a0unul sau mai mul\u0163i markeri serici in func\u0163ie de grupul etnic la care apar\u0163ine mama, de aceea programul va \u0163ine cont de aceasta informa\u0163ie.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Reproducerea asistata<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Studiile au aratat ca nivelul markerilor serici este modificat in sarcinile ob\u0163inute prin reproducere asistata. Din acest motiv este necesar ca medicul trimi\u0163ator sa furnizeze date cu privire la procedura aplicata: fertilizare <em>in vitro<\/em> (IVF), transferul intrafalopian al zigotului (ZIFT), transferul intrafalopian al gametului (GIFT), injectarea intracitoplasmatica a spermatozoizilor (ICSI) etc. De asemenea va fi precizata data extrac\u0163iei \u015fi data transferului ovulului<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><em>Riscul final<\/em> (\u201eprior risk\u201d sau \u201eage risk\u201d) este estimat de catre programul LifeCycle din riscul ini\u0163ial \u015fi valorile markerilor serici pe baza unui model gaussian standard sau a unui model log gaussian. Astfel, pentru fiecare marker (exprimat ca MoM) se va stabili daca distribu\u0163ia in sarcinile afectate \u015fi cele neafectate este de tip gaussian sau log-gaussian. Pentru un singur marker, metoda este echivalenta multiplicarii riscului ini\u0163ial cu raportul de probabilitate pentru acel marker (calculat prin impar\u0163irea procentului de fe\u0163i cu anomalii cromozomiale la procentul de fe\u0163i normali, avand acea valoare a markerului: \u201elikelihood ratio\u201d). Pentru mai mult de un marker distribu\u0163iile sunt multidimensionale \u015fi includ corela\u0163ii intre fiecare pereche de markeri. Metoda este echivalenta multiplicarii riscului ini\u0163ial cu raportul global de probabilitate derivat din distribu\u0163iile multidimensionale<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Parametrii ecografici<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>Translucen\u0163a nucala<\/strong> <strong>(NT)<\/strong> este definita ca grosimea maxima a spa\u0163iului subcutanat creat in mod normal in zona cervicala a fatului, unde se produce o acumulare tranzitorie de lichid, in saptamanile 11-14 de sarcina. In mod obisnuit, marimea translucen\u0163ei nucale estimata ecografic in plan sagital, variaza intre 0.5 si 2 mm. Ca si in cazul celorlal\u0163i markeri, o translucen\u0163a nucala crescuta nu reprezinta in sine o anomalie fetala, aceasta modificare putand sa apara si in sarcinile normale. Totusi s-a constatat ca prezen\u0163a aneuploidiilor fetale se asociaza cu o translucen\u0163a nucala in medie crescuta fa\u0163a de sarcinile normale. Astfel, studiile efectuate au aratat ca rata de detec\u0163ie a sindromului Down bazata pe varsta materna si masurarea translucen\u0163ei nucale este de 72-77%; aproximativ 1:20 femei prezinta o translucen\u0163a nucala crescuta si necesita investiga\u0163ii ulterioare. S-a raportat o asociere a translucen\u0163ei nucale crescute si cu alte aneuploidii fetale, cum ar fi trisomia 18, trisomia 13, sindromul Turner, triploidia, precum si cu alte anomalii genetice, in special defectele cardiace congenitale. Pentru masurarea cu acurate\u0163e a translucen\u0163ei nucale a fost stabilita o tehnica standardizata impreuna cu programe de training si audituri pentru asigurarea calita\u0163ii; specialistii in ecografie trebuie sa fie familiariza\u0163i cu aceste date pentru ob\u0163inerea unor masuratori corecte. Varsta gesta\u0163ionala optima pentru masurarea NT este <b>11 saptamani-13 saptamani +6 zile<\/b> (corespunzatoare unor valori CRL cuprinse intre 40 si 79 mm)<sup>1;4<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Deoarece NT fetala creste odata cu CRL, este esen\u0163ial sa se ia in considerare varsta gesta\u0163ionala pentru a stabili daca valoarea NT este crescuta. In screening-ul defectelor fetale, riscurile individuale specifice sunt calculate prin multiplicarea riscului matern ini\u0163ial cu un factor care depinde de abaterea NT masurate (in mm) fa\u0163a de mediana normala pentru acelasi CRL<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Determinarea PAPP-A impreuna cu free beta-HCG in trimestrul I de sarcina (<strong>saptamanile 10-13+6 zile <\/strong>de sarcina) detecteaza sindromul Down in aproximativ 63% din cazuri. Daca la cei 2 parametri se adauga marimea translucen\u0163ei nucale (masurata ecografic intr-un centru specializat), rata de detec\u0163ie a sindromului Down poate atinge 86% (rata de rezultate fals pozitive fiind de 5%). Astfel, aceasta evaluare combinata \u2013 biochimica si ecografica \u2013 devine mai eficienta decat screening-ul de trimestru II (triplu test). Pentru celelalte aneuploidii fetale rata de detec\u0163ie prin <em>screening-ul combinat<\/em> este de aproximativ 90%, la o rata de rezultate fals-pozitive de 1%<sup>1;3;4<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In prezent sunt practicate doua tipuri de screening combinat in trimestrul I de sarcina:<\/span><\/p>\n<ul style=\"text-align: justify;\">\n<li><span style=\"font-size: medium;\">atat recoltarea probelor cat si masurarea translucen\u0163ei nucale se efectueaza in intervalul <b>11 saptamani \u2013 13 saptamani + 6 zile (<i>CRL minim 40 mm, CRL maxim 79 mm<\/i>), ideal in saptamana 12 de sarcina;<\/b><\/span><\/li>\n<li><span style=\"font-size: medium;\">recoltarea probelor se efectueaza precoce \u2013 in saptamanile 9-10 de sarcina \u2013 iar ecografia in saptamana 12. Riscul va fi calculat dupa ob\u0163inerea parametrilor ecografici<sup>4<\/sup>.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong>Osul nazal<\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Osul nazal fetal poate fi vizualizat ecografic in intervalul 11-13+6 saptamani de sarcina. Mai multe studii au demonstrat ca lipsa de vizualizare a osului nazal in aceasta perioada se asociaza cu un risc crescut de sindrom Down si de alte aneuploidii. Intr-un studiu care a inclus 15822 fetusi, al caror profil a fost examinat cu succes in 97.4% din cazuri, 1.4% din fe\u0163ii normali au prezentat absen\u0163a osului nazal, in timp ce aceasta modificare a fost constatata la 69% dintre fe\u0163ii cu sindrom Down. La fe\u0163ii cu trisomie 18 osul nazal este absent in aproximativ 50% din cazuri, iar la cei cu trisomie 13 in ~ 30% din cazuri. Evaluarea osului nazal a fost inclusa in unele algoritme de screening in primul trimestru de sarcina, insa este esen\u0163ial ca aceasta sa fie efectuata de catre specialisti in ecografie cu experien\u0163a. Atunci cand acest parametru se adauga la screening-ul combinat rata de detec\u0163ie a sindromului Down este de peste 95%, la o rata de rezultate fals-pozitive de 5%<sup>3;4<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><span style=\"text-decoration: underline;\">Sarcina multipla<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Poate rezulta prin doua mecanisme:<\/span><\/p>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2013 fertilizarea a mai mult de un ovocit: <em>sarcini polizigote<\/em>, cu fe\u0163i diferi\u0163i din punct de vedere genetic;<\/span><\/div>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2013 divizarea unei singure mase embrionice cu formarea de doi sau mai multi fetusi identici din punct de vedere genetic: <em>sarcini monozigote<\/em>.<\/span><\/div>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In toate sarcinile polizigote fiecare embrion isi dezvolta propriul amnios, corion si placenta; in sarcinile monozigote splitarea embrionului in primele 3 zile de la fertilizare da nastere la o sarcina diamniotica dicorionica, in zilele 3-9 rezulta o sarcina diamniotica monocorionica, in zilele 9-12 se va forma o sarcina monoamniotica monocorionica, iar dupa 12 zile divizarea embrionului va genera siamezi.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Screening-ul aneuploidiilor fetale in sarcinile multiple continua sa reprezinte o provocare datorita datelor limitate si utilizarii in principal a modelelor matematice. Screening-ul bazat pe parametri serici poate fi dificil de interpretat in sarcinile gemelare deoarece nivelul biomarkerilor la un fat normal poate masca rezultatele anormale la un fat afectat; din acest motiv <span style=\"text-decoration: underline;\">screening-ul nu poate fi aplicat la sarcini cu mai mult de doi fe\u0163i.<\/span><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In sarcinile dizigote riscul ini\u0163ial al mamei (legat de varsta) de anomalii fetale pentru fiecare geaman este acelasi ca pentru sarcina unica; din acest motiv riscul ca cel pu\u0163in unul din fe\u0163i sa prezinte o aneuploidie este dublu comparativ cu sarcina monofetala. Avand in vedere ca rata de dizigo\u0163i creste odata cu varsta materna, propor\u0163ia de sarcini gemelare cu anomalii fetale este mai mare decat in sarcinile unice.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In sarcinile monozigote riscul de anomalii cromozomiale este acelasi ca in sarcinile monofetale; in marea majoritate a cazurilor ambii fe\u0163i sunt afectati.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Deoarece propor\u0163ia relativa de gemeni dizigo\u0163i comparativ cu cei monozigo\u0163i in popula\u0163ia caucaziana este de aproximativ 2:1, prevalen\u0163a anomaliilor cromozomiale ce afecteaza cel pu\u0163in un fat este de 1.6 ori mai mare decat cea corespunzatoare sarcinilor unice.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In cazul sarcinilor duble este important sa se faca distinc\u0163ia ecografica intre sarcinile monocorionice (monoamniotice sau diamniotice) si dicorionice. Pe baza corionicita\u0163ii se pot face estimari mai precise in legatura cu posibila afectare a unuia sau ambilor fe\u0163i. Astfel, in cazul sarcinilor monocorionice ambii fe\u0163i vor fi afecta\u0163i, iar riscul este similar celui din sarcinile unice. Daca sarcina este dicorionica, riscul discordan\u0163ei pentru o anomalie cromozomiala este aproape dublu comparativ cu sarcina unica, in timp ce riscul ca ambii fe\u0163i sa fie afecta\u0163i poate fi derivat din ridicarea la patrat a riscului pentru sarcina unica. De exemplu, o femeie de 40 ani are un risc ini\u0163ial de 1:100 de a prezenta o sarcina cu sindrom Down; in cazul unei sarcini gemelare dizigote riscul ca unul din fe\u0163i sa fie afectat este de 1:50 (1:100 + 1:100), in timp ce riscul ca ambii fe\u0163i sa fie afecta\u0163i este de 1:10000 (1:100 x 1:100). In realitate, aceasta este o simplificare, deoarece, spre deosebire de sarcinile monocorionice care sunt intotdeauna monozigote, sarcinile dicorionice sunt dizigote in numai 90% din cazuri.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">In sarcinile cu doi gemeni, valorile mediane pentru markerii serici materni sunt aproape duble comparativ cu sarcinile monofetale. Daca in evaluarea riscului se utilizeaza numai translucen\u0163a nucala, rata de detec\u0163ie a sindromului Down in sarcinile dicorionice este similara celei din sarcinile unice (~75% la o rata de rezultate fals pozitive de 5% per fat sau de 10% per sarcina); riscurile individuale pentru trisomia 21 sunt calculate <em>separat <\/em>pentru fiecare fat pe baza NT si a varstei materne. Un avantaj important al screening-ului pe baza NT in sarcinile dicorionice este acela ca, in cazul unei discordante pentru o anomalie cromozomiala, examenul ecografic permite identificarea corecta a fatului afectat. In cazul sarcinilor monocorionice rata rezultatelor fals pozitive la screening-ul prin NT este mai mare decat in sarcinile dicorionice \u2013 8 % per fat sau 14% per sarcina; riscul de trisomie 21 este calculat pentru fiecare fat pe baza NT si a varstei materne, dupa care <em>riscul mediu<\/em> intre cei doi fe\u0163i este considerat ca fiind riscul global asociat cu sarcina respectiva<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Screening-ul combinat (markeri serici si NT) al sarcinilor gemelare poate identifica 85-90% din cazurile de trisomie 21 la o rata de rezultate fals pozitive dubla fa\u0163a de sarcina unica (10%). Corionicitatea nu este asociata cu diferente semnificative ale valorilor markerilor serici in primul trimestru de sarcina<sup>3;4<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Un studiu retrospectiv care a inclus sarcini duble a aratat ca adaugarea evaluarii osului nazal la screening-ul combinat de prim trimestru creste rata de detec\u0163ie a sindromului Down la 87-89%<sup>3<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Programul LifeCycle nu considera sarcina dubla ca pe\u00a0 o covariabila pentru care este necesar sa se faca o corec\u0163ie a MoMs. Deoarece toate studiile publicate indica faptul ca devia\u0163iile standard si coeficien\u0163ii de corelare in sarcinile duble, asociate sau nu cu anomalii fetale, sunt aceleasi ca pentru sarcinile monofetale programul utilizeaza acesti parametrii pentru sarcinile unice in calculul de risc pentru sarcinile gemelare<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><span style=\"text-decoration: underline;\">In cazul sarcinilor cu mai mult de doi fe\u0163i <em>numai<\/em> masurarea translucen\u0163ei nucale poate fi utilizata pentru estimarea riscului de aneuploidii fetale<\/span><sup>3<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Screening-ul efectuat in primul trimestru de sarcina ofera posibilitatea unei evaluari precoce si, in cazul unor rezultate pozitive, op\u0163iunea unui diagnostic precoce printr-un examen citogenetic efectuat din vilozita\u0163ile coriale<sup>1<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Intr-un studiu multicentric efectuat in SUA care a inclus un numar foarte mare de femei gravide si care a comparat screening-ul de prim trimestru cu cel de al doilea trimestru (studiul FASTER \u2013 First-and Second-Trimester Evaluation of Risk), s-a constat ca in trimestrul I rata de detec\u0163ie a sindromului Down este pu\u0163in mai mare in compara\u0163ie cu trimestrul II (83%, versus 81%). In Marea Britanie au fost raportate rezultate similare in urma studiului SURUSS (Serum, Urine and Ultrasound Screening Study). Rate de detec\u0163ie mai mari au fost ob\u0163inute la femeile \u226535 ani, dar cu mai multe rezultate fals-pozitive la testele screening<sup>3<\/sup>. Studiul FASTER a aratat de asemenea ca pe baza screening-ului combinat din primul trimestru de sarcina pot fi identificate 78% din sarcinile complicate cu trisomie 18, 13, sindrom Turner sau triploidie, in compara\u0163ie cu o rata de detec\u0163ie de 69% ob\u0163inuta pe baza screening-ului de trimestru II, la o rata de rezultate fals-pozitive de 6% si, respectiv, 8.9%<sup>2<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Pe langa dublu si triplu test, mai exista o metoda de screening prenatal denumita <strong>test integrat<\/strong>, care combina informa\u0163iile furnizate de markerii serici efectua\u0163i in primul si in al doilea trimestru de sarcina. Odata ce toate masuratorile devin disponibile in trimestrul II, programul LifeCycle va calcula un singur risc<sup>3;5<\/sup>. Cu aceasta metoda rata de detec\u0163ie a sindromului Down poate creste la 94-96% (conform studiilor FASTER si SURUSS), ratele variind in func\u0163ie de varsta gesta\u0163ionala, cu o rata de 2% rezultate fals pozitive<sup>3<\/sup>. Pentru trisomia 18 se preconizeaza o rata de detec\u0163ie de 90% cu ajutorului testului integrat, la o rata de numai 0.1% rezultate fals pozitive<sup>1<\/sup>. Screening-ul independent efectuat atat in primul cat si in cel de-al doilea trimestru este descurajat, deoarece rata rezultatelor fals-pozitive este inacceptabil de mare<sup>3<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Pregatire pacienta<\/em><\/strong><em> -<\/em><i> <\/i>\u00e0 jeun (pe nemancate) sau postprandial; pentru furnizarea riscului combinat recoltarea probelor si ecografia se efectueaza in intervalul <b>11 saptamani \u2013 13 saptamani + 6 zile (<i>CRL minim 40 mm, CRL maxim 79 mm<\/i>)<\/b>;<b>\u00a0 <\/b>in acest scop,<b> <\/b>pacientele si medicii trimi\u0163atori vor completa obligatoriu fisa de calcul de risc prenatal (ce include date clinice materne si date ecografice: lungimea cranio-caudala, marimea translucen\u0163ei nucale, prezen\u0163a\/absen\u0163a osului nazal). Inaintea efectuarii testului pacientele trebuie sa fie obligatoriu informate asupra investiga\u0163iei dublu test, precum si asupra riscului de rezultate fals-pozitive si fals-negative.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Daca recoltarea probelor se face in saptamanile 9-10 de sarcina laboratorul va comunica doar valorile marker-ilor serici<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Specimen recoltat<\/em><\/strong><em> - <\/em>sange venos<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Recipient de recoltare <\/em><\/strong><em>\u00a0- <\/em>vacutainer fara anticoagulant, cu\/fara gel separator<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Cauze de respingere<\/em><\/strong> <strong><em>a probei<\/em><\/strong> \u2013 specimen intens hemolizat<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Prelucrare necesara dupa recoltare<\/em><\/strong><em> - <\/em>se separa serul prin centrifugare<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Volum proba<\/em><\/strong> \u2013 minim 2 mL ser<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Stabilitate proba<\/em><\/strong><em> - <\/em>serul separat este stabil:<\/span><\/p>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2013 pentru PAPP-A: <em>24 ore <\/em>la 2-8\u00b0C<em>; 2 luni <\/em>la -20\u00b0C<em>;<\/em><\/span><\/div>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2013 pentru free beta-HCG: <em>6 zile <\/em>la 2-8\u00b0C;<em> timp indelungat<\/em> la -20\u00b0C<em>;<\/em> nu decongela\u0163i\/recongela\u0163i<sup>5<\/sup>.<\/span><\/div>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Metode<\/em><\/strong> <\/span><\/p>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2022 pentru markerii serici: <span style=\"text-decoration: underline;\">metoda imunofluorimetrica (time-resolved fluoroimmunoassay<\/span>); pentru marcare este utilizat europiu cu proprieta\u0163i unice de fluorescen\u0163a;<\/span><\/div>\n<div style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\">\u2022 pentru calcul de risc: programul Wallac LifeCycle<sup>TM<\/sup> (Perkin Elmer) in asociere cu Elipse Screening Engine<sup>5<\/sup>.<\/span><\/div>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Valori de referin\u0163a<\/em><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Sunt utilizate urmatoarele\u00a0 cut-off-uri pentru definirea unui screening normal:<\/span><\/p>\n<table class=\"wp-block-table w-100\" border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td width=\"288\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\"><strong>Anomalie fetala<\/strong><\/span><\/p>\n<\/td>\n<td width=\"295\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\"><strong>Cut-off (limita de risc)<\/strong><\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"288\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">Sindrom Down<\/span><\/p>\n<\/td>\n<td valign=\"top\" width=\"295\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">1\/250<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"288\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">Trisomie 18<\/span><\/p>\n<\/td>\n<td valign=\"top\" width=\"295\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">1\/100<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"288\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">Trisomie 13<\/span><\/p>\n<\/td>\n<td valign=\"top\" width=\"295\">\n<p style=\"text-align: center;\"><span style=\"font-size: 10pt;\">1\/100<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Pentru celelalte aneuploidii este utilizat un cut-off de 1\/100<sup>2<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Interpretarea rezultatelor<\/em><\/strong><\/span><\/p>\n<p style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\"><span style=\"text-decoration: underline;\"><strong>Risc scazut<\/strong><\/span>: valoarea riscului calculat este sub cut-off-urile stabilite. Ob\u0163inerea unui risc scazut nu ofera garan\u0163ia absen\u0163ei sindromului Down, trisomiei 18 sau 13.<\/span><\/p>\n<p style=\"text-align: justify; padding-left: 30px;\"><span style=\"font-size: medium;\"><span style=\"text-decoration: underline;\"><strong>\u0412\u044b\u0441\u043e\u043a\u0438\u0439 \u0440\u0438\u0441\u043a<\/strong><\/span>: valoarea riscului calculat depaseste cut-off-urile stabilite. Ob\u0163inerea unui risc crescut nu stabileste diagnosticul de trisomie 21, 18 sau 13, ci impune necesitatea efectuarii unor investiga\u0163ii suplimentare<sup>4;5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Exista situa\u0163ii in care calculul combinat indica un risc scazut de anomalii fetale la nastere insa valorile marker-ilor serici sunt semnificativ modificate in compara\u0163ie cu medianele corespunzatoare varstei gesta\u0163ionale. Pe buletinul final vor fi precizate aceste informa\u0163ii deoarece valorile MoM extreme ale parametrilor serici pot ajuta la identificarea altor complica\u0163ii obstetricale:<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><span style=\"text-decoration: underline;\">Modific<\/span><span style=\"text-decoration: underline;\">ari izolate <\/span><span style=\"text-decoration: underline;\">PAPP-A<\/span><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Valori scazute PAPP-A (&lt;0.4 MoM) pot indica risc de:<\/span><\/p>\n<ul style=\"text-align: justify;\">\n<li><span style=\"font-size: medium;\">restric\u0163ie de crestere intrauterina (IUGR);<\/span><\/li>\n<li><span style=\"font-size: medium;\">nastere prematura;<\/span><\/li>\n<li><span style=\"font-size: medium;\">moartea fatului &gt; 24 saptamani;<\/span><\/li>\n<li><span style=\"font-size: medium;\">preeclampsie;<\/span><\/li>\n<li><span style=\"font-size: medium;\">avort spontan.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Valori \u2191 PAPP-A nu au fost asociate cu un risc \u2191 de complica\u0163ii obstetricale.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium; text-decoration: underline;\">Modificari izolate free beta-HCG<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Valori foarte scazute free-beta HCG (&lt;0.25 MoM) in trimestrul I de sarcina au fost asociate cu un risc crescut de pierderea sarcinii &lt; 24 saptamani.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Pe de alta parte, valorile crescute de free-beta HCG in trimestrul I de sarcina, in absen\u0163a sarcinii molare nu au fost asociate cu un risc crescute de complica\u0163ii obstetricale<sup>6<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><strong><em>Limite si interferen\u0163e<\/em><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\"><span style=\"text-decoration: underline;\">Dublul test nu reprezinta o metoda de diagnostic<\/span>. In cazul ob\u0163inerii unui risc crescut de anomalii fetale la nastere, medicul obstetrician va hotari oportunitatea efectuarii de investiga\u0163ii suplimentare, inclusiv <span style=\"text-decoration: underline;\">teste diagnostice<\/span>\u00a0 cum ar fi analiza citogenetica prin prelevarea de vilozita\u0163i coriale (trimestrul I) sau amniocenteza (trimestrul II).<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: medium;\">Riscurile calculate depind de acurate\u0163ea informa\u0163iilor furnizate de pacienta\/medic trimi\u0163ator<sup>5<\/sup>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: small;\">\u00a0<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"font-size: 10pt;\"><strong>\u0411\u0438\u0431\u043b\u0438\u043e\u0433\u0440\u0430\u0444\u0438\u044f<\/strong><\/span><\/p>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">1. Andrew R.MacRae, Jacob A.Canick. Maternal Prenatal Screening for Fetal Defects. In Handbook of Clinical Laboratory Testing During Pregnancy. Ann M.Gronowski. Humana Press, USA, Ed. 2004, 105-120.<\/span><\/div>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">2. Breathnach, Fionunuala M, et al. First-and Second-Trimester Screening: Detection of Aneuploides Other Than Down Syndrome. In Obstetriics &amp; Gynecology, September 2007, volume 110, pp 651-657.<\/span><\/div>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">3. Deborah A. Driscoll, Susan Gross. Prenatal Screning for Aneuploidy. In N Engl J Med 2009; 360-2556-2562.<\/span><\/div>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">4.\u00a0Kypros H. Nicolaides. Screening for fetal aneuploides at 11 to 13 weeks. In Prenat Diagn. 2011; 31:7-15.<\/span><\/div>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">5.\u00a0Laborator Synevo. Referin\u0163ele specifice tehnologiei de lucru utilizate. 2013. Ref Type: Catalog.<\/span><\/div>\n<div style=\"text-align: justify;\"><span style=\"font-size: 10pt;\">6.\u00a0Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guidelines.\u00a0 Obstetrical Complications\u00a0 Associated With Abnormal Maternal Serum Markers Analytes. SOGC Technical Update, No.217, October 2008.<\/span><\/div>\n<p style=\"text-align: justify;\">","protected":false},"excerpt":{"rendered":"<p>\u0422\u0435\u0441\u0442 \u0432\u044b\u043f\u043e\u043b\u043d\u044f\u0435\u0442\u0441\u044f \u0434\u043b\u044f \u0441\u043a\u0440\u0438\u043d\u0438\u043d\u0433\u043e\u0432\u043e\u0433\u043e \u043e\u0431\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u0431\u0435\u0440\u0435\u043c\u0435\u043d\u043d\u044b\u0445 \u0441 \u0446\u0435\u043b\u044c\u044e \u043e\u0446\u0435\u043d\u043a\u0438 \u0440\u0438\u0441\u043a\u0430 \u0445\u0440\u043e\u043c\u043e\u0441\u043e\u043c\u043d\u044b\u0445 \u0430\u043d\u043e\u043c\u0430\u043b\u0438\u0439 \u043f\u043b\u043e\u0434\u0430: \u0442\u0440\u0438\u0441\u043e\u043c\u0438\u0438 21 (\u0441\u0438\u043d\u0434\u0440\u043e\u043c \u0414\u0430\u0443\u043d\u0430) \u0438 \u0442\u0440\u0438\u0441\u043e\u043c\u0438\u0439 18, 13 (\u0441\u0438\u043d\u0434\u0440\u043e\u043c \u042d\u0434\u0432\u0430\u0440\u0434\u0441\u0430, \u0441\u0438\u043d\u0434\u0440\u043e\u043c \u041f\u0430\u0442\u0430\u0443). \u041a\u043e\u043b\u0438\u0447\u0435\u0441\u0442\u0432\u0435\u043d\u043d\u0430\u044f \u043e\u0446\u0435\u043d\u043a\u0430 \u0440\u0435\u0437\u0443\u043b\u044c\u0442\u0430\u0442\u043e\u0432 \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u0439 \u043f\u0440\u043e\u0438\u0437\u0432\u043e\u0434\u0438\u0442\u0441\u044f \u0441 \u0438\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u043d\u0438\u0435\u043c \u043f\u0440\u043e\u0433\u0440\u0430\u043c\u043c\u043d\u043e\u0433\u043e \u043e\u0431\u0435\u0441\u043f\u0435\u0447\u0435\u043d\u0438\u044f PRISCA.<\/p>\n<p>\u0412\u043d\u0438\u043c\u0430\u043d\u0438\u0435! \u0414\u043b\u044f \u0434\u0430\u043d\u043d\u043e\u0433\u043e \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u043d\u0435\u043e\u0431\u0445\u043e\u0434\u0438\u043c\u043e \u043d\u0430\u043b\u0438\u0447\u0438\u0435 \u0440\u0435\u0437\u0443\u043b\u044c\u0442\u0430\u0442\u043e\u0432 \u0423\u0417\u0418!<\/p>\n<p>\u0411\u0438\u043e\u0445\u0438\u043c\u0438\u0447\u0435\u0441\u043a\u0438\u0439 \u0441\u043a\u0440\u0438\u043d\u0438\u043d\u0433 I \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430 \u0431\u0435\u0440\u0435\u043c\u0435\u043d\u043d\u043e\u0441\u0442\u0438, \u00ab\u0434\u0432\u043e\u0439\u043d\u043e\u0439 \u0442\u0435\u0441\u0442\u00bb \u043f\u0435\u0440\u0432\u043e\u0433\u043e \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430 \u0441\u043e\u0441\u0442\u043e\u0438\u0442 \u0438\u0437 \u0441\u043b\u0435\u0434\u0443\u044e\u0449\u0438\u0445 \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u0439:<\/p>\n<ul>\n<li>\u0441\u0432\u043e\u0431\u043e\u0434\u043d\u0430\u044f \u03b2-\u0441\u0443\u0431\u044a\u0435\u0434\u0438\u043d\u0438\u0446\u0430 \u0445\u043e\u0440\u0438\u043e\u043d\u0438\u0447\u0435\u0441\u043a\u043e\u0433\u043e \u0433\u043e\u043d\u0430\u0434\u043e\u0442\u0440\u043e\u043f\u0438\u043d\u0430 \u0447\u0435\u043b\u043e\u0432\u0435\u043a\u0430 (\u0441\u0432\u043e\u0431\u043e\u0434\u043d\u044b\u0439 \u03b2-\u0425\u0413\u0427, free \u03b2-hCG);<\/li>\n<li>\u0420\u0410\u0420\u0420-\u0410 (pregnancy associated protein A, \u0431\u0435\u043b\u043e\u043a \u0410 \u043f\u043b\u0430\u0437\u043c\u044b \u0430\u0441\u0441\u043e\u0446\u0438\u0438\u0440\u043e\u0432\u0430\u043d\u043d\u044b\u0439 \u0441 \u0431\u0435\u0440\u0435\u043c\u0435\u043d\u043d\u043e\u0441\u0442\u044c\u044e).<\/li>\n<li>\u0440\u0430\u0441\u0447\u0435\u0442 \u0438\u043d\u0434\u0438\u0432\u0438\u0434\u0443\u0430\u043b\u044c\u043d\u044b\u0445 \u043f\u043e\u043a\u0430\u0437\u0430\u0442\u0435\u043b\u0435\u0439 \u0441\u0442\u0430\u0442\u0438\u0441\u0442\u0438\u0447\u0435\u0441\u043a\u043e\u0433\u043e \u0440\u0438\u0441\u043a\u0430 \u0440\u043e\u0436\u0434\u0435\u043d\u0438\u044f \u0440\u0435\u0431\u0435\u043d\u043a\u0430 \u0441 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\u0441\u043e\u043e\u0442\u0432\u0435\u0442\u0441\u0442\u0432\u0443\u044e\u0449\u0438\u0445 \u0432\u0438\u0434\u043e\u0432 \u043f\u0430\u0442\u043e\u043b\u043e\u0433\u0438\u0438 \u043f\u0440\u0438 \u0441\u0445\u043e\u0434\u043d\u044b\u0445 \u0440\u0435\u0437\u0443\u043b\u044c\u0442\u0430\u0442\u0430\u0445 \u043e\u0431\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u0439 \u0438 \u0438\u043d\u0434\u0438\u0432\u0438\u0434\u0443\u0430\u043b\u044c\u043d\u044b\u0445 \u0434\u0430\u043d\u043d\u044b\u0445.<\/li>\n<\/ul>\n<p>\u041e\u043f\u0442\u0438\u043c\u0430\u043b\u044c\u043d\u044b\u0435 \u0441\u0440\u043e\u043a\u0438 \u043f\u0440\u043e\u0432\u0435\u0434\u0435\u043d\u0438\u044f \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u2013 11-13 \u043d\u0435\u0434\u0435\u043b\u044c \u0431\u0435\u0440\u0435\u043c\u0435\u043d\u043d\u043e\u0441\u0442\u0438.<\/p>\n<p>\u041f\u0440\u043e\u0432\u0435\u0434\u0435\u043d\u0438\u0435 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\u043f\u0440\u043e\u0433\u0440\u0430\u043c\u043c\u043d\u044b\u043c \u043a\u043e\u043c\u043f\u043b\u0435\u043a\u0441\u043d\u044b\u043c \u0440\u0430\u0441\u0447\u0435\u0442\u043e\u043c \u0438\u043d\u0434\u0438\u0432\u0438\u0434\u0443\u0430\u043b\u044c\u043d\u043e\u0433\u043e \u0440\u0438\u0441\u043a\u0430 \u0440\u043e\u0436\u0434\u0435\u043d\u0438\u044f \u0440\u0435\u0431\u0435\u043d\u043a\u0430 \u0441 \u0445\u0440\u043e\u043c\u043e\u0441\u043e\u043c\u043d\u043e\u0439 \u043f\u0430\u0442\u043e\u043b\u043e\u0433\u0438\u0435\u0439.<\/p>\n<p>\u0418\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u0435 \u0432\u044b\u043f\u043e\u043b\u043d\u044f\u0435\u0442\u0441\u044f \u0434\u043b\u044f \u0441\u043a\u0440\u0438\u043d\u0438\u043d\u0433\u043e\u0432\u043e\u0433\u043e \u043e\u0431\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u0431\u0435\u0440\u0435\u043c\u0435\u043d\u043d\u044b\u0445 \u0441 \u0446\u0435\u043b\u044c\u044e \u043e\u0446\u0435\u043d\u043a\u0438 \u0440\u0438\u0441\u043a\u0430 \u0445\u0440\u043e\u043c\u043e\u0441\u043e\u043c\u043d\u044b\u0445 \u0430\u043d\u043e\u043c\u0430\u043b\u0438\u0439 \u043f\u043b\u043e\u0434\u0430 \u2013 \u0442\u0440\u0438\u0441\u043e\u043c\u0438\u0438 21 (\u0441\u0438\u043d\u0434\u0440\u043e\u043c \u0414\u0430\u0443\u043d\u0430) \u0438 \u0442\u0440\u0438\u0441\u043e\u043c\u0438\u0439 18, 13 (\u0441\u0438\u043d\u0434\u0440\u043e\u043c \u042d\u0434\u0432\u0430\u0440\u0434\u0441\u0430, \u0441\u0438\u043d\u0434\u0440\u043e\u043c \u041f\u0430\u0442\u0430\u0443).<\/p>\n<p>\u041f\u0440\u0430\u0432\u0438\u043b\u0430 \u043f\u043e\u0434\u0433\u043e\u0442\u043e\u0432\u043a\u0438 \u043a \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044e:<\/p>\n<ol>\n<li>\u0412\u0437\u044f\u0442\u0438\u0435 \u043a\u0440\u043e\u0432\u0438 \u043f\u0440\u0435\u0434\u043f\u043e\u0447\u0442\u0438\u0442\u0435\u043b\u044c\u043d\u043e \u043f\u0440\u043e\u0432\u043e\u0434\u0438\u0442\u044c \u0443\u0442\u0440\u043e\u043c \u043d\u0430\u0442\u043e\u0449\u0430\u043a, \u043f\u043e\u0441\u043b\u0435 8-14 \u0447\u0430\u0441\u043e\u0432 \u043d\u043e\u0447\u043d\u043e\u0433\u043e \u043f\u0435\u0440\u0438\u043e\u0434\u0430 \u0433\u043e\u043b\u043e\u0434\u0430\u043d\u0438\u044f (\u0432\u043e\u0434\u0443 \u043f\u0438\u0442\u044c \u043c\u043e\u0436\u043d\u043e), \u0434\u043e\u043f\u0443\u0441\u0442\u0438\u043c\u043e \u0434\u043d\u0435\u043c \u0447\u0435\u0440\u0435\u0437 4 \u0447\u0430\u0441\u0430 \u043f\u043e\u0441\u043b\u0435 \u043b\u0435\u0433\u043a\u043e\u0433\u043e \u043f\u0440\u0438\u0435\u043c\u0430 \u043f\u0438\u0449\u0438.<\/li>\n<li>\u041d\u0430\u043a\u0430\u043d\u0443\u043d\u0435 \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u043d\u0435\u043e\u0431\u0445\u043e\u0434\u0438\u043c\u043e \u0438\u0441\u043a\u043b\u044e\u0447\u0438\u0442\u044c \u043f\u043e\u0432\u044b\u0448\u0435\u043d\u043d\u044b\u0435 \u043f\u0441\u0438\u0445\u043e\u044d\u043c\u043e\u0446\u0438\u043e\u043d\u0430\u043b\u044c\u043d\u044b\u0435 \u0438 \u0444\u0438\u0437\u0438\u0447\u0435\u0441\u043a\u0438\u0435 \u043d\u0430\u0433\u0440\u0443\u0437\u043a\u0438 (\u0441\u043f\u043e\u0440\u0442\u0438\u0432\u043d\u044b\u0435 \u0442\u0440\u0435\u043d\u0438\u0440\u043e\u0432\u043a\u0438), \u043f\u0440\u0438\u0451\u043c \u0430\u043b\u043a\u043e\u0433\u043e\u043b\u044f, \u0437\u0430 \u0447\u0430\u0441 \u0434\u043e \u0438\u0441\u0441\u043b\u0435\u0434\u043e\u0432\u0430\u043d\u0438\u044f \u2013 \u043a\u0443\u0440\u0435\u043d\u0438\u0435.<\/li>\n<li>\u0421\u043a\u0440\u0438\u043d\u0438\u043d\u0433 \u043f\u0435\u0440\u0432\u043e\u0433\u043e \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430 \u043e\u043f\u0442\u0438\u043c\u0430\u043b\u0435\u043d \u043d\u0430 11-13 \u043d\u0435\u0434\u0435\u043b\u044f\u0445, \u0432\u0442\u043e\u0440\u043e\u0433\u043e \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430 \u2013 \u043d\u0430 16-18 \u043d\u0435\u0434\u0435\u043b\u044f\u0445. \u0414\u0430\u043d\u043d\u044b\u0435 \u0423\u0417\u0418 I \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430 \u043c\u043e\u0433\u0443\u0442 \u0431\u044b\u0442\u044c \u0438\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u043d\u044b \u0434\u043b\u044f \u0440\u0430\u0441\u0447\u0435\u0442\u0430 \u0440\u0438\u0441\u043a\u0430 \u043f\u0440\u0438 \u043f\u0440\u043e\u0432\u0435\u0434\u0435\u043d\u0438\u0438 \u0431\u0438\u043e\u0445\u0438\u043c\u0438\u0447\u0435\u0441\u043a\u043e\u0433\u043e \u0441\u043a\u0440\u0438\u043d\u0438\u043d\u0433\u0430 II \u0442\u0440\u0438\u043c\u0435\u0441\u0442\u0440\u0430.<\/li>\n<\/ol>","protected":false},"featured_media":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"product_brand":[],"product_cat":[911,920],"product_tag":[],"class_list":{"0":"post-9220","1":"product","2":"type-product","3":"status-publish","5":"product_cat-markeri-endocrini","6":"product_cat-screening-prenatal-anomalii-fetale","8":"first","9":"instock","10":"sold-individually","11":"shipping-taxable","12":"purchasable","13":"product-type-simple"},"_links":{"self":[{"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/product\/9220","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/product"}],"about":[{"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/types\/product"}],"replies":[{"embeddable":true,"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/comments?post=9220"}],"wp:attachment":[{"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/media?parent=9220"}],"wp:term":[{"taxonomy":"product_brand","embeddable":true,"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/product_brand?post=9220"},{"taxonomy":"product_cat","embeddable":true,"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/product_cat?post=9220"},{"taxonomy":"product_tag","embeddable":true,"href":"https:\/\/old.synevo.md\/ru\/wp-json\/wp\/v2\/product_tag?post=9220"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}