The coordination of the various components is critical because it is recommended that the test not be performed until 16 weeks of gestation. If the test indicates a sufficiently increased level of MSAFP, the patient should be offered a second test a week or two later, if time permits. Otherwise ultrasound should be used to correct the gestational age, check for multiple gestation, and, if possible, identify a neural tube defect. Among patients with two high MSAFP levels (or one low one) slightly over half will have a singleton fetus at the appropriate gestational age without an apparent anomaly. These patients should be offered amniocentesis. Of the patients undergoing amniocentesis, one to two will have significantly increased amniotic fluid AFP that indicates a high probability of a fetus with a serious abnormality.At this point further tests can be done to identify the specific defect, but this will be impossible in some cases. If a defect is confirmed, the patient must decide whether she wants an abortion. Many patients choose to abort the fetus. Some may be willing to accept a child with spina bifida but be unwilling to carry a fetus with anencephaly. The woman with an elevated amnionic AFP but no identifiable defect has the more difficult decision. She should be given full information and an opportunity to seek in-depth counseling before making her decision. Once the process of recommending the initial test begins, every following step must be planned carefully and executed. It is critical that the patient be carefully tracked to ensure that there are no delays that can push the abortion into the third trimester, with the attendant medical and legal complications. ACOG Technical Bulletin 154: Prenatal Detection of Neural Tube Defects. April 1991. ACOG Technical Bulletin 154: Prenatal Detection of Neural Tube Defects. April 1991. ACOG Technical Bulletin 154: Prenatal Detection of Neural Tube Defects. April 1991.
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