Yes, and we have 8!

This made me laugh so hard, we have of course heard all of these comments many times, and that is just with the three little girls.

There are 10 in our family, so we have them beat, but she had 7 children, I gave birth to 6.

Meghan having fun

I thought this was a good one of Meghan. She is a duck and runner for pictures too, but sometimes she actually cooperates!

I hope you enjoy her pictures, she is twirling around and showing off her Uggs, she loves to wear them. A gift from Julia for Meghan's birthday.

Showing off her outgrown dress, she wore this in Ukraine last year, this year, too short for me. I like girls dresses at their knees. Meghan has finally out grown size 5T, and is finally wearing 6X exclusively. She does not like giving up favorite dresses though, and I will have to take these and box them away.

After a spin!

Laughing at her mom!

Tink Mom, tink? Her way of asking me if she looks pretty,

and you know I always say YES!

Two worn out girls, they played, ran around, and went nuts, and now they rest, TV time for them! Amanda cannot climb on the sofa, so she is on the floor here. I have to put her up there with her sisters, she can climb down though.

A Levario Christmas

This year was special to all of us; both of our new daughters were finally together from Ukraine and Estonia and all of our children were able to be here. I cherish the time we can spend with them more than I do gifts. I am blessed to have my children close-by still, I know that is rare.

Brian took care of Meghan and Kara while Tom and I were in Estonia adopting Amanda. The girls adore their big brother, Amanda is getting to know all of our adult children, she does not see them as often as she does us. As you can see, Meghan does not like to share Brian with her two little sisters, however today she told me, I love Kara, and I love Moo (Amanda, who we call Manda Moo), so I guess things are not all bad!

This is one of those pictures that came out blurry, doggone it, it was such a good picture of my kids too! In case you can't read what the picture says, it is Julia, Fred, and Brian.

I snuck a picture of Terry, he does not like pictures either, there are three of us in our family who avoid them, Terry, Eric, and ME!

So Terry has to forgive me for putting this one in here, but like Eric, he ducked every time he saw the camera.

Hi Terry!! :o) Terry got some art supplies for Christmas, he enjoys visual art like I do, he and I like pencil art, and he is really good with charcoal and makes amazing ceramic designs. I am thinking of doing some ceramics with the girls, 25 lbs of clay is not too expensive, and we can have lasting memories.

I loved this one of Julia and Brian, it came out so well, so many I took did not, I just do not get why that happens, but oh well...

Brian was 6 when Julia was born and he wanted me to send her back, she got too much attention being the first girls after 4 sons, though it did not take long for him to adore her and take care of her.

Brian is so busy with theater, we do not see him as much as we wished we did.

Julia is also away from home a lot, you know how high school life can get.

Our pictures would not be complete without Eric, yes, that is him behind his hand, yes, the third person who hates getting his picture taken. I keep telling him, he will regret that when he gets to be my age and there are only a handful of pictures of him. I think my brother has some of me, maybe? LOL

Julia holding up her new jacket, she looked cute in this, and I was glad to remember that Julia had said she loved a jacket like this once before. I love finding things my kids enjoy.

Check out the movie in the background; A Christmas Story, Tom's favorite movie for the holidays.
Meghan did not care about her gifts after seeing Enchanted, she adores that movie, and she wanted to go back to our room and watch it, after she put on her new dress that is! She is finally enjoying dressing dolls, and got a lot of clothing for her new Barbies and Our Generation dolls. Of course, Barbie is pretty hard to dress, so mommy gets the honor.

Kara really liked opening her presents this year, last year she looked so confused and somewhat scared by all of the commotion, mommy was sick, a cold I fought while I was in Ukraine hit me like a ton of bricks when I arrived home, I spent the next two weeks in bed, thank goodness for Christmas break, my husband was home take care of me.

Her big brother Fred helped her, she thought it was a lot of fun to toss the toys around, though she hugged her new dolly to her, she threw her as well. Kara adores throwing things. She is really into cause and effect. She is also walking like a champ, no longer has her arms out to the sides and can hold a toy and walk at the same time. Way to go Kara! We are so proud of her.

Amanda and mommy opening her presents. I am hoping this will engage Amanda in play a little more, she barely recognizes that toys are for playing. It is hand over hand right now, but she did push one flap down on her own.

Amanda's favorite thing right now is sitting on our laps and getting hugs and kisses, who can complain about that? She also likes to sit in the sun, smart girl, getting her Vitamin D.

That was the gift opening part of our Christmas day. Right after we had finished, the CO alarm went off and the monitor was flashing DEADLY GAS. We all looked at each other because we felt OK, I was nursing a slight headache, but my allergies was terrible so I figured that was why. My husband looked up the instructions and the papers said, call 911 and evacuate the home. So he did and we all went outside to wait for the fire department, feeling rather foolish about it too, I might add. Still better safe than sorry.

After a 10 minute wait the firemen arrived with their carbon monoxide detectors, they asked if we were OK, Fred and I felt headachey, but everyone else was fine. They went in and took readings, no CO, and they said we could safely return to our home. They also said it was likely our monitor was faulty, oh boy, they sure are not cheap. Thank goodness we were all OK though.

For dinner we had ham, rolls, peas, and mashed potatoes. Tom and Terry did all the cooking. Eric made two cheesecakes, they were really yummy!

Grandma came by for a while, but she is struggling with a knee replacement and tried to enjoy herself, but I think she was in pain. :o( Tom showed her the girls blogs, she had never seen them, and it was the first time she met Amanda.

We finished off our day seeing When the Earth Stood Still, the little girls were so good too, Amanda fell asleep in my arms and Kara intently watched the movie. It is VERY difficult to get all of the kids to the movies together, they all scatter in different directions at the end of the day. Then there is sitting together, there are 10 of us, and we never leave on time, so usually we sit in the front three rows. Our theater decided they needed to charge for all kids over the age of 1, and we had to pay for Kara and Amanda even though they sat in our laps, kind of irked me, and we will not be going to the movies anymore, it was $47 for Tom, Amanda, Meghan, Kara, and I. Ouch!

Not easy being a sick mom

I have been so sick this past week that I am afraid I totally failed in the mom department.

I am always amazed at these selfess women who can continue on through illness and do what they always do regardless of it (not very healthy for them) Me, I get sick and I am down for the count. I may as well just leave the house until I am better because I am useless. I am happy to say my head is less fuzzy and I can actually see again, my eyesight gets very poor when I get a cold. My head no longer feels like it will explode when I cough, and my lungs feel like they may remain in my chest instead of flying out of my mouth. Ugh, I hate having a cold.
I found that things that I normally take more or less in stride are impossible to deal with when I am sick, It just seems so overwhelming and I at times like these, I wish I my Mom was still alive, I sure needed help this wek, though DH did leave work early, thank goodness.

SO here are a few things that drive me crazy when I am sick:

Two sweet girls wetting the bed and having to wash all their bedding AGAIN (I even used cloth diapers in Kara's Target diapers, and it helped, a little. )

Messes made right after the floor is picked up including someone (Kara) emptying an entire bag of corn chips and then stomping on them, and me remembering the broken vacuum cleaner (it can't be fixed Mrs L, but I have another one for $135 and having to sweep the area rugs instead of vacuuming them because it is Christmas and I can't spare the money right now). Resorting to letting the cats eat the corn chips because they were hungry and it got the floor clean didn't it? Did you know that a lint brush works very well in getting hair and lint off the carpets when the broom won't? There is a lot of hair on carpet's...

Kittens and toddlers tearing the house apart, the kittens are into dragging socks, towels, t-shirts, underwear, all pulled from the over-flowing laundry basket, between their legs stage... the girls are in the drag out the toys out and leave them everywhere stage, the kittens using the carpet as their litter box (maybe it was the corn chips)...the girls are using the couch as a potty chair because someone (Kara) keeps taking her diaper off and whoops...

Children that climb on me (all three of em) when I am lying down on the sofa I just sprayed with Pet Stain cleaner and deodorizer, my sweet little girls who are treating my body as part of the sofa, and me hoping I do not get wet too.

Phone calls that come right after the little girls are down for a nap and I am finally resting, kittens who think my hand is a plaything and claw me (after I hang up the phone and I am dozing off again)...

The spilled milk or juice (Meghan, who wants to be independent even though she is not accurate with her pouring), that has to be wiped up while mommy has a throbbing head, and stepping in the spot of juice I missed with clean socks on.

Drinking my bottle of water and wondering why it has chunks in it, can we say backwash (Kara and Meghan) S that was why the water was opaque?

Changing 15 diapers a day.

Changing outfits two to three times a day; today it rained in the morning, but Amanda and Kara went out when Meghan did even though mommy told Meghan, no outside today, the ground it wet..change #1, and Kara took off her diaper with her pants on and sat on the sofa...change two for her, and Meghan put Amanda in the empty bathtub and poured a cup of water on her..change two for her, and Meghan sat in said water, change 2 for her.

Washing at least a load of clothes a today (or more). I just looked down and saw baby food all over my leg, how did that get there, I also have the lovely booger smudge on my right shoulder...

Making food for three girls who cannot eat the same thing, then feeding Amanda who takes 45 minutes to eat, while listening to Kara who cries because I am feeding Amanda even though Kara self-feeds, and then trying to remember to cook something for me after the little girls eat, and did I eat lunch today??

Having daughter #1 asking for a ride right after her sisters fall asleep and I am looking forward to a nap (usually when Meghan and I do two hours of HS). And before, during and after all of the fun; trying to home school with a runny nose, throbbing head, and eyes that cannot focus, wondering if it is a good excuse to skip that day, and when is Christmas break again?

Two of our 9 cats, 4 stay outside, 2 of those 4 just showed up at our house the past month, they are both kittens. Neither will come in the house. The others that stay in the house are Boot's kittens, 3 months old and ready to leave to new homes, please someone take one, they are tearing the house apart. Two look like these kitties, and one is black, one has a home.

Impact of a new National Screening Policy for Down's Syndrome in Denmark: Population Based Cohort Study

You will need to sign up for Medscape membership to read this.

The purpose of this study and the resultant testing is discussed below. I highlighted areas that were important to me.

The decline in children born with Down syndrome since the screening began in 2005.Though it does not say it outright, the decline in births was a combination of decline spontaneous abortion following the testing and termination by the parents. Abortion is what concerns me here, this is exactly what American parents with special needs kids are afraid of. People get upset when the word Eugenics is bandied about, but what else is this?

The definitiion of Eugenics is as follows:

Eugenics is a social philosophy which advocates the improvement of human hereditary traits through various forms of intervention.

Intervention meaning, termination of the fetus? what do you think?

I think God made my girls in his image too, they are not less than any other child because they have Down syndrome.

http://www.medscape.com/

NOTE: To view the article with Web enhancements, go to:http://www.medscape.com/viewarticle/584622

Impact of a new National Screening Policy for Down's Syndrome in Denmark: Population Based Cohort Study

Charlotte K Ekelund; Finn Stener Jørgensen; Olav Bjørn Petersen; Karin Sundberg; Ann Tabor; Danish Fetal Medicine Research Group

BMJ. 2008;337(2547) ©2008 BMJ Publishing Group
Posted 12/08/2008

Objectives: To evaluate the impact of a screening strategy in the first trimester, introduced in Denmark during 2004-6, on the number of infants born with Down's syndrome and the number of chorionic villus samplings and amniocenteses, and to determine detection and false positive rates in the screened population in 2005 and 2006.
Design: Population based cohort study.
Setting: 19 Danish departments of gynaecology and obstetrics and a central cytogenetic registry 2000-7.
Participants: 65 000 pregnancies per year.
Main Outcome Measures:



The primary outcomes measured were number of fetuses and newborn infants with Down's syndrome diagnosed prenatally and postnatally and number of chorionic villus samplings and amniocenteses carried out.



Secondary outcomes measured were number of women screened in 2005 and 2006, screen positive rate, and information on screening in 2005 and 2006 for infants with a postnatal diagnosis of Down's syndrome.Results:



The number of infants born with Down's syndrome decreased from 55-65 per year during 2000-4 to 31 in 2005 and 32 in 2006.



The total number of chorionic villus samplings and amniocenteses carried out decreased from 7524 in 2000 to 3510 in 2006.



The detection rate in the screened population in 2005 was 86% (95% confidence interval 79% to 92%) and in 2006 was 93% (87% to 97%).



The corresponding false positive rates were 3.9% (3.7% to 4.1%) and 3.3% (3.1% to 3.4%).Conclusion: The introduction of a combined risk assessment during the first trimester at a national level in Denmark halved the number of infants born with Down's syndrome. The strategy also resulted in a sharp decline in the number of chorionic villus samplings and amniocenteses carried out, even before full implementation of the policy.


Introduction:
In September 2004 the Danish National Board of Health issued new guidelines for prenatal screening and diagnosis.[1] These recommended that pregnant women should be offered information about screening methods in pregnancy and, if desired, a combined risk assessment for Down's syndrome in the first trimester based on a combination of maternal age, nuchal translucency scanning, and a biochemical test for serum free β human chorionic gonadotrophin and pregnancy associated plasma protein A, called the double test. On the basis of this assessment women were to be informed about their risk (given as odds, such as 1:1250) of carrying a fetus with Down's syndrome. Women with a risk above a defined cut-off (for example, 1:300) were to be offered an invasive diagnostic procedure (chorionic villus sampling or amniocentesis). According to the previous guidelines from the Danish National Board of Health, pregnant women were to be offered chorionic villus sampling or amniocentesis if they were aged 35 or more, were at increased risk of carrying a fetus with Down's syndrome on the basis of serum screening using a triple test in the second trimester, or were at risk of an inherited disease. In 2000 the uptake of invasive diagnostic testing in women aged 35 or more was less than 50%, whereas around 20% of all pregnant women had nuchal translucency ultrasonography.[2] The triple test was not offered to all women but was done in about 10% of the population. Scans for malformations in the second trimester were offered to 28% of women.[2]


All 15 Danish counties decided to follow the guidelines from 2004 and introduce combined risk assessment in the first trimester. The cost of introducing the programme (ultrasound and laboratory equipment, training, wages for new staff) was covered by the counties and local hospitals. In 2004-6 the risk cut-off for referral to invasive diagnostic procedures varied between counties, from 1:250 to 1:400. The new policy was expected to detect 90% of fetuses with Down's syndrome at a 5% false positive rate on the basis of calculations made on the Danish population in 2001.


We evaluated the impact at a national level of the introduction of this new screening strategy on the number of infants born with Down's syndrome and on the number of chorionic villus samplings and amniocenteses. We also assessed whether the detection and false positive rates in the screened population for 2005 and 2006 were as expected.


Methods:
Denmark has a population of 5.4 million primarily white people and about 65 000 liveborn infants per year (http://www.statistikbanken.dk/). At birth everyone is assigned a unique personal registration number, which is used for identification in the Danish social and healthcare system. This centralised, computer based, registration system enables follow-up of individuals through public registries.

From Statistics Denmark (http://www.statistikbanken.dk/) we retrieved data on the number of liveborn infants born per year, the distribution of maternal age at delivery, and the mean maternal age at delivery for the period 2000-6. Using the maternal age specific risk of delivering an infant with Down's syndrome we calculated the expected number of liveborn infants with Down's syndrome.[3]

In Denmark results from prenatal and postnatal chromosome analyses are forwarded to the Danish central cytogenetic registry. From there we obtained information on the number of chorionic villus samplings and amniocenteses carried out during 2000-6, the indications for either procedure, and karyotypes.


In Denmark all newborn infants are examined by a midwife. When an abnormality or malformation such as Down's syndrome is suspected, follow-up with a paediatrician is initiated. The results of postnatal chromosome analysis including the personal registration numbers of the mother and infant are sent to the Danish central cytogenetic registry. The registry provided information on the number of infants with Down's syndrome born during 2000-4 as well as the personal registration number of all infants with Down's syndrome born during 2005-7 and their mothers.


For various political and practical reasons one county (Funen) had not yet reported the results of their chromosome analyses to the registry. We therefore obtained information separately on the number of chorionic villus samplings and amniocenteses and prenatal and postnatal cases of Down's syndrome for 2000-6 from Funen's chromosome laboratory.


Nuchal translucency ultrasonography is carried out by nurses, midwives, and doctors certified by and in accordance with the guidelines of the Fetal Medicine Foundation in London (www.fetalmedicine.com/). All obstetrics and gynaecology departments in Denmark use the same fetal medicine software program (Astraia, Germany) for calculating risk based on formulas derived by the Fetal Medicine Foundation. In some hospitals blood samples collected for the double test (serum free β human chorionic gonadotrophin and pregnancy associated plasma protein A) are analysed at local laboratories, whereas other hospitals send samples to a central laboratory. Most of the laboratories use Brahms Kryptor (Brahms, Immunodiagnostic Systems, UK) for biochemical analyses and a few use an alternative immunoassay (Delfia Xpress; PerkinElmer, Waltham, MA).


Evaluation of Screening Performance in 2005 and 2006


From the 19 obstetrics and gynaecology departments we collected information on the number of women who had had a risk assessment for Down's syndrome in the first trimester in 2005 and 2006, either as the optimal combined test (maternal age, nuchal translucency scan, and biochemistry) or by a combination of maternal age and nuchal translucency scan or biochemistry. To enable us to evaluate the screen positive rate, the departments reported the number of women given a risk assessment of 1:300 or more at the time of screening. We chose this uniform cut-off to simplify the presentation of data, despite some departments using a slightly different cut-off for referral to invasive diagnostic testing.


In the calculation of screening performance we included fetuses and newborn infants with Down's syndrome when a first trimester screening test had been done in 2005 or 2006. Information about gestational age at delivery for all infants with Down's syndrome born during 2005-7 was obtained from the Danish National Board of Health.


We cross checked the personal registration numbers of women who had given birth to an infant with Down's syndrome during 2005-7 with all Astraia database servers in Denmark to obtain information on whether screening had been carried out in the first trimester. Information about screening was also requested in those cases where Down's syndrome was diagnosed prenatally by an invasive procedure carried out for indications other than an increased risk of Down's syndrome.


Results
A combined risk assessment in the first trimester was introduced successively in Denmark. In January 2005 nine of the 15 counties (60%) offered women screening, increasing to 13 counties (87%) by January 2006. By June 2006 the whole of the country was covered.


The yearly number of deliveries in Denmark decreased slightly during 2000-6 (fig 1), whereas the mean maternal age at delivery increased from 29.7 years in 2000 to 30.3 years in 2006. Based on the actual distribution of maternal age and if no prenatal screening or invasive diagnosis had been carried out, the estimated expected number of infants with Down's syndrome increased from 121 in 2000 to 132 in 2005 and 135 in 2006.



Figure 1.


Number of liveborn infants and mean maternal age at delivery in Denmark, 2000-6 (remember, you can click the image to enlarge it)

Number of Newborn Infants With Down's Syndrome

The number of newborn infants with Down's syndrome decreased from 55-65 per year in 2000-4 to 31 in 2005 and 32 in 2006. The total number of fetuses and newborn infants with Down's syndrome diagnosed prenatally or postnatally in 2000-3 was stable at around 135-140 per year, with an increase to 157 in 2004, 161 in 2005, and 149 in 2006 (fig 2). The proportion of cases diagnosed prenatally increased from 53-61% during 2000-4, to 81% in 2005 and 79% in 2006.
Figure 2.

Number of fetuses and newborn infants with Down's syndrome diagnosed prenatally or postnatally in Denmark, 2000-6

Prenatal Diagnostic Procedure Rate
The number of prenatal diagnostic procedures (chorionic villus samplings or amniocenteses) decreased from 7524 in 2000 to 3510 in 2006 (fig 3). The number of chorionic villus samplings decreased from 3322 in 2000 to 2302 in 2006, while the number of amniocenteses carried out decreased from 4202 to 1208 in the same years. This corresponds to an increase in the proportion of chorionic villus samplings from 44% to 66%.
Figure 3.

Number of amniocenteses and chorionic villus samplings carried out in Denmark, 2000-6

Screening Performance in 2005 and 2006
About 65 000 women were pregnant in Denmark during 2005-6. In 2005 40 815 women (62.8%) had a risk assessment carried out in the first trimester, increasing to 54 830 (84.4%) in 2006. The remaining women had no risk assessment done because they were offered an invasive diagnostic test for reasons other than a screen positive test result, declined screening, or failed to receive an offer for reasons such as residency in a county not yet offering screening. Figures 4 and 5 show the distribution of women eligible for screening and the groups in which infants with Down's syndrome were diagnosed prenatally and postnatally.
Figure 4.

Number of fetuses and newborn infants with Down's syndrome diagnosed prenatally or postnatally according to screening results in Denmark, 2005. Invasive procedures are chorionic villus samplings or amniocenteses

Figure 5.

Number of fetuses and newborn infants with Down's syndrome diagnosed prenatally or postnatally according to screening results in Denmark, 2006. Invasive procedures are chorionic villus samplings or amniocenteses

In 2005 a total of 1706 women (4.2%) had a risk of 1:300 or more (screen positive rate) and among these, 1388 women (81.4%) decided to have a diagnostic test (fig 4). Seventy two per cent of the diagnostic procedures done because of a screen positive risk assessment were chorionic villus samplings, the remainder were amniocenteses. In 2006 a total of 1899 women (3.5%) had a risk of 1:300 or more and 1704 (89.7%) underwent diagnostic testing as a consequence of the screening result. Seventy six per cent of the diagnostic procedures carried out because of a screen positive risk assessment were chorionic villus samplings.
In the population screened in 2005 the detection rate of Down's syndrome was 86% (95% confidence interval 79% to 92%) -- (101+3)/(101+3+16+1) -- as 104 of 121 women carrying a fetus with Down's syndrome were screened true positive (fig 4). Thus 17 women received a false negative screening result. One of these women had an amniocentesis on suspicion of a malformation after the 18-20 week scan, and the pregnancy was terminated (fig 4). An adjusted detection rate taking into account fetal loss from screening to time of birth (estimated as 25%[4]) was 82% (95% confidence interval 73% to 90%). The false positive rate was 3.9% (3.7% to 4.1%).
In 2006 the detection rate was 93% (87% to 97%) -- (92+5)/(92+5+6+1) -- as only seven women received a false negative screening result. One of these women had an amniocentesis on suspicion of a malformation, and the pregnancy was terminated (fig 5). The adjusted detection rate taking fetal loss into account was estimated at 92% (83% to 97%). The false positive rate was 3.3% (3.1% to 3.4%).
The odds of being affected (carrying a fetus with Down's syndrome) after receiving a screen positive risk assessment during the first trimester were 1:16 in 2005 and 1:20 in 2006. The odds of being affected after receiving a screen negative result were 1:2301 in 2005 and 1:7562 in 2006.
The odds of being affected after undergoing chorionic villus sampling or amniocentesis owing to advanced maternal age were similar in 2005 and 2006 (1:65 and 1:75); 15 fetuses with Down's syndrome were diagnosed among 980 women in 2005 and eight fetuses among 600 women in 2006. Indications other than advanced maternal age or high risk after screening for undergoing chorionic villus sampling or amniocentesis were mainly family history of chromosomal abnormality, mental retardation or monogenic inherited disease, or a high risk on the basis of serum screened in the second trimester.
Thirty infants with Down's syndrome were born to mothers who had had a risk assessment done in the first trimester during 2005 and 2006. The table gives the details of the risk assessments.

Discussion
Even before full implementation of the policy for combined risk assessment during the first trimester in Denmark, the number of infants born with Down's syndrome decreased by about 50% and the number of cases diagnosed prenatally increased by around 30%.

The number of fetuses and newborn infants with Down's syndrome diagnosed prenatally or postnatally increased in the period 2000-5, with a slight decline in 2006 (fig 2). This was partly due to increasing maternal age, but was as expected because more fetuses with Down's syndrome are lost spontaneously than those that are chromosally normal. This increased rate has been estimated at around 25% from week 14 to term.[4] Based on the known distribution of maternal age at delivery in 2005 and 2006, 132 and 135 infants with Down's syndrome would have been expected in our population of 65 000 liveborn infants if the mothers had no prenatal intervention. Down's syndrome was diagnosed in 31 infants postnatally and 130 prenatally in 2005 and in 32 infants postnatally and 117 prenatally in 2006. Given a rate for fetal loss of 25%, this corresponds to 129 infants with Down's syndrome diagnosed postnatally in 2005 and 120 diagnosed postnatally in 2006. In 2005 the expected numbers were close to those reported, whereas in 2006 the reported number was lower than expected. This may be due to chance fluctuation, as we believe follow-up is complete. The follow-up time for the numbers reported from 2006 is, however, relatively short and a few cases may therefore still be reported.

In 2005 national screening was not fully implemented. One third of the women were either not offered screening or declined. These women gave birth to a total of 17 infants with Down's syndrome. In 2006 the proportion of non-screened women decreased to 15%, as screening was then available for most women. About 8500 women who were not offered screening or declined screening or a diagnostic test in 2006 gave birth to a total of 11 infants with Down's syndrome. The national guidelines on prenatal screening emphasise that risk assessment for Down's syndrome should be done only if women choose the test on the basis of an informed choice. Therefore despite the programme now being accessible to all pregnant women in Denmark, it is expected that a proportion will still choose not to be screened. The size of this proportion when screening is fully available remains to be established; however, in 2005 only 2% of the population in two counties declined screening.[5] Studies on Danish women's attitude, knowledge about screening, and choice of test are ongoing.[6]

We found that the number of prenatal diagnostic tests (chorionic villus samplings and amniocenteses) carried out yearly decreased by more than 50% during 2000-6. A decrease in the number of prenatal diagnostic procedures could be seen even before the policy was changed, probably because pregnant women became aware of alternative prenatal investigations such as nuchal translucency scanning (fig 3). This was certainly the case in and around Copenhagen, when a prospective study of around 10 000 women was done in 1998-2001.[7] Nuchal translucency scanning was introduced in some departments even before the national guidelines were changed.

In 2005 and 2006 about 3% of women still had an invasive diagnostic procedure done because of indications other than a screen positive test result, with a tendency towards a reduced number of tests from 2005 to 2006 (2274 women in 2005, 1805 in 2006). The decrease was mainly due to fewer women choosing invasive diagnostic tests on the basis of advanced maternal age, as 980 invasive procedures were carried out for that indication in 2005 but decreased to 600 in 2006. The relatively high number of women choosing chorionic villus sampling or amniocentesis was probably partly due to lack of implementation of the new screening programme. It is also possible that women who had a diagnostic procedure for a previous pregnancy because they were aged 35 or more may have requested a diagnostic test again. When the new screening strategy based on ultrasound and biochemistry has been available for some years we expect the number of invasive diagnostic tests done because of advanced maternal age to decrease even further.

We found that 10-20% of women with a screen positive test result did not undergo an invasive diagnostic test. This is in accordance with reports from the Copenhagen First Trimester Study.[7] For various reasons (advanced maternal age, conception by assisted reproduction technologies, or risk near the cut-off) some women do not want an invasive diagnostic test, probably because of the associated risk of miscarriage.

The difference in odds of carrying a fetus with Down's syndrome for those who were tested because of a screen positive risk assessment (1:16 in 2005, 1:20 in 2006) compared with that of being tested because of advanced maternal age (1:65 in 2005, 1:75 in 2006) clearly illustrates the rationale in screening using a combined risk assessment in the first trimester. As expected, this strategy reduces the number of unnecessary diagnostic procedures. The procedure related risk of miscarriage after chorionic villus sampling or amniocentesis is reported to be 1%.[8] In the group of women having an invasive diagnostic test done because of advanced maternal age in 2005 and 2006 16 chromosomally normal fetuses would then have been miscarried to diagnose 23 cases of Down's syndrome. This should be compared with the 31 fetuses possibly miscarried to diagnose 193 cases of Down's syndrome in the group of women with a screen positive test result. Combined risk assessment in the first trimester is not only a more effective screening method than maternal age alone, it also reduces the risk of miscarrying chromosomally normal fetuses when used as reason to be referred for testing instead of maternal age. Thus the false positive rate of prenatal diagnostic testing has been much reduced by changing the selection criterion from maternal age to risk assessment in the first trimester. The false negative rate has also changed: previously those women who chose to have chorionic villus sampling or amniocentesis because of advanced maternal age had a diagnostic test. Currently women choose to have a screening test; 0.4 women per 1000 in 2005 and 0.1 per 1000 in 2006 subsequently delivered a child with Down's syndrome, despite having a risk assessment below the 1:300 cut-off. These few women may feel more resentment towards the system that failed them than those women who chose not to have an invasive diagnostic test because of advanced maternal age. This emphasises the importance of informing all women about the limitations of screening.

For false positive rates of 3.9% and 3.3% in the screened populations we found detection rates for Down's syndrome of 86% in 2005 and 93% in 2006. This is in accordance with the screening performance expected by the Danish National Board of Health when it decided to implement this new screening strategy. This performance may be considered high, especially as the programme in 2005 and 2006 in many centres used a completely new screening method. Furthermore, we report the result of routine clinical practice, where not all risk assessments are based on the optimal variables (combination of maternal age, nuchal translucency scan, and biochemistry) as some are given only on maternal age and nuchal translucency scan or biochemistry. Other authors have also reported screening results achieved in routine clinical practice in up to 13 centres, with detection rates between 83% and 93% and false positive rates between 3.9% and 5.9%.[9-13] One study collected data from 44 centres in the Netherlands and found a detection rate of 71% for a false positive rate of 4.7%.[14] The authors explain the relatively low detection rate by too small measurements used for nuchal translucency, and expect to improve the detection rate by establishing quality assurance on the measurements. In a large prospective multicentre study the detection rate using a combined screening programme in the first trimester was 92.6% for a false positive rate of 5.2%.[15] Our data show that it is possible to introduce this screening strategy in as many as 19 different centres and still obtain national detection and false positive rates similar to those from specialised centres.

It is well known that implementation of new screening strategies requires effort, and many countries are currently facing various problems in trying to achieve a national strategy.[16-18] In Denmark, with its public, free of charge hospital system, we have succeeded in establishing a strong national organisation for fetal medicine. Recruitment and training of sonographers as well as quality control are in accordance with the guidelines from the Fetal Medicine Foundation in London (http://www.fetalmedicine.com/). We have implemented national guidelines on screening in the first trimester, and from 1 January 2007 a common cut-off of 1:300 for referral to invasive diagnostic testing at the time of screening. Furthermore, the use of the same database software in all departments allows national data to be merged. A national quality database has been established that merges data from all fetal medicine units, the Danish national cytogenetic registry, and the national patient registry. This will allow follow-up of all screened women at a national level, as well as monitoring of detection rates, false positive rates, and invasive testing rates, a quality control that is considered essential after the implementation of a new screening programme.

References
Danish National Board of Health. Report from a working commission "Prenatal diagnosis and risk assessment." www.sst.dk/upload/fosterdiagnostik1_001.pdf. 2003.
Jorgensen FS. [Organization of obstetric ultrasound in Denmark 2000. Description of the development since 1990]. Ugeskr Laeger 2003;165:4404-9.
Morris JK, Mutton DE, Alberman E. Revised estimates of the maternal age specific live birth prevalence of Down's syndrome. J Med Screen 2002;9:2-6.
Snijders RJ, Sundberg K, Holzgreve W, Henry G, Nicolaides KH. Maternal age- and gestation-specific risk for trisomy 21. Ultrasound Obstet Gynecol 1999;13:167-70.
Torring N, Jolving LR, Petersen OB, Holmskov A, Hertz JM, Uldbjerg N. [Prenatal diagnostics in Arhus and Viborg counties after implementation of first trimester risk assessment]. Ugeskr Laeger 2008;170:50-4.
Bangsgaard L, Tabor A. OC30: Are pregnant women and their partners making an informed choice about first-trimester risk assessment for Down syndrome? Ultrasound Obstet Gynecol 2007;30:376.
Wojdemann KR, Shalmi AC, Christiansen M, Larsen SO, Sundberg K, Brocks V, et al. Improved first-trimester Down syndrome screening performance by lowering the false-positive rate: a prospective study of 9941 low-risk women. Ultrasound Obstet Gynecol 2005;25:227-33.
Alfirevic Z, Sundberg K, Brigham S. Amniocentesis and chorionic villus sampling for prenatal diagnosis. Cochrane Database Syst Rev 2003;(3):CD003252.
Hadlow NC, Hewitt BG, Dickinson JE, Jacoby P, Bower C. Community-based screening for Down's syndrome in the first trimester using ultrasound and maternal serum biochemistry. Br J Obstet Gynaecol 2005;112:1561-4.
O'Leary P, Breheny N, Dickinson JE, Bower C, Goldblatt J, Hewitt B, et al. First-trimester combined screening for Down syndrome and other fetal anomalies. Obstet Gynecol 2006;107:869-76.
Soergel P, Pruggmayer M, Schwerdtfeger R, Muhlhaus K, Scharf A. Screening for trisomy 21 with maternal age, fetal nuchal translucency and maternal serum biochemistry at 11-14 weeks: a regional experience from Germany. Fetal Diagn Ther 2006;21:264-8.
Spencer K, Spencer CE, Power M, Dawson C, Nicolaides KH. Screening for chromosomal abnormalities in the first trimester using ultrasound and maternal serum biochemistry in a one-stop clinic: a review of three years prospective experience. Br J Obstet Gynaecol 2003;110:281-6.
Stenhouse EJ, Crossley JA, Aitken DA, Brogan K, Cameron AD, Connor JM. First-trimester combined ultrasound and biochemical screening for Down syndrome in routine clinical practice. Prenat Diagn 2004;24:774-80.
Schielen PC, van Leeuwen-Spruijt M, Belmouden I, Elvers LH, Jonker M, Loeber JG. Multi-centre first-trimester screening for Down syndrome in the Netherlands in routine clinical practice. Prenat Diagn 2006;26:711-8.
Nicolaides KH, Spencer K, Avgidou K, Faiola S, Falcon O. Multicenter study of first-trimester screening for trisomy 21 in 75 821 pregnancies: results and estimation of the potential impact of individual risk-orientated two-stage first-trimester screening. Ultrasound Obstet Gynecol 2005;25:221-6.
Chang TC. Antenatal screening for Down syndrome in New Zealand: time for a national screening policy? Aust N Z J Obstet Gynaecol 2006;46:92-6.
O'Leary P, Breheny N, Reid G, Charles T, Emery J. Regional variations in prenatal screening across Australia: stepping towards a national policy framework. Aust N Z J Obstet Gynaecol 2006;46:427-32.
Reddy UM, Mennuti MT. Incorporating first-trimester Down syndrome studies into prenatal screening: executive summary of the National Institute of Child Health and Human Development workshop. Obstet Gynecol 2006;107:167-73.

Sidebar: What Is Already Known on This Topic
Many countries are currently trying to achieve national screening strategies for Down's syndrome

None has described how a combined screening strategy in the first trimester affects numbers of infants born with Down's syndrome or rate of invasive procedures

Detection rates and false positive rates for the combined first trimester risk assessment have been reported only from specialised centres or from regional experience

What This Study Adds
After implementation of a national screening policy in Denmark, the number of infants born with Down's syndrome and the rate of invasive procedures was noticeably reduced

The screening strategy achieved high detection rates and low false positive rates

Acknowledgements
We thank Jan Hansen for retrieval of data from the Danish Central Cytogenetic Registry, Kirsten Rasmussen for retrieval of data from the Genetic Database of Funen, Steen Rasmussen (Danish National Board of Health) for providing gestational age at delivery in cases where no screening was done,and the departments of clinical biochemistry for analysing the biochemical samples used in the screening programme.
Disclaimer
Ethical approval: This study was approved by the Danish Data Protection Agency and Danish National Board of Health.Provenance and peer review: Not commissioned; externally peer reviewed.
Reprint Address
A Tabor, Email: ann.tabor@rh.regionh.dk
Charlotte K Ekelund, research assistant,1 Finn Stener Jørgensen, consultant,2 Olav Bjørn Petersen, consultant,3 Karin Sundberg, consultant,1 Ann Tabor, professor,1,4 Danish Fetal Medicine Research Group1 Department of Fetal Medicine, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark,2 Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Denmark,3 Department of Obstetrics and Gynaecology, Skejby University Hospital, Aarhus, Denmark,4 Faculty of Health Sciences, University of CopenhagenMembers of the Danish Fetal Medicine Research Group are: Hans Jakob Andersen, Jeanette Christensen, Vibeke Ersbak, Richard Farlie, Carsten Henriques, Annette Wind Olesen, Anni Holmskov, Lisa Neerup Jensen, Anette Kristiansen, Torben Larsen, Hedvig Poulsen, Jan Ramb, Lillian Skibsted, Peter Skovbo, Steffen Sommer, Lene Sperling, Susanne Vemmelund Juul, Helle Zingenberg.Contributors: AT and CKE planned and did the study in cooperation with FSJ, OBP, and KS. CKE and AT wrote the manuscript and are guarantors. Hans Jakob Andersen, Jeanette Christensen, Vibeke Ersbak, Richard Farlie, Carsten Henriques, Annette Wind Olesen, Anni Holmskov, Lisa Neerup Jensen, FSJ, Anette Kristiansen, Torben Larsen, OBP, Hedvig Poulsen, Jan Ramb, Lillian Skibsted, Peter Skovbo, Steffen Sommer, Lene Sperling, KS, Susanne Vemmelund Juul and Helle Zingenberg retrieved data from the local Astraia servers and reviewed and accepted the final manuscript.
Competing Interests: None declared.

Tucson Families Need Your Help

I received and email about this organization, if you are living in Tucson and can help these families, please contact From One Mother to Another.

So many have sons and I am bummed, because I only have girls clothing, but I am still taking some over there, I am sure they can use them eventually, I have inventory from years of selling children's clothing on EBay, my girls cannot wear all of it, even going through 3 outfits a day.

Families who need help:
http://www.from1mother2another.com/Want_to_help_.html

A few new pictures of Meghan

Meghan says " Help , help, I'm stuck" LOL She was too, no wonder that dress was on clearance...

I was snapping pictures of Kara and Amanda so Meghan picked up some flowers and decided to pose for me. Funny girl, she is growing up so much.

Belated birthday pictures

Meghan's fairy cake, we think she looks like a fairy herself. :o)

She just did not want her picture taken, so I kept snapping away anyway, hoping for some good shots. Here she is eating and apple. LOL

With her new doll, I wanted to get her an American Girl doll, but goodness, I think they are a bit pricey. I ended up getting her a Our Generation doll from Target. She loved her until her oldest brother brought her a frilly Barbie, oh well, she is fickle that way...

Kara always wants her chance to get a picture taken too, who can say no?

I got an email today about this song http://harmonizingwithhumanity.com/ and I am wondering how others feel about it. I liked it until she sang about parents having special needs when they have children born with a disability. I would love to hear your thoughts.

I tried to get a picture of Amanda too, but as you can see, she was having none of it! :oÞ

Happy birthday to my sweet girl

MySpace Layouts
I am so proud of my Meghan, and now she is a wonderful 8 year old! Amazing how fast time passes us by.

Exercise video of the week

Since I am a fitness instructor, I thought I would add an exercise video each week, tips and advice for people who want to worout at home, and do not know where to start.

This one is from Spark People, a diet website that is completely free, if you want to join, enter formerlyfit49 as someone who referred you. :o)

Blog personality test

ISTP - The Mechanics http://www.typealyzer.com/

The independent and problem-solving type. They are especially attuned to the demands of the moment are masters of responding to challenges that arise spontaneously. They generally prefer to think things out for themselves and often avoid inter-personal conflicts. The Mechanics enjoy working together with other independent and highly skilled people and often like seek fun and action both in their work and personal life. They enjoy adventure and risk such as in driving race cars or working as policemen and firefighters