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In pregnancies in which the fetus has trisomy 18, the maternal serum level of hCG, estriol, and -fetoprotein are frequently lower than expected.91 Combined measurements of hCG, -fetoprotein, inhibin-A, and unconjugated estriol are able to detect approximately 80% of fetuses with Down syndrome, with a false-positive rate of approximately 5%.82, 89 More recently, combined first and second trimester maternal serum markers including hCG, in combination with ultrasound screening measuring the fetal nuchal thickness at 1114 weeks' gestation, has achieved 95% detection rates for Down syndrome.29, 30 The usefulness of these maternal serum markers may be a result of altered growth of the extraembryonic tissues when chromosomal abnormalities are present