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do the first tri screen as early as possible, if something looks bad do cvs, otherwise do the amnio? The first tri screen is pretty good at detecting possible problems, particularly for us 40 somethings. Or do the materni21 screen, that will detect things pretty early and you can still do aminio to follow up. I think most severe problems (and most of the other trisomies are pretty severe) will be detected at the u/s, and the downs can be picked up with the materni21 screen.