Download - Interpretation Of Hcg

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INTERPRETATION OF hCG LEVELS?

Glycoprotein with α and β chains β subunit is specific to hCG Secreted by trophoblastic tissue, some amount by

fetal tissues, adult ant pituitary Many isoforms of hCG with variable crossreactivity

between various assays More than 100 commercial assays Sandwich type immunoassay: Sens - 1mIU/ml Immuno radiometric assays: more Sensitive

1. Pregnancy

2. Gestational trophoblastic neoplasia

3. Non gestational Trophpoblastic neoplasiaMixed germ cell tumors

Always rule out pregnancy whenever hCG is positive.

It does not localize the pregnancy USG to lacalise the pregnancy

Significantly higher levelsMultiple pregnancyErythroblastosis fetalisDown’s syndrome

Low levels : ectopic pregnancy, abortions

+ve 7-9 days after the midcycle surge that precedes ovulation.(time of blastocyst implantation)

Blood levels rise rapidly, double every 1.4 - 2 days, max value at 8-10 wks.

Peak values: 60-80 days of LMP(1 lac mIU/ml)

10-20 wks POG: begin to fall, nadir levels by 20 wks & maintained at lower levels thru out pregnancy

Return of hCG

NVD 3 wks

Abortions6 wks

Molar pregnancy8-9 wks

Discriminatory level Lower limit above which one can reliably

visualisepregnancy

1500 mIU/ml for TVS

Doubling timeIUP : serum hCG levels ↑ 66% every 48 hrsInappropirately rising serum hCG→ dying

pregnacy & not its location

Positive urinary hCG

TVS

Pregnancy of Unknown location

Serial serum hCG and progesterone

Initial progesterone<20nmol/L

serial hCG <66% or plateauing hCG

Initial hCG>=1500IU/L

hCG<500IU/LPlateauing, negative TVS & laparoscopy

↑ serial hCG>= 66%

Probable failing PUL

Probable IUP

Possible EP Probable

EP? Persisting PUL

Repeat serum hCG in 1 week

Rescan in 2 weeks

Close monitoring with seial hCG/TVS until diagnosis made or hCG<15IU/L

Laparoscopy

Methotrexate

Mrs. X, 28 yrs G 5 P0+0+4+0

C/O Amenorrhoea - 49 daysPain Abd - 1 day

O/E Haemodynamically stableP/S Uterus soft, bulky, fx free,

No cervical excitationUPT PositiveTVS ET - 13.4mm

No IU sacNo adenexal mass/fluid in

POD

Serum βhCG – 300 IU/L

Failing PUL IUP EP

Rept. Serum βhCG after 48 hrs : 877 IU/L

(Rise > double)

Rescan after 48 hrs

IUP

TVSIUP No IUS

Adenexal mass -EP

No adenexal mass or sac

Rept hCG after 48 hrs

< 66% rise> 66% riseIUPTVS

Failing pregnancy

D&C

Medical treatment Pre T/t level: 5000 mIU/ml – 92% success Follow up: D1 -- baseline

D4 -- level >D1

D7 -- 15% fall from D4 Every week till 15 IU/L

20% will have decline of hCG < 15% : second dose of Methotrexate

Average duration for hCG level to reach normal - 36 days Longest duration - 109 days

Expectant treatment < 1000 mIU/ml < 200 IU/L ----- spontaneous resolution in 88-96 %

High risk molar: > one lac mIU/ml

Follow up : within 48 hrs of evacuationevery wk till hCG is normal x 3

wks every month x 6 months

FIGO criteria for chemo

Plateauing (+ 10% value ,4 values over 3 wks)

Rising hCG (increase of > 10% of 3 values recorde

over a 2 week duration)

Persistent hCG after 6 months of evacuation

FIGO score 0 1 2 4

Age (years) <39 >39

Antecedent pregnancy Hydatidiform mole

Abortion Term pregnancy

Interval from index pregnancy (months)

<4 4-6 6-12 >12

Pretreatment hCG (mIU/mL)

<1000 1000-10,000

10,000-100,000

>100,000

Largest tumor size including uterus (cm)

3-4 5

Site of metastases Spleen Kidney

Gastrointestinal

Brain lever

Number of metastases identified

0 1-4 4-8 >8

Previous failed chemotherapy

Single drug >2 drugs

Category Criteria

Non-metastatic GTN No evidence of metastases; not assigned to prognostic category

Metastatic GTN Any extrauterine metastases

Good prognosismetastatic GTN

No risk factors:Short duration (<4 months)

Pretherapy hCG< 40,000 mIU/ mL

Pretherapy hCG <40,000 mIU/ mLNo brain or liver metastasesNo antecedent term pregnancyNo prior chemotherapy

Poor prognosisMetastatic GTN

Any one risk factor:Long duration (>4 months)Pretherapy hCG > 40,000 mIU/ mLBrain or liver metastasesAntecedent term pregnancyPrior chemotherapy

Surveillance During And After Therapy of GTN

Monitor serum quantitative hCG levels every week during chemotherapy:

1.Response: > 10% decline in hCG during one cycle2.Plateau: + 10% change in hCG during one cycle3.Resistance: > 10% rise in hCG during one cycle or plateau for two Remission: 3 consecutive normal weekly hCG values

Surveillance of remission:1.hCG values every 2 weeks X 3 months2.hCG values every month to complete one year of follow-up3.hCG values every 6-12 months indefinitely; at least 3-5 years