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INTERPRETATION OF hCG LEVELS?
<ul><li>Glycoprotein with  α  and  β  chains </li></ul><ul><li>β  subunit is specific to hCG </li></ul><ul><li>Secreted by...
<ul><li>Pregnancy  </li></ul><ul><li>Gestational trophoblastic neoplasia </li></ul><ul><li>Non gestational  </li></ul><ul>...
<ul><li>Always rule out pregnancy whenever hCG is positive. </li></ul><ul><li>It does not localize the pregnancy  </li></u...
<ul><li>+ve 7-9 days after the midcycle surge that precedes ovulation.(time of blastocyst implantation) </li></ul><ul><li>...
Return of hCG  NVD  3 wks Abortions 6 wks Molar pregnancy 8-9 wks
<ul><li>Discriminatory  level </li></ul><ul><ul><li>Lower limit above which one can reliably visualise </li></ul></ul><ul>...
Positive urinary hCG TVS Pregnancy of Unknown location Serial serum hCG and progesterone Initial progesterone <20nmol/L se...
<ul><li>Mrs. X, 28 yrs G 5 P0+0+4+0 </li></ul><ul><li>C/O  Amenorrhoea  - 49 days </li></ul><ul><li>Pain Abd  - 1 day </li...
<ul><li>Serum  β hCG – 300 IU/L </li></ul><ul><li>Failing PUL IUP   EP </li></ul><ul><li>Rept. Serum  β hCG after 48 hrs :...
TVS IUP No IUS Adenexal mass -EP No adenexal mass or sac Rept  hCG after 48 hrs < 66% rise > 66% rise IUP TVS Failing preg...
<ul><li>Medical treatment </li></ul><ul><ul><li>Pre T/t level:  5000 mIU/ml – 92% success </li></ul></ul><ul><ul><li>Follo...
<ul><li>High risk molar: > one lac mIU/ml </li></ul><ul><li>Follow up :  within 48 hrs of evacuation </li></ul><ul><li>eve...
FIGO score 0 1 2 4 Age (years) <39 >39 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Interval from index ...
Category Criteria Non-metastatic GTN No evidence of metastases; not assigned to prognostic category  Metastatic GTN Any ex...
Surveillance During And After Therapy of GTN <ul><li>Monitor serum quantitative hCG levels every week during chemotherapy:...
<ul><li>75 -110 mIU/L ( max reported 300 mIU/L) </li></ul><ul><li>After chemo/ surgery of GTN </li></ul><ul><li>No clinica...
<ul><li>Phantom hCG </li></ul><ul><li>Heterophilic abs </li></ul><ul><li>React with animal Ag in immuno sandwich assay </l...
 
 
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Interpretation Of Hcg

  1. 1. INTERPRETATION OF hCG LEVELS?
  2. 2. <ul><li>Glycoprotein with α and β chains </li></ul><ul><li>β subunit is specific to hCG </li></ul><ul><li>Secreted by trophoblastic tissue, some amount by fetal tissues, adult ant pituitary </li></ul><ul><li>Many isoforms of hCG with variable crossreactivity between various assays </li></ul><ul><li>More than 100 commercial assays </li></ul><ul><li>Sandwich type immunoassay: Sens - 1mIU/ml </li></ul><ul><li>Immuno radiometric assays: more Sensitive </li></ul>
  3. 3. <ul><li>Pregnancy </li></ul><ul><li>Gestational trophoblastic neoplasia </li></ul><ul><li>Non gestational </li></ul><ul><li>Trophpoblastic neoplasia </li></ul><ul><li>Mixed germ cell tumors </li></ul>
  4. 4. <ul><li>Always rule out pregnancy whenever hCG is positive. </li></ul><ul><li>It does not localize the pregnancy </li></ul><ul><li>USG to lacalise the pregnancy </li></ul><ul><li>Significantly higher levels </li></ul><ul><li>Multiple pregnancy </li></ul><ul><li>Erythroblastosis fetalis </li></ul><ul><li>Down’s syndrome </li></ul><ul><li>Low levels : ectopic pregnancy, abortions </li></ul>
  5. 5. <ul><li>+ve 7-9 days after the midcycle surge that precedes ovulation.(time of blastocyst implantation) </li></ul><ul><li>Blood levels rise rapidly, double every 1.4 - 2 days, max value at 8-10 wks. </li></ul><ul><li>Peak values: 60-80 days of LMP(1 lac mIU/ml) </li></ul><ul><li>10-20 wks POG: begin to fall, nadir levels by 20 wks & maintained at lower levels thru out pregnancy </li></ul>
  6. 6. Return of hCG NVD 3 wks Abortions 6 wks Molar pregnancy 8-9 wks
  7. 7. <ul><li>Discriminatory level </li></ul><ul><ul><li>Lower limit above which one can reliably visualise </li></ul></ul><ul><ul><li>pregnancy </li></ul></ul><ul><ul><li>1500 mIU/ml for TVS </li></ul></ul><ul><li>Doubling time </li></ul><ul><ul><li>IUP : serum hCG levels ↑ 66% every 48 hrs </li></ul></ul><ul><ul><li>Inappropirately rising serum hCG-> dying pregnacy & not its location </li></ul></ul>
  8. 8. 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/L Plateauing, 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
  9. 9. <ul><li>Mrs. X, 28 yrs G 5 P0+0+4+0 </li></ul><ul><li>C/O Amenorrhoea - 49 days </li></ul><ul><li>Pain Abd - 1 day </li></ul><ul><li>O/E Haemodynamically stable </li></ul><ul><li>P/S Uterus soft, bulky, fx free, </li></ul><ul><li>No cervical excitation </li></ul><ul><li>UPT Positive </li></ul><ul><li>TVS ET - 13.4mm </li></ul><ul><li>No IU sac </li></ul><ul><li>No adenexal mass/fluid in POD </li></ul>
  10. 10. <ul><li>Serum β hCG – 300 IU/L </li></ul><ul><li>Failing PUL IUP EP </li></ul><ul><li>Rept. Serum β hCG after 48 hrs : 877 IU/L </li></ul><ul><li>(Rise > double) </li></ul><ul><li>Rescan after 48 hrs </li></ul><ul><li>IUP </li></ul>
  11. 11. TVS IUP No IUS Adenexal mass -EP No adenexal mass or sac Rept hCG after 48 hrs < 66% rise > 66% rise IUP TVS Failing pregnancy D&C
  12. 12. <ul><li>Medical treatment </li></ul><ul><ul><li>Pre T/t level: 5000 mIU/ml – 92% success </li></ul></ul><ul><ul><li>Follow up: D 1 -- baseline </li></ul></ul><ul><li>D 4 -- level >D 1 </li></ul><ul><li>D 7 -- 15% fall from D 4 </li></ul><ul><li>Every week till 15 IU/L </li></ul><ul><ul><li>20% will have decline of hCG < 15% : second dose of Methotrexate </li></ul></ul><ul><ul><li>Average duration for hCG level to reach normal - 36 days </li></ul></ul><ul><li> Longest duration - 109 days </li></ul><ul><li>Expectant treatment </li></ul><ul><li>< 1000 mIU/ml </li></ul><ul><li>< 200 IU/L ----- spontaneous resolution in 88-96 % </li></ul>
  13. 13. <ul><li>High risk molar: > one lac mIU/ml </li></ul><ul><li>Follow up : within 48 hrs of evacuation </li></ul><ul><li>every wk till hCG is normal x 3 wks </li></ul><ul><li>every month x 6 months </li></ul><ul><li>FIGO criteria for chemo </li></ul><ul><li>Plateauing ( + 10% value ,4 values over 3 wks) </li></ul><ul><li>Rising hCG (increase of > 10% of 3 values recorde over a 2 week duration) </li></ul><ul><li>Persistent hCG after 6 months of evacuation </li></ul>
  14. 14. 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
  15. 15. Category Criteria Non-metastatic GTN No evidence of metastases; not assigned to prognostic category Metastatic GTN Any extrauterine metastases Good prognosis metastatic GTN No risk factors: Short duration (<4 months) Pretherapy hCG < 40,000 mIU/ mL Pretherapy hCG <40,000 mIU/ mL No brain or liver metastases No antecedent term pregnancy No prior chemotherapy Poor prognosis Metastatic GTN Any one risk factor: Long duration (>4 months) Pretherapy hCG > 40,000 mIU/ mL Brain or liver metastases Antecedent term pregnancy Prior chemotherapy
  16. 16. Surveillance During And After Therapy of GTN <ul><li>Monitor serum quantitative hCG levels every week during chemotherapy: </li></ul><ul><li>Response: > 10% decline in hCG during one cycle </li></ul><ul><li>Plateau: + 10% change in hCG during one cycle </li></ul><ul><li>Resistance: > 10% rise in hCG during one cycle or plateau for two Remission: 3 consecutive normal weekly hCG values </li></ul><ul><li>Surveillance of remission: </li></ul><ul><li>hCG values every 2 weeks X 3 months </li></ul><ul><li>hCG values every month to complete one year of follow-up </li></ul><ul><li>hCG values every 6-12 months indefinitely; at least 3-5 years </li></ul>
  17. 17. <ul><li>75 -110 mIU/L ( max reported 300 mIU/L) </li></ul><ul><li>After chemo/ surgery of GTN </li></ul><ul><li>No clinical/radiological evidence of trophoblastic tissue </li></ul><ul><li>phantom hCG Quiscent GTN </li></ul><ul><li>(false +ve) (real +ve) </li></ul><ul><li> (Benign or inactive) </li></ul>
  18. 18. <ul><li>Phantom hCG </li></ul><ul><li>Heterophilic abs </li></ul><ul><li>React with animal Ag in immuno sandwich assay </li></ul><ul><li>Confirm by </li></ul><ul><ul><li>Urine hCG –ve </li></ul></ul><ul><ul><li>different assays </li></ul></ul><ul><ul><li>no change in dilutions </li></ul></ul><ul><ul><li>other techniques to srip/ block/ inactivate abs </li></ul></ul><ul><li>Quiscent GTN </li></ul><ul><li>Most often after molar, GTN, pregnancy </li></ul><ul><li>Do not respond to chemo </li></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Hyperglycosylated hCG < 6% </li></ul></ul><ul><ul><li>(hCG – H) </li></ul></ul><ul><ul><li>Serial hCG titres: plateau 5,10,20,22,8,25,24 </li></ul></ul><ul><ul><li>Withhold chemo </li></ul></ul><ul><li>Premalignant (1-11%) </li></ul><ul><li>Monthly FU, glycosylated hCG, </li></ul><ul><li>Slow growing syncytiotrophoblast </li></ul>
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