Pregnancy Test

1. Indications
   1. Pregnancy diagnosis and monitoring
   2. Tumor monitoring
      1. Nonseminomatous germ cell tumor monitoring
      2. Hydatiform mole diagnosis and monitoring
      3. Choriocarcinoma diagnosis and monitoring
2. Physiology
   1. HCG is a glycoprotein hormone with subunits a and b
      1. Composed of 65% polypeptides by molecular weight
      2. Composed of 35% large sugar side chains (8 chains)
         1. Four are N-Linked (2 each on alpha and beta)
         2. Four are O-Linked (all 4 are on beta subunit)
      3. Forms of HCG found in blood and urine
         1. Intact HCG with alpha and beta subunits
         2. Nicked HCG and nicked free beta subunit
         3. Free beta subunit and free alpha subunit
         4. Hyperglycosylated free beta and free alpha subunits
         5. Beta core fragment (present only in urine)
   2. HCG shares the same alpha subunit with other hormones
      1. Luteinizing hormone (LH)
      2. Thyroid Stimulating Hormone (TSH)
   3. Urine and Blood HCG tests are specific for beta subunit
   4. Serum half life of HCG: 24 to 36 hours
   5. Discriminatory values at which bHCG is positive
      1. Urine bHCG: 20-25 IU/ml
      2. Serum bHCG: 10 IU/ml
3. Interpretation: Levels of bHCG in pregnancy
   1. Estimation in pregnancy for weeks 4 to 8
      1. Normal pregnancy
         1. Increases 80% every 48 hours (doubling every 48 to 72 hours)
      2. Fetal demise
         1. Decreases 20% every 48 Hours
      3. Ectopic Pregnancy
         1. Slower than expected rise in bHCG
      4. Faster than expected rise in bHCG
         1. Multiple Gestation
         2. Gestational Trophoblastic Disease (extremely high bHCG)
   2. Chart of corresponding gestational age
      1. Day 23 (3.3 weeks): 100 mIU/ml (correlates with blastocyst implantation)
      2. Day 28 (4.0 weeks): 250 mIU/ml (approximate time of first missed Menses)
      3. Day 35 (5.0 weeks): 1000 mIU/ml
         1. bHCG 1800: Gestational Sac on Transvaginal U/S
         2. bHCG 3500: Gestational Sac on Transabdominal U/S
      4. Day 42 (6.0 weeks): 4000 mIU/ml
      5. Day 49 (7.0 weeks): 15000 mIU/ml
         1. bHCG 20,000: 5-10 mm Embryo with cardiac activity
      6. Day 56 (8.0 weeks): 65000 mIU/ml
      7. Decreases gradually after 8 weeks
      8. Plateaus after 20 weeks
   3. Ranges of bHCG over each Trimester
      1. First Trimester: 30,000 to 100,000 mIU/ml
      2. Second Trimester: 10,000 to 30,000 mIU/ml
      3. Third Trimester: 5,000 to 15,000 mIU/ml
4. Efficacy: Home Pregnancy Tests
   1. Variable efficacy after missed Menses
      1. Wide discrepancy between brands
      2. Cole (2004) Am J Obstet Gynecol 190:100-5
5. Causes: Elevated bHCG in non-pregnant state
   1. HCG-producing tumors in women (extremely high bHCG)
      1. Hydatidiform Mole or Choriocarcinoma (Gestational Trophoblastic Disease)
   2. HCG-producing tumors in men
      1. HCG is usually undetectable in healthy males
      2. Nonseminomatous germ cell tumor (Testicular Cancer)
         1. Used with AFP for monitoring
6. Causes: False positive increased serum hCG
   1. Causes
      1. Heterophilic Antibody (most common)
      2. Human anti-mouse Antibody (HAMA)
      3. Nonspecific protein-binding hCG-like substances
      4. Red Blood Cell interference
      5. Marijuana use
      6. Hypogonadism
   2. Confirmation methods in non-pregnant conditions
      1. Qualitative urine hCG
      2. Serum hCG by different immunoassay method
      3. Serial dilutions of serum hCG sample
7. Causes: False negative bHCG
   1. Dilute urine
   2. High Vitamin C intake
8. Interpretation: HCG in Nonseminomatous germ cell tumor (Men)
   1. Interpretation
      1. Poor prognosis if bHCG >50,000 mIU/ml at diagnosis
      2. Five year survival rate: 50%
   2. Efficacy
      1. High Specificity in men
      2. Low Test Sensitivity
         1. HCG or AFP increased in 85% of patients
         2. HCG or AFP increased in only 20% of Stage 1 Cancer
   3. Protocol
      1. Initial: bHCG with AFP q1-2 months for 1 year
      2. Later: bHCG with AFP q3 months for 1 year
9. References
   1. Bakerman, ABCs Interpretive Lab Data, p. 239-40
   2. (1997) J Clin Oncol 15:594-603
   3. Hay (1988) J Clin Endocrinol Metab 67:1322-4