HORMONAL ASSAY

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HORMONAL ASSAY

• PRESENTED BY
• DR. NABEEL S. BONDAGJI
• Assistant Professor
• Department of Obstetrics and Gynecology
• King Abdulaziz University Hospital

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BhCG

• Protein 2 chain of Aminoacids secreted by
  syncytiotrophoblast.
• Alpha
• Beta subunits
• To avoid cross reactivity with LH
• Detected in blood 7-9 days after ovulation
• Peak 10-12 wks.
• Half life 36 hrs.
• Became ne
• 3 weeks after delivery and abortion

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USES

1. Pregnancy (normal or abnormal).
2. Follow up of
3. Pregnancy
4. Chorio Ca
5. Mixed embryonal Ca

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PITUITARY GONADOTROPINSFSH - LH

• Glycoprotein
• 2 Subunits
• USES
• Diagnosis of ovarian failure
• Diagnosis of PCO
• Synthetic F.S.H. for ovulation induction.

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ESTROGEN

• Estradiol
• Estriol
• Estrone
• USES
• ? I.U.G.R.
• Double ? triple screen for congenital anomalies.
  
• BhCG
• AFP
• Estriol
• Follow up follicular growth in I.V.F.

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PROGESTERONE

• USES
• Diagnosis of ovulation
• ? Ectopic pregnancy

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PROLACTIN

• Protein
• Similar to GH HPL
• ROLE
• Lactation
• High level inhibit GnRH secretion may lead to
  infertility
• Follow-up of pituitary adenoma.

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ENDOCRINE LAB VALUES

• hCG Quantitative RLA
• Normal lt2mIU/ml
• hCG in Pregnancy (indicative) 2nd I.S.
• 1st week 10-30 mIU/ml
• 2nd week 30-100 mIU/ml
• 3rd week 100-1,000 mIU/ml
• 4th week 1,000-10,000 mIU/ml
• 2nd-3rd month 30,000-100,000 mIU/ml
• 2nd trimester 10,000-30,000 mIU/ml
• 3rd trimester 5,000-15,000 mIU/ml

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Estradiol

• Male 6-46 pg/ml
• Female
• Follicular phase 30 90 pg/ml
• Luteal phase 70 300 pg/ml

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Progesterone

• Male lt1.0 ng/ml
• Female
• Follicular phase 0.1-0.8 ng/ml
• Luteal phase 8-33 ng/ml
• Pregnancy 1st Tri. 15-50 ng/ml
• Pregnancy - 3rd Tri. 179-43 ng/ml

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Sex Hormone Binding Globulin (SHBG)

• Male 0.4 1.3 ug DHT/100 ml
• Female 0.4 - 3.5 ug DHT/100 ml
• Pregnancy 6.5 9.7 ug DHT/100 ml
• Prolactive
• Male lt20 ng/ml
• Female lt20 ng/ml
• FSH
• Male lt 20 mIU/ml
• Female lt 25 mIU/ml (except midcycle surge)
• Menopausal 30 250 mIU/ml

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LH

• Male lt15 mIU/ml
• Female lt30 mIU/ml
• (except midcycle surge)
• Menopausal 30 200 mIU/ml

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ULTRASOUND PRINCIPLES

• Indications for Ultrasonography During Pregnancy
• Estimation of gestational age
• - patient unsure of LMP, verification in
  patient likely to undergo
• cesarean delivery or induction of labor or
  pregnancy termination
• Evaluation of fetal growth
• Vaginal bleeding of undetermined etiology in
  pregnancy
• Determination of fetal presentation
• Suspected multiple gestation
• Amniocentesis
• Size/dates discrepancy
• Pelvic mass
• Suspected molar gestation
• Adjunct to cervical cerclage placement

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• Suspected ectopic pregnancy
• Suspected fetal death
• Suspected uterine abnormality
• IUD localization
• Biophysical profile
• Suspected abruption
• External cephalic version
• Suspected polyhydramnios or oligohydramnios
• Estimation of fetal weight/presentation in
  preterm labor or PROM
• Abnormal MSAFP

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• Follow-up on fetal anomaly
• Follow-up on placental location in previously
  identified previa
• History of previous congenital anomaly
• Serial evaluation of growth in multiple gestation
• Evaluation of fetal condition in late registrants
  for prenatal care.

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First Trimester Ultrasonography

• Gestational sac location
• Identification of embryo
• Crown stump length
• Fetal number
• Presence of cardiac activity
• Evaluation of the uterus, adnexa and cervix

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Second Trimester Ultrasonography

• Fetal number
• Fetal presentation
• Placental localization
• Amniotic fluid volume
• Detection and evaluation of maternal pelvic
  masses
• Pessational dating using at least two fetal
  parameters
• Documentation of fetal cardiac activity
  (including arc and rhythm
• Anatomic survey
• - head plane of BPD/HC midline of brain,
  posterior fossa
• - spine sagittal and coronal views
• - heart 4 chamber view
• - abdomen fetal bladder, kidneys, stomach, and
  umbilical cord
• insertion

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Indications

• Diagnosis
• Evaluation of benign pelvic mass
• Pelvic pain
• Acute (torsion, PID, ectopic, appendicitis, etc.)
• Infertility
• Evaluation of uterine perforation
• Evaluation of pelvis prior to vaginal
  hysterectomy

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• Therapy
• Sterilization
• Fulgaration of endometriosis
• Ectopic pregnancy
• GIFT
• Ovarian cystectomy
• Oopherectomy
• Lysis of adhesions
• Appendectomy
• ? Hysterectomy, myomectomy incontinence surgery

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LAPAROSCOPY

• DEFINITION
• Visualization of the peritoneal cavity using a
  fiberoptic magnification system.
• The CO2 insufflation of the peritoneal cavity
  distends the abdominal wall up of the viscera to
  facilitate visualization.

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Contraindications

• Large pelvic mass
• Advanced pregnancy
• Massive pelvic adhesion
• Intestinal obstruction
• Wide spread intra-abdominal carcinomatosis

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• Technique
• Open Laparoscopy
• Complication
• 1. Bleeding (inferior epigastric vessel injury)
• 2. Infections
• 3. Restriction of chest expansion (in
  cardiovascular patients)
• 4. Injury to viscera (Bladder and Bowell, Major
  Blood Vessels).

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• Exceptions to Performing a Complete Survey
• Placental localization in cases of antepartum
  hemorrhage or prior to cesarean
• Determination of fetal lie or presentation in
  labor
• Estimation of fetal size or weight in emergency
  situation
• Determination of multiple gestation
• Ultrasound guided amniocentesis
• External cephalic version
• Confirmation of cardiac activity
• Biophysical profile in patient who has had a
  prior basis or targeted ultrasound
• Amniotic fluid volume
• Previous second trimester basic and/or targeted
  ultrasound

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First Trimester Ultrasound Appearance

• Early Landmarks by Endovaginal Sonography
• 4 weeks Choriodecidual thickening chorionic sac
  
• 5 weeks Chorionic sac (5-15 mm) yolk sac
• 6 weeks Yolk sac/embryo detectable heart motion
• 7 weeks Embryo/fetal movement prominent
  rhombencephalon
• 8 weels Physiologic bowel herniation arms, legs

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Pre-op Evaluation

• Patients must be well informed about all risks of
  planned procedure
• Routine history and physical
• Laboratory studies as indicated (B-hCG, CBC,
  etc.)
• Bowel prep where appropriate (GoLytely or Fleets
  enema)
• Antibiotics at discretion of surgeon

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Critical Analysis

• Fair evidence to suggest superiority of
  laparoscopy in treatment of
• Ectopic pregnancy
• Endometriosis
• PCOD resistant to clomiphen
• Superiority of laparoscopy over laparotomy in
  more advanced procedures requires further
  evaluation and is more surgeon-specific.

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LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCY

The ectopic pregnacy is visualized in the
ampullary region of the left fallopian tube.
Salpingostomy on the antimesenteric border is
perfomed to allow withdraw of the products of
conception and preservation of the tube.
After the tube is opened, a grasper is used to
remove the products of conception.
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Unfortunately, bleeding occurs after removal of
the products of conception, but
electrocoagulation is used to achieve hemostasis.
Once hemostasis is assured, the hemoperitoneum is
evacuated. A single follow-up ß-HCG should be
drawn 2-3 weeks post op.