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HORMONAL ASSAY

HORMONAL ASSAY. PRESENTED BY: DR. NABEEL S. BONDAGJI Assistant Professor Department of Obstetrics and Gynecology King Abdulaziz University Hospital. BhCG . Protein 2 chain of Aminoacids secreted by syncytiotrophoblast. Alpha Beta subunits To avoid cross reactivity with LH

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HORMONAL ASSAY

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  1. HORMONAL ASSAY PRESENTED BY: DR. NABEEL S. BONDAGJI Assistant Professor Department of Obstetrics and Gynecology King Abdulaziz University Hospital

  2. 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

  3. USES • Pregnancy (normal or abnormal). • Follow up of: • Pregnancy • Chorio Ca • Mixed embryonal Ca

  4. PITUITARY GONADOTROPINSFSH - LH • Glycoprotein • 2 Subunits USES: • Diagnosis of ovarian failure • Diagnosis of PCO • Synthetic F.S.H. for ovulation induction.

  5. 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.

  6. PROGESTERONE USES: • Diagnosis of ovulation • ? Ectopic pregnancy

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

  8. ENDOCRINE LAB VALUES • hCG Quantitative RLA Normal <2mIU/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

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

  10. Progesterone • Male <1.0 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

  11. 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 <20 ng/ml • Female <20 ng/ml FSH • Male < 20 mIU/ml • Female < 25 mIU/ml (except midcycle surge) • Menopausal 30 – 250 mIU/ml

  12. LH • Male <15 mIU/ml • Female <30 mIU/ml (except midcycle surge) • Menopausal 30 – 200 mIU/ml

  13. 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

  14. 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

  15. 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.

  16. 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

  17. 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

  18. 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

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

  20. 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.

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

  22. 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).

  23. 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

  24. 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

  25. 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 Fleet’s enema) • Antibiotics at discretion of surgeon

  26. 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.

  27. 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.

  28. 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.

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