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 Detected in blood 7-9 days after ovulation Peak 10-12 wks. Half life 36 hrs. Became –ne 3 weeks after delivery and abortion

USES

1. Pregnancy (normal or abnormal).

2. Follow up of:

3. Pregnancy

4. Chorio Ca

5. Mixed embryonal Ca

PITUITARY GONADOTROPINSFSH - LH

Glycoprotein 2 Subunits

USES:

1. Diagnosis of ovarian failure

2. Diagnosis of PCO

3. Synthetic F.S.H. for ovulation induction.

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.

PROGESTERONE

USES:

1. Diagnosis of ovulation

2. ? Ectopic pregnancy

PROLACTIN

Protein Similar to GH + HPL

ROLE:1. Lactation2. High level inhibit GnRH secretion may lead to

infertility3. Follow-up of pituitary adenoma.

ENDOCRINE LAB VALUES

hCG Quantitative RLANormal <2mIU/mlhCG in Pregnancy (indicative) 2nd I.S.

1st week 10-30 mIU/ml2nd week 30-100 mIU/ml3rd week 100-1,000 mIU/ml4th week 1,000-10,000 mIU/ml2nd-3rd month 30,000-100,000 mIU/ml2nd trimester 10,000-30,000 mIU/ml3rd trimester 5,000-15,000 mIU/ml

Estradiol

Male 6-46 pg/ml Female

Follicular phase 30 – 90 pg/ml

Luteal phase 70 – 300 pg/ml

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

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

LH

Male <15 mIU/ml Female <30 mIU/ml

(except midcycle surge)

Menopausal 30 – 200 mIU/ml

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

• 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

• 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.

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

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

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

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

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.

Contraindications:

1. Large pelvic mass

2. Advanced pregnancy

3. Massive pelvic adhesion

4. Intestinal obstruction

5. Wide spread intra-abdominal carcinomatosis

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).

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

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

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

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.

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.

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.