Human Chorionic Gonadotropin in Maternal Plasma After Induced Abortion, Spontaneous Abortion, and Removed Ectopic Pregnancy JOHAN ARNT STEIER, MD, PER BERGSJ@, MD, AND OLE L. MYKING, MD Human chorionic gonadotropin (hCG) in maternal serum was analyzed by a hCG-f-subunit, radioimmunoassay (hCG-P-RIA) in 36 cases after induced first-trimester abor- tion, 35 cases of spontaneous abortion in the frst trimester, and in 35 cases of ectopic pregnancy to determine the time between the apparent removal of all trophoblastic tissue by surgical intervention and the disappearance of hCG from the blood. In the cases with induced abortion, hCG was detectable from 16 to 60 days, with a median of 30 days after uterine evacuation, in those with spontaneous abortion from, nine to 35 days with a median of 19 days, and in the cases of ectopic pregnancy from one to 31 days with a median of eight, five days after laparotomy and removal ofthe affected tube. There was a significant coreelation between the initial CG levels and the disappearance time in each series. The demonstrated disappearance times are longer than previous- ly recognized, which should be appreciated when hCG is analyzed after termination of early pregnancy. (Obstet Gynecol 64:391, 1988) Determination of plasma human chorionic gonadotro- pin (hCG) by hCG-B-radioimmunoassay (hCG-f-RIA) has been used for the diagnosis of early pregnancy and of ectopic pregnancy, for the diagnosis and control after therapy in trophoblastic disease, and as a prog- nostic aid of threatened abortion during the first tr ester of pregnancy. Several factors will influence the length of time that clapses between the removal of trophoblastic tissue and the disappearance of hCG from the blood, such as the concentration of hCG in body fluids at the time of uterine evacuation, the clearance rate of hCG in the individual, the sensitivity of the test method, and, of course, the completeness of initial tissue removal. Pastorfide et al' have reported that hCG is detectable by hCG-B-RIA up to 27 days after suction curettage and 11 to 16 days after term deliveries. Marrs et al" found that, independent of the Frow the Dapantnent of Oleic nnd Gynesolagy and Hormone Laboratory, Univesity of Bergen Selou of Meticne, Borgen, Nora. VOL. 64, NO. 3, SEP initial values, the time requited to reach the lower limit of detection of 2 miUimL of hCG was similar in all patients with a mean time of 37.5 + 5.1 (SEM) and a range of 29 to 44 days after first-trimester curettage after abortion. Lihteenmaki* found hCG concentra- tions above the detection limit (0.5 ng/mL) up to 23 to 40 days after irs-trimester abortion. Preliminary un- published studies in the authors’ hospital revealed that hCG was detectable even longer after first-trimester abortion, depending on the initial values of RCG. The present study was undertaken to determine the time between the apparent removal of all trophoblastic tissue and the disappearance of hCG from the blood after termination of first-trimester normal and patho- logical pregnancies. Materials and Methods The study consisted of three groups of women. The first group consisted of 36 patients, admitted to the hospital for legal termination of first-timester preg- nancy. They were physically healthy and aged be- tween 16 andl 40 years. All had uneventful pregnancies with a mean amenorrhea of 9.1 = 2.1 (SD) and a range of seven to 13 weeks counted from the first day of the Inst menstrual period. All were terminated with vacu- tum suction followed by curettage Blood samples were drawn, the first before the termination of pregnancy, the subsequent samples after five hours and five days. Thereafter, blood sam- ples were obtained one to two times per week until CG reached a level of less than 10 IU/L. The second group consisted of 35 patients, aged between 18 and 40 years, admitted for spontaneous abortion after amenorthea of between six and 15 weeks, with a mean of 10.2 + 1.9 SD), counted from the first day of the last menstrual period. All had abnormal vaginal bleeding, which, in 34 cases, had 029. 7e40683.00, 391neo so Figure 1. Human chovionic gonadotropin subunit in serum in 36 women with induced abortion before cureage (),fve hours later (and fve day ater (I), mean = SEM. lasted between one and nine days, median three days, before uterine evacuation. In one case, bleeding had lasted 28 days. All had lower abdominal pain with dilatation of the internal cervical os, often with the pregnancy products visible in the cervix. Ultrasonogra- phy did not show intact gestational sac in any case Blood samples were drawn, the first before uterine evacuation, the second the following day, and then twice a week until hCG reached a level less than 10 UML. In the third group 35 19-to 40-year old patients were treated for ectopic pregnancy. The amenorrhea ranged from 2.5 to 11 weeks with a mean of 6.7 + 2.2 (SD) ‘weeks, counted from the frst day of the last menstrual period. In 34 of these cases the pregnancy was located in the fallopian tube, and in one case in an ovary. In ll cases visible pregnancy tissue was removed by Iaparot- omy, and the diagnosis was confirmed by histologic examination. Uterine curettage was also performed. Blood samples for determination of hCG were ob- tained, the first before the operation, then three times during the first week, and then twice a week until hCG reached a level of less than 10 IUIL. ‘Human chorionic gonadotropin was assayed in se- rum by an hCG-6-subunit-radioimmunoassay method without extraction. The technique used is a modifica- tion of a method described by Vaitukaitis et al.* Anti- serum and tracer material were supplied by Hypolab S. A., Coisins, Switzerland. The antiserum had been raised in rabbits immunized with a highly purified - subunit of hCG.‘ The tracer was obtained by radioio- dination of highly purified hCG by the chloramine T method and purification of a Sephadex G 25 column. The Second International Standard for hCG was used as a reference standard. The radioactive complex is precipitated by addition of polyethylenglycol solution at the end of incubation and is collected by centrifuga- tion. Human chorionic gonadotropin-p-values in the first week of pregnancy are 10 to 20 1U/L. The sensitiv- ity limit, based upon tite measurement of plasma from 392 Steier et al Ectopic Pregnancy Mortality 200 nonpregnant women, was 1.24 * 1.44 (SD) IU/L. The within-assay coefficient of variation was 4.7% (N = 50) for the range 1000 to 10,000 IU/L, and the between-assay coefficient of variation was 6.2% (N= 50) for the range 10,000 to 100,000 IU/L. Results Figure 1 shows the baseline values of hCG in the group of patients with induced abortion, which ranged be- tween 122,440 and 5040 IU/L, with a mean of $5,272 = 4500 (SEM) IUIL. After uterine evacuation, hCG fell rapidly during the first five hours and reached a mean concentration of 32,000 = 3189 (SEM) IUIL in all except three who had increasing values. This rapid phase of the elimination of hCG was followed by a more gradu- al decline to a mean of 3780 = 1812 (SEM) after five days, except for one patient who had a temporarily increasing concentration. Depending upon the initial value, the time to reach a level of less than 10 IU/L of hCG ranged between 16 and 60 days with a median of 30 days. Table 1 shows that the elimination time was dependent upon the initial levels of hCG at the time of termination In this group, vaginal bleeding interpreted asa normal menstruation occurred in three women when they still had hCG levels of 200, 90, and 45 IUIL, respectively. In the group of patients with spontaneous abortion, the inital values of hCG ranged between 32,055 and 485 IU/L, with a mean of 7099: 1631 (SEM) IU/L Depending upon the initial values, the time to reach an CG level of less than 10 IU/L had a range of nine to 35 days, with a median of 19 days. The disappearance time was significantly shorter than for the patients with induced abortion (P < .001, Wileoxon test for two samples), although the mean duration of pregnancy at the time of intervention was somewhat longer in the cases of spontaneous abortion. The duration of bleed- ing before curettage did not influence the disappear- ance rates (Table 2) ‘The group with ectopic pregnancy had the shortest ‘Table 1. Disappearance Times of Human Chorionic ‘Gonadotropin-f-Subunit From Serum in the Group of Women With Induced First-Trimester Abortion’ Intl vel on Disappenrance time (days) os (Ui Yo. ace ‘Mean S000 2 355 50,000,000 16 230 ‘=30,000 8 as * By proteminalion eoncentaion Obstetrics & Gynecologyelimination time of hCG, but also the lowest baseline values ranging from 8680 to 17.3 IUIL, with a mean of 1288 +: 342 (SEM) IU/L. The elimination time was from one to 31 days, with a median of 8.5 days. Inall three groups, the disappearance curves of hCG had a similar form (Figure 2). The differences in hCG serum concentration between the groups with sporite- neous and induced abortion were statistically signii- cant (P < 01), both at the time of curettage and up to four weeks thereafter (Figure 2). The correlation between the initial hCG values and the disappearance times was tested by the Spearman rank correlation coefficient and found to be significant for each group (induced abortion: P < .01, spontane- ous abortion: P < .001, ectopic pregnancy: P< .001). Figure 3 shows the proportion of patients. with detectable hCG levels within each group by time after pregnancy termination. Discussion Earlier studies of elimination of hCG have shown disappearance curves that fit with a two-component ‘model, the initial fast phase having a half-life of five to nine hours followed by a slower phase with a half-life of 22 to 32 hours.“ The current results correlate well with this, but they also show that hCG is detectable longer than previously shown, up to 60 days after termination of a first-trimester normal pregnancy. ‘They also indicate that the time for elimination of hCG depends on the clinical status of the pregnancy at the lime of termination. Comiparing the disappearance rates of hCG in the three groups, it was found that the women in the ‘group of legally induced abortion had the longest time span. This may be due to a combination of factors, including the storage of hCG in tissue and the renal clearance rate of hCG. However, it may also signify continued production of hCG from functioning tro- Table 2. Disappearance Times of Human Chorionic Gonadotropin-#-Subunit From Serum in the Group of Women With Spontaneous First ‘Trimester Abortion” Disappearance time (dys) Duration of| leding before evacuation (days) ___Noweases__—__ Median 2 5 19 35 2 0 28" 5 ws By the dation of blading before uterine evacuation. * One cose with 28 days’ Dleeding, the others within the sb to inerday range VOL. 64, NO. 3, SEPTEMBER 1988 nco-s it so009} —— Figure2. The dsappearance cures of hCG fbn in thre groups of women. Senilogarithmie scale. Top curve indicates women with Induced abortion. Middle curve indicates women with spontaneous ‘horton. Lower curve indicates women with etopie pregnaney phoblastic tissue for some time after abortion. This contrasts the situation after spontaneous abortion with more or less devitalized tissue, or even more clearly after termination of an ectopic pregnancy with com- plete removal of the trophoblastic tissue within the fallopian tube, in which cases there was a rapid disap- pearance of hCG. Furthermore, vascular seeding of trophoblastic cells may occur during any pregnancy termination procedure, especially when performed by suction and sharp curettage, while less vascularization and minimal manipulation by removal of the fallopian tube with the ecotopic pregnancy will mean few or no functioning cells left in the circulating system. Regardless of the possibility of retained vital hCG- producing trophoblast, there was a significant correla- umber of persgns 20 OBO days Figure 5. Number of patents with detectable levels of hCG-p: subuni oss than 101UIL in serum after induced abortion, spontane- ‘ous abortion, and ectopic pregnancy by time. Right curve indicates women vith induced abortion. Midale curve indicates women with spontaneous abortion. Laft curve indicates women with ectopic pregnancy. Steier et al Ectopic Pregnancy Mortality 398tion within each clinical group between initial serum levels and the disappearance times. Other investigators have stuclied the elimination of hCG after term deliveries. Goldstein et al? found a fall in the serum hCG concentration to a level less than 1 IU/mL. within the first 9% hours followed by a more gradual decrease during the next two weeks until complete disappearance, in six of eight patients. Inone case, the hCG was detectable up to 30 days. Pastorfde et al! examined two patients after term deliveries and found detectable hCG levels up to 11 days after normal vaginal delivery and 16 days after lective cesarean section. Previous studies have reported that resumption of ovulation may occur within three weeks after inter- ruption of a first-trimester pregnancy™ in spite of levels of hCG up to 35 IU/L, which are thought to be too low to interfere with the release of other gonad~ otropins and ovarian steroidgenesis.* This could ex- plain why three women in this study had vaginal bleeding interpreted as normal menstruation while still having low levels of hCG in the blood. The possiblity cannot be excluded that hCG mea- sured after an interrupted pregnancy is not exactly the same as the hormone measured during the pregnancy. It could be fragments or a changed form that may be biologically inactive but immunologically active and therefore detectable by immunologic methods. Investi- gators have found that hCG secreted during pregnan- cy isa heterogenous substance. Vaitukaitis" has found a “big” hCG in placental extract, whereas other inves- tigators have found differences in the content of sialic acid. Less sialic acid leads to reduced biologic activity ‘but unchanged immunologic activity." This study has focused on the disappearance from the blood of hCG after early pregnancy termination, a problem with clear clinical implications. Considering the paucity of data on hCG elimination after term pregnancy, the authors fee! that similar elimination studies alter term pregnancy may also yield valuable biologic and clinical information. Investigations ofthis problem are currently in progress. ‘The practical conclusion for the clinician is that when a sensitive RIA is used to detect hCG, the long disap: pearance time should be appreciated in women who are examined for gynecologic conditions in the weeks 394 Steier et al_Ectopic Pregnancy Mortality after termination of an early normal or abnormal pregnancy. References 1. Pastorfide GB, Goldstein DP, Kosssa TS, eta Serum chine gonadotropin aetity after molar pregnancy therapeutic abr ton, and term delivery. Am} Obstet Gynec 18233, 1574 2. 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Galdsteln DP Aono, Taumor ML, ea Radoimmunotsay of serum chorionic gonaetropin sty h ofl pregnancy. Am J Obset Gynec! 102210, 1868 10, Vaults: Changing placental concentration of human cho nie gonedatopin and ts subsite during gestation. | Clin Enxdocinol Metab 38755, 174 11. Van Hall EV, Veta, Ross GT: Immunologic an biologi Cal acivty of HCG folowing progressive desjation, End nology 8:56, 1971 ‘Address reprint requests to: J. Art Stier, MD Department of Obstetrics and Gynecology University of Bergen N-B016 Houkeland Hospital Norway Sumit for publicetion July 20,1983. Recised February 14, 198 ‘Accptd or public Februcry 28, 1984. {Copyright © 1981 by The American College of Obstetricians and Gynecologist Obstetrics & Gynecology