Category Archives: Pregnancy

Pregnancy

Anti-Mullerian Hormone: The Blood-Based Biological Clock?


Many women choose to delay starting a family for various reasons, but how long is too long to wait? Is there some way to determine the time remaining on a woman’s “biological clock” to help guide family planning? A new biomarker measured in blood, anti-Müllerian hormone (AMH), has been proposed to do exactly that but there are some important limitations that must be considered before rushing out to the closest doctor’s office to request an AMH measurement.

First, some background. Women are born with approximately one million primordial ovarian follicles and only about one thousand of these remain when a woman reaches menopause. Over the course of a woman’s reproductive years, these primordial follicles come out of hibernation and develop into immature follicles by accumulating theca cells that produce testosterone and granulosa cells that convert testosterone to estradiol. Each cycle, in response to follicle-stimulating hormone (FSH), one of these immature follicles becomes the dominant, mature follicle that ultimately releases an egg through the process of ovulation. Some immature follicles exit the development pathway and become nonviable while others continue to develop for possible selection as the dominant follicle in a subsequent cycle. The key point is that the granulosa cells of these immature follicles produce AMH, which can be measured in serum or plasma as a direct reflection of the number of immature follicles. If more immature follicles are present, the serum/plasma AMH concentration will be higher. If fewer immature follicles are present, the AMH concentration will be lower. At first glance, measuring AMH would seem to be the ideal way to determine a woman’s reproductive lifespan – if AMH is high, many immature follicles remain and menopause is years away.

Unfortunately, it’s not quite that simple. While elevated AMH concentrations do reflect a large number of immature follicles, this doesn’t necessarily guarantee fertility. Polycystic ovary syndrome (PCOS) is a condition marked by the presence of many immature AMH-secreting follicles and women with PCOS typically have elevated serum/plasma AMH concentrations. AMH has been shown to inhibit the effects of FSH and AMH excess prevents immature follicles from reaching the final stages of development, resulting in impaired fertility for many women with PCOS. While an AMH concentration within the age-appropriate reference interval is a favorable indicator of fertility, higher is not necessarily better as very high AMH concentrations may indicate an underlying anovulatory condition.

At the other extreme, low age-specific serum/plasma AMH concentrations have been associated with impaired fertility in women in their 30s and may predict earlier menopause but low AMH concentrations are substantially harder to interpret in girls and younger women – precisely the population for whom an early estimate of reproductive lifespan would be most valuable. Low AMH concentrations in healthy women in their teens and 20s have not been associated with impaired fertility and survivors of childhood cancers with low AMH concentrations have achieved pregnancy. Furthermore, circulating AMH concentrations are reduced by lifestyle factors like oral contraceptive use and smoking, complicating the connection between AMH concentration and reproductive lifespan.

While studies of large numbers of women show that a low age-specific AMH concentration is associated with earlier menopause, it’s difficult to predict the age at menopause for an individual woman using a serum/plasma AMH concentration. The rate of decline in serum/plasma AMH concentrations varies from woman to woman, meaning that two women with identical AMH concentrations one year may have very different AMH concentrations the following year. Furthermore, the onset of menopause is a complex trait determined by genetic factors, environmental exposures and other influences like smoking, alcohol consumption and previous pregnancies. Ultimately, while AMH does reflect the number of immature follicles, its ability to predict onset of menopause and guide family planning decisions is questionable at the present time.

Currently, the most appropriate clinical use of AMH measurement is to predict response to ovarian stimulation in women undergoing in vitro fertilization (IVF). Women with a high AMH concentration (and a large number of immature follicles) who undergo IVF are at increased risk of ovarian hyperstimulation syndrome (OHSS), a potentially fatal condition marked by abdominal fluid retention, blood clots, altered electrolyte concentrations and kidney failure. Using a moderate ovarian stimulation protocol in women with a high AMH concentration has been shown to reduce the risk of OHSS while increasing the number of pregnancies and live births per IVF cycle started. At the other end of the spectrum, women with a low AMH concentration are enrolled in a more intensive stimulation protocol to maximize egg retrieval while those with undetectable AMH are offered alternate treatment options as the chance of IVF success is low.

It’s possible that one day AMH may be routinely measured to predict the onset of menopause but for now, its most promising uses are limited to PCOS diagnosis (still some kinks to be worked out there too) and customization of ovarian stimulation protocols to improve IVF outcomes while minimizing the occurrence of OHSS.

An Update on Zika Virus Testing in Pregnant Women


We have previously blogged about Zika virus   during pregnancy.That post was in February of 2016 and a lot has changed since then.

Zika

For one thing, Zika has been shown to be transmitted via sexual contact from an infected individual (even if he or she does not have symptoms) to a non-infected individual.  The use of condoms can help, and there are guidelines for the pre-conception prevention of sexual transmission. 

In addition, scientists at the CDC have concluded that Zika virus infection does cause microcephaly and other brain defects. This means that women who are infected with Zika virus during pregnancy are at increased risk of having a baby with these problems, but it does not mean that all women with Zika virus infection during pregnancy will have these problems.

Other changes that have occurred since last year include the FDA's Emergency Use Authorization (EUA) for several diagnostic tools for Zika virus, including the Trioplex Real-Time RT-PCR (rRT-PCR) assay and the Zika MAC-ELISA. 

The Trioplex assay is for the detection of RNA from dengue, chikungunya and Zika viruses in serum, whole blood (EDTA), and cerebrospinal fluid (CSF). This is important since dengue and chikungunya are often in the same differential diagnosis with Zika virus. The assay can also be used to detect Zika virus RNA in urine & amniotic fluid.

The Zika MAC-ELISA is intended for the qualitative detection of Zika virus IgM antibodies in human sera or cerebrospinal fluid (CSF).  however, due to cross-reaction with other flaviviruses and possible nonspecific reactivity, results may be difficult to interpret. Consequently, presumed positive, equivocal, or inconclusive tests must be confirmed by plaque-reduction neutralization testing (PRNT).

According to the CDC, who should be tested?

Asymptomatic Pregnant Women

For asymptomatic pregnant women who have traveled to areas with active Zika virus transmission, RNA nucleic acid testing (NAT) testing is recommended on serum and urine within 2 weeks of the date of last possible exposure. Zika virus-specific IgM testing should be performed on women within 2-12 weeks after travel to an area of active transmission or who have had sexual contact with a man confirmed to have Zika virus infection. In areas with active Zika virus transmission, asymptomatic pregnant women should undergo IgM testing as part of routine obstetric care in the 1st and 2nd trimesters. Presumed positive, equivocal, or inconclusive IgM results must be confirmed by plaque reduction neutralization test (PRNT).

Symptomatic Pregnant Women

For symptomatic pregnant women with exposure to Zika virus, RNA nucleic acid testing (NAT) of serum and urine is recommended up to 2 weeks after symptom onset. Whole blood can also be tested for Zika RNA alongside serum and urine. Urine should always be collected with a patient-matched serum specimen. A positive RNA NAT result on any sample confirms Zika virus infection and no additional testing is indicated. A negative RNA NAT result does not exclude Zika virus infection and serum should be tested for the presence of IgM antibodies. If more than 2 weeks have passed since the onset of Zika virus symptoms, specific IgM testing is recommended. Reflex RNA NAT testing should be performed as a subsequent test for pregnant women who are IgM positive.

For recommendations of testing non-pregnant women, and infants, visit the FDA website.

Zika Virus Testing in Pregnant Women


Zika Figure croppedZika virus is a mosquito borne illness that is found in South and Central America. The most common symptoms include fever, rash, joint pain, and conjunctivitis (red eyes). The virus is spread by mosquitos primarily in the Aedes aegypti and Aedes albopictus species which also carry other tropical diseases such as Chikungunya and Dengue. These mosquitos bite humans primarily in the daytime. It is estimated that 80% of people infected with the Zika virus are asymptomatic. In most people with symptoms, the illness is self-limited and resolves in 5-7 days. Disease requiring hospitalization is rare.

Recently, there have been reports in Brazil of an increased rate of microcephaly and other poor pregnancy outcomes in babies from women who were infected with the Zika virus while pregnant.  However, further studies are needed to understand the relationship between these outcomes and infection. In the meantime, the Centers for Disease Control and Prevention (CDC) have issued special travel precautions for pregnant women and women trying to get pregnant.

So who should be tested for Zika virus and what testing is available?

Initially, the CDC advised that a pregnant woman should only be tested if she has symptoms of Zika virus within the first week of being in an endemic area. If the mother is positive, then the infant should be tested for congenital infection.

However, very recently, the CDC updated the guidelines to include asymptomatic pregnant women who live in or have traveled to endemic areas.  The update recommends that serologic testing be offered to pregnant women can be offered testing within 2-12 weeks after they return from travel. For asymptomatic pregnant women who live in endemic areas, testing is recommended at the initiation of prenatal care with follow-up testing mid-second trimester.

For infants that have microcephaly or intracranial calcifications detected prenatally or at birth with a mother who was potentially infected with Zika virus during pregnancy, the infant should be tested. If infants have positive or inconclusive test findings, the case should be reported to the State or local health department for follow-up. If the infant tests negative, other possible etiologies for the microcephaly should be investigated.

For infants without microcephaly or intracranial calcifications with a mother who was potentially infected with Zika virus during pregnancy, subsequent evaluation depends on the mother's results. If the mother test's negative, no further testing is required. If the mother received positive or intermediate results, then the infant should be tested. If the infant test's negative, then no further testing is required. If the infant test's positive then further clinical evaluation (including comprehensive physical exam, cranial ultrasound and ophthalmologic evaluation) should be performed and the infant should be followed for long term sequelae.

No commercial tests are yet available for Zika virus. Testing is performed at the CDC and some local health departments. The tests currently performed include RT-PCR, ELISA for IgM and a plaque reduction neutralization test (PRNT).

Infants who are being evaluated should have RT-PCR performed on serum (from infant or umbilical cord) within 2 days of birth. CSF if available should also be tested by RT-PCR. ELISA for IgM should be performed on infant serum and CSF.

Mothers being evaluated should have serum tested using ELISA. RT-PCR can be performed during the first week of viral infection. Amniocentesis should be offered to pregnant women who test positive or indeterminate and RT-PCR should be performed on the amniotic fluid.

Note that false positives can occur in the ELISA assay due to cross reactivity with other related flaviviruses such as dengue or yellow fever. PRNT can be used to distinguish false positives from true positive results. If neutralizing antibody titers are ≥ 4-fold greater than dengue virus neutralizing antibody titers, then Zika virus is considered positive. Immunohistochemistry can also be performed on fixed placenta or umbilical cord tissue. If any of any of the tests are positive, the infant is considered congenitally infected.

Currently, there is no anti-viral treatment or vaccination for Zika virus. Treatment is supportive. The best defense against Zika is preventing maternal infection by avoiding mosquito bites. It is important to note that, when used as instructed, insect repellants containing DEET, picardin, and IR3535 are safe for pregnant women.

How Early Can Pregnancy Be Detected?


Calendar_2“How early can pregnancy be detected?” is a question we are asked all the time. The short answer is, “It depends.” Let’s answer this question one step at a time.

First, the most common way to detect early pregnancy is by measuring the hormone human chorionic gonadotropin (hCG). If an egg is fertilized, the developing embryo will attach to the lining of the uterus around 6-12 days after ovulation. This is called implantation.  The hormone hCG is produced by trophoblastic cells (the outer layer of the embryo) after implantation. It takes several days for hCG to be detectable in blood or urine. hCG production increases very rapidly with serum concentrations doubling every 1-1.5 days in the first 8-10 weeks of pregnancy. So, detecting pregnancy first depends on how quickly implantation occurs.

Second, it depends on the sample in which hCG is measured; blood or urine. Urine concentrations of hCG are almost always lower than serum concentrations. In addition, urine concentrations of hCG can be affected by fluid intake. If large amounts of fluids are ingested (think Big Gulp)  then urine concentrations will be more dilute. This is why first morning urine samples are often recommended because this urine is usually the most concentrated of the day since people don’t tend to drink anything during the sleeping hours. The amount of water in blood is more regulated that that of urine and generally does not change, even after ingesting large amounts of liquid. Therefore, use of a blood sample will generally detect pregnancy earlier than use of urine. 

Third, it depends on the method used to detect hCG; qualitative or quantitative. Qualitative devices are those that can be purchased over-the-counter to detect hCG in urine. They are also used in hospitals and doctor offices. These devices generally have cutoffs for positivity that vary from about 20-50 IU/L. The cutoff varies widely by brand. Interestingly, we have shown that the devices used at home are often more sensitive than the devices used in the hospital!!  We have previously blogged about this topic. Quantitative hCG assays are performed using blood samples in laboratories and are much more analytically sensitive than qualitative assays. Most quantitative hCG assays can detect hCG at concentrations of 2 IU/L and some can go as low as 0.1 IU/L. Therefore, quantitative assays will be able to detect pregnancy earlier than qualitative assays.

Fourth, when the clinical sensitivity of an hCG test for diagnosing pregnancy is determined, it is usually determined as a function of the number of days relative to the expected day of the menstrual period (EMP). How early an hCG test can detect pregnancy depends on how the EMP is estimated. Most women estimate EMP by counting 28 days from the first day of the last menstrual period (LMP). This 28-day cycle includes the approximate 14 days between first day of menses and ovulation (called the follicular phase) and the approximate 14 days between ovulation and the day before the next menstrual period (called the luteal phase). However, the length of menstrual periods varies between women. Studies have shown that most of the variation occurs in the follicular phase.Therefore, the most accurate way to estimate the EMP is by measuring 14 days from ovulation as estimated by detecting a dramatic rise in the concentration of luteinizing hormone (LH), commonly referred to as the LH surge. Using 14 days from the LH surge can detect 100% of pregnancies by the EMP, as opposed to using 28 days from LMP which did not detect 100% of pregnancies until 7 days after EMP.  By measuring serum hCG, 100% of pregnancies can be detected by EMP and nearly all pregnancies can be  detected by 3 days before EMP. 

In summary, how early pregnancy can be detected depends on many factors. In some cases pregnancy can be detected more than 3 days before EMP. Virtually all pregnancies should be detected by one week after EMP.

Can a personalized approach improve IVF success rates?


Test Tube Baby

This post was written by Robert D. Nerenz, PhD, an assistant professor of pathology and laboratory medicine at the University of Kentucky, in Lexington.

In the United States, an estimated one in seven couples experience infertility and for many of these couples, in vitro fertilization (IVF) represents their best chance of achieving pregnancy. However, IVF cycles constitute a significant expense (approximately $12,500 per cycle), disrupt patients’ daily lives and only result in a healthy, live birth 30% of the time! Furthermore, the majority of IVF cycles performed in the United States involve the transfer of multiple embryos. This is of particular concern because multiple embryo transfer carries a finite risk of a multiple gestation pregnancy. Bringing multiple infants to term is associated with an increased risk of poor fetal and maternal outcomes including decreased birth weight, increased rate of fetal death, preeclampsia, gestational diabetes and preterm labor. Clearly, there is a significant need to improve IVF success rates while also minimizing the likelihood of multiple gestation pregnancies.

One strategy that may accomplish both of these goals is to perform “single embryo transfer” by implanting one embryo that has a high likelihood of producing pregnancy and, ultimately, a live birth. This is the focus of an upcoming symposium at the AACC meeting to be held July 29th at 10:30 am in Atlanta, Georgia. Fertility clinics around the world currently attempt to do this by observing embryos under a microscope and choosing the best embryo on the basis of its physical appearance. Unfortunately, this approach does not provide any information about the embryo’s genetic status. This is an important limitation because aneuploidy (the gain or loss of a chromosome) is the most common cause of pregnancy loss. It is also estimated to occur in ≥10% of clinical pregnancies and becomes more frequent with increasing maternal age.

To ensure that aneuploid embryos are not selected for transfer, several research groups have developed methods collectively known as comprehensive chromosome screening (CCS). CCS involves culturing embryos for 5-6 days, removing a few cells from the trophectoderm (the outer cell layer that develops into the placenta), isolating the DNA from those cells and assessing the copy number of each chromosome using techniques such as quantitative PCR, comparative genomic hybridization, or single nucleotide polymorphism arrays. Following determination of the embryos’ genetic status, only embryos with the normal number of chromosomes are chosen for transfer. In multiple prospective, randomized controlled trials described here and here, CCS has been shown to increase the pregnancy rate and decrease the frequency of multiple gestation pregnancies. As a result, CCS is beginning to make the transition from the research setting to use with patients.

The ability to transfer only euploid embryos represents the most promising application of novel technologies to IVF but ongoing research is focused on other ways to improve the IVF success rate. Many different groups are analyzing the culture medium that embryos are grown in prior to implantation. It is hoped that this will provide information about the embryos’ metabolic health and might help identify which embryos are most likely to result in pregnancy and live birth. Other groups are evaluating endometrial gene expression profiles to assess endometrial receptivity and ultimately determine the best time to perform embryo transfer. While both of these approaches have technical limitations and are not quite ready for primetime, they have the potential to greatly improve our current standard of care and may be ready for clinical use in the near future.

Conventional aneuploidy screening remains “most appropriate” choice for general population


OpinionThe American Congress of Obstetricians and Gynecologists (ACOG) have updated their guidance on cell-free DNA (cfDNA) screening tests for fetal aneuploidy. In it, they state that any patient (i.e. women at high-risk OR low-risk for having an affected pregnancy) may choose cfDNA testing but they caution that conventional screening tests are more appropriate. This document replaces an earlier opinion, published in 2012, which clearly stated that cfDNA screening tests should not be offered to the general obstetrical population because they are considered to be at low-risk.

So ACOG went from recommending that cfDNA testing not be performed on low-risk women to say that they may choose cfDNA testing. Why the subtle change? Well, as ACOG correctly notes, the landscape of cfDNA is changing rapidly. New studies are published frequently and those that have examined the performance of cfDNA tests in  low-risk women have reported that the test performs just as well in them as it does in high-risk women.

However, they make an important point about a metric that doesn't get the attention it deserves. The positive predictive value (PPV). See here for background. Because the prevalence of fetal aneuploidy in low-risk women is lower than it is in high-risk women, a "positive" or "abnormal" test result in low-risk women is more likely to be a false-positive result. For example, a positive result in a 25-year-old woman gives a 33% chance that the fetus is affected but that chance increases to 87% in a high-risk woman.

The report also calls out the "no result" problem. cfDNA tests fail to produce a result in 1-8% of samples tested, usually due to a low amount of fetal DNA in the blood sample. It's becoming clear that women with samples that fail to produce a result are at increased risk of having an affected fetus. According to ACOG, these women she be offered diagnostic testing such as fetal karyotyping using amniotic fluid obtained by amniocentesis.

Other notable points contained within the updated guidance include:

  • Caution about not routinely performing microdeletion screening (offered by some labs) because it has not been fully validated in clinical studies.
  • Clearly indicating that a negative or normal result does not rule out the possibility of an affected fetus.
  • Providing genetic counseling to patients about test limitations and that decisions such as pregnancy termination should not be based on these screening tests.
  • A reminder that cfDNA tests do not screen for neural tube or ventral wall defects

This certainly won't be the final say that ACOG has on cfDNA aneuploidy screening tests. Indeed, they state that "It will be critical to remain abreast of this rapidly changing technology to provide patients with the most effective, accurate, and cost-conscious methods for aneuploidy screening."

Preimplantation Genetic Diagnosis and Screening


BlastocystPreimplantation genetic testing is a way of examining the genetic features of a developing embryo during the process of in vitro fertilization, before pregnancy. After the egg is fertilized with sperm, the embryos develop to the cleavage-stage. On day 3 after fertilization, a single blastomere is removed from the embryo for genetic evaluation using techniques such as PCR, FISH, or comparative genomic hybridization.

Preimplantation genetic diagnosis (PGD) is used to select embryos without certain genetic disorders. This testing including three major groups of disease: sex-linked disorders, single gene defects, and chromosomal disorders.

Preimplantation genetic screening (PGS), is not used to detect disease, but as a screen to select embryos for such things as: matching HLA type in order to be a tissue donor for an affected sibling, selecting gender, selecting embryos with the least predisposition for developing certain cancers, and selecting embryos with a higher chance of implantation and therefore increase the likelihood of achieving pregnancy. Medscape has an excellent overview of PGD and PGS.

For women of advanced maternal age or couples with known genetic mutations, the ability to screen for embryos free of certain genetic mutations is reassuring. However, as with many medical interventions associated with human reproduction, PGS has raised ethical questions. For instance, as stated earlier, PGS can be used to select for a preferred gender. In some cases this is to avoid a sex-specific disease. Other times this is done for so-called "family planning" or "gender balance." In other words, selecting a gender because of personal preference. Some feel this is discriminatory and should not be allowed. In other cases, embryos have been tested so that the resulting child would be compatible to serve as a stem cell donor for a sick sibling (much like the popular fiction book "My Sister's Keeper").   There have also been cases where parents have requested the selection of affected embryos so that the child has the same minor disability, such as deafness or dwarfism, as the parents. Some preimplantation genetics laboratories agree to do this type of testing and some do not.

The New York Times recently ran an article discussing this issue. The article states that:

"In the United States, there are no regulations that limit the method’s use. The Society for Assisted Reproductive Technology, whose members provide preimplantation diagnosis, says it is 'ethically justified' to prevent serious adult diseases for which 'no safe, effective interventions are available.' The method is 'ethically allowed' for conditions 'of lesser severity' or for which the gene increases risk but does not guarantee a disease."

The January issue of Clinical Chemistry published a Question and Answer piece entitled "The Ethical Implications of Preimplantation Genetic Diagnosis." A podcast interview with two of the authors is also available.

The paper summarized the opinions of an ethicist, an attorney, and the director of a preimplantation genetics laboratory. The ethicist indicated that in the past, PGD has focused mainly on reducing the risk of transmitting serious diseases. In the future, he sees a shift away from lifesaving interventions to more ‘eugenically’ inspired interventions. That is, looking for traits that parents do not want in their children and selecting for traits that they do want in an attempt to pass them on. The morality of eugenics is a key moral as this technology moves forward.

Indeed it will be interesting to see where the future of this technology lies. Although it is practiced routinely, the indications, utility, and outcomes of PGD and PGS are still being defined.

Pregnancy testing in the Emergency Department: a physician’s perspective


Today's post is by a guest author, Ian Schwartz, M.D. Dr. Schwartz is an assistant professor of emergency medicine at the Yale University School of Medicine and the former medical director of the adult emergency department at the Yale-New Haven Hospital in New Haven, CT. Here, he provides his perspective on determining a patient’s pregnancy status in an emergency setting and describes the possible consequences of erroneous hCG test results.

EmergencyThe practice of emergency medicine is a daily challenge for providers in the field. Patient histories are varied and nuanced and no two cases are ever the same.  In the hectic, chaotic and over-flowing hallways of the emergency department (ED), providers (not surprisingly) look to hang on to objective evidence in order to come up with diagnoses and treatment plans.

Experienced providers realize, of course, that a diagnosis is usually a best guess. For the majority of patients, emergency room doctors are simply synthesizing a few facts and ideas into a coherent explanation for the symptoms that brought the patient to the ED.

The challenge is that even those elements that we call facts are, themselves, nuanced. Every ED doctor has had the experience of staring at a chest x-ray and debating whether the patient had pneumonia or some fluid in their lungs. X-ray interpretation is literally dealing in shades of grey.

As opposed to evaluating X-rays, laboratory test results would appear to be much more objective. The lab provides a discrete test result along with a reference interval for defining what is considered to be “normal.” For most health care providers the validity and accuracy of most test results go unquestioned. Yes, that patient absolutely has elevated calcium. Yes, this patient is anemic. Decisions for further testing, treatment and disposition are often made based solely on these test results.

Emergency providers (and others who practice evidence-based medicine), think in terms of odds and probability. That is, they think about the likelihood of a disease. Some examples: the likelihood of a blood clot in the lungs given a patient’s risk factors or the 30-day likelihood of a heart attack if a patient with chest pain is sent home. Each ED doc has his or her own acceptable “miss rate” for a given condition.

However, when it comes to pregnancy testing that sort of calculation and prediction simply doesn’t enter the mind of most ED providers. The pregnancy test is often considered to be the one single binary (yes/no) test that they can actually rely on.

Most emergency departments perform qualitative hCG tests using a urine sample to determine a woman’s pregnancy status. The tests are similar to those that can be purchased over-the-counter and performed at home. The person performing the test will be handed the urine sample, perform the test, and (hopefully) chart that result into the medical record and (hopefully) alert a nurse or other care provider of the result.

A provider sees this result and takes the appropriate action. There is usually no second thought about the quality of the test result. If it’s negative then the patient with abdominal pain is not pregnant and the physician can get the CT scan of the abdomen instead of the ultrasound. A negative result is also a license to order antibiotics, pain medications, and other drugs without concern for possible fetal harm. The urine hCG test is the standard way we define pregnancy in the emergency department and it gives the green (or red) light to treat the patient as not pregnant (or pregnant).

There is a problem with this type of reliance: the urine hCG test, itself, is simply not good enough to tell us whether or not a patient is pregnant.

Here are a few facts that most ED providers are unlikely to know about hCG testing:

  1. hCG appears in blood before urine, sometimes up to 5 days earlier.
  2. The claimed analytical sensitivity of most qualitative urine hCG tests is 25 IU/L whereas the quantitative blood assays are sensitive to 1-2 IU/L (commonly pregnancy is defined by greater than 5 IU/L).
  3. Even though common qualitative urine tests claim 99+% accuracy in determining pregnancy status, a recent study suggests that they are actually only 99% sensitive at an hCG concentration of 150-225 IU/L.
  4. There is a potential window of 3 to 7 days during the first trimester of pregnancy where a quantitative blood test will detect hCG while the qualitative urine test might not.
  5. Ectopic pregnancies can occur at hCG concentrations below what is detectable by current qualitative methods.
  6. In one study of over 11,700 urine samples, 69 (0.5%) of ED hCG test results were erroneous due to documentation errors, inherent deficiencies in qualitative tests or because the hCG concentration was below the level of detection.

So what are some real-world consequences of not using the most accurate hCG test at our disposal? If we believe a patient with abdominal pain is not pregnant (when in fact they are) we order CT scans of the abdomen looking for appendicitis or other abdominal diseases. That CT scan just delivered 10 mSv of radiation to the mother and fetus and doubled the risk of the fetus developing a childhood cancer (1 in 1,000). Or we just ordered Motrin, a medication known to cause neural tube defects and a variety of heart defects. And we have just increased the risk of miscarriage two and a half fold.

In a later post, I will address the erroneous belief that qualitative urine hCG tests are quicker to result than quantitative blood tests. However regardless of speed, ED’s across the country are utilizing a test that does not deliver the accuracy that most providers believe they are getting. This is a fact that should be quite troubling to all of us considering the number of urine pregnancy tests that performed each day. How many erroneous results are we are unknowingly receiving and what is the potential harm that is being done to a fetus in its most fragile period of growth?

False Negative Pregnancy Tests Still a Real Problem in Home and Hospital Devices


Neg pregnancy testWe have blogged in the past about false negative pregnancy tests due to hCG beta core fragment (hCGbcf).   After about 5 weeks of pregnancy (i.e. 3 weeks after the expected period) concentrations of hCGbcf, in urine, are higher than all other forms of hCG. Our group has shown previously that the concentration of hCGbcf can saturate one of the antibodies used in the point-of-care hospital pregnancy kits. As a result, test shows a negative result. The variant hook effect can be confirmed if testing shows a positive result after diluting the sample. This phenomenon is referred to as the "variant hook effect" and was reported to the FDA in 2009.

Recently, our group took this observation one step further and examined over-the-counter home pregnancy devices to see if they were subject to the same problem.  We examined six over the counter devices and selected two that seemed to be most affected by the variant hook effect. We then compared those two devices to the hospital device that we had made our original observations in four years ago, and to a hospital device that we thought performs best when compared to various other hospital pregnancy devices. Not surprisingly, we found that the over-the-counter home pregnancy devices are also subject to the variant hook effect. However, what was a surprise was that the hospital pregnancy devices were more affected by hCG beta core fragment than the home pregnancy devices!  Furthermore, despite the fact that the variant hook effect was reported to the FDA in 2009, manufacturers have not changed their devices to avoid this problem. To hear more about this paper you can listen to a podcast describing the findings.

Our laboratory is currently working to better define how much hCGbcf is required to cause the variant hook effect. We hope that this will help manufacturers to produce devices that avoid false negative results. In the meantime, several things need to be done:

  1. Physicians, nurses, and other health care professionals need to be educated about this problem-especially in the hospital setting.
  2. The variant hook effect should be made clearly visible in pregnancy test package inserts and they need to state that when a false negative is suspected, a simple dilution can yield a positive result if the patient is truly pregnant. This is very important for centers that have no alternative way of testing for pregnancy.
  3. Finally, in my opinion, quantitative serum hCG testing should be the preferred pregnancy test in centers where it is available. Serum testing is not subject to the variant hook effect because hCGbcf is not present in serum. Furthermore, quantitative serum assays are much more sensitive than the qualitative assays.

Detecting hCG in urine: how low is low enough?


A recent post on this blog described the inability of qualitative point-of-care (POC) hCG tests to detect hCG when it was present in urine or serum at a concentration that should, according to the test manufacturer, always be detected. The inability of these devices to detect hCG is a serious concern.

A false-negative result from a home pregnancy test can be initially disappointing if a pregnancy is desired or a temporary relief if it is not. By contrast, a false-negative result in the health care setting can result in serious harm to the fetus if a patient who is assumed to not be preganant undergo interventions that are potentially harmul to the pregnancy.

A recent case report has been published that, like other reports, emphasizes the limitations of qualitative urine hCG testing. The case describes a young woman who required radioactive iodine therapy for Grave's disease. Importantly, this young woman was also recently pregnant. That fact would likely not have been discovered had the physician relied on a qualitative urine hCG test. Fortunately, the laboratory had performed a quantiative urine hCG test (note that quantitative hCG tests using urine may be performed by the lab but the results are reported as qualitative (e.g. yes or no) and not the actual hCG concentration) which was interpreted as "positive" because the measured hCG concentration was greater than the lab's cutoff of less than or equal to 5 IU/L (it was 12 IU/L). A serum hCG test performed the same day produced a result 15 IU/L (not pregnant=less than or equal to 5 IU/L). Two days later a repeat serum hCG test produced a result of 147 IU/L confirming that she was in the very early stages of pregnancy. 

As has been noted in this blog in the past (here and here), urine hCG testing is commonly performed in the health care setting because it is convenient. However, the problems with urine hCG tests are so numerous (see here and here) that urine hCG testing should not be relied upon to determine a patient's pregnancy status.

The authors of the case described above correctly point out that the detection thresholds of most qualitative urine hCG tests are stated to be 20–50 IU/L (recent evidence suggest these cutoffs are not always accurate). Further, they call for more sensitive qualitative urine hCG tests in order to decrease the number of false-negative hCG results in the health care setting and suggest that a detection threshold of 5 IU/L (which is the same threshold used for interpreting quantitative serum hCG tests) should be used. Interestingly, this conclusion is similar to the one my group suggested in regards to qualitative serum hCG testing.

I am in complete agreement that when it comes to the detection of early pregnancy, hCG tests that are capable of accurately detecting and/or measuring hCG are required. Currently, this means that serum hCG tests should be used exclusively, in the health care setting, for this purpose. To rely on less sensitive tests and less accurate urine hCG tests is a disservice to our patients.