hCG (assay)

hCG, is human chorionic gonadotrophin. It is a heterodimer hormone belonging to

the same family of hormones as LH, FSH, and TSH. The alpha subunit of these four
hormones are identical. hCG is principally produced by the gestational trophoblast,
but is also produced in small quantity in the post-menopausal pituitary.

hCG is considered a marker of pregnancy, gestational trophoblastic disease, and

also certain testicular tumors. Most hCG assays are licensed for diagnosis of
pregnancy, but not as tumor markers. Apart from these use, hCG is also used for
traditional second-trimester Down syndrome screening.

The forms of hCG found in serum include intact hCG (i.e. alpha-beta heterodimer),
beta-hCG (monomer of beta-subunit), alpha-hCG (alpha-subunit, shared between
TSH, FSH, LH and hCG), nicked hCG (hCG nicked in one of the three positions in
residues 40-50), and in specifically in urine, beta-core fragment (a degradation
product of hCG)

The predominant forms of hCG that exist in body fluid is different dependent on the
cause of the hCG elevation. In early pregnancy, during first two weeks, the
predominant form of hCG is hyperglycosylated hCG, which contains larger, tri-
antennary N-linked glycosylation and hexasaccharide O-linked glycosylation (vs
biantennary N-linked, trisaccharide O-linked glycosylation in normal, intact hCG). In
later pregnancy, intact hCG is the predominant species in serum. In the urine
specimen, however, beta core-fragment is the predominant species. In gestational
trophoblastic disease, especially with persistent or invasive disease,
hyperglycosylated hCG, or free beta-subunit may be the predominant species.

Two major issues surrounds the measurement of hCG. First, there may be
interference towards the assay, for example by heterophilic antibody. While the
usual way of using serial dilution, as well as testing in other platforms, or the use of
antibody-blocking tube are used to work up for interference, some of the
interference are not uncovered by these methods. In these cases, cross-check with
urine hCG level, or using a panel of hCG assays detecting various forms of hCG may
be helpful.

Secondly, in post-menopausal women, there may be low levels of hCG (typically

<15 IU/L), which may lead to confusion of clinical colleagues. In such case, a
pituitary source can be identified by their biochemical profile of high FSH/LH, as well
as the suppressibility of hCG by estrogen administration.

Most immunoassays, no matter automated liquid phase or lateral flow, are based on
the chemiluminescent, sandwich immunoassay principle. Immunoassays from
various manufacturer had varying reactivity towards different species of hCG in
blood or urine. In particular, the Siemens Immulite is the assay which had reactivity
towards beta core-fragment, the predominant species in urine, while such reactivity
is not commonly seen in hCG produced by other large manufacturers. Some
immunoassays are interfered by the presence of high concentration of free beta-
hCG or beta-core fragment in the specimen, thus making the assay not valid for
measurement of urine hCG.

Most modern hCG assays utilizes a washing step between application of detection
antibody in their design. In such cases, despite hCG values may lie across six-seven
orders of magnitude, hook effect is uncommonly seen.

Other than in major automated platforms, there are also laboratories which utilizes
in-house developed assays or manual assays for hCG, sometimes in non-sandwich
format such as RIA. Some of these assays are universal in that most hCG species
are detected, and some are designed specifically for a particular form of hCG such
as the hyperglycosylated hCG.