O efeito Hook em mulheres com mola hidatiforme completa: estudo de uma série de casos
Carregando...
Arquivos
Data
2022-09-02
Autores
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Resumo Objetivo: Apesar dos títulos muito elevados de gonadotrofina coriônica humana (hCG), o efeito Hook pode causar um teste de gravidez na urina falso-negativo ou concentrações séricas falsamente baixas. Isso pode levar a um diagnóstico errado ou atraso no diagnóstico de doença trofoblástica gestacional, particularmente mola hidatiforme completa (MHC). Até o momento, não há estudo de série de casos da ocorrência do efeito Hook em função de hCG sérico pré-esvaziamento uterino. O objetivo deste estudo, portanto, foi determinar o valor de corte de hCG sérico relacionado com a ocorrência significativamente aumentada do efeito Hook. Métodos: Esse estudo transversal incluiu 285 mulheres com MHC encaminhadas ao Centro de Doença Trofoblástica de Botucatu da Universidade Estadual Paulista para tratamento inicial (esvaziamento molar) entre 1990 e 2020. Foram utilizados imunoensaio cromatográfico para a detecção qualitativa de gonadotrofina coriônica na urina e imunoensaio de quimioluminescência de micropartículas para determinar hCG quantitativo no soro sanguíneo. O efeito Hook foi considerado presente quando o teste qualitativo de hCG na urina foi negativo e os títulos de hCG no soro foram elevados após a realização de diluições seriadas automáticas e manuais. Resultados: A proporção do efeito Hook em função de hCG sérico pré-esvaziamento em mulheres com MHC foi de 26% (74/285). A razão de prevalência do efeito Hook (RP) foi maior quando hCG > 750.000– 1.000.000 UI/L [58,6%, RP: 1,80 (IC 95% = 1,56 – 2,06, p=0,001)] e > 1.000.000 UI/L [87,2%, RP: 2,39 (2,12 – 2,70, p=0,001)]. A curva ROC construída para indicar a presença do efeito Hook em função de hCG pré-esvaziamento teve boa discriminação para prever a ocorrência do efeito Hook (área sob a curva ROC = 0,94, IC 95% = 0,91 – 0,96, p < 0,05). O ponto de corte ideal de hCG foi de 507.038 UI/L com sensibilidade de 86,5% e especificidade de 82,0%. A acurácia foi de 83,1%, enquanto os valores preditivos positivo e negativo foram de 62,7% e 94,5%, respectivamente. Conclusão: Este estudo confirma que o efeito Hook é mais provável de ocorrer quando hCG sérico > 500.000 UI/L em mulheres com MHC. Quando as mulheres em idade reprodutiva apresentam sinais e sintomas como náuseas/vômitos e/ou sangramento de escape, têm achados ultrassonográficos sugestivos de MHC, mas têm teste de gravidez na urina negativo ou hCG sérico quantitativo positivo baixo, reconhecer o efeito Hook é fundamental para prevenir erros de conduta médica. Quando há suspeita do efeito Hook, a diluição da urina/soro é fundamental para um teste acurado e diagnóstico preciso.
Abstract Objective: Despite very high human chorionic gonadotropin (hCG) levels, the Hook effect can cause a false-negative urine pregnancy test or falsely low serum levels. This can lead to a misdiagnosis or delayed diagnosis of gestational trophoblastic disease, particularly complete hydatidiform mole (CHM). To our knowledge, there has been no case-series study of the occurrence of the Hook effect as a function of pre-evacuation serum hCG. The purpose of this study therefore was to determine the cutoff value of serum hCG related with a significantly increased occurrence of the Hook effect. Methods: This cross-sectional study included 285 women with CHM referred to the Botucatu Trophoblastic Disease Center of São Paulo State University, Brazil, for initial treatment (molar evacuation) between 1990 and 2020. A chromatographic immunoassay was used for the qualitative detection of human chorionic gonadotropin in urine, and a microparticle chemiluminescence immunoassay was used to determine quantitative hCG in blood serum. The Hook effect was considered to occur when qualitative urine hCG testing was negative and quantitative serum hCG levels were high after automatic and manual serial dilutions were performed. Results: The proportion of the Hook effect as a function of pre-evacuation serum hCG in women with CHM was 26% (74/285). The Hook effect prevalence ratio (PR) was higher when hCG > 750,000 – 1,000,000 IU/L [58.6%, PR: 1.80 (95%CI = 1.56 – 2.06, p=0.001)] and > 1,000,000 IU/L [87.2%, PR: 2.39 (2.12 – 2.70, p=0.001)]. The receiver-operating characteristic (ROC) curve built to indicate the presence of the Hook effect as a function of pre-evacuation hCG had good discrimination to predict the occurrence of the Hook effect (area under the ROC curve = 0.94, 95%CI = 0.91 – 0.96, p < 0.05). The optimal hCG cutoff point was 507,038 IU/L with a sensitivity of 86.5% and specificity of 82.0%. Accuracy was 83.1%, while positive and negative predictive values were 62.7% and 94.5%, respectively. Conclusions: This study confirmed that the Hook effect is more likely to occur when serum hCG > 500,000 IU/L in women with CHM. When women of reproductive age present with signs and symptoms such as nausea/vomiting and/or spotting, have ultrasound findings suggestive of CHM, but have a negative urine or low positive serum quantitative hCG, recognizing the Hook effect is critical in order to prevent medical mismanagement. When the Hook effect is suspected, urine/serum dilution is key to an accurate test and diagnosis.
Abstract Objective: Despite very high human chorionic gonadotropin (hCG) levels, the Hook effect can cause a false-negative urine pregnancy test or falsely low serum levels. This can lead to a misdiagnosis or delayed diagnosis of gestational trophoblastic disease, particularly complete hydatidiform mole (CHM). To our knowledge, there has been no case-series study of the occurrence of the Hook effect as a function of pre-evacuation serum hCG. The purpose of this study therefore was to determine the cutoff value of serum hCG related with a significantly increased occurrence of the Hook effect. Methods: This cross-sectional study included 285 women with CHM referred to the Botucatu Trophoblastic Disease Center of São Paulo State University, Brazil, for initial treatment (molar evacuation) between 1990 and 2020. A chromatographic immunoassay was used for the qualitative detection of human chorionic gonadotropin in urine, and a microparticle chemiluminescence immunoassay was used to determine quantitative hCG in blood serum. The Hook effect was considered to occur when qualitative urine hCG testing was negative and quantitative serum hCG levels were high after automatic and manual serial dilutions were performed. Results: The proportion of the Hook effect as a function of pre-evacuation serum hCG in women with CHM was 26% (74/285). The Hook effect prevalence ratio (PR) was higher when hCG > 750,000 – 1,000,000 IU/L [58.6%, PR: 1.80 (95%CI = 1.56 – 2.06, p=0.001)] and > 1,000,000 IU/L [87.2%, PR: 2.39 (2.12 – 2.70, p=0.001)]. The receiver-operating characteristic (ROC) curve built to indicate the presence of the Hook effect as a function of pre-evacuation hCG had good discrimination to predict the occurrence of the Hook effect (area under the ROC curve = 0.94, 95%CI = 0.91 – 0.96, p < 0.05). The optimal hCG cutoff point was 507,038 IU/L with a sensitivity of 86.5% and specificity of 82.0%. Accuracy was 83.1%, while positive and negative predictive values were 62.7% and 94.5%, respectively. Conclusions: This study confirmed that the Hook effect is more likely to occur when serum hCG > 500,000 IU/L in women with CHM. When women of reproductive age present with signs and symptoms such as nausea/vomiting and/or spotting, have ultrasound findings suggestive of CHM, but have a negative urine or low positive serum quantitative hCG, recognizing the Hook effect is critical in order to prevent medical mismanagement. When the Hook effect is suspected, urine/serum dilution is key to an accurate test and diagnosis.
Descrição
Palavras-chave
Mola hidatiforme completa, Gonadotrofina coriônica humana, Efeito Hook, Imunoensaios, Complete hydatidiform mole, Gonadotropin chorionic human, Hook effect, Immunoassays