Introduction

The human chorionic gonadotropin (hCG) is recognized as a term that describes 4 separate isoforms, each with a distinct biological function and produced by a different type of cell within the body.[1] These include synthesis from villous syncytiotrophoblasts, multiple primary nontrophoblastic malignancies or tumors, the anterior pituitary gland, and cytotrophoblast cells.[1][2] The principal functions of hCG synthesized from villous syncytiotrophoblastic cells include promoting progesterone production by the corpus luteal cells and subsequent growth of cytotrophoblast cells. The actions of hCG allow a coordinated growth of the fetus and uterus, signal the endometrium of impending implantation, support the growth and differentiation of the umbilical cord, and promote fetal growth and organogenesis.[1][2][3][4][5][6]

Hyperglycosylated forms of hCG from cytotrophoblastic cells promote growth and invasion of these cells, thus contributing to the pathogenesis of choriocarcinoma cells. A similar mechanism can occur in hCG-free beta-subunits synthesized by nontrophoblastic tumors. The detection of the free-beta subunit hCG is suggestive of malign cancer and poor prognosis.[7] hCG synthesized by the anterior pituitary gland is produced at low levels throughout the menstrual cycle and mimics the luteinizing hormone (LH) effects.[4]

Development

hCG is a pregnancy-specific hormone that is critical for the development of the fetus and placenta. Villous syncytiotrophoblasts and trophoblastic cells mainly produce hCG from implantation to the completion of pregnancy at various levels. As previously mentioned, one of the most important functions of hCG is to promote progesterone production, as it protects the endometrial lining during pregnancy. hCG has also been implicated in regulating uterine growth, implantation, trophoblast differentiation, angiogenesis, and vasculogenesis in the uterine walls.[4][5][8][4][5][9]

Importantly, hCG stimulates the production of endocrine gland-derived vascular endothelial growth factor (EG-VEGF), which acts on cytotrophoblastic cells. Through this action, the trophoblasts can form plugs that prevent maternal blood from bleeding into the intervillous spaces during early pregnancy.[4][5][6]

Function

The most well-known function of hCG is the promotion of progesterone production during pregnancy. hCG stimulates ovarian corpus luteal cells to produce progesterone, thus reinforcing the endometrial walls and preventing menstrual bleeding. This promotion of progesterone production is active in approximately 10% of the total length of the pregnancy or around 3 to 4 weeks following implantation. In a nonpregnant female, LH promotes progesterone production.[10][5][11]

The hCG hormone is a dimer made of an alpha and beta subunit. As mentioned earlier, the alpha subunit is common to all isomers of hCG except for the free beta-subunit form of the hormone.[8] The alpha subunit is also present in other hormones such as LH, follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). The beta subunit confers a structural differentiation from hormones like LH, though all forms of hCG and LH bind to a common receptor. Besides the absence of a beta subunit in LH, the marked distinction between the 2 hormones is the difference in half-life. With a pI of 8.0, LH has a half-life of approximately 25 to 30 minutes, while hCG has a pI of 3.5 and a much longer half-life at 37 hours.[12][5] This difference in half-life is critical to hCG’s function as a type of "super LH" during pregnancy to support maintaining an optimal intrauterine environment.[8][4][13]

Studies over recent years have shown that hCG is involved in many functions supporting the placenta, uterus, and fetus throughout pregnancy. These functions include promoting angiogenesis, immunosuppression, and blockage of phagocytosis of invading trophoblasts, promoting growth and differentiation of fetal organs, and involvement in the adult brain and brainstem.[9][10][9]

hCG promotes angiogenesis and vasculogenesis through the upregulation of EG-VEGF.[6] Uterine spinal arteries have hCG receptors that, when acted upon by hCG, undergo growth and support the adequate blood supply and nutrition to the placenta. hCG also promotes the fusion of cytotrophoblast cells and their subsequent differentiation into syncytiotrophoblasts.[5][9]

Several studies have supported the function of hCG in preventing fetoplacental tissue rejection through inhibitory immune-mediated mechanisms.[14][15] Some groups have shown that an anti-macrophage inhibitory factor is upregulated by hCG activity during pregnancy, thus reducing macrophage activity at the uterine-placental interface.[16][17][18] Other studies support a more proximate mechanism of action in which hCG directly suppresses immune actions taken against the fetus.[9][10][19][9]

Maternal hCG has implications for the development of fetal organs during development. There are hCG receptors in the fetal liver and kidney that are completely absent in adult organs. hCG has also been shown to support the growth and development of the umbilical cord.[5][11][13][11]

Researchers have found hCG receptors in various areas of the adult female brain, including the hippocampus, hypothalamus, and brain stem. Speculation is that these receptors in the brain are involved in the pathophysiology of hyperemesis gravidarum. Other contributing factors may involve a combination of rising hormone levels, including estrogen, progesterone, and serum thyroxine, in addition to elevated hCG.[5][11][20]

Mechanism

hCG achieves many of its functions by regulating the expression of EG-VEGF and its receptors.[6] The EG-VEGF receptors are GPCRs, prokineticin 1 (PROKR1), and prokineticin 2. EG-VEGF is an angiogenic factor specific to endocrine tissues, including the placenta. EG-VEGF expression peaks around the same time as the peak of hCG concentration at approximately 8 to 11 weeks gestation.[6] As an angiogenic factor, EG-VEGF expression increases in conditions of hypoxia. EG-VEGF and its receptors are regulators of the fetus's pathological and normal development. EG-VEGF, PROKR1, and PROKR2 levels are significantly higher in fetal growth-restricted patients. Some have proposed that increases in EG-VEGF expression and its receptors brought on by increased levels of hCG are a form of compensation for fetal growth restriction.[7][10][11][13][11][11]

Clinical Significance

Abnormal levels of hCG are associated with adverse pregnancy outcomes such as molar pregnancies and fetal growth restrictions. The intrauterine environment must be maintained with certain conditions to properly support fetal development and growth. The intrauterine conditions depend upon placental function, as the placenta is the main source of fetal nourishment. Suboptimal conditions due to an atrophic placenta may contribute to the risk of low birth weight. Several studies support the correlation between low birth weight and the risk of developing chronic conditions such as diabetes and hypertension later in life.[5][21][22][23]

A molar pregnancy, or hydatidiform mole, is a tumor arising from the trophoblast, which surrounds a blastocyst and subsequently develops into the chorion and amnion.[23][24] This condition may manifest as a complete or partial molar pregnancy. A complete hydatidiform mole is usually diploid with a 46 XX karyotype. There is trophoblastic hyperplasia, which produces a mass of multiple vesicles with little evidence of fetal and embryonic development. A partial hydatidiform mole is usually triploid due to dispermous fertilization or fertilization with an unreduced diploid sperm. In contrast to the complete mole, there is usually evidence of fetal development with an enlarged placenta.[10][23]

The development of molar pregnancy correlates with fluxes in the levels of free beta-subunit of hCG. In a complete molar pregnancy, it is not uncommon to see large theca-lutein cysts due to increased stimulation of the ovaries by excess free beta-subunit hCG.[22][23][24]

Patients with a history of prior molar pregnancy are at a 10-fold greater risk of a second hydatidiform pregnancy compared to the general population. The recommendation is that these women have their hCG levels monitored throughout pregnancy and undergo evaluation by early ultrasonography.[5][23][24]

Several clinical studies support the association of hCG concentration abnormalities with adverse fetal outcomes. This association varies with gestational age as hCG levels fluctuate throughout the pregnancy.[22][24][23]

In the first trimester, low levels of hCG have correlated with spontaneous abortion and preeclampsia. Some studies have shown an association between low hCG concentrations (especially of the free beta-subunit of hCG) during the latter half of the first trimester and low birth weight due to attenuated fetal growth. Interestingly, some studies show that higher maternal hCG concentrations at the end of the first trimester are associated with fetal growth acceleration only in female-sex fetuses.[21][22]

In the second trimester, high levels of hCG have associations with gestational hypertension, spontaneous abortion, preeclampsia, fetal growth restriction (low birth weight), and preterm delivery; this is in contrast to the association of low levels of hCG and low birth weight observed in the first trimester of pregnancy.[7][22]

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Disclosure: Mari Ogino declares no relevant financial relationships with ineligible companies.

Disclosure: Prasanna Tadi declares no relevant financial relationships with ineligible companies.