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Okpaise OO, Ahn H, Tonni G, Ruano R. Prenatal diagnosis and in utero treatment of congenital adrenal hyperplasia: An up-to-date comprehensive review. Prenat Diagn 2024; 44:635-643. [PMID: 38448010 DOI: 10.1002/pd.6542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 03/08/2024]
Abstract
Congenital adrenal hyperplasia (CAH) is a term that encompasses a wide range of conditions that affect the adrenals. Diagnosis and treatment before birth are important as irreparable birth defects can be avoided, decreasing the need for surgical intervention later in life, especially regarding genitalia anomalies. Although early implementation of dexamethasone in the prenatal treatment of CAH has been controversial, there is recent evidence that this treatment can reduce long-term complications.
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Affiliation(s)
| | - Hyunyoung Ahn
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gabriele Tonni
- Department of Obstetrics and Neonatology, Prenatal Diagnostic Centre, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
- Women-Children Health Center of Excellence, Americas Group, United Health Care Brazil, São Paulo, Brazil
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Bachelot A, Grouthier V, Courtillot C, Dulon J, Touraine P. MANAGEMENT OF ENDOCRINE DISEASE: Congenital adrenal hyperplasia due to 21-hydroxylase deficiency: update on the management of adult patients and prenatal treatment. Eur J Endocrinol 2017; 176:R167-R181. [PMID: 28115464 DOI: 10.1530/eje-16-0888] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/03/2017] [Accepted: 01/20/2017] [Indexed: 12/28/2022]
Abstract
Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is characterized by cortisol and in some cases aldosterone deficiency associated with androgen excess. Goals of treatment are to replace deficient hormones and control androgen excess, while avoiding the adverse effects of exogenous glucocorticoid. Over the last 5 years, cohorts of adults with CAH due to 21-hydroxylase deficiency from Europe and the United States have been described, allowing us to have a better knowledge of long-term complications of the disease and its treatment. Patients with CAH have increased mortality, morbidity and risk for infertility and metabolic disorders. These comorbidities are due in part to the drawbacks of the currently available glucocorticoid therapy. Consequently, novel therapies are being developed and studied in an attempt to improve patient outcomes. New management strategies in the care of pregnancies at risk for congenital adrenal hyperplasia using fetal sex determination and dexamethasone have also been described, but remain a subject of debate. We focused the present overview on the data published in the last 5 years, concentrating on studies dealing with cardiovascular risk, fertility, treatment and prenatal management in adults with classic CAH to provide the reader with an updated review on this rapidly evolving field of knowledge.
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Affiliation(s)
- Anne Bachelot
- AP-HPIE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
- UPMC Université Pierre et Marie CurieUniv Paris 06, Paris, France
| | - Virginie Grouthier
- AP-HPIE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
- UPMC Université Pierre et Marie CurieUniv Paris 06, Paris, France
| | - Carine Courtillot
- AP-HPIE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Jérôme Dulon
- AP-HPIE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Philippe Touraine
- AP-HPIE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
- UPMC Université Pierre et Marie CurieUniv Paris 06, Paris, France
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Kemp MW, Newnham JP, Challis JG, Jobe AH, Stock SJ. The clinical use of corticosteroids in pregnancy. Hum Reprod Update 2015; 22:240-59. [PMID: 26590298 DOI: 10.1093/humupd/dmv047] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The use of antenatal steroid therapy is common in pregnancy. In early pregnancy, steroids may be used in women for the treatment of recurrent miscarriage or fetal abnormalities such as congenital adrenal hyperplasia. In mid-late pregnancy, the antenatal administration of corticosteroids to expectant mothers in anticipation of preterm birth is one of the most important advances in perinatal medicine; antenatal corticosteroids are now standard care for pregnancies at risk of premature delivery in high- and middle-income countries. The widespread uptake of this therapy is due to a compelling body of evidence demonstrating improved neonatal outcomes following antenatal corticosteroid exposure, stemming most notably from corticosteroid-driven maturation of fetal pulmonary function. As we approach the 50th anniversary of landmark work in this area by Liggins and Howie, it is apparent that much remains to be understood with regards to how we might best apply antenatal corticosteroid therapy to improve pregnancy outcomes at both early and mid to late gestation. METHODS Drawing on advances in laboratory science, pre-clinical and clinical studies, we performed a narrative review of the scientific literature to provide a timely update on the benefits, risks and uncertainties regarding antenatal corticosteroid use in pregnancy. Three, well-established therapeutic uses of antenatal steroids, namely recurrent miscarriage, congenital adrenal hyperplasia and preterm birth, were selected to frame the review. RESULTS Even the most well-established antenatal steroid therapies lack the comprehensive pharmacokinetic and dose-response data necessary to optimize dosing regimens. New insights into complex, tissue-specific corticosteroid signalling by genomic-dependent and independent mechanisms have not been used to inform corticosteroid treatment strategies. There is growing evidence that some fetal corticosteroid treatments are either ineffective, or may result in adverse outcomes, in addition to lasting epigenetic changes in a variety of homeostatic mechanisms. Nowhere is the need to better understand the intricacies of corticosteroid therapy better conveyed than in the findings of Althabe and colleagues who recently reported an increase in overall neonatal mortality and maternal morbidity in association with antenatal corticosteroid administration in low-resource settings. CONCLUSIONS New research to clarify the benefits and potential risks of antenatal corticosteroid therapy is urgently needed, especially with regard to corticosteroid use in low-resource environments. We conclude that there is both significant scope and an urgent need for further research-informed refinement to the use of antenatal corticosteroids in pregnancy.
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Affiliation(s)
- M W Kemp
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia
| | - J P Newnham
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia
| | - J G Challis
- Office of the Pro Vice-Chancellor (Health and Medical Research), The University of Western Australia, Perth, Western Australia, Australia
| | - A H Jobe
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH, USA
| | - S J Stock
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, UK
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Grunt S, Steinlin M, Weisstanner C, Schöning M, Mullis PE, Flück CE. Acute encephalopathy with unilateral cortical-subcortical lesions in two unrelated kindreds treated with glucocorticoids prenatally for congenital adrenal hyperplasia due to 21-hydroxylase deficiency: established facts and novel insight. Horm Res Paediatr 2014; 80:57-63. [PMID: 23816834 DOI: 10.1159/000348515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/25/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prenatal glucocorticoid (GC) treatment of the female fetus with 21-hydroxylase deficiency (21-OHD) may prevent genital virilization and androgen effects on the brain, but prenatal GC therapy is controversial because of possible adverse effects on fetal programming, the cardiovascular system and the brain. CASE REPORTS We report 2 patients with congenital adrenal hyperplasia (CAH) due to 21-OHD who were treated prenatally with dexamethasone, suffered from an acute encephalopathy and showed focal and multifocal cortical and subcortical diffusion restrictions in early MRI and signs of permanent alterations in the follow-up neuroimaging studies. Both patients recovered from the acute episode. Whereas the first patient recovered without neurological sequelae the second patient showed hemianopsia and spastic hemiplegia in the neurological follow-up examination. CONCLUSION These are 2 children with CAH, both treated prenatally with high doses of dexamethasone to prevent virilization. The question arises whether prenatal high-dose GC treatment in patients with CAH might represent a risk factor for brain lesions in later life. Adverse effects/events should be reported systematically in patients undergoing prenatal GC treatment and long-term follow-up studies involving risk factors for cerebrovascular disease should be performed.
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Affiliation(s)
- Sebastian Grunt
- Department of Pediatrics, University Children's Hospital, University Hospital Inselspital, Bern, Switzerland
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Abstract
Endocrine disease is common in pregnancy. Most pre-existing endocrine conditions, if well controlled, have little impact on maternal or fetal morbidity. Uncontrolled endocrine conditions in pregnancy, whether poorly controlled pre-conception or newly diagnosed, are associated with a variety of adverse fetal outcomes and maternal morbidity. Also, transplacental transfer of maternal antibodies can have adverse fetal or neonatal consequences. The initial diagnosis of many conditions is hindered by the overlap of symptoms that occur in normal pregnancy and those that suggest specific endocrine pathologies, and also by the changes in reference ranges for common biochemical measurements that occur as a result of physiological changes in pregnancy. This article summarises the common endocrine disorders in pregnancy and describes how pregnancy can alter their investigation, treatment and ongoing management, as well as the potential effects on the fetus.
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Chitty LS, Chatelain P, Wolffenbuttel KP, Aigrain Y. Prenatal management of disorders of sex development. J Pediatr Urol 2012; 8:576-84. [PMID: 23131529 DOI: 10.1016/j.jpurol.2012.10.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 10/27/2022]
Abstract
Disorders of sex development (DSD) rarely present prenatally but, as they are very complex conditions, management should be directed by highly specialised medical teams to allow consideration of all aspects of diagnosis, treatment and ethical issues. In this brief review, we present an overview of the prenatal presentation and management of DSD, including the sonographic appearance of normal genitalia and methods of determining genetic sex, the prenatal management of pregnancies with the unexpected finding of genital ambiguity on prenatal ultrasound and a review of the prenatal management of pregnancies at high risk of DSD. As this is a rapidly developing field, management options will change over time, making the involvement of clinical geneticists, paediatric endocrinologists and urologists, as well as fetal medicine specialists, essential in the care of these complex pregnancies. The reader should also bear in mind that local social, ethical and legal aspects may also influence management.
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Affiliation(s)
- Lyn S Chitty
- Clinical and Molecular Genetics Unit, UCL Institute of Child Health, London, UK.
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Maryniak A, Ginalska-Malinowska M, Bielawska A, Ondruch A. Cognitive and social function in girls with congenital adrenal hyperplasia — Influence of prenatally administered dexamethasone. Child Neuropsychol 2012. [DOI: 10.1080/09297049.2012.745495] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Endokrine Erkrankungen in der Schwangerschaft. GYNAKOLOGISCHE ENDOKRINOLOGIE 2012. [DOI: 10.1007/s10304-012-0486-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dreger A, Feder EK, Tamar-Mattis A. Prenatal Dexamethasone for Congenital Adrenal Hyperplasia: An Ethics Canary in the Modern Medical Mine. JOURNAL OF BIOETHICAL INQUIRY 2012; 9:277-294. [PMID: 22904609 PMCID: PMC3416978 DOI: 10.1007/s11673-012-9384-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 05/14/2012] [Indexed: 05/04/2023]
Abstract
Following extensive examination of published and unpublished materials, we provide a history of the use of dexamethasone in pregnant women at risk of carrying a female fetus affected by congenital adrenal hyperplasia (CAH). This intervention has been aimed at preventing development of ambiguous genitalia, the urogenital sinus, tomboyism, and lesbianism. We map out ethical problems in this history, including: misleading promotion to physicians and CAH-affected families; de facto experimentation without the necessary protections of approved research; troubling parallels to the history of prenatal use of diethylstilbestrol (DES); and the use of medicine and public monies to attempt prevention of benign behavioral sex variations. Critical attention is directed at recent investigations by the U.S. Food and Drug Administration (FDA) and Office of Human Research Protections (OHRP); we argue that the weak and unsupported conclusions of these investigations indicate major gaps in the systems meant to protect subjects of high-risk medical research.
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Affiliation(s)
- Alice Dreger
- Clinical Medical Humanities and Bioethics, Program in Medical Humanities and Bioethics, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr., Suite 625, Chicago, IL 60611 USA
| | - Ellen K. Feder
- Department of Philosophy and Religion, American University, Washington, DC USA
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Samarasinghe RA, Witchell SF, DeFranco DB. Cooperativity and complementarity: synergies in non-classical and classical glucocorticoid signaling. Cell Cycle 2012; 11:2819-27. [PMID: 22801547 DOI: 10.4161/cc.21018] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoids (GCs) are an ubiquitous class of steroid hormones that exert a wide array of physiological effects. Traditionally, GC action has been considered to primarily involve transcriptional effects following the binding of hormone to the glucocorticoid receptor (GR) and subsequent activation or repression of target genes. However, a number of findings suggest that cellular responses following GC exposure may be mediated by transcription-independent, or "non-classical," mechanisms. We have added to this growing body of work by recently uncovering a novel GC signaling pathway that operates through plasma membrane GRs to limit gap junction intercellular signaling and limit the proliferation of neural progenitor cells (NPCs). In this review, we highlight our current state of knowledge of non-classical GR signaling, in particular as it applies to neuronal function. Using NPCs as a cellular model, we speculate on the components of this non-classical pathway and the mechanisms whereby a number of cytoplasmic and nuclear signaling events may be integrated.
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Affiliation(s)
- Ranmal A Samarasinghe
- Department of Neuroscience, University of Pittsburgh, School of Medicine, and Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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Meyer-Bahlburg HFL, Dolezal C, Haggerty R, Silverman M, New MI. Cognitive outcome of offspring from dexamethasone-treated pregnancies at risk for congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Eur J Endocrinol 2012; 167:103-10. [PMID: 22549088 PMCID: PMC3383400 DOI: 10.1530/eje-11-0789] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To test whether dexamethasone (DEX) treatment in pregnancies at risk for congenital adrenal hyperplasia (CAH) impairs cognitive functioning in the offspring. DESIGN Observational follow-up of prenatally DEX-exposed offspring and controls. METHODS Study 1 included 140 children aged 512 years: 67 DEX-exposed (long-term: eight CAH girls) and 73 unexposed (with 15 CAH girls). Study 2 included 20 participants aged 11-24 years: seven DEX-exposed (long-term: one CAH woman) and 13 unexposed (with four CAH women). Neuropsychological testing was done in hospital settings or at patients' homes. Data analysis aimed at maximizing detection of the effects of DEX exposure. RESULTS The vast majority of group comparisons were not marginally or conventionally significant. The few significant findings on short-term prenatal DEX exposure suggested more positive than adverse outcomes. By contrast, few significant findings in females with CAH and long-term DEX exposure indicated slower mental processing than in controls on several neuropsychological variables, although partial correlations of DEX exposure duration with cognitive outcome did not corroborate this association. CONCLUSIONS Although our studies do not replicate a previously reported adverse effect of short-term prenatal DEX exposure on working memory, our findings on cognitive function in CAH girls with long-term DEX exposure contribute to concerns about potentially adverse cognitive after effects of such exposure. Yet, our studies are not definitive, and replications in larger samples are required.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute and Department of Psychiatry, Columbia University, 1051 Riverside Drive, NYSPI Unit 15, New York, New York 10032, USA.
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12
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Witchel SF, Miller WL. Prenatal Treatment of Congenital Adrenal Hyperplasia—Not Standard of Care. J Genet Couns 2012; 21:615-24. [DOI: 10.1007/s10897-012-9508-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 05/01/2012] [Indexed: 10/28/2022]
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13
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Ultrasound-guided hysteroscopy to remove a levonorgestrel intrauterine system in early pregnancy. Contraception 2012; 86:587-90. [PMID: 22497757 DOI: 10.1016/j.contraception.2012.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 02/24/2012] [Accepted: 03/12/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Correctly placed levonorgestrel-releasing intrauterine systems (LNG-IUSs) are rarely associated with intrauterine pregnancy when pregnancy occurs. LNG-IUS retrieval, termination of pregnancy and conservative management if retracted strings prevent ready removal are the usual clinical options given to women. The conservative course raises concerns about teratogenesis related to high local progestin exposure for the developing fetus. STUDY DESIGN This case report describes combined saline hysteroscopy and ultrasound to retrieve an LNG-IUS at less than 9 weeks of gestational age. A systematic review of the literature was performed to identify similar case reports by contacting the manufacturer and searching Pubmed from 1900 through November 2011 using the terms ((levonorgestrel AND intrauterine) OR mirena) AND (pregnan* OR fetal OR fetus OR teratogen*) NOT (menorrhagia OR hyperplas* OR ectopic OR malig* OR cancer). RESULTS We identified 37 cases of LNG-IUS pregnancy exposures in the absence of spontaneous expulsion or myometrial or intraperitoneal placement of LNG-IUS. Given the presence of two congenital anomalies reported in the group, the anomaly rate is 5.4%, 95% confidence interval 0% to 11.5%. CONCLUSIONS Intrauterine LNG-IUS exposure is associated with a low frequency of congenital anomalies. Combining hysteroscopy with ultrasound facilitates surgically precise LNG-IUS removal despite retracted strings.
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Abstract
Adrenal disorders in pregnancy are relatively rare, yet can lead to significant maternal and fetal morbidity. Making a diagnosis is challenging as pregnancy may alter the manifestation of disease, many signs and symptoms associated with pregnancy are also seen in adrenal disease, and the fetal-placental unit alters the maternal endocrine metabolism and hormonal feedback mechanisms. The most common cause of Cushing's syndrome in pregnancy is an adrenal adenoma, followed by pituitary etiology, adrenal carcinoma, and other exceedingly rare causes. Medical therapy of Cushing's syndrome includes metyrapone and ketoconazole, but generally surgical treatment is more effective. Exogenous corticosteroid administration is the most common cause of adrenal insufficiency, followed by the endogenous causes of ACTH or CRH secretion. Primary adrenal insufficiency is least common. A low early morning cortisol <3 mcg/dL (83 mmol/L) in the non-stressed state and in the setting of typical clinical symptoms confirms the diagnosis. In the second and third trimester cortisol rises to levels 2-3 fold above those in the non-pregnant state, therefore a baseline level of <30 mcg/dL (823 mmol/L) warrants further evaluation. ACTH stimulated normal cortisol values have been established for each trimester. Hydrocortisone, which does not cross the placenta, is the glucocorticoid treatment of choice, and fludrocortisone is used as mineralocorticoid replacement in patients with primary disease. Congenital adrenal hyperplasia is an autosomal recessive disorder; 21-hydroxylase deficiency (21OHD) is the most common form of the disease. Non-classical 21OHD is most common, followed by the salt-wasting and simple virilizing forms. The treatment of choice for pregnant women affected with CAH is hydrocortisone, and fludrocortisones is added for those with the salt-wasting form of the disease. If the fetus is at risk for classical CAH, dexamethasone treatment can be used prenatally to prevent masculinization of the genitalia in a female infant. Because dexamethasone crosses the placenta, it should not be used to treat pregnant women with CAH if the fetus is not at risk for the disease.
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Affiliation(s)
- Oksana Lekarev
- Adrenal Steroid Disorders Group, Division of Pediatric Endocrinology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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15
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Witchel SF, Azziz R. Congenital adrenal hyperplasia. J Pediatr Adolesc Gynecol 2011; 24:116-26. [PMID: 21601808 DOI: 10.1016/j.jpag.2010.10.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 10/04/2010] [Accepted: 10/05/2010] [Indexed: 11/26/2022]
Abstract
Congenital adrenal hyperplasia (CAH) due to P450c21 (21-hydroxylase deficiency) is a common autosomal recessive disorder. This disorder is due to mutations in the CYP21A2 gene which is located at chromosome 6p21. The clinical features reflect the magnitude of the loss of function mutations. Individuals with complete loss of function mutations usually present in the neonatal period. The clinical features of individuals with mild loss of function mutations are predominantly due to androgen excess rather than adrenal insufficiency leading to an ascertainment bias favoring diagnosis in females. Treatment goals include normal linear growth velocity and "on-time" puberty in affected children. For adolescent and adult women, treatment goals include regularization of menses, prevention of progression of hirsutism, and fertility. This article will review key aspects regarding pathophysiology, diagnosis, and treatment of CAH.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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16
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Kulshreshtha B, Khadgawat R, Eunice M, Ammini AC. Congenital adrenal hyperplasia: Results of medical therapy on appearance of external genitalia. J Pediatr Urol 2010; 6:555-9. [PMID: 20117057 DOI: 10.1016/j.jpurol.2010.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 01/04/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Girls with congenital adrenal hyperplasia show a variable degree of genital masculinization at birth. Antenatal dexamethazone treatment for the mother is known to reduce the severity of this condition. There are however few data on the effect of postnatal steroid therapy on the cosmetic appearance of the external genitalia. PATIENTS AND METHOD We report the appearance of the external genitalia of three girls with classical congenital adrenal hyperplasia followed up by steroid therapy alone. RESULTS Growth of the labia majora and a relative reduction in clitoral size improved the appearance of the external genitalia in these three girls. CONCLUSION There seems to be improvement in the external appearance of genitalia with postnatal steroid therapy. This could allay parental concerns and help in the planning of corrective surgery peripubertally with the informed consent of the child.
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Affiliation(s)
- B Kulshreshtha
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Delhi 110029, India
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Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:919707. [PMID: 20981291 PMCID: PMC2963131 DOI: 10.1155/2010/919707] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 08/04/2010] [Accepted: 08/09/2010] [Indexed: 12/01/2022]
Abstract
The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.
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McCullough LB, Chervenak FA, Brent RL, Hippen B. A case study in unethical transgressive bioethics: "Letter of concern from bioethicists" about the prenatal administration of dexamethasone. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:35-45. [PMID: 20818559 DOI: 10.1080/15265161.2010.499745] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
On February 3, 2010, a "Letter of Concern from Bioethicists," organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services (DHHS) Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers "mere opinion" as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it.
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Affiliation(s)
- Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030-3411, USA.
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New M. Description and defense of prenatal diagnosis and treatment with low-dose dexamethasone for congenital adrenal hyperplasia. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:48-51. [PMID: 20818561 DOI: 10.1080/15265161.2010.507652] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Maria New
- Adrenal Steroid Disorders Program, Mount Sinai School of Medicine, Department of Pediatrics, One Gustave L. Levy Place, New York, NY 10029, USA.
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A Summary of the Endocrine Society Clinical Practice Guidelines on Congenital Adrenal Hyperplasia due to Steroid 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:494173. [PMID: 20981249 PMCID: PMC2963799 DOI: 10.1155/2010/494173] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/24/2010] [Indexed: 11/17/2022]
Abstract
Steroid 21-hydroxylase deficiency accounts for about 95% of cases of congenital adrenal hyperplasia (CAH). Newborns are currently being screened for the classical forms of this disease throughout the United States and in 12 other countries. As such, it seems important to develop the best practice guidelines for treating not only infants and children, but affected adults as well. This report gives a brief overview of the most recent expert opinion and clinical practice guidelines for CAH as formulated by The Endocrine Society Task Force.
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Witchel SF, Azziz R. Nonclassic congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:625105. [PMID: 20671993 PMCID: PMC2910408 DOI: 10.1155/2010/625105] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 04/05/2010] [Indexed: 11/26/2022]
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) due to P450c21 (21-hydroxylase deficiency) is a common autosomal recessive disorder. This disorder is due to mutations in the CYP21A2 gene which is located at chromosome 6p21. The clinical features predominantly reflect androgen excess rather than adrenal insufficiency leading to an ascertainment bias favoring diagnosis in females. Treatment goals include normal linear growth velocity and "on-time" puberty in affected children. For adolescent and adult women, treatment goals include regularization of menses, prevention of progression of hirsutism, and fertility. This paper will review key aspects regarding pathophysiology, diagnosis, and treatment of NCAH.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Ricardo Azziz
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Obstetrics and Gynecology, and Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Witchel S, Azziz R. NonClassic Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-625105] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Wang H, Xu D, Peng RX, Yue J. Testosterone-metabolizing capacity and characteristics of adrenal microsomes in human fetus in vitro. J Pediatr Endocrinol Metab 2010; 23:143-52. [PMID: 20432817 DOI: 10.1515/jpem.2010.23.1-2.143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe the metabolite spectrum of testosterone (T) in human fetal adrenal in vitro, and verify possible roles of CYP3A and 2C isoforms of human fetal adrenal in T metabolism which respond to T metabolism in liver. Isolation and identification of T and its metabolites were carried out by isocratic high-performance liquid chromatography. CYP isoforms involved in T metabolism were examined by an inhibition study. Four metabolites formed by fetal adrenal microsomes were androstenedione (A), 16alpha-hydroxytestosterone (16alpha-HT), 16beta-hydroxytestosterone (16beta-HT) and 6beta-hydroxytestosterone (6beta-HT), which made up 61%, 25%, 12% and 2%, respectively, of the total. However, fetal liver microsomes produced six metabolites, which were, from high to low: A, 2alpha-HT, 6beta-HT, 2beta-HT, 16beta-HT and 16alpha-HT. Generation of A, 16alpha-HT and 16beta-HT in the adrenals was much greater than that in the liver. Erythromycin inhibited the formation of 6beta-HT and 16beta-HT with maximal inhibition of 76% and 47%. Sulfaphenazole and omeprazone had no inhibitive effect on the formations of T metabolites. The predominant metabolites of T in fetal adrenal, A and 16alpha-HT, were not decreased by these three inhibitors. These results suggest that the human fetal adrenal has greater T-metabolizing ability and a different metabolizing pathway from adult and fetal liver. Some other CYPs but not CYP3A7, CYP2C9 and CYP2C19 might play the most important part in the metabolism of T in human fetal adrenal although CYP3A7 is responsible for the formation of 6beta-HT and partly participates in the formation of 16beta-HT.
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Affiliation(s)
- Hui Wang
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan, China.
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Speiser P, Azziz R, Baskin L, Ghizzoni L, Hensle T, Merke D, Meyer-Bahlburg H, Miller W, Montori V, Oberfield S, Ritzen M, White P. A Summary of the Endocrine Society Clinical Practice Guidelines on Congenital Adrenal Hyperplasia due to Steroid 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-494173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Neocleous V, Ioannou YS, Bartsota M, Costi C, Skordis N, Phylactou LA. Rare mutations in the CYP21A2 gene detected in congenital adrenal hyperplasia. Clin Biochem 2009; 42:1363-7. [PMID: 19501079 DOI: 10.1016/j.clinbiochem.2009.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 05/19/2009] [Accepted: 05/29/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The purpose of this study was to identify and determine the frequencies of rare CYP21A2 gene mutations in patients with 21-hydroxylase deficiency (21-OHD) in the Cypriot population. DESIGN AND METHODS Direct sequencing and MLPA analysis of the CYP21A2 gene. RESULTS A group of families with 21-OHD were screened for the presence of rare CYP21A2 gene mutations. The rare V304M missense mutation was detected as compound heterozygous in two females with the nonclassical (NC) form of congenital adrenal hyperplasia (CAH). The rare F306insT was also detected in a female with severe salt wasting in the homozygous state and in cis in both alleles with the V281L mutation. Lastly, the rare A391T missense mutation was reported in a female patient with NC-CAH. A carrier rate of 2.1% for the V304M was also observed in a cohort of healthy controls. CONCLUSIONS The frequency of V304M mutation among Cypriots is high and the first reported so far and patients characterized as compound heterozygotes or heterozygotes are most readily identified by a mild phenotype of CAH. Thus, V304M should be included in the panel of mutations associated with the NC forms of 21-OHD.
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Affiliation(s)
- Vassos Neocleous
- Department of Molecular Genetics Function and Therapy, The Cyprus Institute of Neurology and Genetics, P.O. Box 23462, 1683 Nicosia, Cyprus
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26
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Arlt W, Krone N. Adult consequences of congenital adrenal hyperplasia. HORMONE RESEARCH 2007; 68 Suppl 5:158-64. [PMID: 18174737 DOI: 10.1159/000110615] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency accounts for 95% of all CAH cases and is one the most common inborn metabolic disorders. While consensus and guidelines on therapeutic management in infancy and childhood are available, data regarding the treatment of adults with CAH are scarce. This review highlights the issues that need to be addressed when caring for the adult CAH patient. Issues include glucocorticoid and mineralocorticoid replacement, adrenal crisis, female and male fertility, genetic counselling, prenatal dexamethasone treatment, pregnancy and the odds of long-term morbidity and mortality in these patients. CONCLUSIONS Large-scale audit studies are urgently required to help optimise management and long-term outcome of these patients, as are optimisation of glucocorticoid replacement and biochemical monitoring tools. It is very important that the adult CAH patient receive regular monitoring by a multidisciplinary team at the secondary- or tertiary-care level.
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Affiliation(s)
- Wiebke Arlt
- Division of Medical Sciences, University of Birmingham, Birmingham, UK.
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Hanley NA, Arlt W. The human fetal adrenal cortex and the window of sexual differentiation. Trends Endocrinol Metab 2006; 17:391-7. [PMID: 17046275 DOI: 10.1016/j.tem.2006.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 09/14/2006] [Accepted: 10/02/2006] [Indexed: 10/23/2022]
Abstract
Understanding normal development is fundamental to appreciating postnatal morphology, physiology and, in some instances, pathophysiology. Developmental biology tends to interrogate models in nonprimate species, for instance the mouse, where genetic manipulation gives privileged insight into the function of particular genes. Some human developmental processes, as occur in the adrenal gland, are not faithfully reproduced in these rodent models, yet have an impact on the pathophysiology and treatment of endocrine disorders, such as congenital adrenal hyperplasia. In this setting, in vitro research of normal human development complements clinical investigation of patients born with congenital disorders.
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Affiliation(s)
- Neil A Hanley
- Centre for Human Development, Stem Cells & Regeneration, University of Southampton, Southampton, UK.
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Gooren L. The biology of human psychosexual differentiation. Horm Behav 2006; 50:589-601. [PMID: 16870186 DOI: 10.1016/j.yhbeh.2006.06.011] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Revised: 06/15/2006] [Accepted: 06/15/2006] [Indexed: 11/22/2022]
Abstract
Most attempts to identify biological underpinnings of gender identity and sexual orientation in humans have investigated effects of sex steroids, so pivotal in the differentiation of the genitalia, showing strong parallels between animals and the human. The information on humans is derived from the so-called 'experiments of nature', clinical entities with a lesser-than-normal androgen exposure in XY subjects and a higher than normal androgen exposure in XX subjects. Prenatal androgenization appears to predispose to a male gender identity development, but apparently not decisively since 40-50% of 46,XY intersexed children with a history of prenatal androgen exposure do not develop a male gender identity. Obviously, male-to-female transsexuals, with a normal androgen exposure prenatally (there is no serious evidence to the contrary) develop a female gender identity, through unknown biological mechanisms apparently overriding the effects of prenatal androgens. The latest studies in 46, XX subjects exposed to prenatal androgens show that prenatal androgenization of 46,XX fetuses leads to marked masculinization of later gender-related behavior but does not lead to gender confusion/dysphoria. The example of female-to-male transsexuals, without evidence of prenatal androgen exposure, indicates that a male gender identity can develop without a significant androgen stimulus. So we are far away from any comprehensive understanding of hormonal imprinting on gender identity formation. Brain studies in homosexuals have not held up in replication studies or are in need of replication in transsexuals. Genetic studies and the fraternal birth order hypothesis provide indications of familial clustering of homosexuality but in many homosexuals these genetic patterns cannot be identified. The biological explanations advanced for the birth order hypothesis lack any experimental support.
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Affiliation(s)
- Louis Gooren
- Department of Endocrinology, Vrije Universiteit medical center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Affiliation(s)
- John R Lindsay
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Building 10, Bethesda, MD 20892, USA
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Keen-Kim D, Redman JB, Alanes RU, Eachus MM, Wilson RC, New MI, Nakamoto JM, Fenwick RG. Validation and clinical application of a locus-specific polymerase chain reaction- and minisequencing-based assay for congenital adrenal hyperplasia (21-hydroxylase deficiency). J Mol Diagn 2005; 7:236-46. [PMID: 15858147 PMCID: PMC1867523 DOI: 10.1016/s1525-1578(10)60550-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2004] [Indexed: 11/21/2022] Open
Abstract
Congenital adrenal hyperplasia is an autosomal recessive disorder caused by defective adrenal steroid biosynthesis, resulting in reduced glucocorticoid and increased androgen production. The majority of cases are due to inactivation of the 21-hydroxylase gene (CYP21A2), most commonly caused by genomic rearrangements with the adjacent, highly homologous pseudogene CYP21A. The most common deletions and gene conversion events have been defined and are typically detected by Southern hybridization detection of CYP21 rearrangements and/or polymerase chain reaction (PCR). However, Southern hybridization is laborious, and allele-specific PCR results may be difficult to interpret. We have therefore developed a locus-specific, PCR-based, minisequencing method for detecting the 12 most common CYP21A2 mutations. We validated the assay using a panel of 20 previously genotyped samples obtained from individuals who collectively have a broad spectrum of mutations causing 21-hydroxylase deficiency. We also used 19 control samples having no CYP21 mutations. All validation samples were correctly typed, and we identified haplotypes that may be useful for clinical diagnosis. Results from 102 clinical samples demonstrate that this assay is a rapid, reliable, and robust method for locus-specific identification of mutations and is suitable for routine clinical use and prenatal diagnosis.
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Affiliation(s)
- Dianne Keen-Kim
- Department of Molecular Endocrinology, Quest Diagnostics Nichols Institute, 33608 Ortega Highway, San Juan Capistrano, CA 92690-6130, USA
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Coulter CL. Functional biology of the primate fetal adrenal gland: advances in technology provide new insight. Clin Exp Pharmacol Physiol 2005; 31:475-84. [PMID: 15298538 DOI: 10.1111/j.1440-1681.2004.04031.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
1. The main aim of the present review is to summarize recent experimental data from human and non-human primate models that have identified factors essential for adrenal development and other factors that may determine the regulation of the specific structural organization and function of the adrenal gland. 2. The fetal adrenal cortex has two morphologically distinct zones, with the outer definitive zone being comprised of tightly packed small cells, which appear to be steroidogenically quiescent until late gestation, and the inner fetal zone, which appears to be steroidogenically active throughout gestation. 3. In the primate fetus, growth of the adrenal gland involves hyperplasia, hypertrophy, migration and senescence. Cells appear to proliferate in the external portion of the definitive zone and then move centripetally and become non-proliferative in the fetal zone, where they acquire their steroidogenic capacities. 4. A variety of new technologies has been used to identify zonal-specific markers of the cortical zones within the developing human fetal adrenal gland. On microarray, 67 transcripts showed a minimum of a 2.5-fold difference between the fetal and adult adrenal gland. The vast majority of these genes had not been studied in relation to adrenal gland development or function. In combination with techniques such as laser capture microdissection, which has allowed the isolation of fairly pure zone-specific cell populations from the human fetal adrenal cortex, we can begin to unravel the complex interactions regulating adrenal growth and functional differentiation.
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Affiliation(s)
- Catherine L Coulter
- Centre for the Early Origins of Adult Health, Discipline of Physiology, School of Molecular and Biomedical Science, University of Adelaide, Adelaide, South Australia, Australia.
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Affiliation(s)
- Margaret H MacGillivray
- Department of Pediatrics, Division of Pediatric Endocrinology, University at Buffalo School of Medicine and Biological Sciences, Buffalo, New York, USA
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Gatelais F, Berthelot J, Beringue F, Descamps P, Bonneau D, Limal JM, Coutant R. Effect of single and multiple courses of prenatal corticosteroids on 17-hydroxyprogesterone levels: implication for neonatal screening of congenital adrenal hyperplasia. Pediatr Res 2004; 56:701-5. [PMID: 15371568 DOI: 10.1203/01.pdr.0000142733.50918.6e] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Measurement of 17-hydroxyprogesterone (17-OHP) from filter-paper blood is widely used to screen for congenital adrenal hyperplasia (CAH). However, in pregnancies with an expected preterm delivery, prenatal treatment with steroids to induce pulmonary maturation could suppress the fetal adrenals and interfere with this screening. In 160 infants who were born between 25 and 35 wk of gestation, we measured 17-OHP in filter-paper blood at 72-96 h and compared the values between those who had not received antenatal steroids (n=50) and those who had (n=110). A single course of steroids was two 12-mg injections of betamethasone given within a 24-h interval: 30 infants received a half single course, 45 received a full single course, and 35 received multiple courses. Results are expressed as medians (25th percentile; 75th percentile). Blood 17-OHP differed significantly among groups: 23.7 (14.2; 30.7) nmol/L, 26.1 (15.0; 50.1) nmol/L, 20.1 (13.8; 29.1) nmol/L, and 14.9 (9.5; 26.2) nmol/L (for, respectively, no steroid, half a single course, a full single course, and multiple courses; p <0.05, multiple comparisons with the Kruskal-Wallis test). However, only infants who were treated with multiple antenatal courses of steroids had lower blood 17-OHP than those who were untreated (p <0.05 with the Mann-Whitney U test). In multiple regression analysis, steroid treatment and intrauterine growth retardation were significant negative predictors of blood 17-OHP, whereas respiratory distress syndrome was a significant positive predictor (multiple R=0.50, p <0.001). Multiple courses of steroids in preterm infants decrease 17-OHP values by approximately 30% in filter-paper blood, thus raising the risk of false-negative results in screening programs for CAH.
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Affiliation(s)
- Frédérique Gatelais
- Department of Pediatrics, University Hospital, 15 Rue Larrey, 49000 Angers, France.
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Day DJ, Fitness JE, Milsom S. Successful antenatal treatment of an affected congenital adrenal hyperplasia pregnancy using linkage analysis. Aust N Z J Obstet Gynaecol 2004; 44:369-71. [PMID: 15282019 DOI: 10.1111/j.1479-828x.2004.00253.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Darren J Day
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand.
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Wisniewski AB, Migeon CJ, Malouf MA, Gearhart JP. Psychosexual outcome in women affected by congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Urol 2004; 171:2497-501. [PMID: 15126884 DOI: 10.1097/01.ju.0000125269.91938.f7] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency results in increased adrenal androgen secretion. When the deficiency is severe, the result is the salt losing (SL) form, and when the deficiency is partial, the result is the simple virilizing (SV) form of CAH. We documented long-term satisfaction with gender, cosmetic appearance and function of the genitalia, and surgical management practices in a group of women with CAH due to 21-hydroxylase deficiency. MATERIALS AND METHODS Psychosexual and surgical outcome were assessed in 41 women with CAH using an interview, a written questionnaire and a physical examination. When appropriate, outcome measures were compared to those in unaffected control women. RESULTS Women in the SL group were more likely to question their female gender and report sexual concerns, and less likely to have sexual relations with a partner than those with the SV form or control women. Overall women with CAH were moderately satisfied with the cosmetic appearance of the genitalia but the SL group reported worse genital function than the SV group. Physician rated appearance of the genitalia was better than ratings provided by patients and women with the SL form were judged to have a worse cosmetic outcome of genital reconstruction than women with the SV form. The most common response concerning the optimal timing for genital reconstruction was during infancy and early childhood, although a number of women favored waiting until later for these procedures or did not respond to this question. CONCLUSIONS Women with the SV form reported greater satisfaction and fewer concerns regarding their psychosexual and surgical outcome than women with the SL form.
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Affiliation(s)
- Amy B Wisniewski
- Department of Pediatrics, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
Endocrine disorders, in particular, thyroid disorders, are common in pregnancy. The endocrine adaptation to pregnancy, need for adequate iodine supplementation, and thyroxine replacement are presented. In addition, autoimmune diseases of the thyroid and pituitary that may occur subsequent to the immune changes of pregnancy and the postpartum period are discussed. A brief account of the presentation of other endocrine disorders (ie, pituitary,parathyroid, calcium, adrenal and gonadal disorders) also is given, along with their evaluation and management.
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Affiliation(s)
- Shahla Nader
- Division of Endocrinology and Division of Reproductive Endocrinology, University of Texas Medical School-Houston, 6431 Fannin Street, Suite 3.604, Houston, TX 77030, USA.
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37
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Affiliation(s)
- M G Forest
- Department of Paediatrics, Biologie Endocrinienne et Moléculaire, Hôpital Debrousse, Centre Hospitalier Lyon Sud, Lyon, France.
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Coleman MA, Honour JW. Reduced maternal dexamethasone dosage for the prenatal treatment of congenital adrenal hyperplasia. BJOG 2004; 111:176-8. [PMID: 14723758 DOI: 10.1046/j.1471-0528.2003.00040.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- M A Coleman
- Wessex Fetal and Maternal Medicine Unit, Princess Anne Hospital, Southampton, UK
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Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Schneider Children's Hospital-North Shore-Long Island Jewish Health System, New Hyde Park, NY 11042, USA.
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40
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Abstract
A number of maternal endocrine disorders, when active during pregnancy, can have adverse effects on the newborn. Frequently, these affects can be anticipated as in Graves' disease, or the adverse effect can be prevented as in macrosomia in the infant of the diabetic mother. Occasionally, there are opportunities for prenatal treatment of a fetal endocrine disorder. For instance, a large goitre that may cause problems during delivery can be treated with thyroid hormones administered intra-amniotically or as analogues that cross the placenta. A uniquely effective form of treatment for prevention of a major birth defect is administration of dexamethasone to the mother to avoid virilisation of a female fetus with congenital adrenal hyperplasia (CAH). However, such treatment should only be conducted within the framework of a clinical trial as the long-term effects of exposure to potent glucocorticoids in utero are unknown. Intrauterine growth retardation, which affects about 5% of newborns, is currently not amenable to direct pharmacological treatment before birth. However, there are more practical options for managing this condition, including improved maternal nutrition and avoidance of toxins injurious to fetal growth.
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Affiliation(s)
- I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Box 116, Cambridge, CB2 2QQ, UK.
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