Masculinization of female fetuses with congenital adrenal hyperplasia may already be present at 18 weeks

Prenatal and postnatal imaging techniques in the evaluation of disorders of sex development

Imaging of the reproductive tract is challenging and requires a general knowledge of congenital variations in anatomy. The anatomy of the developing fetus, whether a male phenotype or female phenotype, is also a dynamic process with many changes occurring during gestation. Families may ask details about the genitalia during prenatal imaging and when variations in what is thought to be normal are present, further investigation is sometimes needed to make sense of what is seen. This overview will describe categories of disorders of sex development (DSD), whether chromosomal or structural or both, and the current state of imaging of these anomalies.

Prostate gland development and adrenal tumor in a female with congenital adrenal hyperplasia: a case report and review from radiology perspective

We describe a case of a female with simple virilizing congenital adrenal hyperplasia (CAH) reared as a male diagnosed at the late age of 64. Computed Tomography (CT) demonstrated a large adrenal mass, bilateral diffuse adrenal enlargement, female pelvic organs as well as a clearly visualized prostate gland. This is to the best of our knowledge the first case of such a sizable prostate gland in a female CAH patient documented on CT. We review the literature regarding aspects where radiologists may encounter CAH and the finding of presence of a prostate gland in female CAH patients.

Enlarged adrenal glands as a prenatal marker of congenital adrenal hyperplasia: a report of two cases

We report the prenatal findings of congenital adrenal hyperplasia (CAH) in two consecutive fetuses of one family. The first pregnancy was terminated at 23 weeks' gestation due to the presence of a complex heart anomaly. The adrenal glands appeared enlarged on prenatal ultrasound examination and autopsy confirmed CAH. The parents were subsequently examined and were found to be heterozygous for nucleotide 656 of the CYP21B gene. In a subsequent pregnancy, chorionic villus sampling at 11 weeks confirmed CAH in the male fetus. At this gestational age, mild body edema was present and the nuchal translucency measured 2.1 mm. From 14 weeks onwards, enlargement of the adrenal glands was the only sign of CAH. These findings suggest that enlarged adrenal glands may be a prenatal sign for CAH. In fetal medicine, when a pregnancy is terminated due to fetal malformations, autopsy should be performed because it can provide additional information that is helpful in counseling women with regard to subsequent pregnancies.

Increased nuchal translucency as a prenatal manifestation of congenital adrenal hyperplasia

We present two cases of pregnant women with a previous history of congenital adrenal hyperplasia. In both cases the only abnormal feature in the initial pregnancy had been increased nuchal translucency at 10-14 weeks of gestation. The fetal karyotype was normal and a diagnosis of congenital adrenal hyperplasia was made after delivery. In their current pregnancies, both fetuses also had increased nuchal translucency and normal fetal karyotype. Diagnosis of 21-hydroxylase deficiency was made prenatally by DNA analysis. These findings in four affected fetuses suggest that congenital adrenal hyperplasia should be added to the list of genetic anomalies associated with an increase in nuchal translucency.

The masculinized female and investigation of abnormal sexual development

The congenital adrenal hyperplasias are the commonest cause of ambiguity of the external genitalia at birth, although sexual differentiation in these disorders is strictly normal. The masculinized genetic female is invariably the result of 21-hydroxylase deficiency. The molecular features are well characterized and the phenotypic correlates are generally concordant. Prenatal treatment by maternal dexamethasone administration can successfully prevent virilization of the external genitalia in an affected female fetus. Placental aromatase is a rare and recently characterized alternative cause of a masculinized female which should be considered in the absence of fetal adrenal hyperplasia and maternal androgen-secreting tumours. The investigation of abnormal sexual development requires an initial karyotype analysis and serum 17OH progesterone measurement to determine whether 21-hydroxylase deficiency is the likeliest cause. Thereafter, the presence of a 46,XY karyotype determines the mode of investigation according to androgen production and action. Obtaining appropriate samples for DNA, biochemical and immunohistochemical analyses is essential if the diagnostic yield for the investigation of abnormal sexual development is to be improved.

Sonographic finding of undescended testes in fetuses at 35-40 weeks: significance and outcome

PURPOSE

We evaluated the outcome of fetuses with prenatally diagnosed undescended testes at 35 weeks or more of gestation.

METHODS

We identified the fetuses in our database in whom undescended testes were identified sonographically in the last month of pregnancy and for whom outcome information could be obtained. Associated sonographic abnormalities were tabulated from the original reports. Outcomes were obtained through reviews of the pediatric medical records and pathology reports.

RESULTS

Six fetuses in 5 patients (1 had twins) were identified as having an empty scrotum at 35 weeks or later. In 3 fetuses, this finding was the only prenatal sonographic abnormality. One of these fetuses had isolated undescended testes at birth; the twins were found at birth to be females with congenital adrenal hyperplasia and severe masculinization of the genitals. The other 3 fetuses had other malformations seen prenatally, including omphalocele and macroglossia (Beckwith-Wiedemann syndrome), a left diaphragmatic hernia, and multiple congenital abnormalities.

CONCLUSIONS

Although the finding of undescended testes in late gestation may be noted in an otherwise normal fetus, it may also be associated with a potential risk for perinatal problems ranging from severe multiple congenital abnormalities to incorrect sex assignment due to masculinization of female genitalia.