1
|
Maher JY, Gomez-Lobo V, Merke DP. The management of congenital adrenal hyperplasia during preconception, pregnancy, and postpartum. Rev Endocr Metab Disord 2023; 24:71-83. [PMID: 36399318 PMCID: PMC9884653 DOI: 10.1007/s11154-022-09770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/21/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of steroidogenesis of the adrenal cortex, most commonly due to 21-hydroxylase deficiency caused by mutations in the CYP21A2 gene. Although women with CAH have decreased fecundity, they are able to conceive; thus, if pregnancy is not desired, contraception options should be offered. If fertility is desired, women with classic CAH should first optimize glucocorticoid treatment, followed by ovulation induction medications and gonadotropins if needed. Due to the possible pregnancy complications and implications on the offspring, preconception genetic testing and counseling with a high-risk obstetrics specialist is recommended. For couples trying to avoid having a child with CAH, care with a reproductive endocrinology and infertility specialist to utilize in vitro fertilization can be offered, with or without preimplantation genetic testing for monogenic disorders. Prenatal screening and diagnosis options during pregnancy include maternal serum cell free-DNA for sex of the baby, and chorionic villus sampling and amniocentesis for diagnosis of CAH. Pregnant women with classic CAH need glucocorticoids to be adjusted during the pregnancy, at the time of delivery, and postpartum, and should be monitored for adrenal crisis. Maternal and fetal risks may include chorioamnionitis, maternal hypertension, gestational diabetes, cesarean section, and small for gestational age infants. This review on CAH due to 21-hydroxylase deficiency highlights reproductive health including genetic transmission, contraception options, glucocorticoid management, fertility treatments, as well as testing, antenatal monitoring, and management during pregnancy, delivery, and postpartum.
Collapse
Affiliation(s)
- Jacqueline Yano Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Staff Clinician, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Veronica Gomez-Lobo
- Director of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 1-2740, Bethesda, MD, 20892, USA.
| |
Collapse
|
2
|
Cera G, Locantore P, Novizio R, Maggio E, Ramunno V, Corsello A, Policola C, Concolino P, Paragliola RM, Pontecorvi A. Pregnancy and Prenatal Management of Congenital Adrenal Hyperplasia. J Clin Med 2022; 11:jcm11206156. [PMID: 36294476 PMCID: PMC9605322 DOI: 10.3390/jcm11206156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/26/2022] [Accepted: 10/15/2022] [Indexed: 11/21/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive diseases that may cause cortisol insufficiency together with other hormonal alterations. The most common form is 21-hydroxylase deficiency, in which the lack of pituitary negative feedback causes an increase in ACTH and adrenal androgens. Classical forms of CAHs can lead to severe adrenal failure and female virilization. To date, the appropriate management of pregnant CAH patients is still debated regarding appropriate maternal therapy modifications during pregnancy and the risks and benefits of prenatal treatment of the fetus. We conducted a literature search of relevant papers to collect current evidence and experiences on the topic. The most recent and significant articles were selected, and current international guidelines were consulted to update current recommendations and guide clinical practice. Given the lack of randomized clinical trials and other high-quality scientific evidence, the issue is still debated, and great heterogeneity exists in current practice in terms of risk/benefit evaluation and pharmacological choices for pregnancy and prenatal treatment. Glucocorticoid therapy is advised not only in classical CAH patients but also in non-classical, milder forms. The choice of which glucocorticoid to use, and the safety and benefits of dexamethasone therapy aimed at preventing genital virilization are still debated issues. Several advances, however, have been made, especially in terms of fertility and reproduction. This review aims to present the most recent scientific and real-world updates on pregnancy and prenatal management of CAH, with the presentation of various clinical scenarios and specific case-by-case recommendations.
Collapse
Affiliation(s)
- Gianluca Cera
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Pietro Locantore
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
- Correspondence:
| | - Roberto Novizio
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Ettore Maggio
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Vittoria Ramunno
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Andrea Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Caterina Policola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Paola Concolino
- Unit of Clinical Chemistry, Biochemistry and Molecular Biology, Department of Laboratory and Infectiology Sciences, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
- Unicamillus, Saint Camillus International University of Medical Sciences, Via di S. Alessandro 10, 00131 Rome, Italy
| | - Alfredo Pontecorvi
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| |
Collapse
|
3
|
Messina V, van’t Westeinde A, Padilla N, Lajic S. First Trimester Dexamethasone Treatment Is Not Associated With Alteration in Resting-state Connectivity at Adolescent or Adult Age. J Clin Endocrinol Metab 2022; 107:2769-2776. [PMID: 35882216 PMCID: PMC9516042 DOI: 10.1210/clinem/dgac426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Indexed: 11/28/2022]
Abstract
CONTEXT Prenatal treatment with dexamethasone (DEX) has been used to prevent virilization in females at risk of congenital adrenal hyperplasia (CAH). Both affected and unaffected girls, as well boys, are treated until the genotype and sex of the fetus is known (gestational weeks 10-12). After that, only affected girls are treated until term. Exposure to a high synthetic glucocorticoid dosage may alter the developmental trajectory of the brain, with alterations in resting-state functional connectivity of the brain at adult age. OBJECTIVE To investigate resting-state functional connectivity in subjects at risk of having CAH, exposed to DEX treatment during the first trimester of fetal life, both in the whole brain and in 3 regions of interest (amygdala, hippocampus, and superior frontal gyrus). DESIGN, SETTING, AND PARTICIPANTS Eighteen participants (8 females) at risk of having CAH, exposed to DEX treatment, and 38 controls (24 females), age range 16 to 26 years, from a single research institute, underwent functional magnetic resonance imaging of the brain during rest. We used 2 different approaches: an exploratory whole-brain analysis and seed-based analysis. For seed-based analysis, we chose 3 different brain regions (amygdala, hippocampus, and superior frontal gyrus) based on our previous findings and literature evidence. RESULTS We did not observe any differences in functional connectivity during rest, either in the whole brain nor in seed-based connectivity analyses at this adolescent and young adult age. CONCLUSIONS Our results are reassuring; however, future studies on larger samples and with more sensitive methodologies are needed to confirm these findings.
Collapse
Affiliation(s)
- Valeria Messina
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit (QB83), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Annelies van’t Westeinde
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit (QB83), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska vägen 8 (S3:03), Karolinska University Hospital, SE- 171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Correspondence: Svetlana Lajic, MD, Department of Women’s and Children’s Health, Pediatric Endocrinology Unit (QB83), Karolinska vägen 37A, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| |
Collapse
|
4
|
Nowotny H, Neumann U, Tardy-Guidollet V, Ahmed SF, Baronio F, Battelino T, Bertherat J, Blankenstein O, Bonomi M, Bouvattier C, Brac de la Perrière A, Brucker S, Cappa M, Chanson P, Claahsen-van der Grinten HL, Colao A, Cools M, Davies JH, Dörr HG, Fenske WK, Ghigo E, Giordano R, Gravholt CH, Huebner A, Husebye ES, Igbokwe R, Juul A, Kiefer FW, Léger J, Menassa R, Meyer G, Neocleous V, Phylactou LA, Rohayem J, Russo G, Scaroni C, Touraine P, Unger N, Vojtková J, Yeste D, Lajic S, Reisch N. Prenatal dexamethasone treatment for classic 21-hydroxylase deficiency in Europe. Eur J Endocrinol 2022; 186:K17-K24. [PMID: 35235536 PMCID: PMC9010809 DOI: 10.1530/eje-21-0554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the current medical practice in Europe regarding prenatal dexamethasone (Pdex) treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. DESIGN AND METHODS A questionnaire was designed and distributed, including 17 questions collecting quantitative and qualitative data. Thirty-six medical centres from 14 European countries responded and 30 out of 36 centres were reference centres of the European Reference Network on Rare Endocrine Conditions, EndoERN. RESULTS Pdex treatment is currently provided by 36% of the surveyed centres. The treatment is initiated by different specialties, that is paediatricians, endocrinologists, gynaecologists or geneticists. Regarding the starting point of Pdex, 23% stated to initiate therapy at 4-5 weeks postconception (wpc), 31% at 6 wpc and 46 % as early as pregnancy is confirmed and before 7 wpc at the latest. A dose of 20 µg/kg/day is used. Dose distribution among the centres varies from once to thrice daily. Prenatal diagnostics for treated cases are conducted in 72% of the responding centres. Cases treated per country and year vary between 0.5 and 8.25. Registries for long-term follow-up are only available at 46% of the centres that are using Pdex treatment. National registries are only available in Sweden and France. CONCLUSIONS This study reveals a high international variability and discrepancy in the use of Pdex treatment across Europe. It highlights the importance of a European cooperation initiative for a joint international prospective trial to establish evidence-based guidelines on prenatal diagnostics, treatment and follow-up of pregnancies at risk for CAH.
Collapse
Affiliation(s)
- Hanna Nowotny
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Véronique Tardy-Guidollet
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Federico Baronio
- Paediatric Endocrinology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, University Children’s Hospital, Ljubljana, Slovenia
| | - Jérôme Bertherat
- Service d’Endocinologie et Maladies Métaboliques, Hôpitaux Universitaires Paris-Centre, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases and Lab of Endocrine and Metabolic Research, IRCSS Istituto Auxologico Italiano, Milan, Italy
| | - Claire Bouvattier
- Service d’Endocrinologie de l’Enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France
- Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Paris, France
| | - Aude Brac de la Perrière
- Fédération d’Endocrinologie, de Diabétologie et des Maladies Métaboliques, Hospices Civils des Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Lyon, France
| | - Sara Brucker
- Department of Women’s Health, University Women’s Hospital, University of Tübingen, Tübingen, Germany
| | - Marco Cappa
- Endocrinology Unit, Paediatric University Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de Hypophyse, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hedi L Claahsen-van der Grinten
- Department of Paediatric Endocrinology, Amalia Children’s Hospital, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita’ Federico II di Napoli, Naples, Italy
| | - Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium
| | - Justin H Davies
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helmut-Günther Dörr
- Paediatric Endocrinology, Department of Paediatrics, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wiebke K Fenske
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Ezio Ghigo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Roberta Giordano
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Angela Huebner
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Eystein Sverre Husebye
- Department of Clinical Science and KG Jebsen Centre for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rebecca Igbokwe
- West Midlands Regional Genetics Laboratory, Birmingham Women’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Florian W Kiefer
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Juliane Léger
- Department of Paediatric Endocrinology and Diabetology and Reference Centre for Rare Diseases of Growth and Development, AP-HP Paris Nord Université de Paris, CHU Robert-Debre, Paris, France
| | - Rita Menassa
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe University Frankfurt Faculty 16 Medicine, Frankfurt am Main, Germany
| | - Vassos Neocleous
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Leonidas A Phylactou
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Julia Rohayem
- Centre of Reproductive Medicine and Andrology, Clinical and Operative Andrology, University of Münster, Münster, Germany
| | - Gianni Russo
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Carla Scaroni
- Dipartimento di Medicina, U.O.C. Endocrinologia, Università di Padova, Padova, Italy
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Centre for Rare Endocrine and Gynaecological Disorders, Sorbonne Université, Assistance Publique Hopitaux de Paris, Paris, France
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, Essen, Germany
| | - Jarmila Vojtková
- Department of Paediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Hospital in Martin, Martin, Slovakia
| | - Diego Yeste
- Paediatric Endocrinology Service, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- CIBERER, ISCIII, Madrid, Spain
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital, Paediatric Endocrinology Unit (QB83), Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence should be addressed to N Reisch;
| |
Collapse
|
5
|
Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
Collapse
Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
| |
Collapse
|
6
|
Xu L, Lin W, Cai L, Huang H, Liang J, Li L, Zong L, Wang N, Wen J, Chen G. Efficacy and safety of prenatal dexamethasone treatment in offspring at risk for congenital adrenal hyperplasia due to 21-hydroxylase deficiency: A systematic review and meta-analysis. Clin Endocrinol (Oxf) 2020; 92:109-123. [PMID: 31715010 DOI: 10.1111/cen.14126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/10/2019] [Accepted: 11/08/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of prenatal dexamethasone treatment in offspring at risk for congenital adrenal hyperplasia. METHODS MEDLINE, EMBASE, the Cochrane Library, the clinicaltrials.gov website databases were systematically searched from inception through March 2019. WMD and SMD with 95%CIs were calculated using random or fixed effects models. RESULTS There was a significant reduction in virilization in the DEX-treated group (WMD: -2.39, 95%CI: -3.31,-1.47). No significant differences were found in newborn physical outcomes for birth weight (WMD: 0.09, 95%CI: -0.09, 0.27) and birth length (WMD = 0.27, 95%CI: -0.68, 1.21). Concerning cognitive functions, no significant differences in the domains of psychometric intelligence (SMD: 0.05, 95%CI: -0.74, 0.83), verbal memory (SMD: -0.17, 95%CI: -0.58, 0.23), visual memory (SMD: 0.10, 95%CI: -0.14, 0.34), learning (SMD: -0.02, 95%CI: -0.27, 0.22) and verbal processing (SMD: -0.38, 95%CI: -0.93, 0.17). Regarding behavioural problems, no significant differences in the domains of internalizing problems (SMD: 0.16, 95%CI: -0.49, 0.81), externalizing problems (SMD: 0.07, 95%CI: -0.30, 0.43) and total problems (SMD: 0.14, 95%CI: -0.23, 0.51). With respect to temperament, no significant differences in the domains of emotionality (SMD: 0.13, 95%CI: -0.79, 1.05), activity (SMD: 0.04, 95%CI: -0.32, 0.39), shyness (SMD: 0.25, 95%CI: -0.70, 1.20) and sociability (SMD: -0.23, 95%CI: -0.90, 0.44). CONCLUSIONS Prenatal DEX treatment reduced virilization with no significant differences in newborn physical outcomes, cognitive functions, behavioural problems and temperament. The results need to be interpreted cautiously due to the existence of limitations.
Collapse
Affiliation(s)
- Lizhen Xu
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Wei Lin
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Liangchun Cai
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Huibin Huang
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Jixing Liang
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Liantao Li
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Liyao Zong
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Nengying Wang
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Junping Wen
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
| | - Gang Chen
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, China
- Department of Scientific research, Fujian Academy of Medical Sciences, Fuzhou, China
| |
Collapse
|
7
|
46,XX DSD due to Androgen Excess in Monogenic Disorders of Steroidogenesis: Genetic, Biochemical, and Clinical Features. Int J Mol Sci 2019; 20:ijms20184605. [PMID: 31533357 PMCID: PMC6769793 DOI: 10.3390/ijms20184605] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/17/2022] Open
Abstract
The term 'differences of sex development' (DSD) refers to a group of congenital conditions that are associated with atypical development of chromosomal, gonadal, or anatomical sex. Disorders of steroidogenesis comprise autosomal recessive conditions that affect adrenal and gonadal enzymes and are responsible for some conditions of 46,XX DSD where hyperandrogenism interferes with chromosomal and gonadal sex development. Congenital adrenal hyperplasias (CAHs) are disorders of steroidogenesis that mainly involve the adrenals (21-hydroxylase and 11-hydroxylase deficiencies) and sometimes the gonads (3-beta-hydroxysteroidodehydrogenase and P450-oxidoreductase); in contrast, aromatase deficiency mainly involves the steroidogenetic activity of the gonads. This review describes the main genetic, biochemical, and clinical features that apply to the abovementioned conditions. The activities of the steroidogenetic enzymes are modulated by post-translational modifications and cofactors, particularly electron-donating redox partners. The incidences of the rare forms of CAH vary with ethnicity and geography. The elucidation of the precise roles of these enzymes and cofactors has been significantly facilitated by the identification of the genetic bases of rare disorders of steroidogenesis. Understanding steroidogenesis is important to our comprehension of differences in sexual development and other processes that are related to human reproduction and fertility, particularly those that involve androgen excess as consequence of their impairment.
Collapse
|
8
|
Abstract
Fertility rates in classic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency are substantially decreased for various reasons, including hormonal, anatomic, psychosocial, and psychosexual causes. However, fecundity is comparable with the general population. Under optimal hormone replacement, the course and outcome of pregnancies is also good. This article summarizes successful gestational management, including preconceptional considerations, adjustment of hormone replacement during pregnancy, delivery and lactation, as well as the prevention of adrenal crises. In nonclassic 21-hydroxylase deficiency, preconceptional low-dose hydrocortisone replacement normalizes the otherwise increased miscarriage rate. Pregnancy reports in rarer forms of congenital adrenal hyperplasia are summarized as well.
Collapse
Affiliation(s)
- Nicole Reisch
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Ziemssenstraße 1, München 80336, Germany.
| |
Collapse
|
9
|
Pofi R, Tomlinson JW. Glucocorticoids in pregnancy. Obstet Med 2019; 13:62-69. [PMID: 32714437 DOI: 10.1177/1753495x19847832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
The physiological changes that occur during pregnancy include altered regulation of the hypothalamo-pituitary-adrenal axis. The fetoplacental unit plays a major role in this, together with alteration of circulating cortisol-binding globulin levels, with a net effect to increase both total and free cortisol levels. Importantly, there are several pathological conditions that require steroid treatment or replacement during pregnancy, and optimizing therapy is clearly crucial. The potential for acute and chronic adverse effects that can impact upon both the mother and the fetus makes the decision of how and when to instigate steroid therapy particularly challenging. In this review, we describe the physio-pathological changes to the hypothalamo-pituitary-adrenal axis that occur during pregnancy, tools to assess endogenous glucocorticoid reserve as well as discuss treatment strategies and the potential for the development of adverse events.
Collapse
Affiliation(s)
- Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| |
Collapse
|
10
|
Simpson JL, Rechitsky S. Prenatal genetic testing and treatment for congenital adrenal hyperplasia. Fertil Steril 2019; 111:21-23. [PMID: 30611408 DOI: 10.1016/j.fertnstert.2018.11.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/28/2018] [Indexed: 11/18/2022]
Abstract
Couples at risk for autosomal recessive congenital adrenal hyperplasia often request anticipatory guidance and genetic counseling. Initially, hormones in amniotic fluid were measured to distinguish affected female fetuses from unaffected fetuses. With the molecular era, more-targeted approaches became possible. Prenatal genetic diagnosis via amniocentesis or chorionic villus sampling was used to determine the need for continuing fetal therapy (dexamethasone), allowing cessation if the fetus was unaffected. Newer methods now allow diagnosis earlier in gestation, further shortening the treatment time for unaffected female fetuses who will not develop genital ambiguity. Preimplantation genetic testing permits transfer only of an unaffected female or male fetus. Analysis of maternal cell-free DNA based on quantitative differences in the amount of allele parental DNA permits affected pregnancies to be differentiated from unaffected pregnancies.
Collapse
Affiliation(s)
- Joe Leigh Simpson
- Department of Biomedical Engineering, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida.
| | - Svetlana Rechitsky
- Department of Human and Molecular Genetics, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Reproductive Genetic Innovations, LLC, Northbrook, Illinois
| |
Collapse
|
11
|
Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
12
|
Lajic S, Karlsson L, Nordenström A. Prenatal Treatment of Congenital Adrenal Hyperplasia: Long-Term Effects of Excess Glucocorticoid Exposure. Horm Res Paediatr 2018; 89:362-371. [PMID: 29742490 DOI: 10.1159/000485100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/08/2017] [Indexed: 11/19/2022] Open
Abstract
Prenatal treatment of congenital adrenal hyperplasia with dexamethasone (DEX) has been in use since the mid-1980s and has proven effective at reducing virilization of external genitalia in affected girls. However, multiple experimental studies on animals and clinical studies on humans show that prenatal administration of glucocorticoids may cause unwanted adverse effects which have raised concerns about the long-term safety of the treatment. The long-term outcome of prenatal DEX treatment on cognition has been investigated, but the results are still conflicting. Overall, most of the evidence points towards a negative effect on executive functions where girls seem to be more susceptible than boys. Some effects on social behavior have been observed, but results are still contradictory and treated children are mostly well adapted. Cardiovascular, renal, and metabolic function are still areas to be investigated. Larger studies are warranted to investigate areas other than cognition and behavior and to be able to draw more definitive conclusions about prenatal DEX treatment.
Collapse
|
13
|
Karlsson L, Nordenström A, Hirvikoski T, Lajic S. Prenatal dexamethasone treatment in the context of at risk CAH pregnancies: Long-term behavioral and cognitive outcome. Psychoneuroendocrinology 2018. [PMID: 29529521 DOI: 10.1016/j.psyneuen.2018.02.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Dexamethasone (DEX) is used to prevent prenatal virilization in female fetuses with congenital adrenal hyperplasia (CAH). Since treatment has to be started before the genotype of the fetus is known, 7 out of 8 fetuses will be exposed to DEX without benefit. Previously, we have observed negative effects on cognition and behavior in DEX treated children. Here we evaluated neuropsychological functions, psychopathology and autistic traits in non-CAH DEX-treated adults exposed during the first trimester of fetal life (duration 6.2 ± 2.2 weeks). Cognitive functions, psychopathology and autistic traits were compared between DEX-treated subjects (n = 23) and non-exposed controls (n = 58). Cognitive outcome was also evaluated longitudinally for DEX-treated participants. We used neuropsychological tests (Wechsler Scales and the Stroop Interference Test) and questionnaires assessing executive functions (the Barkley Deficit in Executive Functioning Scale), psychopathology (the Montgomery Åsberg Depression Ratings Scale, the Hospital Anxiety and Depression Scale, the Liebowitz Social Anxiety Scale) and autistic traits (Autism Quota). We did not observe any significant differences in cognition, psychopathology or autistic traits between DEX-treated individuals and population controls. A significant improvement in verbal working memory (p = 0.038) and in impulse inhibition (p = 0.011) was seen when subjects were evaluated longitudinally. In summary, first-trimester DEX-exposed adult individuals do not show any significant neuropsychological deficits nor an increase in anxiety, depression or autistic traits, compared with a control group from the general population. The results also suggest that the observed deficits in executive functioning during childhood may improve with time.
Collapse
Affiliation(s)
- Leif Karlsson
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit (Q2:08), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit (Q2:08), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Tatja Hirvikoski
- Department of Women's and Children's Health, Pediatric Neuropsychiatry Unit, Center for Neurodevelopmental Disorders at Karolinska Institutet (KIND), Karolinska Institutet, SE-113 30 Stockholm, Sweden; Habilitation and Health, Stockholm County Council, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit (Q2:08), Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| |
Collapse
|
14
|
Lye P, Bloise E, Nadeem L, Gibb W, Lye SJ, Matthews SG. Glucocorticoids modulate multidrug resistance transporters in the first trimester human placenta. J Cell Mol Med 2018; 22:3652-3660. [PMID: 29691980 PMCID: PMC6010777 DOI: 10.1111/jcmm.13646] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/16/2018] [Indexed: 12/17/2022] Open
Abstract
The placental multidrug transporters, P‐glycoprotein (P‐gp, encoded by ABCB1) and breast cancer resistance protein (BCRP,ABCG2) protect the foetus from exposure to maternally derived glucocorticoids, toxins and xenobiotics. During pregnancy, maternal glucocorticoid levels can be elevated by stress or exogenous administration. We hypothesized that glucocorticoids modulate the expression of ABCB1/P‐gp and ABCG2/BCRP in the first trimester human placenta. Our objective was to examine whether dexamethasone (DEX) or cortisol modulate first trimester placental expression of multidrug transporters and determine whether cytotrophoblasts or the syncytiotrophoblast are/is responsible for mediating these effects. Three models were examined: (i) an ex‐vivo model of placental villous explants (7‐10 weeks), (ii) a model of isolated first trimester syncytiotrophoblast and cytotrophoblast cells and (iii) the BeWo immortalized trophoblast cell line model. These cells/tissues were treated with DEX or cortisol for 24 hour to 72 hour. In first trimester placental explants, DEX (48 hour) increased ABCB1 (P < .001) and ABCG2 (P < .05) mRNA levels, whereas cortisol (48 hour) only increased ABCB1 mRNA levels (P < .01). Dexamethasone (P < .05) and cortisol (P < .01) increased BCRP but did not affect P‐gp protein levels. Breast cancer resistance protein expression was primarily confined to syncytiotrophoblasts. BeWo cells, when syncytialized with forskolin, increased expression of BCRP protein, and this was further augmented by DEX (P < .05). Our data suggest that the protective barrier provided by BCRP increases as cytotrophoblasts fuse to form the syncytiotrophoblast. Increase in glucocorticoid levels during the first trimester may reduce embryo/foetal exposure to clinically relevant BCRP substrates, because of an increase in placental BCRP.
Collapse
Affiliation(s)
- Phetcharawan Lye
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Enrrico Bloise
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Morphology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Lubna Nadeem
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - William Gibb
- Department of Obstetrics & Gynaecology, University of Ottawa, Ottawa, ON, Canada.,Department of Cellular & Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stephen J Lye
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephen G Matthews
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
15
|
Karlsson L, Gezelius A, Nordenström A, Hirvikoski T, Lajic S. Cognitive impairment in adolescents and adults with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2017; 87:651-659. [PMID: 28771762 DOI: 10.1111/cen.13441] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/09/2017] [Accepted: 07/29/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Impaired cognition has been reported in patients with congenital adrenal hyperplasia (CAH), although the findings have been conflicting. It has been hypothesized that the major causes of the deficits are prenatal hormonal imbalances and/or excessive glucocorticoid treatment. DESIGN An observational study investigating cognition in patients with CAH. PATIENTS A total of 55 patients with CAH and 58 control subjects from the general population, aged 16-33 years. Nine CAH subjects had been treated prenatally with dexamethasone. SETTING Singel research institute. MEASUREMENTS Standardized neuropsychological tests (Wechsler Scales and Stroop Interference Test) and questionnaires (Barkley Deficit in Executive Functioning Scale) were used. RESULTS Compared to controls, patients with CAH had impaired performance in tests measuring verbal working memory (P = .024), visual-spatial working memory (P = .005 and P = .003) and inhibition (P = .002). In measures of fluid intelligence/nonverbal logical reasoning, males with CAH performed poorer than control males (P = .033). Patients with salt-wasting CAH performed equally compared to patients with simple virilizing CAH. However, patients with a null genotype performed poorer than patients with a non-null genotype and significantly worse on fluid intelligence/nonverbal logical reasoning (P = .042). Prenatally-treated women performed worse on most cognitive measures than women with CAH not treated prenatally. CONCLUSIONS Patients with CAH had normal psychometric intelligence but impaired executive functions compared with population controls. A null CAH genotype was associated with poorer general cognitive capacity.
Collapse
Affiliation(s)
- Leif Karlsson
- Department of Women's and Children's Health, Pediatric Endocrinology Unit (Q2:08), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anton Gezelius
- Department of Women's and Children's Health, Pediatric Endocrinology Unit (Q2:08), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Pediatric Endocrinology Unit (Q2:08), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tatja Hirvikoski
- Department of Women's and Children's Health, Pediatric Neuropsychiatry Unit, Center for Neurodevelopmental Disorders at Karolinska Institutet (KIND), Karolinska Institutet, Stockholm, Sweden
- Habilitation and Health, Stockholm County Council, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Pediatric Endocrinology Unit (Q2:08), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
16
|
El-Maouche D, Arlt W, Merke DP. Congenital adrenal hyperplasia. Lancet 2017; 390:2194-2210. [PMID: 28576284 DOI: 10.1016/s0140-6736(17)31431-9] [Citation(s) in RCA: 278] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders encompassing enzyme deficiencies in the adrenal steroidogenesis pathway that lead to impaired cortisol biosynthesis. Depending on the type and severity of steroid block, patients can have various alterations in glucocorticoid, mineralocorticoid, and sex steroid production that require hormone replacement therapy. Presentations vary from neonatal salt wasting and atypical genitalia, to adult presentation of hirsutism and irregular menses. Screening of neonates with elevated 17-hydroxyprogesterone concentrations for classic (severe) 21-hydroxylase deficiency, the most common type of congenital adrenal hyperplasia, is in place in many countries, however cosyntropin stimulation testing might be needed to confirm the diagnosis or establish non-classic (milder) subtypes. Challenges in the treatment of congenital adrenal hyperplasia include avoidance of glucocorticoid overtreatment and control of sex hormone imbalances. Long-term complications include abnormal growth and development, adverse effects on bone and the cardiovascular system, and infertility. Novel treatments aim to reduce glucocorticoid exposure, improve excess hormone control, and mimic physiological hormone patterns.
Collapse
Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham & Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA; The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Abstract
Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is a monogenic disorder of adrenal steroidogenesis. To prevent genital ambiguity, in girls, prenatal dexamethasone treatment is administered early in the first trimester. Prenatal genetic diagnosis of CAH and fetal sex determination identify affected female fetuses at risk for genital virilization. Advancements in prenatal diagnosis are owing to improved understanding of the genetic basis of CAH and improved technology. Cloning of the CYP21A2 gene ushered in molecular genetic analysis as the current standard of care. Noninvasive prenatal diagnosis allows for targeted treatment and avoids unnecessary treatment of males and unaffected females.
Collapse
Affiliation(s)
- Mabel Yau
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1198, New York, NY 10029, USA
| | - Ahmed Khattab
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1198, New York, NY 10029, USA
| | - Maria I New
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1198, New York, NY 10029, USA.
| |
Collapse
|
19
|
Latorre S, Garzón C, Manosalva G, Merchán S, Jacomussi L, Maldonado S. Hiperplasia adrenal congénita por déficit de 21 hidroxilasa: un reto diagnóstico y terapéutico. REPERTORIO DE MEDICINA Y CIRUGÍA 2016. [DOI: 10.1016/j.reper.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
20
|
Dörr HG, Binder G, Reisch N, Gembruch U, Oppelt PG, Wieacker P, Kratzsch J. Experts' Opinion on the Prenatal Therapy of Congenital Adrenal Hyperplasia (CAH) Due to 21-Hydroxylase Deficiency - Guideline of DGKED in cooperation with DGGG (S1-Level, AWMF Registry No. 174/013, July 2015). Geburtshilfe Frauenheilkd 2015; 75:1232-1238. [PMID: 28435171 DOI: 10.1055/s-0041-109717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Purpose: This guideline of the German Society of Pediatric Endocrinology and Diabetology (DGKED) is designed to be experts' opinion on the current concept of prenatal therapy for congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH). Several scientific medical societies have also participated in the guideline. It aims to offer guidance to physicians when they counsel affected families about prenatal therapy. Methods: The experts commissioned by the medical societies developed a consensus in an informal process. The consensus was subsequently confirmed by the steering committees of the respective medical societies. Recommendations: Prenatal CAH therapy is an experimental therapy. We recommend designing and using standardized protocols for the prenatal diagnosis, therapy and long-term follow-up of women and children treated prenatally with dexamethasone. If long-term follow-up is not possible, then prenatal therapy should not be performed.
Collapse
Affiliation(s)
- H G Dörr
- Kinder- und Jugendklinik des Universitätsklinikums Erlangen, Erlangen
| | - G Binder
- Univ.-Kinderklinik Tübingen, Sektion Endokrinologie, Tübingen
| | - N Reisch
- Medizinische Klinik und Poliklinik IV. Klinikum der Universität München, München
| | - U Gembruch
- Abteilung für Geburtshilfe und Pränatalmedizin der Universität Bonn, Bonn
| | - P G Oppelt
- Kinder- und Jugendgynäkologie, Frauenklinik des Universitätsklinikums Erlangen, Erlangen
| | - P Wieacker
- Institut für Humangenetik, Universitätsklinikum Münster, Münster
| | - J Kratzsch
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik der Universität Leipzig, Leipzig
| |
Collapse
|
21
|
Turcu AF, Auchus RJ. The next 150 years of congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2015; 153:63-71. [PMID: 26047556 PMCID: PMC4568140 DOI: 10.1016/j.jsbmb.2015.05.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/26/2015] [Accepted: 05/31/2015] [Indexed: 11/25/2022]
Abstract
Congenital adrenal hyperplasias (CAH) are a group of autosomal recessive defects in cortisol biosynthesis. Substantial progress has been made since the description of the first report, 150 years ago. This article reviews some of the recent advances in the genetics, diagnosis and treatment of CAH. In addition, we underline the aspects where further progress is required, including, among others, better diagnostic modalities for the mild phenotype and for some of the rare forms of disease, elucidation of epigenetic factors that lead to different phenotypes in patients with identical genotype and expending on treatment options for controlling the adrenal androgen excess.
Collapse
Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Diabetes, and Endocrinology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48019, United States
| | - Richard J Auchus
- Division of Metabolism, Diabetes, and Endocrinology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48019, United States; Department of Pharmacology, University of Michigan, Ann Arbor, MI 48019, United States.
| |
Collapse
|
22
|
Abstract
Congenital adrenal hyperplasia associated with deficiency of steroid 21-hydroxylase is the most common inborn error in adrenal function and the most common cause of adrenal insufficiency in the pediatric age group. As patients now survive into adulthood, adult health-care providers must also be familiar with this condition. Over the past several years, F1000 has published numerous commentaries updating research and practical guidelines for this condition. The purposes of this review are to summarize basic information defining congenital adrenal hyperplasia and to highlight current knowledge and controversies in management.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Cohen Children's Medical Center and Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY 11040, USA
| |
Collapse
|
23
|
Abstract
Prenatal treatment of congenital adrenal hyperplasia by administering dexamethasone to a woman presumed to be carrying an at-risk fetus remains a controversial experimental treatment. Review of data from animal experimentation and human trials indicates that dexamethasone cannot be considered safe for the fetus. In animals, prenatal dexamethasone decreases birth weight, affects renal, pancreatic beta cell and brain development, increases anxiety and predisposes to adult hypertension and hyperglycemia. In human studies, prenatal dexamethasone is associated with orofacial clefts, decreased birth weight, poorer verbal working memory, and poorer self-perception of scholastic and social competence. Numerous medical societies have cautioned that prenatal treatment of adrenal hyperplasia with dexamethasone is not appropriate for routine clinical practice and should only be done in Institutional Review Board approved, prospective clinical research settings with written informed consent. The data indicate that this treatment is inconsistent with the classic medical ethical maxim to 'first do no harm'.
Collapse
Affiliation(s)
- Walter L Miller
- Department of Pediatrics and Center for Reproductive Sciences, University of California, San Francisco, San Francisco CA 94143-0556, USA.
| |
Collapse
|
24
|
Peffer ME, Zhang JY, Umfrey L, Rudine AC, Monaghan AP, DeFranco DB. Minireview: the impact of antenatal therapeutic synthetic glucocorticoids on the developing fetal brain. Mol Endocrinol 2015; 29:658-66. [PMID: 25763611 DOI: 10.1210/me.2015-1042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The life-threatening, emotional, and economic burdens of premature birth have been greatly alleviated by antenatal glucocorticoid (GC) treatment. Antenatal GCs accelerate tissue development reducing respiratory distress syndrome and intraventricular hemorrhage in premature infants. However, they can also alter developmental processes in the brain and trigger adverse behavioral and metabolic outcomes later in life. This review summarizes animal model and clinical studies that examined the impact of antenatal GCs on the developing brain. In addition, we describe studies that assess glucocorticoid receptor (GR) action in neural stem/progenitor cells (NSPCs) in vivo and in vitro. We highlight recent work from our group on two GR pathways that impact NSPC proliferation, ie, a nongenomic GR pathway that regulates gap junction intercellular communication between coupled NSPCs through site-specific phosphorylation of connexin 43 and a genomic pathway driven by differential promoter recruitment of a specific GR phosphoisoform.
Collapse
Affiliation(s)
- Melanie E Peffer
- Program in Integrative Molecular Biology (M.E.P., D.B.D.), Department of Pharmacology and Chemical Biology (M.E.P., J.Y.Z., L.U., D.B.D.), and Newborn Medicine Program (A.C.R.), Children's Hospital of Pittsburgh, and Department of Neurobiology (A.P.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15260
| | | | | | | | | | | |
Collapse
|
25
|
Late prenatal dexamethasone and phenotype variations in 46,XX CAH: concerns about current protocols and benefits for surgical procedures. J Pediatr Urol 2014; 10:941-7. [PMID: 24679821 DOI: 10.1016/j.jpurol.2014.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/13/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the action of prenatal dexamethasone (PreDex) on the anatomy of female congenital adrenal hyperplasia (CAH) genitalia when started at later stages of gestation. MATERIALS AND METHODS Our group follows a large cohort of French CAH patients who underwent PreDex therapy, of whom 258 were recently reported. Four 46,XX patients with a delayed PreDex treatment presented with a virilized genitalia and required surgical reconstruction. This is a retrospective report on genital phenotyping at the time of surgery of these four patients who began PreDex therapy at 8, 12, 20, and 28 weeks of gestation. RESULTS Although this series is limited in number, the anatomical description of the length of the genital tubercle, the height of the urethra-vaginal confluence, and the degree of fusion of the genital folds seems to be dependent upon the starting date of PreDex. Most PreDex treatments prescribed up to now have covered the full duration of gestation. CONCLUSIONS Our findings suggest that PreDex therapy could be limited to the period of the partitioning window. It is hoped that further prospective multicentric clinical studies will obtain ethical approval in order to elucidate the place and protocols of PreDex therapy in the management of CAH.
Collapse
|
26
|
Tardy-Guidollet V, Menassa R, Costa JM, David M, Bouvattier-Morel C, Baumann C, Houang M, Lorenzini F, Philip N, Odent S, Guichet A, Morel Y. New management strategy of pregnancies at risk of congenital adrenal hyperplasia using fetal sex determination in maternal serum: French cohort of 258 cases (2002-2011). J Clin Endocrinol Metab 2014; 99:1180-8. [PMID: 24471566 DOI: 10.1210/jc.2013-2895] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Prenatal dexamethasone (DEX) treatment has been proposed since 1984 to prevent genital virilization in girls with congenital adrenal hyperplasia (CAH). DEX is effective in CAH females if initiated before the sixth week of gestation, but its safety in children treated in utero remains controversial regarding cognitive functions. OBJECTIVE To avoid prenatal DEX in males and initiate DEX in due time in CAH females, we proposed in 2002 a protocol for fetal sex determination in the maternal serum (SRY test). DESIGN AND SETTING We conducted a retrospective study of the management of 258 fetuses in the period 2002 through 2011 in pregnancies managed in referent medical centers with an institutional practice. PATIENTS A total of 258 fetuses at risk of CAH (134 males and 124 females) were included. INTERVENTION DEX was offered after informed consent to pregnant women. MAIN OUTCOME MEASURE The sensitivity of an early SRY test was evaluated after data collection. RESULTS The SRY test is sensitive from 4 weeks and 5 days of gestation. It avoided prenatal DEX in 68% of males, and this percentage increased over the years. DEX was maintained until prenatal diagnosis in non-CAH females. Virilization was prevented in 12 CAH girls treated at the latest at 6 weeks gestation and minimized in 3 girls treated between 6 and 7 weeks gestation. Maternal tolerance was correct. No fetal malformations were noted in the 154 children treated in utero. CONCLUSIONS The SRY test is reliable to avoid prenatal DEX in males, but its application must be improved. Prenatal DEX should be maintained to prevent virilization and traumatic surgery in CAH girls after informed consent and information provided to families about the benefit to risk ratio in limiting hyperandrogenism during fetal life. Our large multicentric French cohort has helped to better assess the risks previously reported.
Collapse
Affiliation(s)
- Véronique Tardy-Guidollet
- Laboratoire d'Endocrinologie Moléculaire et Maladies Rares (V.T.-G., R.M., Y.M.), Centre de Biologie et de Pathologie Est, Hospices civils de Lyon, 69677 Bron, France; Département de Génétique (J.-M.C), Laboratoire Cerba, 95066 Cergy Pontoise, France; Département d'Endocrinologie, Diabétologie, et Métabolismes Pédiatriques (M.D.), Hôpital Mère-Enfant, HCL, 69677 Bron, France; Unité d'Endocrinologie pédiatrique (C.B.-M.), Centre Hospitalier de Bicêtre, 94275 Le Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Unité de Génétique Clinique (C.B.), Hôpital Robert Debré, AP-HP, 75019 Paris, France; Laboratoire d'Explorations Fonctionnelles (M.H.), Hôpital Trousseau, AP-HP, 75012 Paris, France; Unité d'Endocrinologie et Gynécologie Obstétrique (F.L.), Pôle Femme-Mère-Couple, Hôpital Paule de Viguier, 31059 Toulouse, France; Département de Génétique (N.P.), Hôpital Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille, France; Département de Génétique (S.O.), Hôpital Sud, 35203 Rennes, France; and Département de Génétique (A.G.), Centre Hospitalier UniversitaireAngers, 49033 Angers, France
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Miller WL, Witchel SF. Prenatal treatment of congenital adrenal hyperplasia: risks outweigh benefits. Am J Obstet Gynecol 2013; 208:354-9. [PMID: 23123167 DOI: 10.1016/j.ajog.2012.10.885] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 09/23/2012] [Accepted: 10/24/2012] [Indexed: 01/16/2023]
Abstract
Prenatal treatment of congenital adrenal hyperplasia by administering dexamethasone to a woman presumed to be carrying an at-risk fetus has been described as safe and effective in several reports. A review of data from animal experimentation and human trials indicates that first-trimester dexamethasone decreases birthweight; affects renal, pancreatic beta cell, and brain development; increases anxiety; and predisposes to adult hypertension and hyperglycemia. In human studies, first-trimester dexamethasone is associated with orofacial clefts, decreased birthweight, poorer verbal working memory, and poorer self-perception of scholastic and social competence. Numerous medical societies have cautioned that prenatal treatment of congenital adrenal hyperplasia with dexamethasone should only be done in prospective clinical research settings with institutional review board approval, and therefore is not appropriate for routine community practice.
Collapse
Affiliation(s)
- Walter L Miller
- Department of Pediatrics, University of California-San Francisco, CA, USA.
| | | |
Collapse
|
28
|
Eunice M, Ammini AC. Prenatal treatment of mothers with fetuses at risk for congenital adrenal hyperplasia: How relevant is it to Indian context? Indian J Endocrinol Metab 2013; 17:373-375. [PMID: 23869292 PMCID: PMC3712366 DOI: 10.4103/2230-8210.111596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Management of congenital adrenal hyperplasia (CAH) from embryonic stage to adulthood is a critical challenge. We would like to comment on some of the practical difficulties in offering prenatal treatment for CAH-affected fetuses in Indian population. For initiating the prenatal dexamethasone (DEX) treatment, all members of the family need to be informed about the risks and benefits of the treatment to the mother and the fetus as well as about the available invasive diagnostic tests to determine the gender and genotype of the fetus. Prenatal sex disclosure is not routinely practiced in India due to high female feticide rate. The treatment has to be given to both unaffected and affected female fetuses until the determination of prenatal sex. Moreover, most of our populations reside in rural areas where the antenatal care is not adequate. Prenatal DEX treatment in India outruns the risks rather than the benefits, as evident from the literature on the safety of pregnant mothers and fetuses.
Collapse
Affiliation(s)
- Marumudi Eunice
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ariachery C. Ammini
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
29
|
Saugstad OD, Kwinta P, Wollen EJ, Bik - Multanowski M, Madetko - Talowska A, Jagła M, Tomasik T, Pietrzyk JJ. Impact of antenatal glucocorticosteroids on whole-genome expression in preterm babies. Acta Paediatr 2013; 102:349-55. [PMID: 23347050 DOI: 10.1111/apa.12166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 11/20/2012] [Accepted: 01/11/2013] [Indexed: 12/19/2022]
Abstract
AIM To study the impact that using antenatal steroid to treat threatened preterm delivery has on whole-genome expression. METHODS A prospective whole-genome expression study was carried out on 50 newborn infants, delivered before 32 weeks gestation, who had been exposed to antenatal steroids, including 40 who had received a full antenatal steroid course. Seventy infants not exposed to antenatal steroids formed the control group. Microarray analyses were performed five and 28 days after delivery, and the results were validated by real-time PCR. The study was conducted between September 2008 and November 2010. RESULTS Twenty thousand six hundred and ninety-three genes were studied in the infants' leucocytes. Thirteen were differentially expressed 5 days after delivery, but there were no differences at day 28. Four genes related to cancer or inflammation were up-regulated. Nine genes were down-regulated: six were Y-linked and associated with malignancies, graft-versus-host disease, male infertility and cell differentiation and three were associated with pre-eclampsia, oxidative stress and chloride/bicarbonate exchange. Seven gene pathways were up-regulated at day five and only one at day 28. These were associated with cell growth, cell cycle regulation, metabolism and apoptosis. CONCLUSION Antenatal steroid therapy affects a limited number of genes and gene pathways in leucocytes in preterm babies at day five of life. The effect is short-lived, but long-term effects cannot be ruled out.
Collapse
Affiliation(s)
- Ola Didrik Saugstad
- Department of Pediatric Research; Clinic of Women and Child Health; Oslo University Hospital; University of Oslo; Norway
| | - Przemko Kwinta
- Department of Pediatrics; Jagiellonian University; Medical College; Krakow Poland
| | - Embjørg Julianne Wollen
- Department of Pediatric Research; Clinic of Women and Child Health; Oslo University Hospital; University of Oslo; Norway
| | | | | | - Mateusz Jagła
- Department of Pediatrics; Jagiellonian University; Medical College; Krakow Poland
| | - Tomasz Tomasik
- Department of Pediatrics; Jagiellonian University; Medical College; Krakow Poland
| | - Jacek Józef Pietrzyk
- Department of Pediatrics; Jagiellonian University; Medical College; Krakow Poland
- Department of Clinical Genetics; Jagiellonian University; Medical College; Krakow Poland
| |
Collapse
|
30
|
Feder EK, Dreger A, Tamar-Mattis A. More rhetoric than argument? Hastings Cent Rep 2013; 43:4-6. [PMID: 23494692 DOI: 10.1002/hast.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
31
|
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) can present management challenges to the pediatric clinician. Glucocorticoid replacement remains the cornerstone of treatment; however, there are new formulations and delivery mechanisms being studied. Clinicians continue to discuss the optimal treatment of patients from the prenatal stage, through infancy to adulthood. As well, the role of genetics in the clinical care of patients with CAH, and screening for complications, remain topics of discussion. This review will highlight advances made in the past year, as they pertain to the management of pediatric patients with CAH. RECENT FINDINGS This article covers recent studies pertaining to optimal medication regimens, including prenatal dexamethasone treatment; medication delivery; monitoring of hormonal control; and the role of genotyping and genetics in the management of children with CAH. SUMMARY Much remains to be learned about the optimal management of children with CAH, including fludrocortisone replacement in simple-virilizing patients, frequency of specific monitoring strategies (e.g., electrolytes, bone age), catecholamine status, stress-dosing in nonclassical adrenal hyperplasia, and early screening for complications or metabolic sequelae. Further randomized and prospective studies are needed to address these issues.
Collapse
Affiliation(s)
- Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California 90027, USA
| | | | | |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. In the past, pregnancy was considered to be unlikely for women with CAH, particularly the classical forms. The purpose of this review is to provide current information regarding the pathophysiology of CAH, factors relevant for female and male fertility, and recommendations for management during pregnancy. RECENT FINDINGS Individuals with CAH, both female and male, have reduced fertility. For women, chronic anovulation, elevated progestin levels, and aberrant endometrial implantation have been identified as reasons for the subfertility. Testicular adrenal rest tumors, oligospermia, and hypogonadotropic hypogonadism are frequently associated with subfertility in men with all forms of CAH. SUMMARY Adequate suppression of progesterone appears to be an essential aspect of preconception management for women. Most importantly, treatment needs to be individualized. Awareness of these factors and appropriate therapeutic interventions can lead to successful outcome defined as a healthy live born infant.
Collapse
Affiliation(s)
- Selma Feldman Witchel
- Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania 15224, USA.
| |
Collapse
|
33
|
Abstract
Disorders of sex development (DSDs) are estimated to be prevalent in 0.1-2% of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation-processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5-20% of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63%). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.
Collapse
|
34
|
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.
Collapse
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
| | | |
Collapse
|
35
|
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]
|