Hyperandrogenic States in Pregnancy

Association between maternal androgen levels and early fetal sex differentiation: Anogenital distance and genital tubercle length in the first trimester

PURPOSE

To evaluate the use of anogenital distance (AGD) and genital tubercle length (GTL) between 11 and 13 + 6 weeks of gestation for fetal sex determination and to assess the impact of maternal androgen levels on these measurements.

METHODS

A cross-sectional study was conducted from February to June 2017 with patients undergoing first trimester Down syndrome screening. Inclusion criteria were: (1) female age 18-49, (2) gestational age between 11 and 13 + 6 weeks, (3) optimal visualization of AGD and GTL, and (4) nonsmoking status. Maternal androgen levels (total testosterone, free testosterone, androstenedione, and dehydroepiandrostenedione) were measured simultaneously with ultrasound.

RESULTS

AGD was significantly higher in male fetuses compared to females. With a cutoff of 5.0 mm, fetal sex was identified in 82 % of female fetuses and 70 % of male fetuses after the 12th week. Linear regression analysis showed that only AGD was a significant predictor of fetal sex (β: 0.54, p < 0.001). In the 12-12 + 6 week group, a positive correlation between AGD and maternal androstenedione was found in female fetuses (r: 0.23, p = 0.038). In contrast, negative correlations were observed between AGD and both androstenedione (r: -0.475, p < 0.001) and total testosterone (r: -0.282, p = 0.026) in male fetuses.

CONCLUSION

AGD and GTL measurements show sexual dimorphism in the first trimester, with AGD correlating positively with maternal androstenedione in females and negatively in males. These findings suggest that AGD and GTL are reliable, non-invasive methods for early fetal sex determination.

Discrepancies Between Sex Prediction and Fetal Sex After Prenatal Noninvasive Cell-Free DNA Screening

In the last 10 years the field of prenatal diagnosis has been significantly reshaped followed by the implementation of noninvasive prenatal cell-free DNA (cfDNA) testing methodologies in clinical practice. Based on a superior performance and higher sensitivity and specificity than the former practice of biochemical markers screening, the American College of Obstetricians and Gynecologists and American College of Medical Genetics and Genomics recommend noninvasive prenatal cfDNA screening for trisomy 21, 18, 13, and sex chromosome aneuploidy to all pregnant people. While cfDNA screening is helpful in risk assessment for the most common autosomal trisomies, cfDNA also provides information about fetal sex chromosomes. Prediction of fetal sex is highly desired by the parents and also useful to healthcare providers for management of pregnancies that are at-risk for X-linked conditions. In fact, utilization of cfDNA screening has resulted in a significant number of referrals to evaluate discordant results for cfDNA sex prediction and appearance of fetal genitalia by prenatal ultrasound scan or at birth raising concerns about the fetus/infant atypical sex development known as a difference in sex development (DSD). In this mini-review, we outline principles and limitations of cfDNA technology, summarize recent findings related to cfDNA test performance in prediction of sex chromosome abnormalities and DSD conditions, define the technical and biological causes of discrepant results, provide recommendations to consolidate efforts by prenatal and clinical management teams in challenging situations, and discuss ethical considerations associated with fetal sex prediction and prenatal DSD diagnosis.

Ovarian Hyperstimulation and Maternal Virilisation with Successful Pregnancy Outcome: A case report

Hyperreactio luteinalis (HL) and ovarian hyperstimulation syndrome during pregnancy are both benign conditions where the ovaries are enlarged with presence of multiple thin-walled cysts. The differential diagnosis is ovarian malignancy. Hyperandrogenism with resultant maternal virilisation could be seen in some cases of HL as well as in androgen secreting tumours. We report a 41-year-old female patient who underwent ovulation induction due to secondary infertility at a high-risk pregnancy unit in Muscat, Oman, in 2022. She had recurrent hospital admission with abdominal pain and large multicystic enlargement of both ovaries. She developed virilisation features by 35 weeks of pregnancy. Lower segment caesarean section was done at 36 weeks gestation for breech presentation with intra-uterine growth restriction. Magnetic resonance imaging confirmed the benign nature of the cysts. Ovarian cysts and hyperandrogenism gradually resolved 3-months post-delivery. Awareness, judicious imaging and close monitoring in such cases can result in live birth and avoid oophorectomies.

A Complete Hydatidiform Mole Complicated by Theca Lutein Cysts in a Teenager: A Rare Case

A hydatidiform mole (HM), often known as molar pregnancy, is a type of prenatal trophoblastic illness that develops in the placenta and has the potential to spread. HMs are caused by genetic issues with either the egg or the sperm. They are typically discovered in the first trimester of pregnancy. Abnormal bleeding is one of the initial symptoms, which can seldom be accompanied by the passage of hydropic villi. Theca lutein cysts, absent fetal heart tones, enlarged uterus more than anticipated for gestational age, pregnancy-induced hypertension in the first trimester, hyperemesis, and increased levels of human chorionic gonadotropin (HCG) for gestational dates are other characteristic symptoms and signs. A rare type of follicular cyst known as a theca lutein cyst is a benign ovarian disease caused by natural overstimulation of follicles, also known as hyperreactio lutealis (HL). This is linked to choriocarcinomas, multiple gestations, and prenatal trophoblastic illness (molar pregnancy). Unless exacerbated by torsion, rupture, or bleeding, the majority of theca lutein cysts are treated conservatively. Theca lutein cysts do not impact the course of pregnancy and spontaneously recede following delivery. However, HL may mistakenly be diagnosed by doctors as a cancer during pregnancy if it has the potential to look like one. Frequently, inappropriate surgical intervention is caused by the fear of failing to diagnose malignancy. These treatments may therefore result in decreased fertility in the future. Here we present a case of a young unmarried female with an HM and cysts.

[Hyperreactio Luteinalis and an Incidentally Detected FIGO IIIB Borderline Tumor of the Ovary in Pregnancy - Diagnostic, Therapy and Review of Literature]

Adnexal masses affect 2-10% of all pregnancies. The highest incidence of 1-6% can be seen in the first trimester, with a high rate of spontaneous remission. Two percent of these masses are malignant neoplasms or borderline tumors. A rare benign mass of the adnexa in pregnancy is hyperreactio luteinalis characterised by bilateral, multicystic ovaries with a frequent occurrence in the 3rd trimester. Clinical signs include maternal hyperandrogenaemia with virilisation, hyperemesis, nonspecific abdominal pain or laboratory findings of hyperthyroidism and elevated ß-HCG. Hyperreactio luteinalis does not require therapy due to complete spontaneous remission postpartum, but is often treated surgically in graviditate. In our case we report a first-time gravida in the 31st week of pregnancy with a symptomatic 25-cm multicystic, partly solid mass. After antenatal corticosteroid therapy, an exploratory laparotomy with right adnexectomy was performed on suspicion of malignancy. Histology revealed a hyperreactio luteinalis with an incidental finding of a serous borderline tumor of the ovary (FIGO IIIB). At 33 weeks of gestation, a pathological CTG was observed, and an urgent secondary caesarean section by re-longitudinal laparotomy was performed. Postpartum completion surgery revealed no further neoplastic cells.

Impact of Adverse Gestational Milieu on Maternal Cardiovascular Health

Cardiovascular disease affects 1% to 4% of the nearly 4 million pregnancies in the United States each year and is the primary cause of pregnancy-related mortality. Adverse pregnancy outcomes are associated with cardiovascular complications during pregnancy persisting into the postpartum period. Recently, investigations have identified an altered sex hormone milieu, such as in the case of hyperandrogenism, as a causative factor in the development of gestational cardiovascular dysfunction. The mechanisms involved in the development of cardiovascular disease in postpartum women are largely unknown. Animal studies have attempted to recapitulate adverse pregnancy outcomes to investigate causal relationships and molecular underpinnings of adverse gestational cardiac events and progression to the development of cardiovascular disease postpartum. This review will focus on summarizing clinical and animal studies detailing the impact of adverse pregnancy outcomes, including preeclampsia, gestational diabetes mellitus, and maternal obesity, on gestational cardiometabolic dysfunction and postpartum cardiovascular disease. Specifically, we will highlight the adverse impact of gestational hyperandrogenism and its potential to serve as a biomarker for maternal gestational and postpartum cardiovascular dysfunctions.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

The effect of pregnancy on meibomian gland, tear film, cornea and anterior segment parameters

AIM

In this prospective study, we aimed to examine the effect of physiological and pathological changes that occur during pregnancy in regard to Meibomian Gland (MG) structure, tear film, cornea and anterior segment parameters.

METHODS

The following groups were compared: 49 eyes of 49 pregnant women at 16-20 weeks of pregnancy (P16 Group), 46 eyes of 46 pregnant women at 32-36 weeks of pregnancy (P32 Group) and 51 eyes of 51 participants who were not pregnant (P0 Group). The groups were compared in terms of the first break-up time (NIF-BUT) and average break-up time (NIAvg-BUT) values. Non-contact meibography and MG loss rates were also compared.

RESULTS

The groups were found to be compatible in terms of age (P=0.052). The mean NIF-BUT values in the P16, P32 and P0 groups were 4.7 ±2.7, 6 ±3 and 6.7 ±3.1 seconds, respectively (P=0.055). The mean MG loss rates for the upper lid in the P16, P32 and P0 groups were 35.3%±12.6, 33.4%±11.4 and 15.5%±5.4, respectively. The loss rates for the lower lid in the P16, P32 and P0 groups were found to be 40.5%±18.6, 40.5%± 14.4 and 20.1%±8.1, respectively (P=0.000, p=0.000). The mean anterior chamber value (ACV) was found in the P16, P32 and P0 groups with 160.8 ±31.8, 150.9 ±26.5 and 165.9 ±26.5 µm³, respectively (P=0.035).

CONCLUSION

MG loss was found to be higher in pregnant groups compared to the non-pregnant groups. We found minimal instability in the tear film of the pregnant groups. We believe that pregnant women should be followed closely in terms of ocular surface diseases.

Rare manifestation of hyperreactio luteinalis: when both the mother and baby girl are virilised

Hyperreactio luteinalis is a benign, pregnancy-related condition with cystic enlargement of the ovaries and elevated androgen. However, only one-third of patients manifest as maternal virilisation and rarely does it cause fetal virilisation. Here, we report a virilised baby girl born to a virilised mother because of hyperreactio luteinalis. This case illustrates our management to maternal and fetal virilisation.

Severe intrahepatic cholestasis of pregnancy due to a Sertoli-Leydig cell tumour in a woman with polycystic ovary syndrome: a case report

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a common gestational complication characterized by pruritus and elevated bile acids, usually occurring in the third trimester when the serum estrogen and progesterone levels are highest. Hyperandrogenism during pregnancy is a pathological state that is mostly induced by polycystic ovary syndrome (PCOS) but rarely by concomitant androgen-secreting ovarian tumours. To date, no correlation has been drawn between ICP and hyperandrogenism.

CASE PRESENTATION

Here, we present a rare case of early-onset severe ICP in a PCOS patient conceived via in vitro fertilization-embryo transfer, with worsening hirsutism and acne due to high levels of testosterone and dehydroepiandrosterone sulphate, both of which were produced by a fast-growing ovarian Sertoli-Leydig cell tumour. Her serum estradiol was also very high, which was speculated to be converted from the circulating androgens by the placenta. She had preterm premature rupture of membranes and delivered at 30 weeks, followed by a rapid remission of ICP as her serum estradiol dropped. However, the excessive androgens did not retreat until the large ovarian tumour was surgically removed.

CONCLUSION

This unusual case highlights the concurrence of original hyperandrogenism and subsequent hyperestrogenism during pregnancy and the resultant confounding manifestations. Obstetricians should be aware of the potential association between androgen excess and ICP via placental aromatization.

Hyperreactio luteinalis associated with fetal hyperandrogenism and cystic hygroma

A 23-year-old woman with a gestational age of 17 weeks presented with abdominal pain. The ultrasound showed maternal hyperreactio luteinalis with fetal cystic hygroma. After termination of pregnancy, the female fetus showed masculinization features with muscular hypertrophy. The hyperreactio luteinalis regressed under hormonal suppression therapy.

Challenges in treatment of patients with non-classic congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) due to 21α-hydroxylase deficiency (21OHD) or 11β-hydroxylase deficiency (11OHD) are congenital conditions with affected adrenal steroidogenesis. Patients with classic 21OHD and 11OHD have a (nearly) complete enzyme deficiency resulting in impaired cortisol synthesis. Elevated precursor steroids are shunted into the unaffected adrenal androgen synthesis pathway leading to elevated adrenal androgen concentrations in these patients. Classic patients are treated with glucocorticoid substitution to compensate for the low cortisol levels and to decrease elevated adrenal androgens levels via negative feedback on the pituitary gland. On the contrary, non-classic CAH (NCCAH) patients have more residual enzymatic activity and do generally not suffer from clinically relevant glucocorticoid deficiency. However, these patients may develop symptoms due to elevated adrenal androgen levels, which are most often less elevated compared to classic patients. Although glucocorticoid treatment can lower adrenal androgen production, the supraphysiological dosages also may have a negative impact on the cardiovascular system and bone health. Therefore, the benefit of glucocorticoid treatment is questionable. An individualized treatment plan is desirable as patients can present with various symptoms or may be asymptomatic. In this review, we discuss the advantages and disadvantages of different treatment options used in patients with NCCAH due to 21OHD and 11OHD.

Disorders of Sex Development of Adrenal Origin

Disorders of Sex Development (DSD) are anomalies occurring in the process of fetal sexual differentiation that result in a discordance between the chromosomal sex and the sex of the gonads and/or the internal and/or external genitalia. Congenital disorders affecting adrenal function may be associated with DSD in both 46,XX and 46,XY individuals, but the pathogenic mechanisms differ. While in 46,XX cases, the adrenal steroidogenic disorder is responsible for the genital anomalies, in 46,XY patients DSD results from the associated testicular dysfunction. Primary adrenal insufficiency, characterized by a reduction in cortisol secretion and overproduction of ACTH, is the rule. In addition, patients may exhibit aldosterone deficiency leading to salt-wasting crises that may be life-threatening. The trophic effect of ACTH provokes congenital adrenal hyperplasia (CAH). Adrenal steroidogenic defects leading to 46,XX DSD are 21-hydroxylase deficiency, by far the most prevalent, and 11β-hydroxylase deficiency. Lipoid Congenital Adrenal Hyperplasia due to StAR defects, and cytochrome P450scc and P450c17 deficiencies cause DSD in 46,XY newborns. Mutations in SF1 may also result in combined adrenal and testicular failure leading to DSD in 46,XY individuals. Finally, impaired activities of 3βHSD2 or POR may lead to DSD in both 46,XX and 46,XY individuals. The pathophysiology, clinical presentation and management of the above-mentioned disorders are critically reviewed, with a special focus on the latest biomarkers and therapeutic development.

Delayed postpartum regression of theca lutein cysts with maternal virilization: A case report

Theca lutein cysts are rare, benign lesions responsible for gross cystic enlargement of both ovaries during pregnancy. This condition is also termed hyperreactio luteinalis. Elevated human chorionic gonadotropin (hCG) levels or states of hCG hypersensitivity seem to promote these changes, which in up to 30% of patients produce clinical signs of hyperandrogenism. Given the self-limiting course of theca lutein cysts, which are subject to spontaneous postpartum resolution, conservative treatment is the mainstay of patient management. Described herein is a rare case of theca lutein cysts with maternal virilization that failed to regress by 9 months after childbirth. Surgical intervention was eventually undertaken, necessitated by adnexal torsion.

Practical Approach to Hyperandrogenism in Women

The approach to hyperandrogenism in women varies depending on the woman's age and severity of symptoms. Once tumorous hyperandrogenism is excluded, the most common cause is PCOS. Hirsutism is the most common presenting symptom. The woman's concern about her symptoms plays an important role in the management of disease. Although measurement of testosterone is useful in identifying an underlying cause, care must be taken when interpreting the less accurate assays that are available commercially. Surgical resection is curative in tumorous etiologies, whereas medical management is the mainstay for non-tumorous causes.

Meibomian Gland Dysfunction and Lipid Profile: A Study Among Pregnant Women

PURPOSE

This study aimed to estimate the frequency of meibomian gland dysfunction (MGD) and its associated factors among pregnant women.

METHODS

This was a hospital-based cross-sectional study of consecutive pregnant women visiting the University of Cape Coast hospital's antenatal clinic. Meibomian gland assessment and tear function test were performed along with the administration of a symptom questionnaire. Correlation, analysis of variance, and logistic regression analyses were used to examine predictors of MGD.

RESULTS

All 201 pregnant women who met the inclusion criteria and gave informed consent were included in the study. The mean age of the entire sample was 29.96 (±4.74) years. The frequency of MGD among the cohort of pregnant women was 22.9% (95% confidence interval, 17.4%-28.9%). Univariate logistic regression revealed that the following factors were significantly associated with MGD: high-density lipoprotein (HDL) (odds ratio [OR] 1.017; 95% confidence interval [CI], 1.001-1.034; P=0.042), total cholesterol (TC) (OR 1.009; 95% CI, 1.003-1.016; P=0.006), and low-density lipoprotein (LDL) (OR 1.008; 95% CI, 1.00-1.016; P=0.049). In multivariate analysis, the model confirmed that MGD was not significantly associated with TC, LDL, and HDL.

CONCLUSIONS

In summary, this study showed a high frequency of MGD in pregnant women but comparable with that reported in the normal population. Clinicians examining pregnant women for dry eye disease may need to pay attention to other causative instigators aside MGD to enable the clinicians to make an appropriate etiology-based diagnosis.

Sildenafil augments fetal weight and placental adiponectin in gestational testosterone-induced glucose intolerant rats

Testosterone induces intra-uterine growth restriction (IUGR) with maternal glucose dysregulation and oxidant release in various tissues. Adiponectin, which modulates the antioxidant nuclear factor erythroid 2-related factor 2 (Nrf2) signaling is expressed in the placenta and affects fetal growth. Sildenafil, a phosphodiesterase type 5 inhibitor (PDE5i), used mainly in erectile dysfunction has been widely studied as a plausible pharmacologic candidate in IUGR. Therefore, the present study sought to determine the effect of PDE5i on placental adiponectin/Nrf2 pathway in gestational testosterone-induced impaired glucose tolerance and fetal growth. Fifteen pregnant Wistar rats were allotted into three groups (n = 5/group) receiving vehicles (Ctr; distilled water and olive oil), testosterone propionate (Tes; 3.0 mg/kg; sc) or combination of testosterone propionate (3.0 mg/kg; sc) and sildenafil (50.0 mg/kg; po) from gestational day 14-19. On gestational day 20, plasma and placenta homogenates were obtained for biochemical analysis as well as fetal biometry. Pregnant rats exposed to testosterone had 4-fold increase in circulating testosterone compared with control (20.9 ± 2.8 vs 5.1 ± 1.7 ng/mL; p < 0.05) whereas placenta testosterone levels were similar in testosterone- and vehicle-treated rats. Exposure to gestational testosterone caused reduction in fetal and placental weights, placental Nrf2 and adiponectin. Moreover, impaired glucose tolerance, elevated plasma triglyceride-glucose (TyG) index, placental triglyceride, total cholesterol, lactate, malondialdehyde and alanine aminotransferase were observed in testosterone-exposed rats. Treatment with sildenafil improved glucose tolerance, plasma TyG index, fetal and placental weights and reversed placental adiponectin in testosterone-exposed pregnant rats without any effect on placental Nrf2. Therefore, in testosterone-exposed rats, sildenafil improves impaired glucose tolerance, poor fetal outcome which is accompanied by augmented placental adiponectin regardless of depressed Nrf2.

Foetal virilisation caused by overproduction of non-aromatisable 11-oxygenated C19 steroids in maternal adrenal tumour

It is widely believed that adrenal tumours and ovarian luteomas in pregnant women cause virilisation of female foetuses through overproduction of testosterone and/or androstenedione. However, this notion raises a fundamental question as to how these classic androgens pass through the placenta without being converted by aromatase into oestrogens. Here, we report a case of maternal adrenal tumour, in which overproduction of 11-oxygenated C19 steroids (11ox C19s), newly characterised non-aromatisable androgens in humans, caused foetal virilisation. The female proband presented with severely virilised external genitalia at birth. The mother exhibited hirsutism, hyperglycaemia and hypertension and was diagnosed as having adrenal tumour. The mother was subjected to comprehensive steroid measurement. Serum levels of 11ox C19s were markedly elevated. In contrast, testosterone and androstenedione levels remained within the normal range, and levels of most other steroids in the conventional and backdoor androgenic pathways were normal or only mildly elevated. After tumour removal, levels of 11ox C19s were markedly reduced. These results provide the first evidence that 11ox C19s can be synthesised in adrenal adenomas and, due to their non-aromatisable nature, can pass through the placental barrier to cause foetal virilisation. These findings highlight a unique pathogenic property of these newly specified androgens in humans.

The role of androgens in clitorophallus development and possible applications to transgender patients

BACKGROUND

The clitorophallus, or glans, is a critical structure in sexual development and plays an important role in how gender is conceptualized across the life span. This can be seen in both the evaluation and treatment of intersex individuals and the use of gender-affirming masculinizing therapies to help those born with a clitoris (small clitorophallus with separate urethra) enlarge or alter the function of that structure.

OBJECTIVES

To review the role of testosterone in clitorophallus development from embryo to adulthood, including how exogenous testosterone is used to stimulate clitorophallus enlargement in masculinizing gender-affirming therapy.

MATERIALS AND METHODS

Relevant English-language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals and the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micropenis, penis).

RESULTS

Endogenous testosterone, and its more active metabolite dihydrotestosterone, plays an important role in the development of the genital tubercle into the clitorophallus, primarily during the prenatal and early postnatal periods and then again during puberty. Androgens contribute to not only growth but also the inclusion of a urethra on the ventral aspect. Exogenous testosterone can be used to enlarge the small clitorophallus (clitoris or micropenis) as part of both intersex and gender-affirming care (in transmasculine patients, up to 2 cm of additional growth). Where testosterone is insufficient to provide the degree of masculinization desired, surgical options including phalloplasty and metoidioplasty are available.

DISCUSSION AND CONCLUSION

Endogenous testosterone plays an important role in clitorophallus development, and there are circumstances where exogenous testosterone may be useful for masculinization. Surgical options may also help some patients reach their personal goals. As masculinizing gender-affirming care advances, the options available for clitorophallus modifications will likely continue to expand and improve.

Development and validation of a model for individualized prediction of cervical insufficiency risks in patients undergoing IVF/ICSI treatment

BACKGROUND

Women who conceived with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are more likely to experience adverse pregnancy outcomes than women who conceived naturally. Cervical insufficiency (CI) is one of the important causes of miscarriage and premature birth, however there is no published data available focusing on the potential risk factors predicting CI occurrence in women who received IVF/ICSI treatment. This study aimed to identify the risk factors that could be integrated into a predictive model for CI, which could provide further personalized and clinically specific information related to the incidence of CI after IVF/ICSI treatment.

PATIENTS AND METHODS

This retrospective study included 4710 patients who conceived after IVF/ICSI treatment from Jan 2011 to Dec 2018 at a public university hospital. The patients were randomly divided into development (n = 3108) and validation (n = 1602) samples for the building and testing of the nomogram, respectively. Multivariate logistic regression was developed on the basis of pre-pregnancy clinical covariates assessed for their association with CI occurrence.

RESULTS

A total of 109 patients (2.31%) experienced CI among all the enrolled patients. Body mass index (BMI), basal serum testosterone (T), gravidity and uterine length were associated with CI occurrence. The statistical nomogram was built based on BMI, serum T, gravidity and uterine length, with an area under the curve (AUC) of 0.84 (95% confidence interval: 0.76-0.90) for the developing cohort. The AUC for the validation cohort was 0.71 (95% confidence interval: 0.69-0.83), showing a satisfactory goodness-of-fit and discrimination ability in this nomogram.

CONCLUSION

The user-friendly nomogram which graphically represents the risk factors and a pre-pregnancy predicted tool for the incidence of CI in patients undergoing IVF/ICSI treatment, provides a useful guide for medical staff on individualized decisions making, where preventive measures could be carried out during the IVF/ICSI procedure and subsequent pregnancy.

Testosterone serum levels are not predictive of maternal virilization in hyperreactio luteinalis

Background

Elevated concentrations of circulating testosterone are present in hyperreactio luteinalis (HL), a pregnancy-specific, self-limited condition. HL is associated with maternal virilization in about 30% of cases. The correlation between testosterone levels and maternal virilization has not yet been quantified. Our aim was to identify a testosterone cut-off level which may allow to predict maternal virilization.

Methods

A literature research was performed. Publications were chosen if serum testosterone concentrations and presence or absence of maternal virilization was mentioned. Additionally, we report serial levels of steroids analyzed by Liquid chromatography–tandem mass spectrometry (LC–MS/MS) in one case of HL managed at our institution.

Results

In all, 31 cases fulfilled the search criteria. We found significant overlap between testosterone levels in asymptomatic women and women with signs of virilization (range 6.2–37.3 nmol/l and 13.7–197.5 nmol/l, respectively). The method applied for testosterone analysis was mentioned in three reports only. Peak serum testosterone concentration in our case was 120.3 nmol/l.

Conclusion

From the available data, maternal virilization in HL cannot be predicted by the level of circulating testosterone. However, comparability of results is hampered by the analytical methods applied. LC–MS/MS should preferably be used for reporting concentrations of circulating testosterone.

Motherhood: What every ophthalmologist needs to know

The aim of this review article is to summarize the available literature on physiologic and pathologic ocular changes during pregnancy and the effect of diseases in pregnancy. A literature search was conducted using PUBMED, MEDLINE, and Cochrane library in English. In addition, the cited references in the published articles were manually reviewed for the relevant results. Pregnancy encompasses a multitude of changes in all body systems, including the visual system of the female. The changes can be physiological, i.e., changes occurring in the lids and adnexa, cornea, conjunctiva, changes in tear film composition and intraocular pressure, retina, choroid, and visual field. Pathological changes in a pregnant woman's eye include changes related to preeclampsia and eclampsia, central serous chorioretinopathy, retinal artery or vein occlusions, and disseminated intravascular coagulation. Preexisting diseases like diabetic retinopathy, Graves' disease, idiopathic intracranial hypertension, various inflammatory conditions can undergo changes in their course during pregnancy. Ophthalmic medications can have an effect on both mother and the baby and hence should be used cautiously. In addition, intrauterine infections play a major role in causing inflammation in the eye of the baby. Hence, vaccination of the mother prior to pregnancy plays an important role in preventing intrauterine infections in the neonate. A regular eye examination in the perinatal period plays a vital role in recognizing ophthalmic pathologies which might require a prompt medical intervention. Pathological ocular diseases should be discriminated from physiologic changes to establish an individualized treatment or preventive plan. This approach to ocular benefits of treatment to the mother should always weigh against the potential harm to the fetus.

Intraocular pressure and tear production changes in pregnant women at term pregnancy and immediate post-partum: A pilot study

Aim:

To study the intraocular pressure (IOP) and tear production changes in uncomplicated pregnant women at term pregnancy and immediate postpartum.

Materials and methods:

The patients admitted in the Department of Obstetrics and Gynaecology for delivery were included in the study. A total of 106 participants who were at term uncomplicated pregnancy were selected according to the inclusion and exclusion criteria. They were subjected to type 1 Schirmer's testing and intraocular pressure measurement by Perkin's tonometer before and after delivery.

Result:

There was no significant pre- and postdelivery IOP difference between the different age groups (<30 and ≥30 years), mode of delivery, and parity. There was a statistically significant (P < 0.001) increase in mean tear production (Schirmer's test) after delivery, irrespective of age group, mode of delivery, and gravida status. However, no significant intergroup difference was observed.

Conclusion:

There was no significant change in IOP before and after delivery in uncomplicated pregnancies. However, a statistically significant increase in tear production was observed in the immediate postpartum period.

Dydrogesterone: pharmacological profile and mechanism of action as luteal phase support in assisted reproduction

The pharmacological and physiological profiles of progestogens used for luteal phase support during assisted reproductive technology are likely to be important in guiding clinical choice towards the most appropriate treatment option. Various micronized progesterone formulations with differing pharmacological profiles have been investigated for several purposes. Dydrogesterone, a stereoisomer of progesterone, is available in an oral form with high oral bioavailability; it has been used to treat a variety of conditions related to progesterone deficiency since the 1960s and has recently been approved for luteal phase support as part of an assisted reproductive technology treatment. The primary objective of this review is to critically analyse the clinical implications of the pharmacological and physiological properties of dydrogesterone for its uses in luteal phase support and in early pregnancy.

Incidentally found hyperreactio luteinalis in pregnancy

Hyperreactio luteinalis (HL) is a rare pregnancy-related condition in which the ovaries become massively enlarged bilaterally, occupied by multiple benign theca lutein cysts, secondary to increased ovarian stimulation by beta-human chorionic gonadotropin (B-hCG). HL should resolve spontaneously postpartum, however, their occurrence has led some physicians unfamiliar with the natural history of the condition to perform unnecessary ovarian cystectomies or oophorectomies. A healthy 32-year-old woman was incidentally found to have new onset multicystic ovaries on ultrasound at 31 + 3 weeks gestational age, which continued to enlarge, with a maximum volume of ∼448.0 cm³ and ∼323.5 cm³ in right and left ovaries, respectively. She also developed signs and symptoms of hyperandrogenism, and later abdominal pain which ultimately expedited delivery. This paper demonstrates that familiarity with HL as a clinical entity, its typical presentation and natural history, and targeting conservative management is paramount in minimizing iatrogenic harm by obstetricians given the increased use of ultrasound in pregnancy. Patients presenting after the first trimester with bilateral multicystic ovaries with a "spoke wheel" appearance on ultrasound, hyperandrogenism, abnormally elevated B-hCG, or symptoms consistent with elevated B-hCG should prompt a possible diagnosis.

RAPIDLY PROGRESSIVE AND SEVERE HIRSUTISM FROM HYPERREACTIO LUTEINALIS WITHIN A BACKGROUND OF POLYCYSTIC OVARY SYNDROME

Objective

Gestational trophoblastic disease and hyperreactio luteinalis (HL) are rare, but important, etiologies of hyperandrogenism that need to be further studied.

Methods

We present a case of rapidly progressing hirsutism and marked biochemical androgen excess in the context of pregnancy.

Results

A 26-year-old woman with a past medical history of obesity, prediabetes, and polycystic ovary syndrome presented with worsening hirsutism and markedly elevated testosterone levels. She was subsequently found to be pregnant, with extremely elevated levels of serum β-human chorionic gonadotropin. Subsequent work-up led to the identification of molar pregnancy and bilaterally enlarged ovaries, suggestive of HL. Following surgical intervention and therapy with methotrexate for invasive mole, she experienced improvement in both biochemical and clinical androgen excess features.

Conclusion

With the prevalence of polycystic ovary syndrome, many women present to medical providers with hirsutism or other findings of hyperandrogenism. However, rapid progression of existing hirsutism or severe hirsutism should prompt more extensive evaluations to rule out rare etiologies. One such etiology found in pregnancy is HL, in which high levels of β-human chorionic gonadotropin can stimulate production of benign theca lutein cysts, leading to marked hyperandrogenism and virilizing symptoms.

Recurrent maternal virilization during pregnancy in patients with PCOS: two clinical cases

BACKGROUND

Maternal virilization during pregnancy is a rare phenomenon. Polycystic ovary syndrome (PCOS), luteoma and luteinic cysts are the most frequent and benign etiologies. This article presents two cases of recurrent maternal virilization during pregnancy.

CLINICAL CASES

Our reported cases were young women with Afro-Caribbean and Nigerian origins. Data were collected by history-taking, clinical examination, laboratory investigations, transabdominal ultrasonographic examination and Magnetic Resonance Imaging. Both patients were diagnosed with PCOS according to the Rotterdam criteria. During each of their pregnancies they both developed an explosive hirsutism, a deepening in the voice, a clitoromegaly. Gestational diabetes occurred during pregnancies. There was no fetal virilization, despite raising androgen levels, more than tenfold to normal. Improvement of hirsutism and normalization of androgens were described in postpartum.

CONCLUSION

Only few cases of maternal virilization during pregnancy were reported in literature and even fewer concern recurrent and bilateral ovarian etiology. Hyperplasia of ovarian theca cells seems to be the most likely explanation, which would suggest that PCOS belongs to a spectrum of abnormal reactivity of the ovary to human Chorionic Gonadotrophin (hCG) stimulation along with luteoma and luteinic cyst of pregnancy.  Insulin resistance could worsen hyperandrogenism but is not enough to explain virilization. Treatment should focus on protecting the fetus of possible virilization as well as its mother, but also on preserving the subsequent fertility in both.

Anogenital distance in newborn daughters of women with polycystic ovary syndrome indicates fetal testosterone exposure

Polycystic ovary syndrome (PCOS) affects ~7% of reproductive age women. Although its etiology is unknown, in animals, excess prenatal testosterone (T) exposure induces PCOS-like phenotypes. While measuring fetal T in humans is infeasible, demonstrating in utero androgen exposure using a reliable newborn biomarker, anogenital distance (AGD), would provide evidence for a fetal origin of PCOS and potentially identify girls at risk. Using data from a pregnancy cohort (The Infant Development and Environment Study), we tested the novel hypothesis that infant girls born to women with PCOS have longer AGD, suggesting higher fetal T exposure, than girls born to women without PCOS. During pregnancy, women reported whether they ever had a PCOS diagnosis. After birth, infant girls underwent two AGD measurements: anofourchette distance (AGD-AF) and anoclitoral distance (AGD-AC). We fit adjusted linear regression models to examine the association between maternal PCOS and girls' AGD. In total, 300 mother-daughter dyads had complete data and 23 mothers reported PCOS. AGD was longer in the daughters of women with a PCOS diagnosis compared with daughters of women with no diagnosis (AGD-AF: β=1.21, P=0.05; AGD-AC: β=1.05, P=0.18). Results were stronger in analyses limited to term births (AGD-AF: β=1.65, P=0.02; AGD-AC: β=1.43, P=0.09). Our study is the first to examine AGD in offspring of women with PCOS. Our results are consistent with findings that women with PCOS have longer AGD and suggest that during PCOS pregnancies, daughters may experience elevated T exposure. Identifying the underlying causes of PCOS may facilitate early identification and intervention for those at risk.

Sex hormone-binding globulin levels during the first trimester may predict gestational diabetes mellitus development

Aim: To investigate the association of sex hormone-binding globulin (SHBG) levels of early pregnancy with gestational diabetes mellitus (GDM) development. Methods: A total of 443 pregnant women during the first trimester (<12 weeks) were enrolled. SHBG levels were measured. Results: SHBG level was lower in women with GDM than in women without GDM (93.9 ± 34.4 nmol/l vs 128.1 ± 60.3 nmol/l; p = 0.001). Among the four quartiles (Q1–Q4) according to SHBG levels, GDM incidences were 17.5, 27.8, 5.1 and 2.6%, respectively. No differences were found between Q1 and Q2, and Q3 and Q4. The risk of developing GDM among women in Q1 + Q2 compared with Q3 + Q4 was 5.7. Conclusion: Decreased SHBG concentrations during the first trimester may predict GDM development.

Gestational Hyperandrogenism in Developmental Programming

Androgen excess (hyperandrogenism) is a common endocrine disorder affecting women of reproductive age. The potential causes of androgen excess in women include polycystic ovary syndrome, congenital adrenal hyperplasia (CAH), adrenal tumors, and racial disparity among many others. During pregnancy, luteoma, placental aromatase deficiency, and fetal CAH are additional causes of gestational hyperandrogenism. The present report reviews the various phenotypes of hyperandrogenism during pregnancy and its origin, pathophysiology, and the effect of hyperandrogenism on the fetal developmental trajectory and offspring consequences.

The effect of assisted reproductive technology on ocular assessments

PURPOSE

The aim was to study the various ocular assessments in women undergoing assisted reproductive techniques (ART).

METHODS

A total of 117 women with infertility were enrolled for study and the ART protocol was followed. The outcome measures were intraocular pressure (IOP), central corneal thickness, corneal endothelial cell counts, Schirmer I test done at baseline (V0), post-oral contraceptive (V1), post-GnRH agonist induction phase (V2), post-conception (V3), third trimester of pregnancy (V4) and three months post-partum (V5). Schirmer I test (without topical anaesthesia) less than 10 mm in at least one eye was considered a criterion for dry eye.

RESULTS

Out of 117 women enrolled for in vitro fertilisation (IVF), only 48 patients conceived. Sixteen women had abortions and remaining 32 women, who had childbirth were followed until three months post-partum. Baseline mean IOP showed a slight decrement and corneal pachymetry and corneal endothelial cell counts showed slight increment from phases V1 to V4 of ART but statistically they were not significant (p > 0.05). At three months post-partum (V5) mean IOP, corneal pachymetry, corneal endothelial cell counts become closer to baseline in both eyes. The number of patients with at least one eye with dryness (Schirmer I less than 10 mm) significantly increased at the third trimester (p = 0.02) and three months post-partum (p = 0.035), whereas in the rest of the phases, it was comparable to baseline (p > 0.05).

CONCLUSION

The ocular physiological changes (IOP, corneal pachymetry and corneal endothelial cell counts) seen in various phases of ART were non-specific. The ART appears to reduce tear secretions as measured by Schirmer I; however, further research would be required to determine the impact of ART on the tear film and whether ART is associated with symptoms and signs of dry eye.

Evolution of steroids during pregnancy: Maternal, placental and fetal synthesis

Progesterone, estrogens, androgens and glucocorticoids are involved in pregnancy from implantation to parturition. Their biosynthesis and their metabolism result from complex pathways involving the fetus, the placenta and the mother. The absence of expression of some steroïdogenic enzymes as CYP17 in placenta and in adrenal fetal zone and the better determination of the onset and variation of others especially HSD3B2 during the pregnancy explain the production of the steroid hormones. Moreover the consequences of some disorders of steroidogenesis (especially aromatase, POR, CYP11A1 and 21-hydroxylase deficiencies) in fetus and mother during the pregnancy have permit to elucidate these complex pathways. This better knowledge of steroid hormones production associated with their dosages in maternal plasma/urine or amniotic fluid using new specific assays as LC-MS MS could facilitate the follow-up of normal and pathological pregnancies. Moreover, these advances should be a basis to evaluate the impact of multiple pathologies of the pregnancy and pharmacologic and xenobiotic consequences on their metabolism.

Dydrogesterone use in early pregnancy

Successful oocyte implantation and a favorable pregnancy outcome rely on optimal progesterone levels. Therefore, progesterone deficiencies associated with infertility and miscarriage have commonly been treated with progestogens that mimic the activity of progesterone. Among those is dydrogesterone, an oral retrosteroid with a structure closely related to that of progesterone yet with a greater bioavailability and higher selectivity for the progesterone receptor. This review describes the efficacy of dydrogesterone for the treatment of threatened and recurrent miscarriage, and infertility due to luteal phase insufficiency. Data from clinical trials evaluating dydrogesterone in assisted reproductive technology are also discussed. Prospective clinical trials, systematic reviews and meta-analyses have demonstrated that dydrogesterone significantly improves pregnancy outcomes in women with threatened miscarriage or with a history of miscarriage. Although this is not yet a registered indication, dydrogesterone was as effective as vaginal micronized progesterone for luteal phase support in the setting of assisted reproductive technology. The safety and tolerability of dydrogesterone treatment in pregnant women are also briefly addressed and the data support a well-established and favorable benefit-risk profile.

Hyperreactio luteinalis encountered during caesarean delivery of an uncomplicated spontaneous singleton pregnancy

We report a rare case of hyperreactio luteinalis presenting as an incidental finding during caesarean section in an uncomplicated spontaneous singleton pregnancy. Caesarean section was performed due to failure to progress in labour, and delivered a healthy male neonate. The mother's analytical tests revealed a hyperandrogenic state without any other relevant alterations. Ovarian volume and testosterone serum concentration normalised in 2 months. The expectant management of this case permitted conservation of both ovaries in a young woman without adding morbidity.

Cushing's syndrome in pregnancy

Cushing's syndrome is a rare condition in the general population and is even less common during pregnancy with only a few cases reported in literature. The diagnosis of Cushing's syndrome may be difficult during pregnancy because the typical features of the disorder and pregnancy may overlap. However, Cushing's syndrome results in increased fetal and maternal complications, and diagnosis and treatment are critical. This report describes a case of 26-year-old female at the 19th week of pregnancy with symptoms and signs of hypercortisolism, where ACTH-independent Cushing's syndrome was diagnosed and treated by robotic laparoscopic adrenalectomy at the 21th week of gestation.

Androgens in pregnancy: roles in parturition

BACKGROUND

Understanding the physiology of pregnancy enables effective management of pregnancy complications that could otherwise be life threatening for both mother and fetus. A functional uterus (i) retains the fetus in utero during pregnancy without initiating stretch-induced contractions and (ii) is able to dilate the cervix and contract the myometrium at term to deliver the fetus. The onset of labour is associated with successful cervical remodelling and contraction of myometrium, arising from concomitant activation of uterine immune and endocrine systems. A large body of evidence suggests that actions of local steroid hormones may drive changes occurring in the uterine microenvironment at term. Although there have been a number of studies considering the potential role(s) played by progesterone and estrogen at the time of parturition, the bio-availability and effects of androgens during pregnancy have received less scrutiny. The aim of this review is to highlight potential roles of androgens in the biology of pregnancy and parturition.

METHODS

A review of published literature was performed to address (i) androgen concentrations, including biosynthesis and clearance, in maternal and fetal compartments throughout gestation, (ii) associations of androgen concentrations with adverse pregnancy outcomes, (iii) the role of androgens in the physiology of cervical remodelling and finally (iv) the role of androgens in the physiology of myometrial function including any impact on contractility.

RESULTS

Some, but not all, androgens increase throughout gestation in maternal circulation. The effects of this increase are not fully understood; however, evidence suggests that increased androgens might regulate key processes during pregnancy and parturition. For example, androgens are believed to be critical for cervical remodelling at term, in particular cervical ripening, via regulation of cervical collagen fibril organization. Additionally, a number of studies highlight potential roles for androgens in myometrial relaxation via non-genomic, AR-independent pathways critical for the pregnancy reaching term. Understanding of the molecular events leading to myometrial relaxation is an important step towards development of novel targeted tocolytic drugs.

CONCLUSIONS

The increase in androgen levels throughout gestation is likely to be important for establishment and maintenance of pregnancy and initiation of parturition. Further investigation of the underlying mechanisms of androgen action on cervical remodelling and myometrial contractility is needed. The insights gained may facilitate the development of new therapeutic approaches to manage pregnancy complications such as preterm birth.

Sex, stroke, and inflammation: the potential for estrogen-mediated immunoprotection in stroke

Stroke is the third leading cause of death and the primary cause of disability in the developed world. Experimental and clinical data indicate that stroke is a sexually dimorphic disease, with males demonstrating an enhanced intrinsic sensitivity to ischemic damage throughout most of their lifespan. The neuroprotective role of estrogen in the female brain is well established, however, estrogen exposure can also be deleterious, especially in older women. The mechanisms for this remain unclear. Our current understanding is based on studies examining estrogen as it relates to neuronal injury, yet cerebral ischemia also induces a robust sterile inflammatory response involving local and systemic immune cells. Despite the potent anti-inflammatory effects of estrogen, few studies have investigated the contribution of estrogen to sex differences in the inflammatory response to stroke. This review examines the potential role for estrogen-mediated immunoprotection in ischemic injury.

Virilisation during Pregnancy in a Patient with Metastatic Colorectal Cancer

This paper describes the case of a 25-year-old woman with virilisation occurring during pregnancy in the presence of metastatic colorectal cancer. Virilisation during pregnancy is rare. The potential causes include adrenal, foetal, or ovarian pathologies. The most common causes during pregnancy are pregnancy luteoma and hyperreactio luteinalis. The incidence of cancer during pregnancy is rare and the incidence of colorectal cancer (CRC) in pregnancy is even rarer. The presenting signs and symptoms of CRC can be confused with symptoms commonly encountered during pregnancy, thereby delaying diagnosis and commencement of treatment. Diagnosis and staging also proves more problematic in the pregnant patient as the usual modalities of colonoscopy with biopsy and imaging with CT are relatively contraindicated. Treatment is dependent on gestational age of the foetus. There is currently no agreed best practice as to the role of prophylactic oophorectomy in the prevention of metachronous ovarian metastases. Surgical and adjuvant treatments have implications for females of child-bearing age.