Pregnancy and Prenatal Management of Congenital Adrenal Hyperplasia

Severe Hyperandrogenism in 46,XX Congenital Adrenal Hyperplasia: Molecular Physiopathology, Late Diagnoses, and Personalized Management

Congenital Adrenal Hyperplasia (CAH) is a group of autosomal recessive endocrine disorders characterized by alteration in adrenal hormonal secretions. The most common form is caused by CYP21A2 mutations that result in 21-hydroxylase deficiency. Clinical features can vary, from salt-wasting forms, characterized by a lack of mineralocorticoid activity with a risk of perinatal-onset adrenal crises, to "simple-virilizing" forms with sufficient aldosterone secretion, up to milder "non-classical" forms, with a variable grade of hyperandrogenism but no severe hormonal deficiencies. During pregnancy, CAH 46,XX fetuses are exposed to elevated androgen levels, leading to a variable grade of virilization and potential central nervous system effects if untreated. These patients are usually (but not always) assigned female at birth, but some cases may be misdiagnosed and assigned male, potentially inducing fertility, gender identity, and sexual behavior issues in adulthood. In these patients, the benefits and risks of a late gender transition should be carefully evaluated. In this paper, we reviewed the literature concerning the most interesting peculiarities of these conditions.

Prenatal diagnosis and in utero treatment of congenital adrenal hyperplasia: An up-to-date comprehensive review

Congenital adrenal hyperplasia (CAH) is a term that encompasses a wide range of conditions that affect the adrenals. Diagnosis and treatment before birth are important as irreparable birth defects can be avoided, decreasing the need for surgical intervention later in life, especially regarding genitalia anomalies. Although early implementation of dexamethasone in the prenatal treatment of CAH has been controversial, there is recent evidence that this treatment can reduce long-term complications.

Pregnancy management of IVF-ET pregnancies in a patient with classical 21-hydroxylase deficiency: A case report and review of the literature

OBJECTIVE

To report a rare case of a woman with classical 21-hydroxylase deficiency who twice had singleton pregnancies with live births after in vitro fertilization and embryo transfer (IVF-ET).

DESIGN

Case report and literature review.

PATIENT

A 35-year-old woman with classical 21-hydroxylase deficiency underwent external genital plastic surgery during adolescence and achieved second pregnancy after IVF-ET with long-term glucocorticoid replacement therapy.

METHODS

During regular antenatal testing, we focus on monitoring patients' weight gain, blood pressure, increasing trend of uterine height and abdominal circumference, and fetal growth trend. Individualized glucocorticoid therapy during pregnancy, glucocorticoid stress dose at delivery, management of systemic metabolism to prevent maternal and infant complications, and newborn screening are realized.

RESULT

In the second pregnancy, the glucocorticoid dosage was not increased. 17-hydroxyprogesterone and testosterone tended to increase in late pregnancy, but they were lower than in the first pregnancy. Blood pressure and blood glucose were normal, but lipids were abnormally elevated, D-dimer also showed a sharp rise under labor stress. A mature male infant was delivered by cesarean at 33+4 weeks of gestation due to placental abruption.

CONCLUSION

Repeated pregnancies in patients with classical 21-hydroxylase deficiency are rare, especially with Assisted Reproductive Technology. We present a case including a comparison of her two pregnancy monitoring indicators, glucocorticoid medication and delivery to achieve a successful delivery. We review the available literature to analyze pregnancies with classical 21-hydroxylase deficiency.

Recent insights into the role of hormones during development and their functional regulation

Introduction

Hormones play a vital role in development from conception to birth and throughout the human lifespan. These periods are logically divided into fetal development, pre-pubertal growth, puberty, and adulthood. Deviations from standard physiological levels and release patterns of constituent hormones can lead to pathology affecting the normal developmental trajectory. Research is ongoing to better understand the mechanisms of these hormones and how their modulation affects development.

Methods

This article focuses on recent developments in understanding the role hormones play in development. We also cover recent discoveries in signaling pathways and hormonal regulation.

Results

New and continuing research into functional hormone regulation focuses on sex hormones, gonadotropic hormones, growth hormones, insulin-like growth factor, thyroid hormone, and the interconnectedness of each of these functional axes. Currently, the abundance of work focuses on fertility and correction of sex hormone levels based on an individual's condition and stage in life.

Discussion

Continuing research is needed to fully understand the long-term effects of hormone modulation in growth and sexual development. The role of each hormone in parallel endocrine axes should also be more thoroughly investigated to help improve the safety and efficacy in endocrine pharmacotherapeutics.

Extensive Expertise in Endocrinology: Adrenal crisis in assisted reproduction and pregnancy

Appropriate management of adrenal insufficiency in pregnancy is challenging due to the rarity of both primary, secondary and tertiary forms of the disease as well as the lack of evidence-based recommendations to guide clinicians to glucocorticoid and sometimes also mineralocorticoid dosage adjustments. Debut of adrenal insufficiency during pregnancy requires immediate diagnosis as it can lead to adrenal crisis, intrauterine growth restriction and foetal demise. Diagnosis is difficult due to overlap of symptoms of adrenal insufficiency and its crisis with those of pregnancy. Adrenal insufficiency in stable replacement treatment needs careful monitoring during pregnancy to adapt to the physiological changes in the requirement of the adrenal hormones. This is hampered because the diagnostic threshold of most adrenocortical hormones is not applicable during pregnancy. The frequent use of assisted reproduction technology with controlled ovarian hyperstimulation in these patient groups with disease induced low fertility has created an unrecognised risk of adrenal crises due to accelerated oestrogen stimulation with increased risk of even be life-threatening complications for both the woman and foetus. The area needs consensus recommendations between gynaecologists and endocrinologists in tertiary referral centres to alleviate such increased gestational risk. Patient and partner education, use of the EU emergency card for management of adrenal crises can also contribute to better pregnancy outcomes. There is a strong need of more research on e.g. improvement of glucocorticoid replacement as well as crisis management treatment, and biomarkers for treatment optimisation in this field, which suffers from the rare nature of the diseases and poor funding.

Landscape of Adrenal Tumours in Patients with Congenital Adrenal Hyperplasia

Our aim is to update the topic of adrenal tumours (ATs) in congenital adrenal hyperplasia (CAH) based on a multidisciplinary, clinical perspective via an endocrine approach. This narrative review is based on a PubMed search of full-length, English articles between January 2014 and July 2023. We included 52 original papers: 9 studies, 8 case series, and 35 single case reports. Firstly, we introduce a case-based analysis of 59 CAH-ATs cases with four types of enzymatic defects (CYP21A2, CYP17A1, CYP17B1, and HSD3B2). Secondarily, we analysed prevalence studies; their sample size varied from 53 to 26,000 individuals. AT prevalence among CAH was of 13.3-20%. CAH prevalence among individuals with previous imaging diagnosis of AT was of 0.3-3.6%. Overall, this 10-year, sample-based analysis represents one of the most complex studies in the area of CAH-ATs so far. These masses should be taken into consideration. They may reach impressive sizes of up to 30-40 cm, with compressive effects. Adrenalectomy was chosen based on an individual multidisciplinary decision. Many tumours are detected in subjects with a poor disease control, or they represent the first step toward CAH identification. We noted a left lateralization with a less clear pathogenic explanation. The most frequent tumour remains myelolipoma. The risk of adrenocortical carcinoma should not be overlooked. Noting the increasing prevalence of adrenal incidentalomas, CAH testing might be indicated to identify non-classical forms of CAH.

Caring for Patients With Congenital Adrenal Hyperplasia Throughout the Lifespan

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting cortisol and aldosterone biosynthesis, which can lead to virilization in fetuses with a 46,XX karyotype. 21-hydroxylase deficiency is the most common cause of CAH, accounting for 90-99% of all patients with the condition. The management of patients with CAH should be done with a multidisciplinary team, which would address all of the complex components of their care throughout their lifespans. Many multidisciplinary teams have adopted shared decision-making approaches to genital surgery in which parents and patients can be part of the decision-making process. Continued research is needed to best serve these patients throughout their lifespans.