CONGENITAL ADRENAL HYPERPLASIA
`
`PREFACE
`
`PHYLLIS W. SPEISER, MD
`Guest Editor
`
`Congenital adrenal hyperplasia (CAH) is among the most common and best
`characterized inborn errors of metabolism. This volume brings together an
`outstanding group of authors from the disciplines of psychology, clinical and
`molecular medicine, and surgery in an attempt to present a comprehensive and
`current summary of various forms of CAH.
`In the first article, New presents data on prenatal treatment from her group's
`extensive experience. These data indicate no irreversible serious adverse effects
`in mothers, fetuses, or infants who have undergone such treatment. There are
`still long-term safety concerns surrounding prenatal administration of dexameth-
`asone, but in approximately 12 years' follow-up the offspring of these treated
`pregnancies have been generally healthy. Half of the girls who were prenatally
`treated were born with normal genitalia, while most of the others show consider-
`ably less genital ambiguity compared with their elder non-prenatally-treated
`sisters. Given the powerful and far-reaching psychosexual impact of a child born
`with abnormal genitals, judicious use of prenatal dexamethasone to pregnancies
`at 25% risk for classic CAH is advised with careful monitoring.
`Therrell discusses the now widespread practice of neonatal screening for
`CAH by hormonal assays. Pitfalls do exist in these diagnostic studies, but refined
`algorithms accounting for altered cut-off values of 17-hydroxyprogesterone in
`low birth weight and repeated sampling to detect delayed disease expression
`help clarify the picture for clinicians. Since about 95% of CAH alleles are readily
`identified in most populations, genotyping may ultimately improve the accuracy
`of screening. Screening undoubtedly rescues some infants who would have been
`unrecognized with the disease. Surprisingly, we do not know the exact rate of
`infant mortality for CAH.
`CAH is most often caused by deficiency of steroid 21-hydroxylase; less
`common causes include deficiencies of Lljs-hydroxylase, 313-hydroxysteroid de-
`hydrogenase, and 17a-hydroxylase/17,20-lyase. Genetic characterization of these
`disorders has enhanced our understanding of phenotypic differences among
`patients. These topics are discussed in individual chapters authored by myself,
`and White, Pang, and Auchus, highlighting areas of recent clinical and research
`interest.
`
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`Gene therapy is still a distant gleam on the horizon. Replacing glucocorti-
`coids and, as needed, mineralocorticoid, remains the cornerstone of therapy for
`CAH. Merke and Cutler present data supporting the use of new multidrug
`regimens including lower doses of the standard drugs, hydrocortisone and
`fludrocortisone, and drugs to block androgen action (flutamide) and reduce
`estrogen production (testolactone). Schnitzer and Donahoe detail the surgical
`approach to the child with genital ambiguity, with special attention to the CAH
`female. There is hope that newer surgical techniques may improve functional
`outcome; however, since these procedures have been employed only for the past
`decade, there are insufficient long-term data.
`Meyer-Bahlburg points out that although much attention has been focused
`on psychosexual pathology, most CAH women function without problems. We
`also ought to recognize that
`the health professionals counseling parents of
`infants regarding "optimal gender policy" are not always experienced in dealing
`with problems of gender and sexuality prominent in adolescents and adults.
`The newly established North American Task Force on Intersexuality will begin
`to address the issue of long-term psychosexual outcome for individuals with
`genital anomalies, including CAH, in a cooperative multicenter study involving
`psychologists, endocrinologists, geneticists, and surgeons.
`Berenbaum reviews the data on cognitive function, and concludes that the
`studies demonstrating IQ differences among CAH patients compared with sib-
`lings are methodologically weak. Perhaps the only measure credibly distinguish-
`ing brain function in CAH females is visual-spatial abilities, presumably en-
`hanced in these individuals by prenatal exposure to androgens. The cohort of
`prenatally treated girls with CAH should provide an interesting control group
`for future psychological studies.
`Migeon and Wisniewski argue for restraint in using suppressive doses of
`glucocorticoids, especially during the first year of life. The goal of medical
`therapy should be to promote a good linear growth outcome, while avoiding
`adiposity and virilization.
`A final indicator of how far we have come in the management of CAH is
`the article from Lo and Grumbach, analyzing pregnancy outcome among af-
`fected women. These authors stress the need for titrating the dose of hydrocorti-
`sone or prednisone in order to maintain serum testosterone in the high normal
`range for pregnancy (i.e., approximately 200 ng! dl after the first trimester), and
`using stress doses during and immediately following labor and delivery. Most
`offspring have been healthy, and because of the protective effect of placental
`aromatase, virilization of female fetuses is very rare.
`I wish to thank all the contributors to this volume for their efforts, and John
`Vassallo and the editorial staff at W.B. Saunders for initiating and facilitating
`this project. This valuable collection of articles should serve as a focal point
`for discussions of practice guidelines for CAH, and trigger interest in further
`investigations aimed at improving patient outcomes.
`
`Division of Pediatric Endocrinology
`New York University School of Medicine
`North Shore-Long Island Jewish Health System
`Manhasset, NY 11030
`
`PHYLLIS W. SPEISER, MD
`Guest Editor
`
`xii
`
`PREFACE
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`CONGENITAL ADRENAL HYPERPLASIA
`
`0889-8529/01 $15.00 + .00
`
`PRENATAL TREATMENT OF
`CONGENITAL ADRENAL
`HYPERPLASIA
`The United States Experience
`
`Maria 1. New, MD
`
`Congenital adrenal hyperplasia (CAH) refers to a family of inherited
`disorders in which defects occur in one of the enzymatic steps required
`to synthesize cortisol from cholesterol in the adrenal gland. Because of
`the impaired cortisol secretion, adrenocorticotropic hormone (ACTH)
`levels rise owing to impairment of a negative feedback system, which
`results in hyperplasia of the adrenal cortex. The enzyme defects are
`translated as autosomal recessive traits, with the enzyme 21-hydroxylase
`in more than 90% of CAH cases." Owing to the blocked
`deficient
`enzymatic step, cortisol precursors accumulate in excess and are con-
`verted to potent androgens, which are secreted and cause in utero
`virilization of the genitalia in affected female fetuses in the classic
`form of 21-hydroxylase deficiency. These effects are also seen in 1113-
`hydroxylase deficiency, which is the second-most common cause of
`CAH.
`
`STEROIDOGENESIS
`
`Aldosterone, cortisol, and testosterone are derived from cholesterol,
`and many of the same enzymes are used for their synthesis in the
`
`Significant sections of the work herein were supported by United States Public Health
`Service grant HDooon and Children's Clinical Research Center grant 06020.
`
`From the Department of Pediatrics, Division of Pediatric Endocrinology, New York Presby-
`terian Hospital, Weill Medical College of Cornell University, New York, New York
`
`ENDOCRINOLOGY AND METABOLISM CLINICS OF NORTH AMERICA
`
`VOLUME 30 • NUMBER 1 • MARCH 2001
`
`1
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`2
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`NEW
`
`Cholesterol
`~RALOCORnCOIOS GLUCOCORTICOIDS
`
`SEX HORMONES
`
`DHEA
`13~-HSD
`17,20-Lyase +
`
`64 -Androstenedione
`t17~-HSD
`
`11-Deoxy-
`corticosterone (DOC)
`
`11-Deoxycortisol (5)
`
`Corticosterone
`
`Cortisol (F)
`
`18-0H Corticosterone
`
`Dihydrotestosterone
`(DHT)
`
`Estradiol
`
`17,20-Lyase
`17a.-OH
`17-Hydroxypregnenolone -
`Pregnenolone -
`I 3~-HSD
`I 3~-HSD
`+
`17a.-OH +
`i 21-0H
`i 21-0H
`Progesterone -17-Hydroxyprogesterone -
`i 11~-OH
`! 11~-OH
`i 18-0H
`i 18-HSD
`
`Testosterone
`
`/ \
`
`Aldosterone
`
`Figure 1. Adrenal steroidogenesis. OH = hydroxylase (for enzymes); HSD = hydroxyste-
`roid dehydrogenase (for enzymes); DHEA = dehydroepiandroslerone.
`
`adrenal cortex (Fig. 1). Deficiencies in any of the enzymatic steps that
`are common to the synthesis pathway of these hormones can result in
`the loss of a combination of some or all of their production, or unchecked
`negative feedback loops can lead to overproduction. In 21-hydroxylase
`deficiency (and 1113-hydroxylase deficiency), the enzyme deficiency cre-
`ates the effect of a dam behind which steroid precursors accumulate,
`which then overflow into biosynthetic pathways unaffected by the block,
`resulting in the production of excess androgens.
`Cortisol synthesis is regulated by a negative feedback loop in which
`high serum levels of cortisol
`inhibit
`the release of ACTH from the
`pituitary, whereas low serum levels of cortisol stimulate the release of
`ACTH. This loop defines the hypothalamic-pituitary-adrenal axis. The
`central nervous system determines the hypothalamic set point for the
`expected plasma cortisol level. Plasma cortisol levels lower than the
`hypothalamic-pituitary set point will increase the rate and intensity of
`ACTH secretory pulses (the net ACTH release has basal, diurnal, and
`stress-induced components). A deficiency of 21-hydroxylase, causing
`impaired synthesis and decreased secretion of cortisol, leads to chronic
`elevations of ACTH with overstimulation and consequent hyperplasia
`of the adrenal cortex. Because the pathways for testosterone, dehydroepi-
`androsterone, and ~4-androstenedionepreceding the 21-hydroxylase step
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`PRENATAL TREATMENT OF CONGENITAL ADRENAL HYPERPLASIA
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`3
`
`are unblocked, the precursors (17-hydroxyprogesterone, pregnenolone,
`17-hydroxypregnenolone, and progesterone) are routed to these path-
`ways, androgens are oversecreted in the adrenals in utero, and the
`genitals of the female fetus are masculinized.
`
`21-HYDROXYLASE DEFICIENCY
`
`Classic
`
`In the classic form of CAH owing to 21-hydroxylase deficiency,
`androgen excess causes external genital ambiguity in newborn females
`(female pseudohermaphroditism), who may present with a urogenital
`sinus, scrotalization of the labia majora, labial fusion, or clitoromegaly.
`After birth, males and females exhibit progressive postnatal virilization,
`which can include central precocious puberty later in childhood, pro-
`gressive penile or clitoral enlargement, precocious pubic hair, hirsutism,
`acne, advanced somatic and epiphyseal development, reduced fertility,
`menstrual abnormalities in women, and small testes in men. There are
`two forms of classic steroid 21-hydroxylase deficiency: simple virilizing
`and salt-wasting. Three fourths of classic cases are salt-wasting." To
`some extent, the symptoms can be arrested or reversed by treatment
`with glucocorticoids, which suppresses ACTH stimulation of the adrenal
`cortex. Patients with aldosterone deficiency require treatment with salt-
`retaining steroids as well.
`
`Nonclassic
`
`Nonclassic 21-hydroxylase deficiency refers to the condition in
`which partial deficiencies of 21-hydroxylation produce late-onset, less
`extreme hyperandrogenemia and milder or no symptoms. Females do
`not demonstrate genital ambiguity at birth, although males and females
`may manifest signs of androgen excess at any phase of postnatal devel-
`insulin
`opment. Short stature, premature development of pubic hair,
`resistance, acne, reduced fertility, and, in women, polycystic ovaries,
`hirsutism, and male pattern baldness, may be seen in untreated patients.
`Some individuals are never affected with overt signs of androgen excess
`and require no treatment. Symptomatic nonclassic patients respond to
`treatment with a glucocorticoid to suppress ACTH, thereby suppressing
`the androgens.
`
`Frequency
`
`Analysis of CAH incidence data from almost 6.5 million newborns
`screened in the general population worldwide has demonstrated an
`overall incidence ranging from 1 in 13,000 to 1 in 15,000 live births for
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`the classic form of CAH.24,25 Applying the Hardy-Weinberg equilibrium
`formula, the carrier rate for a classic CAH mutation is approximately 1
`in 63.24
`The overall frequency of nonclassic 21-hydroxylase deficiency is
`high. Speiser and co-workers'? assessed the population genetics of the
`nonclassic disorder and found nonclassic 21-hydroxylase deficiency to
`be more common than the classic deficiency causing CAH. In fact, it
`was the most common human autosomal recessive disease trait. The
`disease frequency in the general heterogeneous population of New York
`City is 1 in 100, and 1 in 7 persons is a carrier. The highest ethnic
`frequency is found among Ashkenazi Jews, occurring in 1 in 27 persons.
`Other specific ethnic groups also exhibit high disease frequency: 1 in 40
`Hispanics, 1 in 50 Slavs, and 1 in 300 Italians. These results have been
`confirmed by other studies.29. 42
`
`Diagnosis at Birth
`
`Patients who have CAH present with a unique hormonal profile
`owing to their enzymatic deficiency. The best diagnostic test for 21-
`hydroxylase deficiency is the ACTH stimulation test measuring the
`serum concentration of 17-hydroxyprogesterone. A logarithmic nomo-
`gram has been developed and provides hormonal standards for assign-
`ment of the type of 21-hydroxylase deficiency by relating baseline to
`ACTH-stimulated serum concentrations of 17-hydroxyprogesterone.22
`The nomogram can clearly distinguish patients with classic CAH from
`those with nonclassic CAH, as well as identify classic and nonclassic
`heterozygotes.
`The ACTH test to measure 17-hydroxyprogesterone levels in sus-
`pected CAH cases should not be performed during the initial 24 hours
`of life because samples from this period are typically elevated in all
`infants and may yield false-positive results. Aldosterone, plasma renin,
`and serum sodium and potassium levels are measured to assess salt-
`preserving ability. Karyotyping or other genetic analysis will establish
`the genetic sex in cases of ambiguous genitalia. Imaging the internal
`anatomy by pelvic sonography will reveal a uterus, fallopian tubes, and
`ovaries in females affected with CAH. Such findings are often the first
`indication that the infant with genital ambiguity is a genetic female.
`The diagnosis of 1113-hydroxylase deficiency is made on the basis of
`elevated serum deoxycorticosterone (DOC) levels or ll-deoxycortisol
`(compound S) levels, as well as marked urinary elevation of their tetra-
`hydrometabolites. Further characterization by molecular genetic analysis
`can be performed. Diagnosis in a newborn is difficult because the charac-
`teristic hypertension does not generally appear during the newborn
`period. Distinction from 21-hydroxylase deficiency on the basis of steroid
`patterns is also problematic at this age because 17-hydroxyprogesterone
`levels will typically be elevated in cases of llP-hydroxylase deficiency;
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`PRENATAL TREATMENT OF CONGENITAL ADRENAL HYPERPLASIA
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`5
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`however, in 21-hydroxylase deficiency, deoxycortisol and DOC are not
`elevated.
`
`MOLECULAR GENETICS
`
`21-Hydroxylase Deficiency
`
`The gene encoding 21-hydroxylase (a microsomal cytochrome P450
`called CYP21, previously known as P450c21) is located on the short arm
`of chromosome 6 in the human lymphocyte antigen (HLA) complex."
`The gene for the 21-hydroxylase enzyme, CYP21, and its homologue, the
`pseudogene CYP21P,21 alternate with two genes called C4B and C4A6,36
`that encode the two isoforms of the fourth component (C4) of serum
`complement.' CYP21 and CYP21P, which each contain 10 exons, share
`98% sequence homology in exons and approximately 96% sequence
`homology in introns.l- 37
`Approximately 50 mutations in the CYP21 gene causing 21-hydroxy-
`lase deficiency have been identified thus far," The author and her col-
`leagues have demonstrated deletional mutations of the 21-hydroxylase
`deficiency genes and characterized specific point mutations in many
`patients.! 13, 31, 33, 34, 37, 38 The most common mutations are the result of
`two types of recombination events between CYP21 and CYP21P: (1)
`misalignment and unequal crossing over, resulting in large-scale DNA
`deletions; or
`(2) apparent gene conversion events that result
`in the
`transfer to CYP21 of smaller-scale deleterious mutations present in the
`CYP21P pseudogene."
`
`Correlation/Noncorrelation of Genotype to Phenotype
`In general, there is a good correlation between the severity of the
`clinical disease and the discrete mutations observed. In 1995, the author
`and her colleagues compared the genotypes and phenotypes in approxi-
`mately 200 patients and divided them into mutation-identical groups."
`That study and another by Krone and co-workers" demonstrated that
`the 10 most common mutations observed in CYP21 cause variable phe-
`notypic effects and are not always concordant with genotype. Subse-
`quently, the author has genotyped over 600 patients and identified 85
`mutational groups, 23 of which had more than one phenotype. DNA
`sequencing analysis ruled out rare undetected mutations on the same al-
`lele.
`
`The noncorrelation of genotype to phenotype may present a diffi-
`culty for the clinician in directing prenatal treatment.
`
`11p-Hydroxylase Deficiency
`
`The disorder of 1113-hydroxylase deficiency, which has a frequency
`of approximately 1 in 100,000 live births," is caused by an autosomal
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`recessive defect of the enzyme protein-encoding gene CYPllBl. The
`CYPllBl gene comprises nine exons. Approximately 30 mutations in
`CYPllBl have been identified in cases of l1~-hydroxylase deficiency."
`The gene is located on chromosome 8q22, about 40 kb from the highly
`homologous gene CYPllB2, which encodes aldosterone synthase. Muta-
`tions in the CYPllBl gene have been identified throughout the coding
`region, but there is clustering around exons 2, 6, 7, and 8, suggestive of
`mutational hot spots.'? Although gene conversions do occur between
`CYPllBl and CYPllB2,19.20 most of the mutations found in CYPllBl are
`random point mutations." These mutations have been identified from
`diverse ethnic backgrounds, with the highest incidence among a highly
`inbred group of Moroccan (Sephardic) Jews. 26
`27
`•
`
`PRENATAL DIAGNOSIS AND TREATMENT
`
`Breakthrough in Prenatal Diagnosis and Treatment in
`Congenital Adrenal Hyperplasia
`
`When it was discovered that CAH-affected fetuses had elevated 17-
`hydroxyprogesterone and ,:l4-androstenedione in their amniotic fluid,
`measuring the levels of these substances by amniocentesis and hormonal
`assay became the first method of prenatal diagnosis for this disorder;
`however, amniocentesis is performed in the second trimester, and, to
`prevent prenatal virilization of an affected female, treatment must begin
`before 10 weeks' gestation. After beginning prenatal treatment, dexa-
`methasone for the developing fetus would suppress 17-hydroxyproges-
`terone in amniotic fluid; hence, this hormonal test could not be relied on
`for diagnosis. When HLA was found to be linked to CAH, diagnoses
`were made using HLA genetic linkage marker analysis. This method
`resulted in many diagnostic errors owing to recombination or haplotype
`sharing. The method generally used now is direct DNA analysis of the
`21-hydroxylase gene (CYP21) with molecular genetic techniques.
`
`Establishment of Algorithm
`
`Prenatal treatment of 21-hydroxylase deficiency with dexametha-
`sone has been performed for approximately 15 years to suppress excess
`adrenal androgen secretion and prevent virilization should the fetus be
`an affected female. An algorithm has been developed for the prenatal
`diagnosis of 21-hydroxylase deficiency and CAH using direct molecular
`analysis of the 21-hydroxylase locus and dexamethasone treatment (Fig.
`2). When properly administered, dexamethasone is effective in pre-
`venting ambiguous genitalia in the affected female and has been shown
`to be safe for the mother and fetus." The largest human studies thus far
`have shown no congenital abnormalities, and the birth weight, birth
`length, and head circumference were not different in the offspring of
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`1.Clinical,Recordingofbirthweight,birthlength,headcircumference,developmentalassessment,andotherpertinent
`
`gonadotropin;GA=gestation.Neonatalconfirmation/postnatalfollow-upforalltreatedanduntreatedcases:
`Figure2.Prenatalmanagementofpregnancyinfamiliesatriskforafetusaffectedwith21-0HD.hCG=humanchorionic
`
`physicalfindings;
`
`2.Hormonal,Measurementof17-hydroxyprogesteronelevels(cordblood),post-72hourbloodsample,eitherdried
`
`(FromMercadoAB,WilsonRC,ChengKC,etal:JClinEndocrinolMetab80:2014-2020,1995;withpermission.)
`3.Molecular,Bloodsample(peripheralblood)forDNAanalysis.
`
`bloodspotonfilterpaperorwholeblood(serum),electrolytesandplasmareninactivity(PRA)foraffectedinfants;
`
`'I
`
`term
`treatmentto
`Continue
`
`term
`treatmentto
`Continue
`
`Ii
`Cl«
`Q.
`<'
`
`Gl
`
`c0
`
`Cl
`Gl
`II
`
`SI
`
`:;:l
`
`BIRTH
`Term
`40wk
`
`35wk
`
`30wk
`
`25wk
`
`20wk
`
`15wk
`
`lOwk
`
`5wk
`
`Amniocentesis(15·18wkGA):
`
`i
`
`I~
`
`ifunaffected
`
`female
`
`ifmalesex
`
`STOPI:
`
`STOP
`
`STOP
`:I=STOP
`
`ifunaffected
`
`female
`
`ifmalesex
`
`Conception
`
`gestation.
`beforethe9thweekof
`or3doses)beginning
`perday(dividedin2
`pre-pregnancyweight
`tomother:20Ilg/kg
`Dexamethasoneorally
`
`i
`
`1
`
`(at9·11wkGA):
`sampling(CVS)
`Chorionicvillus
`
`ofpregnancy:
`Confirmation
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`8
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`NEW
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`dexamethasone-treated pregnancies when compared with a nontreated
`group.v- 17, 18 provided patients and physicians adhered to the recom-
`mended therapeutic protocol.
`Dexamethasone (20 /-Lg/kg/ d in three divided doses) is adminis-
`tered to the pregnant woman not later than the ninth week of gestation,
`blind to the sex or the affected status of the fetus (Fig. 2). Diagnosis by
`DNA analysis requires chorionic villus sampling at approximately the
`10th week of gestation, or sampling of amniotic fluid cells obtained by
`amniocentesis in the second trimester. The fetal DNA is used for specific
`the CYP21 gene using polymerase chain reaction
`amplification of
`(PCR).40 If the fetus is determined to be an unaffected female on DNA
`analysis or a male on karyotype analysis, treatment is discontinued;
`otherwise, treatment is continued to term.
`Monitoring of the pregnant woman during prenatal treatment re-
`duces the risk of complications to her and her fetus. Blood pressure,
`insulin resistance, and weight gain should be evaluated periodically
`throughout pregnancy. During the second half of pregnancy, maternal
`serum or urinary cortisol and estriol levels can be measured to ensure
`suppression of the maternal and fetal pituitary-adrenal axis."
`
`The New York Hospital-Cornell Medical Center
`Experience
`
`From 1986 to 1998, prenatal examination for CAH owing to 21-
`hydroxylase deficiency was carried out in 403 pregnancies at The New
`York Hospital-Cornell Medical Center. In 280 pregnancies, diagnoses
`in 123, chorionic villus sampling was
`were made by amniocentesis;
`performed. The rapid allele-specific PCR was used for DNA analysis in
`some cases." The Intron2 mutation was the most common in the New
`York City population, followed by a 30-kb deletion encompassing most
`of CYP21. Figure 3 describes other genotype combinations. Because of
`genetic variability, there is no shared mutation that distinctly identifies
`a CAH diagnosis.
`Of the 403 pregnancies evaluated, 84 fetuses were found to be
`affected with classic 21-hydroxylase deficiency. Fifty-two of these fetuses
`were female, 36 of whom were treated prenatally with dexamethasone.
`Dexamethasone administered before 10 weeks' gestation (23 affected
`female fetuses) was effective in reducing virilization. Thirteen cases had
`affected female sibs (Prader stages 1-4). Six these 13 fetuses were born
`with entirely normal female genitalia, whereas 6 others were signifi-
`cantly less virilized (Prader stages 1-2) than their sibs. One fetus was
`Prader stage 3 (Fig. 4). Among the rest, for whom the index cases were
`either cousins or male sibs, four were born with normal genitalia, three
`were Prader stages 1 to 2, and three were Prader stages 3 to 4. The
`newborns who were Prader stages 3 and 4 were born to women who
`were either extremely obese (and, because of a limit on the amount of
`dexamethasone given prenatally, undertreated) or were noncompliant
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`9
`
`Mutation Group
`Int2/1nt2
`Del/Ex1 Int2 Ex3
`Delllnt2
`Ex1 Int2 Ex3/1nt2
`Ex4/1nt2
`DellEx7v
`DellEx4
`DellEx8318
`Ex6/Ex6
`Ex8318/lnt2
`Ex1 Int2 Ex3/
`Ex1 Int2 Ex3
`Ex8356/1nt2 Ex7v
`Int2/ND*
`Del/lnt2 Ex3
`Del/Ex3
`DelfEx8356
`
`n
`10
`7
`6
`5
`4
`4
`4
`3
`2
`2
`
`2
`2
`2
`2
`1
`1
`
`Mutation Group
`Ex1 Int2 Ex3/ND*
`Del/Ex7v Ex7T
`Ex8318 Ex8356
`Ex1 Int2 Ex3/Ex7v
`Ex1 Int2 Ex3/Ex8318
`Del/Del
`Ex3/Ex3
`Ex3/Ex6
`Ex311nt2
`Ex4/ND*
`Ex4/Ex8318
`Ex4/Ex8356
`Ex6/1nt2
`Ex7v/Ex8356
`Ex8318/ND*
`Ex1 Int2 Ex3/Ex8356
`
`n
`1
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`Figure 3. Mutation groups identified in the CYP21 locus in the prenatal 21-hydroxylase
`deficiency congenital adrenal hyperplasia referrals (n = 72). Del = gene deletion; Ex1 =
`Exon 1 (P30L); Ex3 = Exon 3 (8 base pair deletion); Ex4 = Exon 4 (172N), Ex6 = Exon
`6 (cluster: 1236N, V237Q, M239K); Ex7v = Exon 7 (V281L); ExIT = Exon 7 (T306
`insertion); Ex8318 = Exon 8 (Q318X); Ex8356 = Exon 8 (R356W); Int2 = Intron 2 (A or
`C to G).* ND = no mutation detected.
`
`,
`
`!
`
`1
`
`~
`
`;.
`
`)..
`
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`Figure 4. Prader stages of affected female infants in monitored, dexamethasone (Dex)
`prenatally treated pregnancies, in relation to gestational age when dexamethasone was
`started. Affected untreated siblings are shown attached by a dotted line. Affected female
`siblings are represented by solid circles, affected male siblings are represented by solid
`squares, and dexamethasone-treated pregnancies are represented by open circles. The
`solid circles in the right-hand column indicate affected untreated female referrals.
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`and stopped treatment. Overall, the average Prader score for affected
`females treated prenatally was 1.7 (including the partially treated). In
`contrast, the average score for untreated affected females was 3.9. Insuf-
`ficient data exist to correlate the degree of genital ambiguity with muta-
`tion group in prenatally treated patients.
`No significant or enduring side effects were noted in the fetuses
`who were treated prenatally. Fetal demise was approximately the same
`for the dexamethasone-treated and untreated groups (1 female at 35
`weeks and 1 male at 19 weeks prenatally treated, and 2 females [13 and
`36 weeks] and 1 male at 24 weeks untreated). In addition, as reported
`in previous studies, prenatally treated newborns did not differ signifi-
`cantly in birth weight from untreated newborns. The mean birth weight
`for dexamethasone prenatally treated fetuses was 3.4 kg in comparison
`with 3.5 kg for untreated fetuses (P = 0.26) (mean for treated affected
`fetuses, 3.3 kg, and for unaffected fetuses, 3.4 kg; mean for untreated
`affected fetuses, 3.6 kg, and for unaffected, 3.5). Quantitative follow-up
`studies are currently in progress regarding cognition, gender, tempera-
`ment, and handedness (an indicator of prenatal androgen effect) in
`children and adults prenatally treated with dexamethasone.
`There were no significant differences in side effects in the women
`treated with dexamethasone when compared with those in the women
`not treated, which had been a concern of some investigators, except in
`weight gain. By self-report, women who were not treated with dexa-
`methasone gained an average of 28.6 pounds, whereas treated mothers
`gained an average of 36.8 pounds, which was statistically significant
`(P < 0.005). No statistically significant differences were found for the
`presence of striae (P = 0.14), edema (P = 0.56), hypertension (P =
`0.60), or gestational diabetes (P = 0.42) by the self-reports. In a random
`survey of the mothers, 14 who had CAR-affected girls and who were
`prenatally treated with dexamethasone were satisfied with the treatment
`outcome. Of the 35 mothers asked whether they would take dexametha-
`sone again if they got pregnant, 33 said yes, 2 said no, and 1 said she
`would abort.
`
`1113-Hydroxylase Deficiency
`
`The experience in prenatal treatment for 1113-hydroxylase deficiency
`is limited when compared with the experience with 21-hydroxylase defi-
`ciency. In 1989 Bouchard and co-workers' reported the first attempt at
`prenatal treatment with dexamethasone in an affected female with 1113-
`hydroxylase deficiency, which failed to prevent ambiguous genitalia in
`the newborn. Subsequently, prenatal diagnosis for 1113-hydroxylase defi-
`ciency was performed in four additional families. In three of the cases,
`the fetus was either a heterozygote or unaffected. Two families were
`reported on by Curnow and co-workers," one by Geley and co-workers,"
`and another by Cerame and co-workers? In 1999 Cerame and colleagues
`reported the first prenatal diagnosis and treatment of an affected female
`with 1113-hydroxylase deficiency and CAR. The treatment was successful
`because the newborn had normal female external genitalia.
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`PRENATAL TREATMENT OF CONGENITAL ADRENAL HYPERPLASIA
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`Controversy of Prenatal Treatment
`
`A recent report has questioned the safety of long-term prenatal
`glucocorticoid treatment of fetuses potentially affected with CAH.28 The
`report claims that prenatal treatment with dexamethasone contributes to
`low birth weight, fetal demise, serious maternal complications, and
`cognitive and developmental deficiencies. The cited references are pre-
`dominantly based on animal studies in which excess glucocorticoid
`dosages were used. The author finds these claims to be unfounded based
`on her experience with the largest number of treated human pregnancies
`in the world, in addition to the results of other large studies.t""
`The risk-to-benefit ratio in view of no enduring side effects in
`the mother or child favors prenatal treatment. Additionally, males and
`unaffected females treated with short-term dexamethasone show no side
`effects." Treatment of affected females alleviates potential sex misassign-
`ment, repeated genital surgeries that cannot easily recreate natural geni-
`tal structures, and psychologic effects. Long-term studies, currently in
`progress, are needed to determine the outcome of treatment conclusively.
`
`SUMMARY
`
`Based on the author's experience, prenatal diagnosis and treatment
`of 21-hydroxylase deficiency is safe and effective in significantly reduc-
`ing or eliminating virilization in the affected female, and the same
`outcome seems to be true in the treatment of 1113-hydroxylase deficiency.
`Prenatal treatment spares the newborn female the consequences of geni-
`tal ambiguity, genital surgery, sex misassignment, and gender confusion.
`Of the monogenic disorders, steroid 21- and 1113-hydroxylase deficiency
`are two of the few in which prenatal treatment is effective and influences
`postnatal life.
`
`ACKNOWLEDGMENT
`
`The author wishes to express her appreciation to Laurie Vandermolen and Andrea
`Putnam for their extensive editorial assistance.
`
`References
`
`L Amor M, Parker KL, Globerman H, et al: Mutation in the CYP21B gene (Ile-l72----Asn)
`causes steroid 21-hydroxylase deficiency. Proc Nat! Acad Sci USA 85:1600-1604, 1988
`2. Belt KT, Carroll MC, Porter RR: The structural basis of the multiple forms of human
`complement component C4. Cell 36:907-914, 1984
`3. Bouchard M, Forest MG, David M, et al: [Familial congenital adrenal hyperplasia
`caused by 11 beta-hydroxylase: Failure of prevention of sexual ambiguity and prenatal
`diagnosis]. Pediatrie 44:637--640, 1989
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`4. Carlson AD, Obeid JS, Kanellopoulou N, et al: Congenital adrenal hyperplasia: Update
`on prenatal diagnosis and treatment. J Steroid Biochem Mol Biol 69:19-29, 1999
`5. Carlson AD, Obeid JS, Kanellopoulou N, et al: Prenatal treatment and diagnosis of
`congenital adrenal hyperplasia owing to steroid 21-hydroxylase deficiency. In New MI
`(ed): Diagnosis and Treatment of the U