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Pregnancy following treatment of congenital adrenal hyperplasia with cortisone
PREGNANCY FOLLOWING TREATMENT OF CONGENITAL ADRENAL HYPERPLASIA WITH CORTISONE” ROBERT B. WILSON, ROCHESTER, MINN.
(From the Section of and Mayo Foundation-j-)
Obstetrics
and
M.D.,
Gynecology,
AND
F.
RAYMOND
and
the
Section
JR., M.D.,
KEATING,
of
Medicine,
Mayo
Clinic
T
HE congenital adrenogenital syndrome is the striking consequence of pathologic secretion of androgens by an abnormal and hyperplastic adrenal cortex beginning in intrauterine life. Interest in this bizarre condition was increased by the finding of Wilkins and co-worker+ 2 in 1950 and 1951 that cortisone therapy effectively abolished the excessive excretion of 17-ketosteroids as well as the clinical evidence of excessive production of androgen, and permitted the emergence of normal ovarian function, as manifested by regular menstruation. Soon after, Bartter and co-workers3 reported similar results. The study of pregnancy following cort)isone therapy in patients with this condition should therefore be of especial interest. We have had the fortunate experience of observing 2 women with congenital adrenogenital syndrome who, after responding characteristically to adrenal steroid therapy, conceived and gave birth to live normal infants at term. Except for the report of the patient of Yamashita and Kozakae,4 we have found no reports of live birth at term of normal infants in association with this condition. In 19375 and 193@ 7 Ingle and co-workers reported that cortin administered to rats caused atrophy of the adrenal cortex, and they presented evidence to show that the atrophy was due to suppression of the adrenotropic function of the pituitary. It was not until 19508 and 1951 that Sprague and co-workers9 reported that similar suppression of the adrenal cortex occurred in human beings They warned that endogenous adrenal cortical function treated with cortisone. might be depressed during and for an interval after administration of this hormone. In 1951 and 1952 Wilkins and co-workers+ lo-l2 reported the successful use of cortisone in the treatment of patients with congenital adrenogenital syndrome. In attempts to elucidate the abnormal physiology involved, Bongiovanni and co-workersI noted the regular presence of pregnanetriol in the urine of these patients and observed that pregnanetriol is the urinary excretion product of 17-hydroxyprogesterone presumed to be the immediate precursor of 17-hydroxycorticosterone (compound F) . These findings suggest that the essential pathologic physiology in this syndrome is an inborn inability of the adrenal cortex to synthesize 17-hydroxycorticosterone. The absence of the suppression normally furnished by ‘Presented at the Twenty-fifth Annual Gynecologists, Omaha, Neb.. Oct. 24, tThe Mayo Foundation, Rochester. University of Minnesota. and
Meeting of the Central 25, and 26. 1957. Minn., is a part of 388
Association the
Graduate
of Obstetricians School
of
the
~uhmri,9'?"
PREGNANCY
AFTER
CORTISONE
FOR
ADRENAL
HYPERPLASIA
389
17-hydroxycorticosterone is followed by hypersecretion of pituitary adrenocorticotropin, and this in turn causes the adrenal cortex both to undergo hyperplastics changes and to produce androgenic steroids in excess. These, however, do not suppress endogenous adrenocorticotropin, and the vicious cycle that resu1t.s when this occurs in utero may produce the clinical picture of pseudohermaphroditistn in females or macrogenitosomia praecox in males. Atypical and mild forms of the adrenogenital syndrome have been found by some authors to respond successfully to treatment with cortisone. JonesI and JonesI and also Greenblatt16* Ii and their co-workers reported that it number of patients with clinical and laboratory evidence of increased adrenal androgenic function ovulated, became pregnant, and were delivered of normal children when treated with cortisone. In patients with congenital adrenogenital syndrome treated with cortisone, return of menstruation has been almost universal, but the occurrence of pregnancy in such patients has to date been rare]) reported. Yamashita and Kozakae4 have reported upon one patient with congenital adrenogenital syndrome who was treated with cortisone and was delivered at term. de Alvarez and SmithI described 2 such patients, one of whom became pregnant but aborted at the fourth month. Wilhelm and MarksI reported 2 cases of adult adrenogenital syndrome. One patient was delivered ot 2 children after partial adrenalectomy. The other, after cortisone treatment, was delivered of a premature infant (30 weeks) that died neonatally, on thca thircl (3a.v.
Report
of Cases
CASE 1.-A healthy white woman, aged 29 years, was first seen at the Mayo Clinic in March, 1955, because of infertility. The patient recalled some vaginal staining at the age of 17, which did not require a pad. Such staining had recurred from time to time. She had been married 3% years previously but no pregnancies had occurred. Physical examination revealed a receding hair line, thin scalp hair, mild facial and bodily hirsutism, promineut. jaw, minimal development of the breasts, and a masculine muscular habitus. Her height was 60 inches, her weight 122 pounds, and her blood pressure 114 mm. of mercury systolic and 7X diastolic. Pelvic examination showed normal pubic hair and considerable enlargement of the clitoris; her mother stated that this enlargement had been present since birt,h. TherP were no other vulvar abnormalities, the vagina was of normal depth, and the uterus am1 ovaries mere palpably normal. The tubes mere patent. No t,issue was obt,ained when au endometrial biopsy was done.
Routine laboratory examinations gave negative results. The sella turcica appeared normal on x-ray examination. The basal metabolic rate was minus 1 per cent. Urinar) excretion of 17-ketosteroids measured 19.3 mg. in 24 hours; a second det,ermination war 27.7 mg. in 24 hours. Subsequent assay data are summarized in Table I. An excretory urogram on May 10 was of normal appearance. A diagnosis of female pseudohermaphroditism (c*oogenital adrenogenital syndrome) was made. Shortly thereafter the patient moved to another community, but we were able to collaborate with her local physicians in her management. Hydrocortisone therapy was started in May, 1955 (Table I), and was continued with adjustment in dosage as indicated by determinations of 17.ketosteroids. Menstruation began in May, 1955, and occurred regularly and normally each month. No menses occurred after October, 1955, and a pregnanr:y test in December, 1955, gave positive results. Hydrocortisone therapy was continued during pregnancy in a dosage (Table I) that seemed to maintain excretion of urinary 17.ketosteroidx between 8 and 13 mg. each 24 hours. Following a normal labor the patient was spontaneousl\ delivered of a normal female infant at term on July 6, 1956.
390
WILSON
AND
Am. J. Obst. 8; Gynec. Allprint. 1958
REATING
After delivery the patient stopped hydrocortisone therapy of her own volition. As indicated in Table I, this did not result in any immediate increase of 17-ketosteroids. Following parturition the menstrual function returned, with a cycle of 21 to 28 days. However, the patient has had no menses since June, 1957. The first determination of 17-ketosteroids thereafter, on August 17, 1957, was somewhat greater than it was previously (12.3 mg. in 24 hours) but this was not thought to be great enough to require cortisone therapy. A pregnancy test in August, 1957, gave negative results. At present we are in doubt as to whether the patient is again pregnant or whether the original abnormality has returned. TABLE
DATE 1955.-
I.
LABORATORY
I
4/7 5/10 ACTH 5/12
test,
40 units
5/11 5/12
6’1 6/15 6/22 7/17 7/25 8/17 8/.24 10/l lO/ll 12/17 12/29
Cortisone, day
7/6 7/6 8/27 lO/ll U/27 19*57.-l/7 412 6/18 a/17
50 mg.
daily
Hydrocortisone acetate, repeated approximately
Pregnancy Hydrocortisone, weeks
1956.4113 4/13
TREATMENT
DATA
IN
17-KETOSTEROIDS (MG. IN 24 HOURS) -
414
5/14 5/26
AND
test
(MG.
CORTICOIDS IN 24 HOURS)
-
1.15
19.3 27.7 28.1 intramuscularly 57.8 32.3 for 3 days
CASE 1
0.57 on 5/11
and 0.93 1.00
then
every
other 0.69 0.74
40.8 4.4 250 mg. intramuscularly every 2 weeks 18.5 11.3 17.7 20.0 10.1 11.9 10.9 15.9
0.93 0.67 0.81 0.81 0.77 0.54 1.08 0.68
positive 250
11.2 mg. intramusoularly
12.7 Hydrocortisone, 250 mg. intramuscularly weeks Delivery Cortisone therapy discontinued 2.2 2.2 8.2 7.5 5.9 12.7 12.3
every
2
every
2
0.87
1.13 0.39 0.66 0.68 0.77 1.09 0.51
The clinical features of congenital virilization in this patient were much less conspicuous than in the second case, but these features together with a definite developmental history and a characteristic pattern of hormone excretion were regarded as affording a decisive diagnosis. The response to the administration of adrenocorticotropin was characteristic of the adrenal hyperplasia of the adrenogenital syndrome (Table I) : excretion of 1’7-ketosteroids increased to 57.8 mg. per 24 hours without significant change
~$I;w~‘Z”
PREGNANCY
AFTER
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FOR
ADRENAL
HYPERPLASIA
391
in the excretion of corticoids. Such marked increase is not customarily seen in patients with normal adrenal function or in those with adrenal tumor. The prompt return of the excretion of l7-ketosteroids to normal, associated with the appearance of menstrual function upon initiation of hpdrocortisone therapy! constitutes further evidence of adrenogenital syndrome.
Fig. l.---Case 2. a, May 30. 1946. The masculine physique of this patient striking. There is no development of the breasts. 71, Feb. 13, 1957. Appearance the seventh month of gestation. The deformity of the left breast is due to surgical of a large area of cystic mastitis.
is quite during removal
The dose of cortisone was not changed during pregnancy, since urinary excretion of 17-ketosteroids remained within the normal range, although not as low as the 8 mg. in 24 hours that Wilkins and co-workers recommended. The patient was prepared for delivery by the intramuscular administration of 200 mg. of cortisone at the onset of labor. It was planned to repeat this dose every 8 to 12 hours during labor and to give additional hydrocortisone intravenously
as needed to maintain the blood pressure or treat clinical evidence of adrenal insufficiency. The patient’s labor was normal in all respects, however, and such measures were not required. A thorough examination of the infant revealed no abnormalities. CASE 2.-A white woman, aged 22 years, when first seen at the Mayo Clinic, in May, 1946, complained of a growth on the vulva and that she had never menstruated. Physical examination disclosed a very masculinized woman (Fig. &a). The patient’s height was 61 inches, her weight 115 pounds, and her blood pressure 120/70. Marked growth of hair on face, arms, and legs was present and the voice was husky. The “growth” on the vulva was a clitoris, 4 to 5 cm. long (Fig. 2,a), the vagina was deep and narrow with a small cervix in the vault, the uterus was very small, and nothing was felt in the adnexa. At this time (1946) the results of routine laboratory studies were within normal limits, the basal metabolic rate was plus 13 per cent, the value for urinary estrogens, 53 rat units in 24 hours, and the value for urinary pituitary gonadotropin, zero. The excretion of 17-ketosteroids was 86 mg. per 24 hours. A diagnosis of classic pseudohermaphroditism associated with congenital adrenogenital hyperplasia was made. Surgical exploration with consideration of subtotal adrenalectomy was suggested, but the patient elected to defer this.
Fig. 2.-Case 2. a, May 30, 1946. External genitals show little 13, 1957. enlarged clitoris more clearly.
External change
genitals with in 7 years.
prominent clitoris. b, Feb. This photograph shows the
The patient returned in January, 1955, having attained the age of 31 and having been married. Complaints suggestive of disease of the gall bladder were voiced. Her appearance and the physical findings had not changed appreciably since the first visit in 1946. The clitoris was still enlarged as before with the uterus remaining small. The patient had had no menstrual periods. Treatment with adrenal steroids was started on Jan. data are summarized in Table II. The patient experienced March; thereafter menses occurred at intervals of 26 days “last menstrual period ’ ’ occurred on Aug. 15, 1956. When intrauterine pregnancy was obvious.
15, 1955. Therapy and assay her first menstrual period in and lasted 6 or 7 days until a she was seen on Nov. 30, 1956,
i;;;xr76
?
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The prenatal course was uneventful in nearly all respects. The gain in weight was minimal, from 123% pounds in November, 1956, to 129% pounds at term. There was no increase in blood pressure at any time, and the results of urinalysis were consistently negative. The patient’s appearance at the seventh month of gestation and the appearance of the external genitals are shown in Figs. l,b and 2,b. The pelvis both clinically and roentgenographically was contract,ed and it was thought that a cesarean section would probably be necessary. The patient went into labor spontaneously on May 14, 1957, at the thirty-ninth wecnk of gestation. The membranes ruptured at the onset of labor. The cervix dilated to 6 cm., with the presenting vertex at station minus 2. There was no further cervical dilation or descent of the vertex during the next 4M hours of labor in spite of excellent uterine con tractions. Consequently, with the patient under local anesthesia, a low cervical cpsarean section was done with delivery of a normal female infant who wclighed 2,890 grams. ‘l’hr postoperative course was uncomplicated. This patient also discontinued cortisone therapy when she left the hospital. Nu withdrawal symptoms were experienced. She noticed a scanty brownish discharge on July 27, and experienced a seemingly normal menstrual period from Aug. 10 to 15, 19.57. During the month of September, 1957, scant daily bleeding occurred but we have had no I.WHII~ opportunity to examine the patient. TABLE
II.
LABORATORY
AND
TREATMENT
DATA
IN
CASE
2 ~.__._
DATE
1 j
17-EETOSTEROIDS (MO. IN 24 HOURS)
5/31/46 l/15/55 2/15;55 3/15/55 g/19/55 10/22/55 3/14/56 7/10/56 IO/ 9/56 ll/ 7/56 11/30/56 l/26/57 3/27/57 t5/14/57
86.0 18.1 19.4 5.4 6.4 16.5 10.7 2.9 11.5 8.0 6.3 8.3 11.8 Corticoids
S/28/57 Corticoids
TREATMENT
None Cortisone, 50 mg. in 24 hours Cortisone. 75 mg. in 24 hours No change Hydroeortisone, 200 mg. intramuscularly Hydrocortisone, 375 mg. intramuscularly No change No change No change No change Prednisone, 5 mg. every 12 hours No change No change No change Cortisone therapy discontinued
Delivery 6/29/X
1 /
every every
2 wpeks 3 weeks
8.6 0.56 16.6 0.41
This patient’s response to therapy was amount of cortisone was given. No particular the type of cortisone was changed, first to injection and then to prednisone by mouth. no signs of hypercortisonism were noted.
excellent as soon as an adequate difficulties were encountered when hydrocortisone by intramuscular During the 17 months of therapy
The management after the onset of labor included intramuscular administration of 200 mg. of cortisone on admission to the hospital. This dose was repeated twice before cesarean section and on the fifth, sixth, and seventh postoperative days. No cortisone was required intra.venously although it was available had there been any evidence of an adrenal crisis.
394
WILSON
AND
KEATING
,\m. .I. Oht. s: c;vnei. Ailgust. .I!riX
Commt?Ilt
These 2 cases illustrate marked quantitative differences in the severity of virilization, but careful comparison of symptoms, response to treatment, and patterns of hormone excretion provides an adequate basis for considering that they represent degrees of the same disorder. The congenital adrenogenital syndrome also varies greatly from case to case with regard to the degree of genital deformity, depending upon the time in intrauterine life at whirl1 abnormal adrenal function begins. When this occurs before the external genitals are differentiated (about the third or fourth month of gestation) anatomic abnormalities of the external genitals generally result. In extreme cases the vagina may be reduced to an offshoot of the urethra and the external genitals may resemble those of a male with cryptorchid testes and hypospadias. “female pseudohermaphroditism” is most appropriat,e in The designation cases of this sort but it should be emphasized that the endocrine disorder is t,he same whether such anatomic abnormalities are present or absent. Both patients here presented had anatomically normal female genitourinary tracts and both were raised as females. From a therapeutic standpoint they posed no particular problem once adrenal suppression had been effected with cortisone. Howcvrr, patients in whom early onset of virilization has produced irreversible and anomalous genital changes usually require more than suppressive treatment alone. Provided the patient is recognized as a female infant at birth and is raised in the psychological and cultural pattern of females, adequate treatment, may also require some plastic surgical procedure to establish normal anatomic No instance has yet been reported of pregnancy following relationships. treatment of such complete pseudohermaphrodites. There is, however, no theoretical reason why it might not occur. The management of patients with adrenogenital syndrome requires periodic assay of urinary 17-ketosteroids as a guide to the regulation of cortisone dosage necessary to suppress production of corticotropin. Periodic evaluation of blood electrolytes is usually unnecessary except in occasional instances (usually male children) in which there is concomitant adrenal insufficiency similar to that of Addison’s disease. Protecting the patient with large quantities of cortisone prior to delivery or any other stress should be emphasized. The nature of the metabolic defect in the adrenal cortices makes it improbable that they can protect the patient against stress in a normal way. We have followed the practice of treating these patients before and following delivery or surgical treatment in the same manner as patients with Addison’s disease. Cortisone, 200 mg., is given intramuscularly two or three times within the 36 hours preceding the event to provide a high level of circulatory steroid at t,he time of stress ; blood pressure levels and parenteral fluid therapy are closely watched subsequently, and further replacement therapy is dictated by the course of the patient. de Alvarez18 theorized that an increase in 17-ketosteroids from 5 to 13 mg. in 24 hours reflected an increase in adrenal androgen sufficient to interfere with normal ovarian function and contributed to the abortion that occurred in his patient. Jones and JonesI reported that abortion occurred in half of their patients. We noticed fluctuation in excretion of 17-ketosteroids as great as or greater than this (Tables I and II) in these 2 patients on a number of occasions, Marked fluctuayet neither experienced any symptoms suggestive of abortion. tions should probably be prevented when possible, but this experience suggests that moderate fluctuation in urinary 17-ketosteroids is not harmful and we have considered it unnecessary to alter the dose of cortisone with every minor change in urinary 17-ketosteroids.
76 PREGKANCY Number 2
\-dume
.WTER
CORTISONE
FOR
;kDRENBT,
TTY PERPLASTA
39i-i
Should it prove possible that a patient might maintain pregnancy despite abnormal levels of adrenal androgen, the question might arise as to the possiblt> Theoretically, if one assumes that androeffects of such levels upon the fetus. gens may penetrate the placental barrier, one might anticipate ririlization in the fetus analogous to that of a fetus that itself had the adrenogenital .s~ndrome. that is, macrogenitosomia praecos in a male or pseudohermaphrodltlsm in ;I female, provided the abnormal levels were present prior to the fourth month Such children might not necessarily have the adrenogenit’al o-f gestation. syndrome, but might nevertheless bear stigmas of it, from temporary exposures to virilizing influences in utero, which in females at least, could prove disastrous. It is therefore of particular interest that both babies reported here were females, and both were entirely normal in all respects. This indicates at least, that the levels of androgen secretion in these cases were insufficient to produce harmful rffrcts upon the genitourinary development of these girl babies. The course of the patients after delivery and following unplanned cessation of therapy has been of considerable interest. In the first patient, norm;! I menstrual function returned and the values for urinary 17-ketosteroids ha ~1’ remained within normal range. We are currently in doubt whether she has become amenorrheic because of another pregnancy or because of a return ol excess adrenoeortical androgens. In any event, for approximately 1 pear following delivery the level of l?-ketasterolds has remained sat.isfactorg. Sinc,cl only 4 months have elapsed since delivery of the second patient, It is not possible to assess her adrenal function at this time. The most, recent assay ma.y be slightly elevated but at least one menstrual period has occurred without cortisone therapy. In 1951 Wilkins and co-workers2 suggested that perhaps long-continued treatment might render the adrenals permanently incapable of their former hyperactivity. There is evidence that short-term cortisone therapy certainI!There have been does not prevent the return of the adrenal hyperactivity.20 no specific studies that indicate what long-term therapy might accomplish iI1 this regard. In at least one, and perhaps bot,h, of onr patients such sustainer1 suppression of adrenal androgenic hyperactivity may ha.ve occurred. At birth the infants of both patients were normal by all the usual standards. lrears have been expressed that treatment, of pregnant patients might 1~ followed by adrenal insufficiency in the infants in the neonatal period. Ncithcl infant showed such effects nor has there been mention of fhis difficnlty in similar instances in t,he literature. It appears, therefore, thn.t t.his possibility need br of little concern.
References 1. Wilkins, 2. 3. 4. 5. 6. 7. 8.
L., Lewis, R. A., Klein, R., and Rosemherg, E.: Rull. Johns Hopkins Hcq. 86: 249, 1950. Wilkins, Lawson, Lewis, R. A., Klein, Robert, Gardner, I,. I., Crigler, J. F., Jr., Rosembr~g, Eugenia, and Migeon, C. J.: J. Clin. Endocrinol. 11: 1, 1951. Bartter, F. C., Albright, Fuller? Forbes, Anne P., Leaf, Alexander, Dempsey, ElPal(or, and Carroll, Evelyn: J. Chn. Invest. 30: 237, 1951. Tamashita, T., and Kozakae, F.: Endocrinologia japonica 3: li6, 1956. Ingle, D. J., and Kendall, E. C.: Science 86: 245, 1937. Am. J. Physiol. 124: 369, 1938. Ingle, D. J.: Proc. Sot. Exper. Biol. & Med. 39: 154, 1938. Ingle, D. J., and Mason, H. L.: Sprague, R. G., Power, M. H., Mason, H. L., Albert, A., Mathieson, D. R., Hen&, P. S., Kendall, E. C., Slocumb, C. H., and Polley, J-I. F.: Arrh. Int. Med. 85: 199, 1950.
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Am. J Obst. br Gym Augurr, 1458
9. Sprague, In Pineus, Gregory, editor: Recent R. G., Mason, H. L., and Power, M. H.: Progress in Hormone Research, New York, 1951, Academic Press, Inc., vol. 6, pp 315-372. 10. Wilkins, Lawson, Gardner, L. I., Crigler, J. I?., Jr., Silverman, S. H., and Migeon, C. J.: J. Clin. Endoerinol. 12: 257, 1952. 11. Wilkins, Lawson, Crigler, J. F., Jr., Silverman? S. H., Gardner, L. I., and Migeon, C. J.: J. Clin. Endocrinol. 12: 1015, 1952. 12. Wilkins, Lawson, Crigler, J. F., Jr., Silverman, S. H., Gardner, L. I., and Migeon, C. J.: J. Clin. Endocrinol. 12: 277, 1952. 13. Bongiovanni, A. M., Eberlein, W. R., and Cars, Jose: J. Clin. Endocrinol. 14: 409, 1954. Jones, H. W., Jr., and Jones, G. E. S.: AM. J. OBST. & GYNEC. 68: 1330, 1954. :2: Jones, G. E. S., Howard, J. E., and Langford, H.: Fertil. & Steril. 4: 49, 1953. 16. Greenblatt, R. B.: AM. J. OBST. & GYNEC. 66: 700, 1953. 17. Greenblatt, R. B., Barfield, W. E., and Lampros, C. P.: Fertil. & Steril. 7: 203, 1956. 18. de Alvarez, R. R., and Smith, E. K.: Obst. & Gynec. 9: 426, 1957. Wilhelm, 5. F.,. and Marks, R. G.: J. Ural. 73: 17, 1955. ii: Goldberg, Minnie B. : J. Clin. Endocrinol. 14: 389, 1954.
Discussion DR. E. STEWART TAYLOR, Denver, Cola.-These 2 cases illustrate one of the forms of the adrenogenital syndrome. This, of course, is dependent on the time of development as well as the sex of the individual affected. The condition is about five times as common in the female as in the male. Children with congenital adrenal hyperplasia show excessive masculinization, increased protein anabolism, rapid somatic growth, and accelerated epiphyseal ossification, in addition to characteristic laboratory findings. When the syndrome develops in the postnatal period before puberty, it is usually secondary to a functioning adrenal tumor, but it may be from acquired adrenal cortical hyperplasia. Seborrhea, acne, and development of sexual hair may be the first signs. These are followed by hypertrophy of the clitoris, deepening of the voice, rapid growth, and epiphyseal development. When the condition develops near or after puberty, it may be secondary to either tumor or hyperplasia. Hirsutism (masculine in type), hypertrophy of the clitoris, deep voice, and excessive Although all patients with the syndrome show virilization musculature suggest the condition. and increased protein anabolism because of excessive secretion of androgens, there are Briefly, one fourth show a tendency differences in the other functions of the adrenal cortex. to sodium loss and elevated serum potassium with resultant dehydration, circulatory collapse, and even cardiac arrest from hyperkalemia. Some may have hypertension, possibly from sodium retention. There may be a tendency to hypoglycemia in some patients caused by a deficit of glyeogenic hormone. We would classify these 2 cases as androgenital syndrome with postnatal virilization instead of congenital androgenitalism. Whether the condition is congenital or acquired, the basic abnormality appears to be an enzymatic defect in the adrenal cortex preventing the synthesis of compound F and the subsequent formation of abnormal amounts of metabolites from An pregnenolone, progesterone, and 17.hydroxyprogesterone. The pathology consists of enlargement of the adrenals primarily because of hyperplasia of the reticular zone. The fascicular zone is disorganized and is infiltrated with cells from the reticular zone. The glomerular zone may be absent. The condition occurs frequently in siblings born from apparently Childs and Grumbach suggest that the disorder may be a manifestation which may express itself only in a homozygous offspring. Theoretically, may occur about once in 125 individuals.
normal parents. of a recessive trait the mutant gene
We currently are following 2 sisters at the Colorado General Hospital who in most respects are similar to the first patient reported by Dr. Wilson. The older sister was treated with cortisone in 1955. Menses ensued one month later and she soon became pregnant. The patient began labor spontaneously at term and after a short tria1 was delivered by cesarean section because of a contracted, android-type pelvis. Her 2,520 gram daughter was normal
Volume 76 PREGNANCY
Number
2
AFTER
CORTISONE
FOR
ADRENAL
HYPERPLASJA
397
in all respects. It is interesting to note that the only vaginal bleeding this patient had ever had before cortisone therapy was after the administration of estrogen by her private physician. The patient continued to menstruate normally for eight months following delivery, without steroid therapy, when she had an episode of menorrhagia which was suctessful1.y treated by uterine curettage. The younger sister was also treated with cortisone. Prompt menses occurred, she has since married, and is now in her second month of pregnancy. It was interesting to us that the first response to cortisone therapy in each of these patients was enlarging, painful breasts which occurred about 2 weeks after treatment started. Isot11 of the patients had little or no noticeable breast tissue before cortisone treatment. Dr. Dalton Jenkins, our endocrinologist, has a patient, a third patient, who falls in the category of the 2 reported by Dr. Wilson, and the 2 patients discussed from our clinic. Two of the 3 patients from the Colorado General Hospital have shown increasing excretions of pregnanetriol while excreting normal amounts of 17-ketosteroids. It is Dr. Jenkins’ feeling that, in the early phases of this syndrome, pathological levels of excreted pregnanetriol may antedate the appearance of abnormal levels of 17-ketosteroids in the urine.
(From the Section of and Mayo Foundation-j-)
Obstetrics
and
M.D.,
Gynecology,
AND
F.
RAYMOND
and
the
Section
JR., M.D.,
KEATING,
of
Medicine,
Mayo
Clinic
T
HE congenital adrenogenital syndrome is the striking consequence of pathologic secretion of androgens by an abnormal and hyperplastic adrenal cortex beginning in intrauterine life. Interest in this bizarre condition was increased by the finding of Wilkins and co-worker+ 2 in 1950 and 1951 that cortisone therapy effectively abolished the excessive excretion of 17-ketosteroids as well as the clinical evidence of excessive production of androgen, and permitted the emergence of normal ovarian function, as manifested by regular menstruation. Soon after, Bartter and co-workers3 reported similar results. The study of pregnancy following cort)isone therapy in patients with this condition should therefore be of especial interest. We have had the fortunate experience of observing 2 women with congenital adrenogenital syndrome who, after responding characteristically to adrenal steroid therapy, conceived and gave birth to live normal infants at term. Except for the report of the patient of Yamashita and Kozakae,4 we have found no reports of live birth at term of normal infants in association with this condition. In 19375 and 193@ 7 Ingle and co-workers reported that cortin administered to rats caused atrophy of the adrenal cortex, and they presented evidence to show that the atrophy was due to suppression of the adrenotropic function of the pituitary. It was not until 19508 and 1951 that Sprague and co-workers9 reported that similar suppression of the adrenal cortex occurred in human beings They warned that endogenous adrenal cortical function treated with cortisone. might be depressed during and for an interval after administration of this hormone. In 1951 and 1952 Wilkins and co-workers+ lo-l2 reported the successful use of cortisone in the treatment of patients with congenital adrenogenital syndrome. In attempts to elucidate the abnormal physiology involved, Bongiovanni and co-workersI noted the regular presence of pregnanetriol in the urine of these patients and observed that pregnanetriol is the urinary excretion product of 17-hydroxyprogesterone presumed to be the immediate precursor of 17-hydroxycorticosterone (compound F) . These findings suggest that the essential pathologic physiology in this syndrome is an inborn inability of the adrenal cortex to synthesize 17-hydroxycorticosterone. The absence of the suppression normally furnished by ‘Presented at the Twenty-fifth Annual Gynecologists, Omaha, Neb.. Oct. 24, tThe Mayo Foundation, Rochester. University of Minnesota. and
Meeting of the Central 25, and 26. 1957. Minn., is a part of 388
Association the
Graduate
of Obstetricians School
of
the
~uhmri,9'?"
PREGNANCY
AFTER
CORTISONE
FOR
ADRENAL
HYPERPLASIA
389
17-hydroxycorticosterone is followed by hypersecretion of pituitary adrenocorticotropin, and this in turn causes the adrenal cortex both to undergo hyperplastics changes and to produce androgenic steroids in excess. These, however, do not suppress endogenous adrenocorticotropin, and the vicious cycle that resu1t.s when this occurs in utero may produce the clinical picture of pseudohermaphroditistn in females or macrogenitosomia praecox in males. Atypical and mild forms of the adrenogenital syndrome have been found by some authors to respond successfully to treatment with cortisone. JonesI and JonesI and also Greenblatt16* Ii and their co-workers reported that it number of patients with clinical and laboratory evidence of increased adrenal androgenic function ovulated, became pregnant, and were delivered of normal children when treated with cortisone. In patients with congenital adrenogenital syndrome treated with cortisone, return of menstruation has been almost universal, but the occurrence of pregnancy in such patients has to date been rare]) reported. Yamashita and Kozakae4 have reported upon one patient with congenital adrenogenital syndrome who was treated with cortisone and was delivered at term. de Alvarez and SmithI described 2 such patients, one of whom became pregnant but aborted at the fourth month. Wilhelm and MarksI reported 2 cases of adult adrenogenital syndrome. One patient was delivered ot 2 children after partial adrenalectomy. The other, after cortisone treatment, was delivered of a premature infant (30 weeks) that died neonatally, on thca thircl (3a.v.
Report
of Cases
CASE 1.-A healthy white woman, aged 29 years, was first seen at the Mayo Clinic in March, 1955, because of infertility. The patient recalled some vaginal staining at the age of 17, which did not require a pad. Such staining had recurred from time to time. She had been married 3% years previously but no pregnancies had occurred. Physical examination revealed a receding hair line, thin scalp hair, mild facial and bodily hirsutism, promineut. jaw, minimal development of the breasts, and a masculine muscular habitus. Her height was 60 inches, her weight 122 pounds, and her blood pressure 114 mm. of mercury systolic and 7X diastolic. Pelvic examination showed normal pubic hair and considerable enlargement of the clitoris; her mother stated that this enlargement had been present since birt,h. TherP were no other vulvar abnormalities, the vagina was of normal depth, and the uterus am1 ovaries mere palpably normal. The tubes mere patent. No t,issue was obt,ained when au endometrial biopsy was done.
Routine laboratory examinations gave negative results. The sella turcica appeared normal on x-ray examination. The basal metabolic rate was minus 1 per cent. Urinar) excretion of 17-ketosteroids measured 19.3 mg. in 24 hours; a second det,ermination war 27.7 mg. in 24 hours. Subsequent assay data are summarized in Table I. An excretory urogram on May 10 was of normal appearance. A diagnosis of female pseudohermaphroditism (c*oogenital adrenogenital syndrome) was made. Shortly thereafter the patient moved to another community, but we were able to collaborate with her local physicians in her management. Hydrocortisone therapy was started in May, 1955 (Table I), and was continued with adjustment in dosage as indicated by determinations of 17.ketosteroids. Menstruation began in May, 1955, and occurred regularly and normally each month. No menses occurred after October, 1955, and a pregnanr:y test in December, 1955, gave positive results. Hydrocortisone therapy was continued during pregnancy in a dosage (Table I) that seemed to maintain excretion of urinary 17.ketosteroidx between 8 and 13 mg. each 24 hours. Following a normal labor the patient was spontaneousl\ delivered of a normal female infant at term on July 6, 1956.
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REATING
After delivery the patient stopped hydrocortisone therapy of her own volition. As indicated in Table I, this did not result in any immediate increase of 17-ketosteroids. Following parturition the menstrual function returned, with a cycle of 21 to 28 days. However, the patient has had no menses since June, 1957. The first determination of 17-ketosteroids thereafter, on August 17, 1957, was somewhat greater than it was previously (12.3 mg. in 24 hours) but this was not thought to be great enough to require cortisone therapy. A pregnancy test in August, 1957, gave negative results. At present we are in doubt as to whether the patient is again pregnant or whether the original abnormality has returned. TABLE
DATE 1955.-
I.
LABORATORY
I
4/7 5/10 ACTH 5/12
test,
40 units
5/11 5/12
6’1 6/15 6/22 7/17 7/25 8/17 8/.24 10/l lO/ll 12/17 12/29
Cortisone, day
7/6 7/6 8/27 lO/ll U/27 19*57.-l/7 412 6/18 a/17
50 mg.
daily
Hydrocortisone acetate, repeated approximately
Pregnancy Hydrocortisone, weeks
1956.4113 4/13
TREATMENT
DATA
IN
17-KETOSTEROIDS (MG. IN 24 HOURS) -
414
5/14 5/26
AND
test
(MG.
CORTICOIDS IN 24 HOURS)
-
1.15
19.3 27.7 28.1 intramuscularly 57.8 32.3 for 3 days
CASE 1
0.57 on 5/11
and 0.93 1.00
then
every
other 0.69 0.74
40.8 4.4 250 mg. intramuscularly every 2 weeks 18.5 11.3 17.7 20.0 10.1 11.9 10.9 15.9
0.93 0.67 0.81 0.81 0.77 0.54 1.08 0.68
positive 250
11.2 mg. intramusoularly
12.7 Hydrocortisone, 250 mg. intramuscularly weeks Delivery Cortisone therapy discontinued 2.2 2.2 8.2 7.5 5.9 12.7 12.3
every
2
every
2
0.87
1.13 0.39 0.66 0.68 0.77 1.09 0.51
The clinical features of congenital virilization in this patient were much less conspicuous than in the second case, but these features together with a definite developmental history and a characteristic pattern of hormone excretion were regarded as affording a decisive diagnosis. The response to the administration of adrenocorticotropin was characteristic of the adrenal hyperplasia of the adrenogenital syndrome (Table I) : excretion of 1’7-ketosteroids increased to 57.8 mg. per 24 hours without significant change
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in the excretion of corticoids. Such marked increase is not customarily seen in patients with normal adrenal function or in those with adrenal tumor. The prompt return of the excretion of l7-ketosteroids to normal, associated with the appearance of menstrual function upon initiation of hpdrocortisone therapy! constitutes further evidence of adrenogenital syndrome.
Fig. l.---Case 2. a, May 30. 1946. The masculine physique of this patient striking. There is no development of the breasts. 71, Feb. 13, 1957. Appearance the seventh month of gestation. The deformity of the left breast is due to surgical of a large area of cystic mastitis.
is quite during removal
The dose of cortisone was not changed during pregnancy, since urinary excretion of 17-ketosteroids remained within the normal range, although not as low as the 8 mg. in 24 hours that Wilkins and co-workers recommended. The patient was prepared for delivery by the intramuscular administration of 200 mg. of cortisone at the onset of labor. It was planned to repeat this dose every 8 to 12 hours during labor and to give additional hydrocortisone intravenously
as needed to maintain the blood pressure or treat clinical evidence of adrenal insufficiency. The patient’s labor was normal in all respects, however, and such measures were not required. A thorough examination of the infant revealed no abnormalities. CASE 2.-A white woman, aged 22 years, when first seen at the Mayo Clinic, in May, 1946, complained of a growth on the vulva and that she had never menstruated. Physical examination disclosed a very masculinized woman (Fig. &a). The patient’s height was 61 inches, her weight 115 pounds, and her blood pressure 120/70. Marked growth of hair on face, arms, and legs was present and the voice was husky. The “growth” on the vulva was a clitoris, 4 to 5 cm. long (Fig. 2,a), the vagina was deep and narrow with a small cervix in the vault, the uterus was very small, and nothing was felt in the adnexa. At this time (1946) the results of routine laboratory studies were within normal limits, the basal metabolic rate was plus 13 per cent, the value for urinary estrogens, 53 rat units in 24 hours, and the value for urinary pituitary gonadotropin, zero. The excretion of 17-ketosteroids was 86 mg. per 24 hours. A diagnosis of classic pseudohermaphroditism associated with congenital adrenogenital hyperplasia was made. Surgical exploration with consideration of subtotal adrenalectomy was suggested, but the patient elected to defer this.
Fig. 2.-Case 2. a, May 30, 1946. External genitals show little 13, 1957. enlarged clitoris more clearly.
External change
genitals with in 7 years.
prominent clitoris. b, Feb. This photograph shows the
The patient returned in January, 1955, having attained the age of 31 and having been married. Complaints suggestive of disease of the gall bladder were voiced. Her appearance and the physical findings had not changed appreciably since the first visit in 1946. The clitoris was still enlarged as before with the uterus remaining small. The patient had had no menstrual periods. Treatment with adrenal steroids was started on Jan. data are summarized in Table II. The patient experienced March; thereafter menses occurred at intervals of 26 days “last menstrual period ’ ’ occurred on Aug. 15, 1956. When intrauterine pregnancy was obvious.
15, 1955. Therapy and assay her first menstrual period in and lasted 6 or 7 days until a she was seen on Nov. 30, 1956,
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The prenatal course was uneventful in nearly all respects. The gain in weight was minimal, from 123% pounds in November, 1956, to 129% pounds at term. There was no increase in blood pressure at any time, and the results of urinalysis were consistently negative. The patient’s appearance at the seventh month of gestation and the appearance of the external genitals are shown in Figs. l,b and 2,b. The pelvis both clinically and roentgenographically was contract,ed and it was thought that a cesarean section would probably be necessary. The patient went into labor spontaneously on May 14, 1957, at the thirty-ninth wecnk of gestation. The membranes ruptured at the onset of labor. The cervix dilated to 6 cm., with the presenting vertex at station minus 2. There was no further cervical dilation or descent of the vertex during the next 4M hours of labor in spite of excellent uterine con tractions. Consequently, with the patient under local anesthesia, a low cervical cpsarean section was done with delivery of a normal female infant who wclighed 2,890 grams. ‘l’hr postoperative course was uncomplicated. This patient also discontinued cortisone therapy when she left the hospital. Nu withdrawal symptoms were experienced. She noticed a scanty brownish discharge on July 27, and experienced a seemingly normal menstrual period from Aug. 10 to 15, 19.57. During the month of September, 1957, scant daily bleeding occurred but we have had no I.WHII~ opportunity to examine the patient. TABLE
II.
LABORATORY
AND
TREATMENT
DATA
IN
CASE
2 ~.__._
DATE
1 j
17-EETOSTEROIDS (MO. IN 24 HOURS)
5/31/46 l/15/55 2/15;55 3/15/55 g/19/55 10/22/55 3/14/56 7/10/56 IO/ 9/56 ll/ 7/56 11/30/56 l/26/57 3/27/57 t5/14/57
86.0 18.1 19.4 5.4 6.4 16.5 10.7 2.9 11.5 8.0 6.3 8.3 11.8 Corticoids
S/28/57 Corticoids
TREATMENT
None Cortisone, 50 mg. in 24 hours Cortisone. 75 mg. in 24 hours No change Hydroeortisone, 200 mg. intramuscularly Hydrocortisone, 375 mg. intramuscularly No change No change No change No change Prednisone, 5 mg. every 12 hours No change No change No change Cortisone therapy discontinued
Delivery 6/29/X
1 /
every every
2 wpeks 3 weeks
8.6 0.56 16.6 0.41
This patient’s response to therapy was amount of cortisone was given. No particular the type of cortisone was changed, first to injection and then to prednisone by mouth. no signs of hypercortisonism were noted.
excellent as soon as an adequate difficulties were encountered when hydrocortisone by intramuscular During the 17 months of therapy
The management after the onset of labor included intramuscular administration of 200 mg. of cortisone on admission to the hospital. This dose was repeated twice before cesarean section and on the fifth, sixth, and seventh postoperative days. No cortisone was required intra.venously although it was available had there been any evidence of an adrenal crisis.
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,\m. .I. Oht. s: c;vnei. Ailgust. .I!riX
Commt?Ilt
These 2 cases illustrate marked quantitative differences in the severity of virilization, but careful comparison of symptoms, response to treatment, and patterns of hormone excretion provides an adequate basis for considering that they represent degrees of the same disorder. The congenital adrenogenital syndrome also varies greatly from case to case with regard to the degree of genital deformity, depending upon the time in intrauterine life at whirl1 abnormal adrenal function begins. When this occurs before the external genitals are differentiated (about the third or fourth month of gestation) anatomic abnormalities of the external genitals generally result. In extreme cases the vagina may be reduced to an offshoot of the urethra and the external genitals may resemble those of a male with cryptorchid testes and hypospadias. “female pseudohermaphroditism” is most appropriat,e in The designation cases of this sort but it should be emphasized that the endocrine disorder is t,he same whether such anatomic abnormalities are present or absent. Both patients here presented had anatomically normal female genitourinary tracts and both were raised as females. From a therapeutic standpoint they posed no particular problem once adrenal suppression had been effected with cortisone. Howcvrr, patients in whom early onset of virilization has produced irreversible and anomalous genital changes usually require more than suppressive treatment alone. Provided the patient is recognized as a female infant at birth and is raised in the psychological and cultural pattern of females, adequate treatment, may also require some plastic surgical procedure to establish normal anatomic No instance has yet been reported of pregnancy following relationships. treatment of such complete pseudohermaphrodites. There is, however, no theoretical reason why it might not occur. The management of patients with adrenogenital syndrome requires periodic assay of urinary 17-ketosteroids as a guide to the regulation of cortisone dosage necessary to suppress production of corticotropin. Periodic evaluation of blood electrolytes is usually unnecessary except in occasional instances (usually male children) in which there is concomitant adrenal insufficiency similar to that of Addison’s disease. Protecting the patient with large quantities of cortisone prior to delivery or any other stress should be emphasized. The nature of the metabolic defect in the adrenal cortices makes it improbable that they can protect the patient against stress in a normal way. We have followed the practice of treating these patients before and following delivery or surgical treatment in the same manner as patients with Addison’s disease. Cortisone, 200 mg., is given intramuscularly two or three times within the 36 hours preceding the event to provide a high level of circulatory steroid at t,he time of stress ; blood pressure levels and parenteral fluid therapy are closely watched subsequently, and further replacement therapy is dictated by the course of the patient. de Alvarez18 theorized that an increase in 17-ketosteroids from 5 to 13 mg. in 24 hours reflected an increase in adrenal androgen sufficient to interfere with normal ovarian function and contributed to the abortion that occurred in his patient. Jones and JonesI reported that abortion occurred in half of their patients. We noticed fluctuation in excretion of 17-ketosteroids as great as or greater than this (Tables I and II) in these 2 patients on a number of occasions, Marked fluctuayet neither experienced any symptoms suggestive of abortion. tions should probably be prevented when possible, but this experience suggests that moderate fluctuation in urinary 17-ketosteroids is not harmful and we have considered it unnecessary to alter the dose of cortisone with every minor change in urinary 17-ketosteroids.
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39i-i
Should it prove possible that a patient might maintain pregnancy despite abnormal levels of adrenal androgen, the question might arise as to the possiblt> Theoretically, if one assumes that androeffects of such levels upon the fetus. gens may penetrate the placental barrier, one might anticipate ririlization in the fetus analogous to that of a fetus that itself had the adrenogenital .s~ndrome. that is, macrogenitosomia praecos in a male or pseudohermaphrodltlsm in ;I female, provided the abnormal levels were present prior to the fourth month Such children might not necessarily have the adrenogenit’al o-f gestation. syndrome, but might nevertheless bear stigmas of it, from temporary exposures to virilizing influences in utero, which in females at least, could prove disastrous. It is therefore of particular interest that both babies reported here were females, and both were entirely normal in all respects. This indicates at least, that the levels of androgen secretion in these cases were insufficient to produce harmful rffrcts upon the genitourinary development of these girl babies. The course of the patients after delivery and following unplanned cessation of therapy has been of considerable interest. In the first patient, norm;! I menstrual function returned and the values for urinary 17-ketosteroids ha ~1’ remained within normal range. We are currently in doubt whether she has become amenorrheic because of another pregnancy or because of a return ol excess adrenoeortical androgens. In any event, for approximately 1 pear following delivery the level of l?-ketasterolds has remained sat.isfactorg. Sinc,cl only 4 months have elapsed since delivery of the second patient, It is not possible to assess her adrenal function at this time. The most, recent assay ma.y be slightly elevated but at least one menstrual period has occurred without cortisone therapy. In 1951 Wilkins and co-workers2 suggested that perhaps long-continued treatment might render the adrenals permanently incapable of their former hyperactivity. There is evidence that short-term cortisone therapy certainI!There have been does not prevent the return of the adrenal hyperactivity.20 no specific studies that indicate what long-term therapy might accomplish iI1 this regard. In at least one, and perhaps bot,h, of onr patients such sustainer1 suppression of adrenal androgenic hyperactivity may ha.ve occurred. At birth the infants of both patients were normal by all the usual standards. lrears have been expressed that treatment, of pregnant patients might 1~ followed by adrenal insufficiency in the infants in the neonatal period. Ncithcl infant showed such effects nor has there been mention of fhis difficnlty in similar instances in t,he literature. It appears, therefore, thn.t t.his possibility need br of little concern.
References 1. Wilkins, 2. 3. 4. 5. 6. 7. 8.
L., Lewis, R. A., Klein, R., and Rosemherg, E.: Rull. Johns Hopkins Hcq. 86: 249, 1950. Wilkins, Lawson, Lewis, R. A., Klein, Robert, Gardner, I,. I., Crigler, J. F., Jr., Rosembr~g, Eugenia, and Migeon, C. J.: J. Clin. Endocrinol. 11: 1, 1951. Bartter, F. C., Albright, Fuller? Forbes, Anne P., Leaf, Alexander, Dempsey, ElPal(or, and Carroll, Evelyn: J. Chn. Invest. 30: 237, 1951. Tamashita, T., and Kozakae, F.: Endocrinologia japonica 3: li6, 1956. Ingle, D. J., and Kendall, E. C.: Science 86: 245, 1937. Am. J. Physiol. 124: 369, 1938. Ingle, D. J.: Proc. Sot. Exper. Biol. & Med. 39: 154, 1938. Ingle, D. J., and Mason, H. L.: Sprague, R. G., Power, M. H., Mason, H. L., Albert, A., Mathieson, D. R., Hen&, P. S., Kendall, E. C., Slocumb, C. H., and Polley, J-I. F.: Arrh. Int. Med. 85: 199, 1950.
396
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Am. J Obst. br Gym Augurr, 1458
9. Sprague, In Pineus, Gregory, editor: Recent R. G., Mason, H. L., and Power, M. H.: Progress in Hormone Research, New York, 1951, Academic Press, Inc., vol. 6, pp 315-372. 10. Wilkins, Lawson, Gardner, L. I., Crigler, J. I?., Jr., Silverman, S. H., and Migeon, C. J.: J. Clin. Endoerinol. 12: 257, 1952. 11. Wilkins, Lawson, Crigler, J. F., Jr., Silverman? S. H., Gardner, L. I., and Migeon, C. J.: J. Clin. Endocrinol. 12: 1015, 1952. 12. Wilkins, Lawson, Crigler, J. F., Jr., Silverman, S. H., Gardner, L. I., and Migeon, C. J.: J. Clin. Endocrinol. 12: 277, 1952. 13. Bongiovanni, A. M., Eberlein, W. R., and Cars, Jose: J. Clin. Endocrinol. 14: 409, 1954. Jones, H. W., Jr., and Jones, G. E. S.: AM. J. OBST. & GYNEC. 68: 1330, 1954. :2: Jones, G. E. S., Howard, J. E., and Langford, H.: Fertil. & Steril. 4: 49, 1953. 16. Greenblatt, R. B.: AM. J. OBST. & GYNEC. 66: 700, 1953. 17. Greenblatt, R. B., Barfield, W. E., and Lampros, C. P.: Fertil. & Steril. 7: 203, 1956. 18. de Alvarez, R. R., and Smith, E. K.: Obst. & Gynec. 9: 426, 1957. Wilhelm, 5. F.,. and Marks, R. G.: J. Ural. 73: 17, 1955. ii: Goldberg, Minnie B. : J. Clin. Endocrinol. 14: 389, 1954.
Discussion DR. E. STEWART TAYLOR, Denver, Cola.-These 2 cases illustrate one of the forms of the adrenogenital syndrome. This, of course, is dependent on the time of development as well as the sex of the individual affected. The condition is about five times as common in the female as in the male. Children with congenital adrenal hyperplasia show excessive masculinization, increased protein anabolism, rapid somatic growth, and accelerated epiphyseal ossification, in addition to characteristic laboratory findings. When the syndrome develops in the postnatal period before puberty, it is usually secondary to a functioning adrenal tumor, but it may be from acquired adrenal cortical hyperplasia. Seborrhea, acne, and development of sexual hair may be the first signs. These are followed by hypertrophy of the clitoris, deepening of the voice, rapid growth, and epiphyseal development. When the condition develops near or after puberty, it may be secondary to either tumor or hyperplasia. Hirsutism (masculine in type), hypertrophy of the clitoris, deep voice, and excessive Although all patients with the syndrome show virilization musculature suggest the condition. and increased protein anabolism because of excessive secretion of androgens, there are Briefly, one fourth show a tendency differences in the other functions of the adrenal cortex. to sodium loss and elevated serum potassium with resultant dehydration, circulatory collapse, and even cardiac arrest from hyperkalemia. Some may have hypertension, possibly from sodium retention. There may be a tendency to hypoglycemia in some patients caused by a deficit of glyeogenic hormone. We would classify these 2 cases as androgenital syndrome with postnatal virilization instead of congenital androgenitalism. Whether the condition is congenital or acquired, the basic abnormality appears to be an enzymatic defect in the adrenal cortex preventing the synthesis of compound F and the subsequent formation of abnormal amounts of metabolites from An pregnenolone, progesterone, and 17.hydroxyprogesterone. The pathology consists of enlargement of the adrenals primarily because of hyperplasia of the reticular zone. The fascicular zone is disorganized and is infiltrated with cells from the reticular zone. The glomerular zone may be absent. The condition occurs frequently in siblings born from apparently Childs and Grumbach suggest that the disorder may be a manifestation which may express itself only in a homozygous offspring. Theoretically, may occur about once in 125 individuals.
normal parents. of a recessive trait the mutant gene
We currently are following 2 sisters at the Colorado General Hospital who in most respects are similar to the first patient reported by Dr. Wilson. The older sister was treated with cortisone in 1955. Menses ensued one month later and she soon became pregnant. The patient began labor spontaneously at term and after a short tria1 was delivered by cesarean section because of a contracted, android-type pelvis. Her 2,520 gram daughter was normal
Volume 76 PREGNANCY
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AFTER
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ADRENAL
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397
in all respects. It is interesting to note that the only vaginal bleeding this patient had ever had before cortisone therapy was after the administration of estrogen by her private physician. The patient continued to menstruate normally for eight months following delivery, without steroid therapy, when she had an episode of menorrhagia which was suctessful1.y treated by uterine curettage. The younger sister was also treated with cortisone. Prompt menses occurred, she has since married, and is now in her second month of pregnancy. It was interesting to us that the first response to cortisone therapy in each of these patients was enlarging, painful breasts which occurred about 2 weeks after treatment started. Isot11 of the patients had little or no noticeable breast tissue before cortisone treatment. Dr. Dalton Jenkins, our endocrinologist, has a patient, a third patient, who falls in the category of the 2 reported by Dr. Wilson, and the 2 patients discussed from our clinic. Two of the 3 patients from the Colorado General Hospital have shown increasing excretions of pregnanetriol while excreting normal amounts of 17-ketosteroids. It is Dr. Jenkins’ feeling that, in the early phases of this syndrome, pathological levels of excreted pregnanetriol may antedate the appearance of abnormal levels of 17-ketosteroids in the urine.