Prenatal diagnosis of placental steroid sulfatase deficiency

Prenatal diagnosis of placental steroid sulfatase deficiency GLENN

D.

BRAUNSTEIN,

FREDERICK

H.

ARTHUR

ZIEL,

ALLEN,

ROBERT

VAN

MACLYN

E.

Los Angeles,

M.D. B.A.*

M.D. DE

VELDE,

WADE,

PH.D.

M.D.

Cal{fornia

Placental steroid suqatase dejkiency is an unusual cause oj low estriol production during of this disorder from the more pregnancy. Its importance lips in the diff erentiation ominous fetal defects that result in low estriol lez~el.~. Serum free estriol levek were found to be low or absent in a 25-year-old gravida 3, para 2 woman, while placental lactogetl and chorionic gonadotropin levels were normal. An abdominal x-ray revealed no apparent congenital abnormalities and an oxytocin challenge te,st was negative. The dehydroepiandrosterone &&ate (DHEA-S) level i.11 the patient’? amniotkjluid ua~ 6.8 to la.4 times greater than those found in control amniotic,guids. The patient? amniotic ,&id cortisol level was normal. Twenty-four hours folloujing a normal, spontawous labor and delivev at 39 weeks, the male infant underujent a .synthetic ACTHle2’ stimulation test, with serum cortisok rising from 3.7 to 46 pgldl at I hour. The plucenta was morphologically normal on gross, light, and electron mkroscojk examinations. Steroid J-alcohol suqatasp an.d arylsu!fatase activities in the patient’s placenta were virtually absent. These data indicate that this benign cause of 10~1 ,serum estriol levels may be diagnosed prenata& by elezlated amniotic,j?uid DHEA-S l~zvl.~ (AM. J. OBSTET. GYXEC~L. 126: 716, 1976.)

THE UTILIZATION of urine and serum estriol measurements in the management of high-risk pregnancies has been well established.‘. ’ Approximately 90 per cent of the estriol present in the maternal serum or urine is derived from placental conversion of steroid precursors produced in the fetus. Therefore, maternal serum or urine estriol levels reflect primarily the status of the “fetal-placental unit.“’ Very low maternal estriol levels are associated with fetal death, high-dose corticosteroid therapy, anencephaly, fetal adrenal hypoplasia, and placental steroid sulfatase deficiency. The first

three disorders may be differentiated on clinical, historic, and radiographic grounds, whereas the latter two are difficult to distinguish from each other. Since fetal adrenal hypoplasia is associated with a high neonatal mortality rate, ’ a reliable prenatal method for discriminating between fetal adrenal hypoplasia and placental sulfatase deficiency would be desirable. During the study of the pregnant patient described below, low serum and urinary estriol levels were found. A method for diagnosing placental steroid sulfatase deficiency antepartum was developed.

Case report

From the Departments of Medicine, Obstetrtis and Gynecoloa, and Pathology, CedawSinai Medical Center and U.C.L.A. School of Medicine. Supported in part Grant RR05468. Received

for

Revised

May

Accepted

by United

p,ublzcation IO,

June

24,

States Public

October

Health

A 25-year-old gravida 3, para 2 Spanish-American woman was first seen at the Cedars-Sinai Medical Center 0bstetric Clinic at 10% weeks of gestation. Her prenatal course was normal until 34.5 weeks of gestation, when a discrepancy between fundal size and gestational dates was noted. A serum estriol was found to be undetectable. At 36 weeks of gestation, a flat-plate radiograph of the abdomen revealed no apparent congenital abnormalities, and an oxytocin challenge test’ performed at 37 weeks did not indicate fetal distress. An amniocentesis was performed at 38% weeks, and at

Service

14, 1975.

1976. 1976.

Reprint reques&: Glena D. Braunstein, M.D., Department of Medicine* Cedars-Sinai Medical Center, 8700 Beverly Blzjd., Los Angeles, California 90048. *Bioscience

Enterprikes

Summer

Student

Research

Fellow.

716

Placental steroid suifatase deficiency

39 weeks the patient entered labor spontaneously with normal first and second stages of labor. A 7 pound 8 ounce male infant was delivered vaginally, with Apgar scores of 9 at both I and 5 minutes. A 588 gram placenta was delivered spontaneously. The mother’s postpartum course was uneventful. The male infant was judged to be normal by physical examination. His hospital course was complicated only by transient jaundice with a total bilirubin of 10.6 mg. per deciliter, indirect bilirubin of 8.8 mg. per deciliter, and direct bilirubin of 1.8 mg. per deciliter. Serum electrolytes were normal throughout the infant’s hospital stay. At 24 hours of age 0.25 mg. of synthetic ACTH’-” (Cortrosyn) was injected intravenously Serum cortisol levels rose from a baseline of 3.6 pg per deciliter to 46 pg per deciliter at I hour. The mother’s family history was noncontributory. Her previous obstetric history revealed normal gestations, labor, and deliveries of male infants, 2 and 5 years prior to the above pregnancy.

Materials and methods Radioimmunoassay. Serum estriol,5 human chorionic gonadotropin (hCG),’ human placental lactogen (hPL),* amniotic fluid dehydroepiandrosterone sulfate (DHEA-Sj,t and cortisol* levels were determined by radioimmunoassays. The steroid levels in the patient’s amniotic fluid were compared to those present in three normal amniotic fluids obtained from pregnant women of comparable gestational age. Placental sulfatase activities. Placental tissue obtained from the patient and two women with normal term deliveries were immediately frozen and stored at -20° c:. At the time of analysis, the placentas were thawed, dissected free of membranes, washed with saline, and minced. Placental alcohol 3-steroid sulfatase activity was measured by the method of Townsley and associates.9 DHEA-7(N)-3H sulfate$ (.%A. 4.6 Ci/mmol) served as a substrate and DHEA-4-C14§ (S.A. 57.5 mCi/mmol) was used for recovery purposes. Placental arylsulfatase activity was measured by the procedure described by Oakey and associates.1o Estrone-6,7-‘H (N) sulfates (S.A. 45 Ci/mmol) and estronr-4-C’4$ (S.A. 52 mCi/mmol) were used as substrate and recovery steroids, respectively. Urinary estriol. The method of Goebelsman” was used to measure urinary estriol in the 24 hour urine sample collected at 38 weeks of gestation. *Human chorionic somatomammotropin Radioimmunoassay Kit, New England Nuclear Corporation, Boston, Massachusetts. tPerformed by Radioassay Systems, Inc., Carson, California. tAmersham-Searie Corp., Arlington Heights, Ill. $New England Nuclear, Boston, Mass.

Table

I. Maternal

34.5 35 36.5 37 37.5 38.5

serum

t-i.2 4.75 8.0 6.75 7.625 7.9 3.8-38.5

Normal

Table II. Amniotic sulfate

hCG, hPL+ and c,str-iol levels

4.7 3.3 2. 7 6.1 -4.x 5.0 3.0-8.0

ff uid dehy~~r~)e~~i~~r~~lroste~.o~~e DHEA-,sul,iat~~ (ng. imi.)

Patient Control No. I Control No. 2 Control

No.

3

717

450

~~ort;wll ( pghnl. ) -4.6

ti0 60

Ii.4 5.2

22

3.3

Placental morphology. The placental tissue obtained immediately after delivery was embedded in paraffin and stained with hematoxylin and eosin for light microscopic examination. One millimeter cubes of fresh placenta were fixed in cacodylate-buffered 3 per cent glutaraldehyde, postosmicated. dehydrated in graded series of acetones, and embedded in Epone 812. Following polymerization, orientation sections were cut at 1 p and stained with Azure LI in methylene blue. They were then examined with a Jeol 1OOB electron microscope.

Results The estriol, placental lactogenq and chorionic gonadotropin levels in the maternal serum samples collected serially from 34.5 weeks of gestation until term are shown in Table I. The serum estriol levels were extremely low or undetectable; the placental lactogen and chorionic gonadotropin levels were normal. Twenty-four hour urinary estriol excretion was also low, at less than 2 mg. per 24 hours (wtmal = 21.5 k 7.4 mg. per 24 hours). The DHEA-S levels in the patient’s amniotic fluid were 6.8 to 18.4 times greater than the three control amniotic fluids. At the same time thr amniotic fluid coritsol level was normal (Table 11). The patient’s placenta was morphologically normal h>. both light and electron microscopy. The placental steroid alcohol 3-steroid sulfatase and arylsulfatase activities were virtually absent in the patient’s placenta as compared to controls (Figs. 1 and 2).

718

6raunstein

et al.

CONTROL

SO z-

PLACENTA

#I

noCONTROL

I*= I 0

IO

z

e

I 20

1 30

INCUBATION

. I 40

r so

PLACENTA

PATIENT’S

CONTROL PLACENTA

#I

CONTROL

#2

PLACENTA

882

PLACENTA

I 60

0

1 10

-

1 20

1 30

INCUSATION

TIME WIN)

Fig. 1. Comparison of placental steroid 3-alcohol suifatase a&vity determined by the per cent conversion of DHEA-S to DHEA during 60 minute incubations of the patient’s placenta and two control placentas.

Comment

1 40

t 50

8) PATlENT’S 1 60

PLACENTA

TIME (MIN)

Fig. 2. Comparison of placental arylsulfatase activity determined by the per cent conversion of esn-one sulfate to estrone during 60 minute incubations of the patient’s placenta and two control placentas.

The absence of a history of maternal glucocorticoid ingestion in the patient described above eliminated the transplacental passage of corticosteroids, with their attendant suppression of the fetal hypothalamicpituitary-adrenal axis, as the cause of the low maternal serum and urinary estriol levels. Similarly, the presence of normal fetal heart tones and the absence of discernible fetal malformations on abdominal x-ray of the mother removed fetal death and anencephaly from consideration. The elevated levels of amniotic fluid DHEA-S with a normal cortisol concentration suggested a block in the ability of the placenta to remove the sulfate from 16 OH-DHEA-S, the fetal precursor of estriol. Had fetal adrenal hypoplasia been present, both the DHEA-S and cortisol levels would be expected to be low. Additional evidence against congenital fetal adrenal hypoplasia was obtained by the normal rise in the serum cortisol level in the infant following adrenal

tion and occasionally an inability to induce labor. Multiparous women have usually undergone spontaneous labor and delivery. All the pregnancies resulted in the delivery of male infants, suggesting that this is an x-linked trait. Further support for the x-linked hypothesis has been provided by Oakey and associates.“’ They studied a patient whose first pregnancy was associated with placental sulfatase deficiency and de&r> of a male infant; the second was characterized by normal urinary estrogen levels followed by the delivery of a female infant. Since the placental enzyme responsible for hydrolyzing steroid alcohol-3-sulfates is different from that involved in the hydrolysis of arylsulfates,‘6 the activity of the latter enzyme was also measured in our patient’s placenta and was found to be extremely low. Other patients with similar, combined deficiencies of steroid and arylsulfatase activities have been reported.“‘. I’. ” The major importance of placental steroid sulfatase

stimulation

deficiency

with

synthetic

ACTHlet4.

The

presence

of

placental steroid sulfatase deficiency was confirmed by the extremely low levels of steroid alcohol 3-sulfatase activity in the patient’s placenta. Eleven pregnancies have been previously described in which the placenta was shown to be deficient in steroid sulfatase activity.“, lo. ‘*G” In an additional five pregnancies, this defect was suspected.‘, I4 The frequency of this enzymatic deficiency appears to be less than this

1 in 5,000 defect

has

pregnancies.“’ been

associated

In

primiparous with

prolonged

women, gesta-

is in the

differentiation

of this

benign

disor-

der from congenital adrenal hypoplasia. Neither human pIacenta1 lactogen or chorionic gonadotropin is useful for this, since the production of both these placental proteins is not dependent upon placental steroid sulfatase activity, nor precursors of fetal adrenal origin. A DHEA and DHEA-S loading test has also been used to make a prenatal diagnosis of placental steroid sulfatase deficiency. France and associates’4 infused both of these substances into a pregnant woman \vho had

demonstrated

low

urinar!,

estriol

excretion.

‘rhtz

Placental steroid sulfatase deficiency

DHEA resulted in a rise in urinary estrogen excretion, indicating normal placental aromacase activity. DHEA-S did not result in a significant increase in urinary estrogens. This indirAted an inability to remove the sulfate from the precursor of estriol. More recently, Tahei and Heinrichs” noted an absence in rise of urinary estriol excretion in two women with placental steroid sulfatase deficiency after the intra-amniotic installation of DHEA-S These loading tests as described require several days of urine collections, and are not geneI-ally available to clinicians in this country. &nversely, amniotic fluid may be easily obtained in the last trimester of. pregnancy, carries littIc risk to the patient and fetus. and reference laboratories capable of measuring DHE,4-S in the amniotic fluid are availahle.

719

Dr. Jeffrey Travis, city of Hope S4edical c;enter, Duarte, California, kindly detern~ined the human placental lactogen levels. The secretarIa a~ststancc~ of .Wt-s. Star
Addsndum Since submission of this tnanus’ has heen dcscribed (Osathanondh, R., (Zanick, J., Kw~, K. J., and Tulchinsky. D.: Placental sulfatasc &f~cienc~: A case study. J. (Zlin. Endocrinol. Yletal). 4Z3: YO9, 1976). An elesated DHEA-S level was also tound in the amniotic fluid. confirming the results c)f the prt:sent ~r3~dy.

REFERENCES

I. BeischeI-, N. A., and Brown, J. B.: Current status of estrogen assay3 in obstetrics and gynecology. II. Estrogen assays in pregnancy, Obstet. Gynecol. Surv. 27: 303, 1972. 2. Tukhinsky, D., Hobel, C. J., and Korenman, S. G.: A radioligand assay l’or plasma unconjugated estriol in normal and abnormal pregnancies, AM. J. OBSTET. CwiEcot..

111:

311,

1971.

3. Fliegner, J. R. H.. Schindler, I., and Brown, J. B.: Low urinary estriol excretion during pregnancy associated with placental sulphatase deficiency or congenita1 adrenal bypophasia. J. Obstct. Gynecol. Br. Commonw. 79: 810, 1972. 4. Freeman. K. K.: The use of the oxytocin challenge test for antepartum clmical evaluation of uteroplacental respiratory function. AM. 1. ~BSTET. GYNECOL. 121: 481, 1975. ~5. Kao,’ M., Braunstei;, G., Rasor, J., and Horton, R.: A simple radioimmunoassay for unconjugated estriol in pregnancy plasma, J. Lab. Ctin. Med. 86: 513, 1975. 6. Vaitukaitis, J. L., Braunstein, G. D., and Ross, T.: A radioimmunoassay which specifically measures human chorionic gonadotropin in the presence of human luteinizing hormone, Ah!. J. OBSTET. GYNECOL. 11% 751, 1973. 7. Buster. J. E., and Abraham, G. E.: Radioimmunoassay of plasma dvhvdroepiandrosterone sutphate, Ann. Lett. 5: 543, 1972. 8. KU, M., Voina, L., Nichols. A. N.> and Horton, R.: parallel radioimmunoassay for plasma cortisol and 1 ldeoxycortisol, Clin. Chem. 21: 1644, 1975,

Fifth International

9. To~nsley, J. D., Scheel, D, A., and Ruben, E. J.: inbibition of steroid 3+ulfatase by cndogenous steroids. ,% possible mechanism controlling placeuf;ll estrogen syncthesis from conjugated prec~~rsors. J. C&II. Endwrind Metab. 31: 670, 1970. 10. Oakey, R. E., Cawood, M. L.. and MacDonald, K. R.: Biochemical and clinical observations in x pregnancy with placental sulphatase and other enzyme deficiencies. Clin. Endocrinol. 3: 131, 1974. 1 1. Goebelsmann, LI.: A reliable method fat t be determine. tion of urinarv estriol in pregnamy, (Zlzn. (ihim. Acta 23: 469, 1969. 12. France, J. T.- and Liggins. G. of. Metab. 36: I, i 973. 5. Tab& T.. and Henrichs, W. L,: 1Xa~uosis nf placentat sulfatase deficiency, AM. J, OLWTF 1.. ~~YXKOI.. 124: 409. 1976.

6. Roy, A. R.: EmLymological aspects ol tBernstein, S., and Solomon, S.. edits s: (:hemica! and Biological Aspects of Steroid Conjugation. sew I’o~.l,. 1970, Springer-Vrrlag, pp. 74.130.

Gender Dysphoria Symposium

The Gender Identity clinic of Eastern Virginia Medical School will host rhe Filth International Gender Dysphoria Symposium in Norfolk, Virginia. February 10-13, 1?!77. Presentations will he made in the areas of “Psychiatric Aspects of the Gender Dysphoria Syndrwne~ ” “Considerations of Male to Female and Female to Male rranssexu&.” “Diagnostic Dilemmas and Treatment FaiIures,” and .‘F&~u.-L!~ Studies.” Additionaliv. guest speakers will address such topics as Therapebtic Guidelines, Legal and Social PlobIems. Nursing ,4spects, and Theoretical Aspects of rhe Gender Dysphoria S! ndrc>me. This continuing medical education program will he accredited hy the American Me& al Association and the associations of the various disciplines involved. All professionals :II’< contact: Terry Salasky, Cbordinx~)r. invited to attend. For registration information, Gender LIysphoria Sy-mposium, P. 0. Bnx 1980. Norfolk. \Tir,qinia 23.50’1,