Luteoma of Pregnancy Associated with Nearly Complete Virilization of Genetically Female Twins

ObjectiveTo describe a pregnancy that was complicated by the virilization of the mother and two 46XX infants.MethodsWe outline the clinical presentation and diagnosis of the virilization of a mother and her twins, reviewing pertinent literature.ResultsWe report the case of a 40-year-old Caucasian female who conceived a trichorionic triplet pregnancy through in vitro fertilization (IVF) but underwent cytoreduction at 13 weeks of gestation, leaving a diamniotic dichorionic twin pregnancy. At 16 weeks of gestation the mother experienced increasing acne, facial hair, and deepening of her voice. Due to preeclampsia, the twins were delivered via caesarean section at 33 weeks of gestation. The infants had male-appearing external genitalia (Prader score IV-V) but no palpable gonads. Congenital adrenal hyperplasia was ruled out for both twins and they were both found to have a uterus and a 46XX karyotype. Maternal testosterone level was elevated at birth (1,981 ng/dL), but the infants had normal levels. Maternal testosterone levels returned to normal after delivery, consistent with a luteoma of pregnancy, although imaging was negative for a mass.ConclusionThis is the second reported case of complete virilization associated with a luteoma of pregnancy. Whether or not IVF and related procedures increase the risk for a luteoma and whether or not fetal reduction procedures disrupt placental aromatases and increase the risk of virilization in the face of elevated androgen levels are questions that require further research. (Endocr Pract. 2014;20:e18-e23)     

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

Background

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

Clinical cases

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

Conclusion

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

     

17,20-desmolase deficiency in a female newborn, paradoxically virilized in utero

The patient was born with ambiguous genitalia (stade III of Prader). The karyotype revealed a normal female genotype. A defect in 21-hydroxylase, at first suspected, was denied by the hormonal studies. Indeed, extremely high levels of pregnenolone, pregnenolone sulfate, progesterone were found in association with low plasma levels of delta 4-androstenedione, testosterone, dehydroepiandrosterone and its sulfate, while cortisol 17OH-progesterone and ACTH levels and plasma renin activity were normal. The hormonal pattern was thus consistent with 17,20-desmolase deficiency. The dynamic studies further supported this contention: all the progestagens rose further after ACTH stimulation and were suppressed by dexamethasone. Meanwhile, all androgens failed to rise after ACTH: the responses of cortisol were normal. The in utero virilization of the female fetus was not understood until an history of virilization was allegedly found in the mother (luteoma of pregnancy). This is the first case of 17-20 desmolase defect recognized in a female newborn. This child, born with ambiguous genitalia had presented the concurrence of two very rare conditions. The in utero virilization of maternal origin enabled us to make the diagnosis of the 17-20 desmolase defect, which otherwise would have been ignored in a XX subject in the neonatal period because it would obviously be unsymptomatic at this age.     

The role of HLA-G in human pregnancy

Pregnancy in mammals featuring hemochorial placentation introduces a major conflict with the mother's immune system, which is dedicated to repelling invaders bearing foreign DNA and RNA. Numerous and highly sophisticated strategies for preventing mothers from rejecting their genetically different fetus(es) have now been identified. These involve production of novel soluble and membrane-bound molecules by uterine and placental cells. In humans, the placenta-derived molecules include glycoproteins derived from the HLA class Ib gene, HLA-G. Isoforms of HLA-G saturate the maternal-fetal interface and circulate in mothers throughout pregnancy. Uteroplacental immune privilege for the fetus and its associated tissues is believed to result when immune cells encounter HLA-G. Unequivocally demonstration of this concept requires experiments in animal models. Both the monkey and the baboon express molecules that are similar but not identical to HLA-G, and may comprise suitable animal models for establishing a central role for these proteins in pregnancy.     

Virilization of a female infant by a maternal adrenocortical carcinoma

ObjectiveTo describe a possible mechanism underlying the partial virilization of a 46, XX infant by a functional maternal adrenocortical carcinoma (ACC).MethodsWe performed immunocytochemical staining of tumor sections for luteinizing hormone (LH)/human chorionic gonadotropin (hCG) receptors. In addition, related reports in the literature are discussed.ResultsA previously healthy mother developed a large cortisoland androgen-producing stage III adrenal tumor that did not interfere with conception or early morphogenesis. The tumor eluded detection until after delivery of a partially virilized 46, XX female infant with ambiguous genitalia. Immunohistochemical staining of tumor sections revealed overexpression of the LH/hCG receptor. Virilization of the genetically female fetus may have resulted from hCG-stimulated steroid secretion by the ACC.ConclusionBecause hypercortisolism and hyperandrogenism are associated with menstrual disturbances and spontaneous abortion, pregnancy in patients with functional adrenal tumors is uncommon. Rarely, maternal steroid excess from a functional adrenal tumor has caused 46, XX disordered sex differentiation. This unusual case demonstrates the influence of hCG on the functionality of an ACC and demonstrates the rare phenomenon of virilization of a female infant by a functional maternal adrenal tumor. (Endocr Pract. 2011;17:e26-e31)     

Metals content in placentas from moderate cigarette consumers: correlation with newborn birth weight

Cigarette consumption during pregnancy produces deleterious effects in both, mother and fetus, some of them due to the presence of toxic elements in cigarette smoke, such as cadmium. Placenta constitutes a dual-purpose specimen for evaluating the pollutant burden exerted on the mother as well as on the fetus. The main objective of this study was to establish a correlation between placental concentration and distribution of some metal elements and birth weight of neonates delivered by mothers, who were either moderate smokers or nonsmokers. Forty nonsmoking and moderate smoking pregnant women paired per age, parity, weight, height and body mass index were selected. Smoking was assessed by self-reported cigarette consumption during pregnancy and urine cotinine concentration before delivery. Placental metal concentrations were evaluated by atomic absorption spectrometry (copper and cadmium) and neutron activation analysis (zinc and iron). Newborns from smokers had lower birth weights compared to infants from nonsmokers. Birth weights were correlated with placental cadmium concentrations in both, smokers and nonsmokers. Placental zinc and cadmium of smokers were mainly located at the maternal side and their levels were higher than those found in nonsmokers placentas. In addition, all metal nutrient/pollutant ratios were decreased in the smoker group. In this first study performed in our region, we found that moderate smoking mothers deliver neonates with decreased birth weight and highly correlated to placental cadmium concentration. Decreased metal nutrient/pollutant ratios, a condition here found in smokers, may indicate a placental dysfunction, contributing to impair birth weight.     

The effect of unfavorable environmental factors on the mother-fetus system]

The paper provides a generalization of data and the results of own experiments with Wistar rats in the conditions of hypokinesia, immobilization, water deprivation, hypergravity, weightlessness and other factors affecting mother and fetus as a system. It gives a comparison of reactivity of pregnant and non-pregnant animals under stress, and also of the effects of unfavorable impacts sustained during various phases of ontogenesis: in pubertation period, directly before pregnancy and during various phases of pregnancy. It demonstrated that exposition of pregnant animals to unfavorable conditions is accompanied by significant stress of the compensatory-adaptive possibilities of mother aiming to support of homeostasis of the developing fetus. Clear changes develop in fetus only in case the adaptive possibilities of mother turn out inadequate or when the developing organs of fetus become active components of adaptive reaction of mother-fetus system and compensate for functional inadequacy of some mother's organ. The paper discusses the problem of individual features of resistivity and reactivity.     

Pathogenesis of in utero infections with abortogenic and non-abortogenic alphaviruses in mice.

The initial stages of infection of pregnant mice at gestation day 11 with either the T48 strain of Ross River virus or avirulent Semliki Forest virus are similar. With both infections, a hematogenous spread of virus to the placenta occurs. The viruses subsequently replicate to high titer in all placentas and are able to persist in the presence of specific maternal antiviral antibodies. There is a delay of at least 1 to 2 days between the initial detection of virus in the placenta and the onset of fetal infection. With Semliki Forest virus, abortion occurred in all mothers and appeared to be preceded by infection of all fetuses. However, when Semliki Forest virus was given at other stages of pregnancy, abortion was less common, and in all non-aborted pregnancies at least one uninfected fetus was observed. This situation was similar to that with Ross River virus, in which abortion was not observed and fetal infection and death were only seen in a proportion of fetuses. Within each pregnancy, the outcome of the two in utero infections appeared to result from similar mechanisms, with the fate of an individual fetus depending upon the timing of the passive transfer of anti-viral immunoglobulin G from the mother relative to the timing of fetal infection by virus from the placenta. Although the passive maternal immunoglobulin G protected susceptible fetuses against infection, antibody did not mediate in utero recovery of infected fetuses or clear placental infection.     

The expectant brain: adapting for motherhood

A successful pregnancy requires multiple adaptations of the mother's physiology to optimize fetal growth and development, to protect the fetus from adverse programming, to provide impetus for timely parturition and to ensure that adequate maternal care is provided after parturition. Many of these adaptations are organized by the mother's brain, predominantly through changes in neuroendocrine systems, and these changes are primarily driven by the hormones of pregnancy. By contrast, adaptations in the mother's brain during lactation are maintained by external stimuli from the young. The changes in pregnancy are not necessarily innocuous: they may predispose the mother to post-partum mood disorders.     

The placental transfer of IgG in the cynomolgus monkey

The placental transfer of IgG from the mother to her fetus was investigated with colony-bred cynomolgus monkeys. Very low levels of IgG were detected in sera of 84 days old fetus, indicating that transplacental transfer of IgG had started by this fetal age. Afterwards, gradual increase in the IgG level continued till 140 days of fetal age. A marked increase in the level was noted after 140 days of fetal age, during the last 4 weeks of full gestation term. Fetal anti-measles antibody increased in a pattern similar to that in the IgG level. The IgG level and anti-measles and anti-streptolysin O antibody titers of newborns never exceeded those of their mothers.     

Sexually dimorphic effects of maternal asthma during pregnancy on placental glucocorticoid metabolism and fetal growth

Human pregnancy is associated with sexually dimorphic differences in mortality and morbidity of the fetus with the male fetus experiencing the poorest outcome following complications such as pre-eclampsia, pre-term delivery and infection. The physiological mechanisms that confer these differences have not been well characterised in the human. Work conducted on the effect of maternal asthma during pregnancy, combining data collected from the mother, placenta and fetus has found some significant sex-related mechanistic differences associated with fetal growth in both normal pregnancies and pregnancies complicated by asthma. Specifically, sexually dimorphic differences have been found in placental glucocorticoid metabolism in male and female fetuses of normal pregnancies. In response to the presence of maternal asthma, only the female fetus alters placental glucocorticoid metabolism resulting in decreased growth. The male fetus does not alter placental function or growth in response to maternal asthma. As a result of the alterations in glucocorticoid metabolism in the female, downstream changes occur in pathways regulated by glucocorticoids. These data suggest that the female fetus adjusts placental function and reduces growth to compensate for maternal disease. However, the male fetus continues to grow in response to maternal asthma with no changes in placental function. This response by the male fetus may partially contribute to the increased risk of morbidity and mortality in this sex.     

Prenatal Adversity Modulates the Quality of Maternal Care Via the Exposed Offspring

Adversities in pregnancy, including poor diet and stress, are associated with increased risk of developing both metabolic and mental health disorders later in life, a phenomenon described as fetal programming or developmental origins of disease. Predominant hypotheses proposed to explain this relationship suggest that the adversity imposes direct changes to the developing fetus which are maintained after birth resulting in an increased susceptibility to ill health. However, during pregnancy the mother, the developing fetus, and the placenta are all exposed to the adversity. The same adversities linked to altered offspring outcome can also result in suboptimal maternal care, which is considered an independent adverse exposure for the offspring. Recent key experiments in mice reveal the potential of prenatal adversity to drive alterations in maternal care through abnormal maternal–pup interactions and via alterations in placental signaling. Together, these data highlight the critical importance of viewing fetal programming holistically paying attention to the intimate, bidirectional, and reiterative relationship between mothers and their offspring.     

Immunology of placentation in eutherian mammals

The traditional way to study the immunology of pregnancy follows the classical transplantation model, which views the fetus as an allograft. A more recent approach, which is the subject of this Review, focuses on the unique, local uterine immune response to the implanting placenta. This approach requires knowledge of placental structure and its variations in different species, as this greatly affects the type of immune response that is generated by the mother. At the implantation site, cells from the mother and the fetus intermingle during pregnancy. Unravelling what happens here is crucial to our understanding of why some human pregnancies are successful whereas others are not.     

Ovine placental aromatase: studies of activity levels, kinetic characteristics and effects of aromatase inhibitors

We have measured microsomal steroid aromatase activity in the fetal component of ovine placental cotyledons collected from pregnant ewes between 124 days and 127 days of gestation. Aromatase activity was determined by quantifying the [3H]water by-product when [1 beta-3H(N)] androstenedione was used as substrate. The mean microsomal aromatase activity (+/- SD) was 5.7 +/- 2.2 pmol.min-1.mg protein-1 (n = 12) and was 9% of the aromatase activity of human placental microsomes [mean (+/- SD) of 66.1 +/- 25.0 pmol.min-1.mg protein-1 (n = 7)]. The apparent Km for ovine placental aromatase for androstenedione, at pH 7.4 and 37 degrees C, was 50 nM while the Vmax was 20.6 pmol.min-1.mg protein-1. The respective concentrations effecting 50% inhibition of ovine placental aromatase activity (the I50) for econazole, 4-hydroxyandrostenedione, imazalil, miconazole, ketoconazole and aminoglutethimide were 0.03, 0.05, 0.15, 0.50, 5.0 and 5.5 microM. The order of relative potencies were similar to those obtained for human placental aromatase. Ketoconazole and aminoglutethimide were approx 10 times more potent inhibitors of the sheep enzyme relative to the human. Aromatase activity was not confined to the microsomal fraction of ovine placental tissue but was distributed throughout all the particulate subcellular fractions. The proportionally high activity of the tissue homogenate (1.75 pmol.min-1.mg protein-1) is suggestive that in the last third of pregnancy, aromatase is not rate limiting with regard to placental estrogen production. It would appear, therefore, that the major factor regulating placental estrogen synthesis in ovine pregnancy is the availability of substrate.     

Effect of mother's physical condition during pregnancy and lactation on postnatal growth and reproductive success of offspring in water vole Arvicola terrestris L

Postnatal growth, life span, and probability of reproduction in the adult state depended on the mother's physical condition during pregnancy and lactation in water vole. The white fat weight in the female abdominal cavity was shown to significantly increase in pregnancy and to decrease in late lactation. As an indicators for nutritional state of females, their body weight difference after parturition (or in late lactation) and expected from the regression equation relating individual body weight at the beginning and the end of each reproductive stage were used (physical condition indexes in pregnancy or lactation). The correlation of the physical condition index in pregnancy with the storage fat weight was 0.67. The metabolic resources of the mother's body proved to favor faster offspring development. The female offspring weight at the age of 3 and 10 weeks as well as adult ones positively correlated with the mother's nutritional state in pregnancy, while the male offspring weight demonstrated a similar correlation at the age of 3 and 6 weeks. Increased negative energy balance during lactation proved to decrease the offspring weight in both sexes after separation from mother and at the age of 6 weeks. High nutritional state of mother in pregnancy favored both the probability of reproduction and life span of female offspring. The reproduction of male offspring did not depend on the mother's physical condition. The life span peaked in male offspring of mothers in a nutritional state below average in pregnancy and above average in lactation. Thus, the physical condition of the mother's body is an important sex-dependent factor of phenotypic variation in the offspring body weight, reproductive competence, and life span.     

Early treatment of the pregnant guinea pig with IGFs promotes placental transport and nutrient partitioning near term

Appropriate partitioning of nutrients between the mother and conceptus is a major determinant of pregnancy success, with placental transfer playing a key role. Insulin-like growth factors (IGFs) increase in the maternal circulation during early pregnancy and are predictive of fetal and placental growth. We have previously shown in the guinea pig that increasing maternal IGF abundance in early to midpregnancy enhances fetal growth and viability near term. We now show that this treatment promotes placental transport to the fetus, fetal substrate utilization, and nutrient partitioning near term. Pregnant guinea pigs were infused with IGF-I, IGF-II (both 1 mg.kg-1.day-1) or vehicle subcutaneously from days 20-38 of pregnancy (term=69 days). Tissue uptake and placental transfer of the nonmetabolizable radio analogs [3H]methyl-D-glucose (MG) and [14C]aminoisobutyric acid (AIB) in vivo was measured on day 62. Early pregnancy exposure to elevated maternal IGF-I increased placental MG uptake by>70% (P=0.004), whereas each IGF increased fetal plasma MG concentrations by 40-50% (P<0.012). Both IGFs increased fetal tissue MG uptake (P<0.048), whereas IGF-I also increased AIB uptake by visceral organs (P=0.046). In the mother, earlier exposure to either IGF increased AIB uptake by visceral organs (P<0.014), whereas IGF-I also enhanced uptake of AIB by muscle (P=0.044) and MG uptake by visceral organs (P=0.016) and muscle (P=0.046). In conclusion, exogenous maternal IGFs in early pregnancy sustainedly increase maternal substrate utilization, placental transport of MG to the fetus, and fetal utilization of substrates near term. This was consistent with the previously observed increase in fetal growth and survival following IGF treatment.     

Developmental and nutritional determinants of pregnancy outcome among teenagers

To investigate the determinants of low birth weight in infants born to adolescent mothers, we studied the obstetric population attended at the Maternity Hospital of Lima, Peru. From this population, 1256 gravidas, ranging in age from 12 to 25 years, volunteered to participate in this study. Anthropometric and biochemical measurements were used to evaluate the nutritional status and physiological maturity of the mother and newborn. For analytical reasons the young teenaged mothers (less than 15 years) were classified as either still-growing or having completed their growth, depending on their height relative to their parents' height. Similarly, the young teenagers were classified as either gynecologically immature or gynecologically mature depending on whether their gynecological age was less than or greater than 2 years. Our results indicate that young still-growing teenagers, even when matched for nutritional status, have smaller newborns than adult mothers. The data also demonstrate that maternal gynecological age per se does not affect prenatal growth. As inferred from multivariate analyses, it appears that the reduction in birth weight among young teenagers can be explained in part by a decreased net availability of nutrients resulting from the competition for nutrients between the mother's growth needs and the growth needs of her fetus and by an inability of the teenage placenta to maintain placental function adequately for active fetal growth.     

The metabolism of radium-226 during pregnancy in the rat

Metabolism of radium including the transfer to the fetus through the placenta was studied during three successive pregnancies 92, 155, and 213 days after injection of 226Ra in young female rats. The cumulative fecal and urinary excretions of 226Ra in a 213-day period following injection were about 30 and 15% injected dose (%ID), respectively, most of them occurring during the first 42 days. The excretions were similar in both the pregnant and control (unmated) rats. The whole-body burden of radium (mostly in the skeleton) determined by actual analysis of the entire body was similar in the two groups and was about 53, 48, and 44 %ID at the first, second, and third pregnancy, respectively. Pregnancy alone, therefore, did not significantly affect metabolism of radium. At 20 days of gestation the mean placental content of radium was 0.005, 0.0045, and 0.0036 %ID in the first, second, and third litter, respectively; the corresponding mean fetal content was 0.01, 0.008, and 0.005 %ID. The radium burden of the full-term neonate (21-22 days) was 0.014 and 0.011 %ID for the first and second delivery, respectively. The total amount calculated of radium transferred from the mother to the 8-10 fetuses in a litter did not exceed about 0.3% of the maternal content per each pregnancy. Comparison of the ratio of radium and calcium in the fetus and maternal skeleton shows that there is a Ra-Ca discrimination during their passage from the mother to the fetus.     

Cigarette smoking during pregnancy lowers aromatase cytochrome P-450 in the human placenta

To clarify whether cigarette smoking during pregnancy causes an organic alteration in placental estrogen producing ability, we determined the catalytic activity of aromatase by the tritiated water assay, and tissue level of aromatase cytochrome P-450 (P-450_arom) by the specific enzyme-linked immunosorbent assay, in placental samples from nonsmokers and smokers. As pregnancy progressed, both aromatase activity and P-450_arom concentration increased in placentas from nonsmokers and smokers. However, the gradient of the increase was significantly less in heavy smokers (20 cigarettes a day) than in normal and moderate smokers (<20 cigarettes a day). At term, the mean aromatase activity and P-450_arom concentration in placentas from heavy smokers were significantly lower than in nonsmokers and moderate smokers, while aromatase activity per P-450_arom (turnover rate) and the mean placental weight were comparable among the three groups. In contrast, the ratio of aryl hydrocarbon hydroxylase activity to aromatase activity was higher in placentas from heavy smokers. Immunohistochemical studies showed that P-450_arom was localized in the cytoplasm of syncytiotrophoblasts of chorionic villi in placentas from both nonsmokers and smokers. These results suggest that the induction of placental P-450_arom during gestation is suppressed by maternal smoking, resulting in a reduction in estrogen producing ability, while placental xenobiotic P-450 is induced.