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disorders of sex development_dr.navanitha_5th_feb2021
1. DISORDERS OF SEX DEVELOPMENT AND
MANAGEMENT OF
CONGENITAL ADRENAL HYPERPLASIA
-Dr.K.Navanitha Reddy
-Dr.Arnab Sengupta
2. DEFINITION
• DSD (intersex): Defined as condition in which development of
chromosomal, gonadal, (or) anatomical sex is atypical
• Ambiguous(atypical) genitalia: When the external genitalia do not
have the typical anatomic appearance of normal male or female
genitalia, the condition is known as ambiguous genitalia
3. • Sexual differentiation: is the process of development of the
differences between male and female from an undifferentiated zygote
(fertilised egg).
• The term “gender” describes those characteristics of females and
males that are largely socially created, whereas “sex” encompasses
those characteristics that are biologically determined.
4.
5. gonadal sex (primary sex determination)
Whether the gonads develop as testes or ovaries. Depends on the
presence or absence of the SRY gene, usually found on the Y chromosome
If SRY present in the indifferent gonad at 7 weeks, it gets activated. This in
turn activates other genes(SF1, SOX9 MAP3K1,DMRT1 DHH, ATRX,
TSPYL1), and the indifferent gonad is converted to a testes
6. gonadal sex (primary sex determination)
• In the absence of SRY, a different set of genes(RSPO1 WNT4,DAX1) is
activated, and the indifferent gonad becomes an ovary. Ovary
development is active process
• The germ cells, which actually become sperm or eggs, migrate into the
gonad about this time.
7.
8. phenotypic sex (secondary sex determination)
All of the internal and external structures develop along male or female lines
depending on which hormones are secreted by the gonads
9.
10.
11.
12. WHEN TO SUSPECT DSD?
Neonatal period:
A penis and bilaterally non palpable testes
Unilateral cryptorchidism with hypospadias
Penoscrotal or perineoscrotal hypospadias, with or without microphallus,
even if the testes are descended
13. WHEN TO SUSPECT DSD?
Neonatal period:
Apparently female appearance with enlarged clitoris or inguinal
hernia
Overtly abnormal genital development such as cloacal exstrophy
Asymmetry of labioscrotal folds, with or without cryptorchidism
Discordance of external genitalia with prenatal karyotype
18. PRENATAL FINDINGS
Genital ambiguity
Sex chromosome mosaicism
A karyotype discordant with phenotypic sex
Associated conditions
-Oligohydramnios
-Renal anomalies (genitourinary malformations)
-Skeletal abnormalities (campomelic dysplasia)
19. FAMILY HISTORY
CAH
Atypical genitalia (severe degrees of hypospadias or
cryptorchidism
Infertility
Pubertal delay
20. FAMILY HISTORY
Corrective genital surgery
Genetic syndromes, or consanguinity.
Neonatal death or unexplained death with features
such as vomiting/shock/dehydration in family may suggest
undiagnosed CAH
22. EXTERNAL GENITALIA
The examiner should note the stretched penile length, width of the
corpora
Presence of chordee
Position of the urethral orifice
Presence of a vaginal opening
Pigmentation and symmetry of the scrotum or labioscrotal folds
23. EXTERNAL GENITALIA
The normal full-term male infant penile
-Length of at least 2.5 cm
(Measured stretched from the pubic ramus to the tip of the glans)
-Usually 1 cm or more in width
Normal full-term female infant clitoris
-<1 cm in length
-<0.5 cm in width
Posterior fusion of the labioscrotal folds is assessed by determining
the Anogenital ratio >0.5 indicates first-trimester androgen
exposure
24. GONADAL SIZE, POSITION, AND DESCENT
A gonad below the inguinal ligament is usually a testis
-Normal or dysgenetic
Ovotestis
Uterus herniating into the inguinal canal
abnormal genital development with bilateral non palpable gonads
should raise immediate concern for salt-wasting CAH
25. ASSOCIATED ANOMALIES
Additional features may indicate a more generalized disorder,
although such features may not be present at birth
WAGR-due to mutations of WT1 (11p13)
Denys – Drash syndrome
34. INVESTIGATIONS
Serum electrolytes
blood urea nitrogen (BUN), and creatinine
First-line testing- 17-hydroxyprogesterone, LH, testosterone
Other tests such as plasma renin activity, follicle-stimulating
hormone(FSH), AMH, or other adrenal precursors, hormones
Chromosome analysis, karyotyping
35. Targeted genetic testing and/or chromosomal microarray
Endoscopic examination of the genitourinary tract
Pelvic ultrasound; renal and adrenal ultrasound
Pelvic CT or MRI
Voiding cystourethrogram (VCUG) or genitogram
Exploratory laparoscopy
36. • Testosterone(T), DHT, androstenedione(ASD) D2
• N T at birth 100ng/dl 50 in the 1st WK
↑T at 4-6Wk T at 6M rarely detectable
• ↑ T:DHT 5α reductase deficiency
• ↑ ASD:T 17 ketosteroid reductase deficiency.
•
37. Human chorionic gonadotropin stimulation test to assess the
testicular function
Adrenocorticotropin (ACTH) stimulation tests to assess testicular and
adrenal steroid biosynthesis
Urinary steroid analysis by gas chromatography mass spectroscopy
(GCMS)
Imaging studies (Pelvic CT or MRI abdomen)
Biopsies of gonadal material
38. Ideal tests to confirmclinical diagnosis
CLINICAL DIAGNOSIS BEST TESTS
CAH (21-hydroxylase deficiency) Serum 17-hydroxyprogesterone
Serum electrolytes
Glucose
Gonadal dysgenesis Chromosome analysis, Pelvic ultrasound
Serum FSH, LH, AMH
Gonadal biopsy
Androgen insensitivity Chromosome analysis
Serum AMH
hCG stimulation test (measure testosterone before and
after )
Testosterone biosynthetic defect Chromosome analysis
Serum AMH
hCG stimulation test (measure testosterone before and
after )
39. Pediatric endocrine disorders-3rd edition by
M.P. Desai, P.S.N Menon , V Bhatia
Indicator POSSIBLEIMPLICATION
Perineal hypospadias Severe defect in androgen secretion or
action.
Absence of one or both testes with
abnormal phallus
Gonadal dysgenesis or possibly
external virilisation of a genetic female
Systemic illness in a child with genital
anomaly
Adrenal insufficiency due to CAH
Hyperpigmentation of genital skin
with abnormal genitalia
Increased ACTH secretion associated
with adrenal insufficiency
Asymmetry of genitalia MGD or ovotesticular DSD
Virilisation in mother Virilising tumor in mother or placental
aromatase deficiency.
42. CLINICAL FEATURES
Dehydration, hypotension, or shock out of proportion to severity of
current illness
Nausea and vomiting with a history of weight loss and anorexia
Abdominal pain, so-called acute abdomen
Unexplained hypoglycemia
44. MANAGEMENT
Establish intravenous access with a large-gauge cannula
Draw blood for immediate serum electrolytes and glucose, routine
measurement of plasma cortisol and ACTH
Hypoglycaemia- D10% bolus
Hypovolemic shock-0.9%NS @ 20ml/kg
45. MANAGEMENT
D 5% in 0.9% saline infuse as maintenance fluid to correct
hypoglycemia, hypovolemia, and hyponatremia. Twice the
maintenance dose.
If severe hyperkalemia-IV calcium and/or bicarbonate
-Intrarectal potassium-binding resin
(Kayexalate)
-Intravenous infusion of glucose and insulin
46. MANAGEMENT
In an infant suspected of 21-OHase deficiency, treatment should be
started as soon as the laboratory tests mentioned have been obtained
GLUCOCORTICOIDS:
Hydrocortisone 20 mg/m2/day, divided into dosing every
8 hours, should be given to all infants suspected of 21-OHase deficiency
Body surface area (m2) = Square root of
Length (cm)*weight (kg)
___ -----------------------------
3600
47. MANAGEMENT
Neonates with CAH presenting in adrenal crisis:
Stress dosage of steroids, initial bolus of 25 mg hydrocostisone, followed
by 50 to 100 mg/m2/day TDS or QID
Hydrocortisone dose is reduced to reach the maintenance dose once
baby is clinically stable
48. MINERALOCORTICOIDS:
In cases of salt-wasting CAH
Fludrocortisone acetate (Florinef)-0.1 to 0.2 mg daily
Salt-wasting crises usually develop between the 5th and the 14th day of
life but can occur as late as 1 month and may occur even in affected
infants whose virilization is not severe
Weight, fluid balance, and electrolytes-monitored closely
Blood samples at least every 2 days during the first few weeks of life to
detect hyponatremia or hyperkalemia
49. If salt wasting occurs
Salt loss should be replaced initially with intravenous normal saline with
glucose added
Salt wasting due to aldosterone deficiency-requires replacement of about
8 mEq/kg/day of sodium
Once the infant is stabilized, salt 1 to 2 g daily QID,
should be given mixed with milk in the initial days of life
(each gram of salt, NaCl, contains 17 mEq of sodium)
50. REFERENCES
Cloherty and Stark’s Manual of Neonatal Care,8th Edition
Avery’s Diseases of the Newborn,10th Edition
Fanaroff’s Neonatal & Perinatal Medicine,11th Edition