Tactics of pregnancy management for adrenal hyperandrogenism

Treatment is carried out throughout the pregnancy, given the inherent defect of the pathology. If you stop taking dexamethasone, pregnancy can not be interrupted due to the fact that the fetus will take over the supply of glucocorticoids. In this connection, the hyperfunction of the adrenal cortex can be in utero, and at the time of stress (the birth process) the child may die. When pathoanatomical research is found atrophy of the adrenal cortex. Therefore, if under the influence of therapy with dexamethasone, the level of 17C decreases more than we would like, the dose of dexamethasone can be reduced to one-fourth of a tablet every other day, but it's not advisable to stop taking it. Particular attention should be paid to the timing of pregnancy 13.24 and 28 weeks. These terms are associated with the entry of fruit endocrine organs into active production, which can provoke increased production of androgens. On the 3-4th day after the birth, gradually reduce the dose of dexamethasone and stop the therapy on the 7-8th day after the birth.

In adrenogenital syndrome with a normal level of 17KS or 17OP, but with an increased level of DEAS, dexamethasone therapy can be performed only up to 16 weeks of pregnancy (counting from ovulation). By this time, the placenta is completing its development, and already steroidogenesis provides enough estrogens, so that the proportion of adrenal glands in their products is not so significant.

The appointment of progesterone drugs in the hyperandrogenic adrenal genesis is inappropriate, since they usually have hyperprogesteronemia. It is necessary to monitor the state of the cervix, since it is possible to have an ischemic-cervical insufficiency, which is observed in 2/3 of pregnant women with adrenogenital syndrome, including with its erased manifestations. During pregnancy, the fetus is monitored and placental insufficiency is prevented from the first trimester. When developing tactics for labor, attention should be paid to the peculiarities of the structure of the pelvis, as in patients with hyperandrogenia the structure of the pelvis with narrowing of the exit, which can complicate the course of labor. With extremely burdened history, pelvic presentation and anatomical features of the pelvis, delivery by cesarean section is advisable. At the birth of a child, it is necessary to inform the neonatologist about the doses and duration of dexamethasone, so that the child can have glucocorticoid cancellation syndrome.

Given that patients with adrenogenital syndrome can transmit this gene to the fetus, prenatal diagnosis is needed, which we carry out simultaneously with the diagnosis in the fetus of Down's disease. At 17-18 weeks, a mother's blood test is performed to determine the levels of alpha fetoprotein, chorionic gonadotropin and 17OP. With an elevated level of 17OP, amniocentesis should be performed and the level of 17OP in the amniotic fluid determined. With a high level of 17OP, adrenogenital syndrome in the fetus is diagnosed. Unfortunately, modern tests can be diagnosed, but it is very difficult to determine the degree of severity of adrenogenital syndrome, which can be from the nonclassical easily; form of the disease until the solitary heavy form of adrenogenital syndrome. The question of whether to save pregnancy or interrupt in connection with adrenogenital syndrome in the fetus is decided by the parents

In the event that the mother does not have adrenogenital syndrome, but the husband of the adrenogenital syndrome gene and in the family had children with adrenogenital syndrome, the world practice adopted the following tactics. The patient receives dexamethasone from the moment of pregnancy diagnosis (the earlier, the better) for the prevention of virilization in the fetus, in the event that he is sick with adrenogenital syndrome.

Tactics of pregnancy management in patients with ovarian and mixed form of hyperandrogenism

At the onset of pregnancy strict control is necessary, since the most frequent complication is the threat of termination of pregnancy, according to our data, in 36 % of patients. Determination of the level and dynamics of chorionic gonadotropin, DEA-C, 17KS, E2 and P is necessary for the selection of hormone therapy.

Dexamethasone therapy should be proposed to reduce the combined effect of androgens on the development of the embryo. Hyperandrogenism in a much greater degree disrupts the development of the embryo than the dose of glucocorticoids, which we recommend to use - no more than 0.5 mg of dexamethasone. Given the history of NLF and those who have been stimulated ovulation, it is advisable to appoint Dufaston or Utrozhestan in usual doses. At low levels of the chorionic gonadotropin, maintenance doses of the chorionic gonadotropin can be administered. The appointment of hormonal drugs should be controlled by the level of 17KS. The appointment of Dufaston or Utrozhestan is indicated with relative hyperestrogenia, when the ratio of B and P is more than 1.5. If the ratio in the normal levels, then treatment with gestagens can not be prescribed. Hormonal therapy with gestagens, we stop in the 16th week of pregnancy, when the formation of the placenta is completed.

In the ovarian form of hyperandrogenism, treatment with dexamethasone may be discontinued after 16 weeks, and with a mixed form continued almost to the end of pregnancy - up to 35-36 weeks. Often at the end of pregnancy, toxicosis of the second half of pregnancy may develop (according to our data, this was a complication in 34.2% of patients in these groups), in connection with which dexamethasone treatment is not indicated after 35-36 weeks. However, in all cases of threat of premature termination of pregnancy, treatment with glucocorticoids should be continued.

When administering the second trimester of pregnancy, control of the cervix is necessary because of the possibility of ischemic-cervical insufficiency, which, according to our data, was 30.8%. Due to the fact that ischemic-cervical insufficiency is functional, it is necessary not only to monitor the ultrasound data, but also to assess the condition of the cervix during vaginal examination.

From the first weeks of pregnancy, prevention of placental insufficiency, possible activation of a viral-bacterial infection is necessary.

Despite the preparation for pregnancy, 76.8% of women with ovarian hyperandrogenism succeeded in carefully controlling during pregnancy and rational therapy, keeping the pregnancy and safely delivering the child alive, 77.8% with mixed hyperandrogenism and 92% with adrenal hyperandrogenism.

As a result of differentiated rehabilitation therapy in patients with different forms of hyperandrogenism, the incidence of secondary infertility decreased fourfold (from 36.4% to 9.3%) of spontaneous abortion 11 times (from 63.6% to 5.7%). The most optimal results of therapy were achieved in women with adrenal hyperandrogenism.

According to many researchers, after delivery in most women with hyperandrogenic pathological symptom complex again manifests itself. Currently, there are no therapies that can cure patients. Due to the fact that hyperandrogenism in the miscarriage clinic is less severe than in the infertility clinic, considerable interest was expressed in the restoration of menstrual and reproductive functions, taking into account a successfully and unfairly completed pregnancy.

In studies, it was shown that the state of menstrual and generative functions in the long term depended both on the outcome of pregnancy, and on the form of hyperandrogenia. In women with interrupted pregnancy, the menstrual function was further significantly impaired, including amenorrhoea, hirsutism progressed, there was a significant increase in DEA, prolactin, and cortisol in the blood plasma. The majority of them (67.7%) experienced persistent secondary infertility, which in frequency was 8 times higher than infertility after successful delivery.

Successful termination of pregnancy helped restore a stable normalization of androgen levels in the majority of women who had been disturbed in the past menstrual cycle, and had a favorable end in 74.5% of normal repeated childbirth without corrective hormonal therapy. Recurrence of spontaneous termination of pregnancy was in 15.7% of women with a mixed form of hyperandrogenism.

The successful completion of pregnancy in patients with hyperandrogenia with miscarriage indicates a functional nature of the disorder or an indistinctly expressed form of the pathological process. When assessing the state of target organs, taking into account the successful delivery and unfavorable outcomes of pregnancy, the following data were obtained: each third patient (31.4%) had hyperplastic processes in the uterus and mammary glands. In patients with mixed (35.7%) and ovarian (48%) hyperandrogenic pathological processes in hormone-dependent organs were observed 3-4 times more often than in women with adrenal hyperandrogenism (11.9%).

Among patients with adrenal hyperandrogenism, fibro-cystic mastopathy and thyroid disease prevailed, in women with ovarian form - hyperplastic diseases of the uterus, pathology of the cardiovascular system. These diseases were 1.5-4 times more frequent in women who did not manage to restore their reproductive function. When assessing the condition of children born to women with hyperandrogenia, depending on the type of hyperandrogenism and the duration of treatment with glucocorticoids in the period of the onset of their reproductive function (from the moment of birth to 25 years), it was revealed that all children grew and developed normally, mental and physical retardation development was not noted. In the structure of the disease of children up to 4-5 years, slightly exudative exudative diathesis, allergy and colds prevailed, in the older age groups - diseases of the gastrointestinal tract and respiratory organs, which were most often affected by offspring of mothers with ovarian and mixed forms of hyperandrogenism. However, the specific gravity of these diseases did not exceed the frequency in the general population. The close correlation of the frequency of these diseases with such factors as the feeding characteristics, the parents' propensity to the same pathology, the age of the mother at the time of the child's birth (over 35 years), and the dependence on the presence or absence, as well as the duration, of glucocorticoid therapy in the mother during pregnancy .

Together, the period of formation of menstrual and reproductive functions in the offspring of women with ovarian and mixed forms of hyperandrogenia not receiving glucocorticoids was characterized by a number of complications: early and late menarche (25%), oligomenorrhea (36.6%), anovulation (33.3% ), various endocrine disorders (45.4%), hirsutism (27.3%), small-cystic ovarian changes (18.5%), androgen excess (43.7%).