Prenatal dexamethasone use for the prevention of virilization in pregnancies at risk for classical congenital adrenal hyperplasia because of 21-hydroxylase (CYP21A2) deficiency: a systematic review and meta-analyses.
BACKGROUND
Prenatal treatment with dexamethasone to prevent virilization in pregnancies at risk for classical congenital adrenal hyperplasia (CAH) remains controversial.


OBJECTIVE
To conduct a systematic review and meta-analyses of studies that evaluated the effects of dexamethasone administration during pregnancies at risk for classical CAH because of 21-hydroxylase deficiency (CYP21A2).


METHODS
We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception through August 2009. Review of reference lists and contact with CAH experts further identified candidate studies.


METHODS
Reviewers working independently and in duplicate determined trial eligibility. Eligible studies reported the effects on either foetal or maternal outcomes of dexamethasone administered during pregnancy compared to a control group that did not receive any treatment.


METHODS
Reviewers working independently and in duplicate determined the methodological quality of studies and collected data on patient characteristics, interventions, and outcomes.


RESULTS
We identified only four eligible observational studies (325 pregnancies treated with dexamethasone). The methodological quality of the included studies was overall low. Meta-analysis demonstrates a reduction in foetus virilization measured by Prader score in female foetuses treated with dexamethasone initiated early during pregnancy (weighted mean difference, -2.33, 95% CI, -3.38, -1.27). No deleterious effects of dexamethasone on stillbirths, spontaneous abortions, foetal malformations, neuropsychological or developmental outcomes were found although these data are quite sparse. There was increased oedema and striae in the mothers treated with dexamethasone. There were no data on long-term follow-up of physical and metabolic outcomes in children exposed to dexamethasone.


CONCLUSIONS
The observational nature of the available evidence and the overall small sample size of the whole body of the literature significantly weaken inferences about the benefits and harms of dexamethasone in this setting. Dexamethasone seems to be associated with reduction in foetus virilization without significant maternal or foetal adverse effects. However, this review underscores the current uncertainty and further investigation is clearly needed. The decision about initiating treatment should be based on patients' values and preferences and requires fully informed and consenting parents.
Mercè Fernández-Balsells
M
M
Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, MN 55905, USA.
Muthusamy
Kalpana
K
Smushkin
Galina
G
Lampropulos
Julianna F
JF
Elamin
Mohamed B
MB
Abu Elnour
Nisrin O
NO
Elamin
Khalid B
KB
Agrwal
Neera
N
Gallegos-Orozco
Juan F
JF
Lane
Melanie A
MA
Erwin
Patricia J
PJ
Montori
Victor M
VM
Murad
M Hassan
MH
D000312:Adrenal Hyperplasia, Congenital / Q000139:chemically induced; D003907:Dexamethasone / Q000009:adverse effects*; D005260:Female; D005333:Fetus / Q000187:drug effects*; D006801:Humans; D011247:Pregnancy; D012306:Risk; D014770:Virilism / Q000517:prevention & control*
D003907:Dexamethasone