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Blackwell Science, LtdOxford, UKBJUBJU International1465-5101BJU InternationalJune 2004
93Supplement 3
Original Article
PRENATAL GENDER DETERMINATION
E. PAJKRT and L.S. CHITTY

Prenatal gender determination and the diagnosis of
genital anomalies

E. PAJKRT and L.S. CHITTY*

University College London Hospital, and *Institute of Child Health, London, UK

INTRODUCTION

For centuries guessing the sex of the unborn
child has been a popular activity amongst
expectant parents and their families. With the
introduction of ultrasonography (US) of the
fetus visualization of the genitalia has
become possible. Fetal sex can be assigned
reasonably accurately from

12 weeks of
gestation onwards. In the second trimester
routine US for fetal anomalies is offered at

20 weeks of gestation, as part of standard
antenatal care in many parts of the developed
world. Although determining the gender at
this US is still mainly attempted because of
parental curiosity, it can sometimes form part
of the protocol, as it can be clinically
important. For example, accurately assessing
fetal sex can assist in assigning zygosity in
twin pregnancies. Whilst ambiguity of the
genitalia can occasionally be detected at the
time of routine US it is more commonly found
when at a detailed US after detecting other
abnormalities, or because of a relevant family
history. Some cases are diagnosed after
careful evaluation of fetal gender because of
an antenatal discrepancy between the fetal
karyotype and the genital anatomy [13]. In
women at risk of X-linked genetic disease or
of ambiguous development of the external
genitalia, early gender assignment may give
parents the option to avoid invasive testing in
up to half of cases where the fetus would not
be affected.
Here we rst give a short overview of the
embryology of the urogenital system, to
facilitate understanding of the possibilities of
prenatal US and causes leading to ambiguous
genitalia. We describe the noninvasive
methods used for assigning gender prenatally,
before giving examples of abnormalities that
may be detected using fetal US.

GONADAL DIFFERENTIATION AND
DEVELOPMENT OF EXTERNAL GENITALIA

Human gonads of both sexes begin
developing at 4 weeks of gestation. At this
early stage they are identical and capable
of differentiating into either testes or
ovaries. They are situated next to the
mesonephric or Wolfan duct and the
paramesonephric or Mllerian duct, which
are prominent in the development of the
male and female reproductive system,
respectively [4]. Testicular differentiation
begins at

7 weeks and is regulated by the
testes-determining factor, a gene located
on the short arm of the Y chromosome.
Production of anti-Mllerian factor by
Sertoli cells in fetal testes inhibits Mllerian
duct development and is important in
descent of the testes. Testosterone
production stimulates the development of
the Wolfan duct into epididymis, vas
deferens and seminal vesicles. In fetuses
with a normal ovary, or absence of any
gonad, the Mllerian duct develops into
Fallopian tubes, uterus and upper vagina
[5]. The external genitalia develop from
common bipotential primordia in both
sexes; the genital tubercle, labioscrotal
swellings and urethral fold. Early in the
fourth week of fetal life the genital
tubercle develops and soon elongates to
form a phallus, which is initially of equal
size in male and female fetuses. Growth
and differentiation of external genitalia is
identical during most of the rst trimester
and it is not until 11 weeks of gestation
that the external genitalia assume specic
sexual characteristics [6]. To achieve
masculinization of the indifferent external
genitalia testosterone has to be converted
into dihydrotestosterone by 5

-reductase.
This androgen dominated virilization takes
place at 814 weeks of gestation, resulting
in elongation of the phallus to form the
penis, fusion of the labioscrotal swellings
to form the scrotum and formation of the
urethra by the urogenital sinus. In the
absence of androgens feminization of the
external genitalia occurs. The indifferent
phallus forms a clitoris, the labioscrotal
swellings remain unfused to shape the
labia majora and the urogenital sinus
develops into the lower vagina and the
urethra [7].

SECOND TRIMESTER US AND PRENATAL
GENDER ASSIGNMENT

The rst publication on fetal sex
determination by US described an
examination of the fetal perineal area after
30 weeks and reported an accurate
identication of male fetuses in 96% of cases
[8]. Diagnosis of a female fetus at this time
was based on the absence of scrotum and
penis. With advances in ultrasound
technology gender assignment using US
became possible from early in the second
trimester. In the male the penis and scrotum
are visible (Fig. 1) and in the female the labia
can be positively identied, appearing as
two or four parallel lines [9] (Fig. 2). Table 1
[1021] shows studies reporting the
successful identication and accuracy of fetal
gender determination from the early second
trimester onward. Visualization rates of fetal
gender were initially reported to be 4797%,
but with further advances in ultrasound
technology during the last decade fetal sexing
is now possible in

90% of fetuses, with
consistently better results in male fetuses.
Accuracy varies with technical factors, e.g.
fetal position, machine use, maternal body
habitus and operator skill [18].
As determining the fetal male gender is based
on the identication of a penis and scrotum, it
did not take long to focus attention on
testicular descent. In 1983 Birnholz [13]
reported that the testes do not descend into
the scrotum before 26 weeks of gestation. In
that study, 62% of fetuses had descent at
2832 weeks and 95% after 32 weeks. Fifteen
years later these results were conrmed by
Achiron

et al.

[22], who also developed a
nomogram for scrotal circumference,
showing that scrotal size increases with
gestational age. To assist in assessing the
development of the fetal penis, reference
ranges for penile length were constructed
[23,24]. The penile length increases from
3.9 mm at 14 weeks of gestation to 23.8 mm
at 38 weeks. Development of the fetal uterus
at 1938 weeks has also been studied [25].
The uterus was measured on an axial view

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through the fetal pelvis at the fetal bladder
level. Both the transverse diameter and the
circumference of the uterus could be
measured successfully in 78% of the study
population, and showed a linear association
with gestational age.

FIRST TRIMESTER US AND PRENATAL
GENDER ASSIGNMENT

The improvement of high-resolution US
equipment has provided the possibility of
detailed visualization of the fetal anatomy in
the rst trimester. As with the second
trimester scan, the determination of fetal
gender in the rst trimester can be obtained
from a transverse section by visualizing the
penis and the scrotum in male fetuses.
However, because of the way in which the
genitalia develop, this is not the most
accurate way of assigning gender in early
pregnancy.
Up to 11 weeks of gestation the growth and
development of the external genitalia is
identical in both sexes. After this there is rapid
differentiation of the genital tubercle into the
male or the female phallus [6]. As signicant
differences in the rate of penile and clitoral
growth only become evident after 14 weeks,
when most of the prenatal growth of the
penis occurs [26], evaluating phallic size
before this time will lead to erroneous gender
assignment. Examined in the transverse
section the clitoris appears similar to the
penis in early pregnancy, but in the mid-
sagittal section the direction in which the
genital tubercle points can be evaluated, and
this differs in males and females. In the male
fetus the orientation of the phallus is anterior,
perpendicular to the lumbosacral spine (Fig. 3)
and in the female fetus the orientation is
caudal, parallel to the axis of the lumbosacral
spine (Fig. 4) [18]. The orientation of the
phallus in early pregnancy was termed the
sagittal sign [9] and several authors [2732]
have used various permutations of this sign to
attempt accurate gender assignment in early
pregnancy (Table 2). For example, Efrat

et al.


[28] examined the angle between the genital
tubercle to a horizontal line through the
lumbosacral skin surface, to provide an
accurate prediction of the fetal sex from
12 weeks onward. In male fetuses the angle
was >30

from the horizontal line and
increased with advancing gestation. In female
fetuses the angle is near 0

(range

20

to
+20

). The ability of the operator to assign
male/female genitalia increases with
advancing gestation and is a little higher in
female fetuses than in males.

FREE-FETAL DNA (ffDNA) AND PRENATAL
GENDER ASSIGNMENT

Ever since fetal nucleated cells were found to
cross the placental barrier and to circulate in
the maternal peripheral blood they have been
widely pursued as a potential source of fetal
material for noninvasive prenatal diagnosis
without endangering the fetus. However,
there are few such fetal cells in maternal
blood and this has been a major obstacle to
the routine application of this concept. More
recently, FFDNA in maternal serum has been
identied as a possible source of fetal
material for genetic investigation [33]. To
differentiate between maternal and fetal
DNA in the maternal serum and plasma,
technicians rely on the presence of genes that
are present in the fetus and not in the mother.
For fetal sex determination the diagnosis
relies on the presence or absence of fetal
male DNA. This can be detected by PCR
amplication with primers specic for Y-
specic sequences. Prenatal identication of
circulating fetal male DNA in maternal plasma
offers the possibility of noninvasive prenatal

FIG. 1.

Normal male genitalia seen in the sagittal
plane at 19 weeks' gestation (a) and the axial plane
at 24 weeks' gestation (b).
(a)
(b)

FIG. 2.

Views of the female genitalia showing the
labia at 19 (a) and 27 (b) weeks' gestation.
(a)
(b)

TABLE 1

Accuracy of second
trimester US for fetal
gender assignment

Study Gestation, weeks N Not possible % Accuracy %
[10] 2540 112 35.7 100
[11] 2042 393 4.3 95.7
[12] 1025 113 53.0 94.0
[13] 1540 855 31.0 98.8
[14] 1440 367 30.7 93.0
[15] 1618 100 ? 100
[16] 1240 1879 2.9 99.9
[17] 1620 115 16.5 92.7
[18] 1316 1091 11.3 97.9
[19] 1319 100 9.0 92.3
[20] 20 473 10.8 96.7
[21] 1420 843 8.7 99.3

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diagnosis in pregnancies at risk of severe sex-
linked diseases and in fetal disorders involving
the genitalia. Several groups [3349] have
now conrmed that fetal gender can be
determined with high levels of certainty
(Table 3). In some studies the efcacy of
different protocols was established using
either single PCR rather than nested PCR on
maternal serum and/or plasma and/or blood
cell DNA [33,36,44]. In two other studies
[37,38] PCR amplication was used on fetal
DNA extracted from urine.
The disadvantage of using fetal-derived Y-
chromosomal sequences in maternal plasma
is that the diagnosis of a female fetus is based
on a negative test result and therefore carries
the risk of erroneous gender assignment.
Adding rst trimester US of the fetal genitalia
to the PCR-based DNA analysis, and using
a combination of these two techniques,
minimizes the chance of incorrect or
equivocal results. In our unit we recently
assessed the efcacy of using a combined
approach, using FFDNA and early US to
determine fetal gender in a series of women
at risk of X-linked genetic disease or of
ambiguous development of the external
genitalia (Hyett

et al.

submitted for
publication). Fetal gender was accurately
determined by analysis of FFDNA at a mean of
10 (712) weeks of gestation in all 17 cases.
US was possible in 12 of the 14 cases where
this was attempted at a mean of 12 (1013)

FIG. 3.

An ultrasonogram at 11 weeks' gestation
showing the cranial orientation of the genital
tubercle (*) in a male fetus.

FIG. 4.

An ultrasonogram at 11+ weeks' gestation
showing the caudal orientation of the genital
tubercle (*) in a female fetus.

TABLE 2

Accuracy of rst trimester
US for fetal gender
assignment

Study
Gestation,
weeks/day
Not possible,
%
Accuracy, %
Males Overall Females
[27] 1111/6 33.3 100 100 100
1212/6 50.0 100 100 100
1313/6 24.0 100 100 100
>14 8.9 100 100 100
[28] 1111/6 7.5 70.3 94.7 44.4
1212/6 7.2 98.7 100 97.1
1313/6 12.2 100 100 100
[29] 1212/6 46.2 98.5 100 97.5
1313/6 20.2 100 100 100
[30] 1111/6 76.5 80.0 75.0
1212/6 87.9 92.7 84.0
1313/6 99.1 98.5 100
>14 100 100 100
[31] 1111/6 40.8 77.8 83.3 66.7
1212/6 13.3 86.0 82.6 89.2
1313/6 8.4 86.6 82.0 90.1
>14 2.0 92.0 95.5 89.3
[32] 11/212/6 24.1 75.9 100 46.2
1213/2 0.0 100 100 100
Totals 1111/6 25.2 60.0 89.3 75.5
1212/6 31.5 93.2 94.1 93.8
1313/6 16.1 96.5 94.5 96.1
>14 6.2 95.5 98.1 97.9

TABLE 3

Studies examining sex determination with free fetal DNA

Study
Gestation
weeks N Source
Accuracy
Overall
Males
(sensitivity, %)
Females
(specicity, %)
[33] 1240 43 plasma
serum
blood
24/30 (80)
21/30 (70)
5/30 (17)
13/13 (100)
13/13 (100)
13/13 (100)
86.0
79.1
41.9
[34] 636 137 blood 77/93 (83) 41/44 (93) 86.1
[35] 711 50 blood 17/26 (65) 20/24 (83) 74.0
[36] 732 16 plasma*
plasma
blood
15/16 (94)
16/16 (100)
11/16 (69)
5/11 (46)
10/11 (91)
11/11 (100)
74.1
96.3
81.5
[37] 710 19 urine 8/10 (80) 9/9 (100) 89.5
[38] 740 80 plasma
urine
53/55 (96)
21/55 (38)
22/25 (88)
24/25 (96)
88.0
96.0
[39] 814 121 serum 61/61 (100) 60/60 (100) 100
[40] 934 18 plasma 18/18 (100) ? ?
[41] ? 34 plasma 17/18 (94) 16/16 (100) 97.1
[42] 1029 30 plasma 19/19 (100) 11/11 (100) 100
[43] 814 45 plasma 14/15 (93) 11/11 (100) 96.2
[44] 1017 61 plasma
serum
27/31 (87)
31/31 (100)
30/30 (100)
30/30 (100)
93.4
100
[45] 716 302 plasma 139/143 (97) 159/159 (100) 98.7
[46] 912 7 serum 2/2 5/5 (100) 100
[47] 510 81 serum 38/40 (95) 41/41 (100) 97.5
[48] 712 18 blood 4/8 10/10 (100) 77.8
[49] 1013 129 serum 70/70 (100) 59/59 (100) 100

*single PCR; nested PCR.

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weeks of gestation, with complete accuracy.
These data compare favourably with two
previous studies. Mazza

et al.

[48] included 18
fetuses at risk of an X-linked recessive
disorder in their study (eight males and 10
female). US was used to correctly assign fetal
gender in 18 fetuses at 1213 weeks of
gestation. There were no false Y-positive
results in DNA from mothers with female
fetuses, whereas four of the male fetuses
showed Y-negative results. Costa

et al.

[49]
used a combined approach in 129 pregnant
women at risk of a fetus with an X-linked
genetic disease. In all cases the identication
of fetal gender based on both FFDNA
analysis in maternal plasma and US was
in complete agreement with the actual
fetal sex. However, the authors did not
report the gestational age at which both
tests were used.
These studies suggest that the combination of
rst trimester US and amplication of FFDNA
in maternal plasma can be used to predict
fetal sex. The advantage of the molecular
technique is that it can be used early in
gestation. Fetal Y-specic sequences could be
detected as early as the seventh week of
gestation with an increasing amount of
circulating fetal DNA with progression of
pregnancy [47]. In contrast, US determination
of fetal sex cannot be used until 11 weeks
because of the process of embryological
development, but has the advantage that
diagnostic signs are sought in both sexes.
Both noninvasive techniques require skilled
technicians, but used together offer an
accurate means of assessing fetal gender,
giving parents the option of avoiding invasive
testing in the half of cases where the fetus
would not be affected.

THREE-DIMENSIONAL US

One of the more recent advances in
ultrasound technology includes the
development of 3- and 4-dimensional US.
These techniques are particularly useful for
examining subtle external features in fetuses
at risk of anomalies or in fetuses found to
have a congenital malformation. As this is
such a new technique there is relatively little
published describing the applications in terms
of diagnosis of ambiguous genitalia [50]. The
3-dimensional appearance of normal male
development at 16 and 23 weeks of gestation
is shown in Fig. 5.

AMBIGUOUS GENITALIA

Ambiguity of the genitalia is a congenital
anomaly that may be the result of defects in
gene expression or the inuence of
environmental factors on gene expression
[51]. They can occur as isolated events or in
association with other symptoms as part of
a syndrome, and therefore the differential
diagnosis is long (Appendix) [52,53]. With
current ultrasound machines structurally
abnormal genitalia can be detected as early
as 15 weeks of gestation [54]. The suspicion
of ambiguity of the genitalia can arise under
several circumstances, including a reduction
in penile size for gestational age or an
absent phallus (Fig. 6), curvature of the
phallus, scrotal phallic malposition or fusion,
apparent fusion of the labia or
indeterminate sex (Fig. 7). The other stimulus
to the diagnosis is when discordance
between the US fetal sex and the fetal
karyotype is identied [13]. It is not always
possible to differentiate between

FIG. 5.

Three-dimensional ultrasonogram of a male
fetus at 16 weeks of gestation (a). The femora (f) and
umbilicus (u) are marked to aid orientation. The
scrotum and phallus can be seen more clearly at
27 weeks (b).
(a)
(b)

FIG. 6.

Severe hypospadias detected at 21 weeks'
gestation in a karyotypically male fetus with
multiple abnormalities.

FIG. 7.

Ambiguous appearance of genitalia in a twin
fetus (a). Amniocentesis showed a female karyotype
with normal steroid levels, and examination after
birth showed a cloacal anomaly with anal atresia,
with fusion of the labia (b).
(a)
(b)

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clitoromegaly (Fig. 7) and micropenis (Fig. 8)
unless there is normal development of the
scrotum with evidence of testicular descent.
In any event it is always wise to establish
the genetic sex by formal karyotyping and
cytogenetic analysis of fetal cells. Given the
role of steroids in early genital development,
amniotic uid should be kept for further
biochemical analysis if necessary. Additional
information may sometimes be obtained by
assessing the uterus after 19 weeks of
gestation [25].
To date several case series have been
published on the prenatal diagnosis of
ambiguous genitalia [5457]. There is one
study [58] that assessed the accuracy of the
prenatal diagnosis of abnormal genitalia; they
reported complete accuracy in male and 46%
in female fetuses.
HYPOSPADIAS
Hypospadias detected by prenatal US is
usually of the severe type (Fig. 6), although
occasionally less severe forms can be detected
when the external genitalia are carefully
examined after detecting associated
urogenital tract anomalies (Fig. 9). Meizner

et al.

[59] described the tulip sign as a US
clue for the in-utero diagnosis of severe
hypospadias, the tulip being formed by the
ventrally orientated penis located between
the scrotal folds. These authors considered
that this sign may help to distinguish between
severe hypospadias and other forms of
ambiguous genitalia, but in practice this may
not be that easy (Fig. 7b).
EPISPADIAS, BLADDER EXSTROPHY AND
CLOACAL EXSTROPHY
These anomalies are a spectrum of disease
including developmental abnormalities of
increasing severity, all of which may be
associated with ambiguous development of
the genitalia. The prenatal diagnosis of
epispadias has only rarely been reported, the
diagnosis being suggested by an absence of
an intra-abdominal bladder, normal liquor
volume and with cleavage of the phallus in a
karyotypically male fetus [54]. Exstrophy of
the bladder may be suspected when US after
16 weeks of gestation reveals a normal liquor
volume but no intra-abdominal bladder is
visible on repeated US [60]. The rarity of this
abnormality makes US diagnosis difcult,
although some characteristic ndings have
been described (Fig. 10). In a retrospective
review of cases the diagnosis was only correct
in three of 17 cases [61], but detection of
genital anomalies can aid the diagnosis. In
this review a lower abdominal bulge was seen
in eight cases, a small penis and anteriorly
displaced penis in eight of 14 males and
widening of the iliac crests in three cases [61].
Correct prenatal diagnosis is extremely
important for counselling and subsequent
management. Differential diagnosis includes
all other anterior abdominal wall defects, e.g.
omphalocele, gastroschisis and cloacal
exstrophy. In the rst two there is an extruded
sac or herniated bowel, but a normally
lled bladder should be seen within the
pelvis. The diagnosis in cloacal exstrophy is
often difcult but can be made when
anomalies of bowel and genital tract are also
visible.
FEMALE PSEUDOHERMAPHRODITISM
The diagnosis of female
pseudohermaphroditism is made in
genotypically female fetuses (XX) with ovaries
and normal Mllerian duct structures,
presenting with ambiguous genitalia of
varying degrees. However, the accuracy of
prenatal diagnosis is not particularly good. In
one series of 12 cases, the diagnosis was only
conrmed after birth in ve [58]. Diagnosis
was improved in cases with multiple
anomalies or aneuploidy.
MALE PSEUDOHERMAPHRODITISM
The diagnosis of male
pseudohermaphroditism is made in
genotypically male fetuses (XY) with normal
testes, but absent or incomplete
masculinization because of defects of
testosterone biosynthesis or abnormal
responses of target tissues to testosterone.
Male pseudohermaphroditism can be
diagnosed with a greater degree of accuracy

FIG. 8.

Sagittal view of a fetus with a micropenis (p).
The scrotal sac (s) is visible.

FIG. 9.

A slightly short phallus with abnormally
situated urethral orice detected after detailed
examination of the urinary tract in a fetus with
upper tract dilatation. The scrotum is normal with
testes descended. Small hydroceles are visible, but
this is a normal nding in late gestation.

FIG. 10.

A male fetus with bladder exstrophy seen in
the parasagittal plane (a) showing the low cord
insertion (C) inserting just below the abdominal
mass (A) and scrotum (S). (b) Another view showing
the genitalia with the scrotum and small phallus.
(a)
(b)

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using fetal US [58]. In one series there was
complete accuracy in 17 cases diagnosed
prenatally because of a bid scrotum,
hypospadias, micropenis and/or chordee seen
in a variety of combinations.

THE ROLE OF FETAL US IN MANAGING
PREGNANCIES AT HIGH RISK OF
AMBIGUOUS DEVELOPMENT OF
THE GENITALIA

Congenital adrenal hyperplasia

(CAH) refers to
a family of autosomal recessive enzymatic
defects of steroidogenesis causing a
disruption of the conversion of cholesterol
to cortisol, and leading to excessive
overproduction of androgen by the adrenal
cortex. Classical CAH caused by adrenal
21-hydroxylase deciency is the most frequent
cause of ambiguous genitalia, occurring in
4045% of the female neonates with this
anomaly. Moreover 21-hydroxylase deciency
constitutes 95% of the cases with CAH. It can
present in the simple virilizing form causing
only ambiguous genitalia in females, or in the
more frequent (75%) salt-wasting form
causing, besides masculinization in females,
potentially life-threatening aldosterone
deciency in both sexes [62]. The discovery of
elevated 17-OHP and

-androstenedione
levels in amniotic uid made prenatal
diagnosis [63] by hormonal assays possible.
However, this method has largely been
abandoned in high-risk families after the
location of the 21-hydroxylase gene (CYP21),
which made direct DNA analysis possible [64].
Prenatal treatment of CAH based on 21-
hydroxylase deciency is based on an
algorithm described by Mercado

et al.

[65].
After conrming pregnancy by a positive hCG-
test in urine, dexamethasone is prescribed to
the pregnant woman at risk of CAH to prevent
or reduce virilization in possibly affected
female fetuses. Dexamethasone is preferably
given before 9 weeks of gestation. Diagnosis
by chorionic villous sampling is required for
fetal sexing, and in female fetuses for DNA
analysis of the CYP21 gene. In a male fetus or
an unaffected girl the use of dexamethasone
can be discontinued. The advent of early
gender assignment using FFDNA analysis from
7 weeks of gestation [43] allows restriction of
dexamethasone treatment to female fetuses.
Moreover, this molecular analysis can be used
in combination with US determination of
fetal gender from 12 weeks onwards [48],
potentially reducing the invasive testing rate
for this condition by half.

Androgen insensitivity syndrome

: The
heterogeneous syndromes of androgen
insensitivity are the most common cause of
male pseudohermaphroditism, also referred
to as testicular feminization [66]. This is a
group of X-linked disorders causing structural
or functional abnormalities in the androgen
receptor. Affected individuals present with
female or ambiguous genitalia, and although
testes are normally developed they are
wrongly positioned. The rst report on
testicular feminization was based on a
discrepancy between the US visualization of
the external genitalia and the amniotic uid
chromosomes [67]. Early gender assignment
using FFDNA and US avoids invasive testing in
half the fetuses shown to be female.

Sex chromosome mosaicism

is one of the
commonest forms of mosaicism detected
after antenatal karyotyping, particularly after
chorionic villous sampling. In this case it is
often an anomaly conned to chorionic villi
with no particular signicance to the
developing fetus. However, it is of grave
concern to the parents and careful
examination of the genitalia using fetal US is
a useful aid to diagnosis in these situations,
and may avoid a second invasive procedure
[68]. In a review of eight cases found to have
varying degrees of 45X/46XY mosaicism (18
73% 45XO), seven had normal male external
genitalia on US. Male gender was conrmed
phenotypically in all cases after birth. In the
eighth there was ambiguity of the genitalia
and mixed gonadal dysgenesis was diagnosed
after birth [68]. Postnatally diagnosed 45X/
46XY mosaicism is diagnosed when
karyotyping is used because of a phenotypic
abnormality, usually ambiguity of the
genitalia. This is in contrast to that detected
prenatally, which is usually an unexpected
nding in phenotypically normal male
fetuses. In the two large series of prenatally
diagnosed cases reported only 5% resulted in
phenotypically abnormal fetuses with
signicant genital abnormalities or mixed
gonadal dysgenesis [69,70], and thus invasive
testing is avoided if possible.

MULTIPLE MALFORMATION SYNDROMES

Ambiguous development of the genitalia
forms part of many malformation syndromes
(Appendix). Aids to accurate diagnosis and
thus prediction of outcome are an invaluable
part of fetal diagnosis, facilitating the
accurate counselling of parents who are then
in a better position to make informed choices.
Probably the most common genetic syndrome
diagnosed antenatally with associated
ambiguity of the genitalia is Smith-Lemli-
Opitz syndrome [54,57]. In our institution the
identication of ambiguity of the genitalia in
two of the three cases of this syndrome we
have seen enabled targeted invasive testing to
measure the 7-dehydrocholesterol levels.
Elevated levels allowed us to conrm the
diagnosis and facilitated accurate parental
counselling. Another example is that of
campomelic dysplasia, where identication of
sex reversal in a genetically male fetus with
short, bowed lower limbs will facilitate the
diagnosis and help to predict the outcome.

CONCLUSION

Fetal US can be used to accurately predict
gender from around 11 week of gestation.
Fetal sex assignment in the rst trimester can
be useful in pregnancies at risk of severe
sex-linked diseases, in disorders involving
ambiguous development of the genitalia, and
in determining zygosity in multiple fetuses.
Prenatal diagnosis of ambiguous genitalia can
assist in the diagnosis of many malformation
syndromes, and in other cases alert the health
professional and parents to the possibility of
underlying hormonal abnormalities that may
require urgent intervention in the newborn
period.

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APPENDIX
The differential diagnosis of ambiguous
genitalia
Female pseudohermaphroditism
CAH
21-hydroxylase deciency;
11-hydroxylase deciency;
3-hydroxysteroid dehydrogenase
deciency.
Maternally derived androgens
Drugs
Placental aromatase deciency
Male pseudohermaphroditism
Inadequate production of testosterone
Testosterone biosynthetic defects
Congenital lipoid adrenal hyperplasia
3-hydroxysteroid dehydrogenase
deciency
17-hydroxylase deciency
17,20-lyase deciency
17-hydroxysteroid dehydrogenase
deciency
Leydig cell hypoplasia
Anti-Mllerian factor defect
Peripheral unresponsiveness to androgen
Androgen insensitivity syndrome
5-reductase deciency
Gonadal differentiation disorders
Gonadal dysgenesis
46XY partial gonadal dysgenesis
45X/46XY gonadal dysgenesis
Chromosomal
Trisomy 13
Trisomy 18
Triploidy
4p-, 13q-
Aniridia-Wilms'
Single gene disorder
shortrib polydactyly syndromes
Smith-Lemli-Opitz
Opitz
Opitz-Frias
Rieger
Robinow
Carpenter
Meckel-Gruber
Camptomelic dysplasia
Association
CHARGE
Vater