Dietary docosahexaenoic acid alleviates autistic-like behaviors resulting from maternal immune activation in mice

The prevalence of autism spectrum disorders over the last several decades has risen at an alarming rate. Factors such as broadened clinical definitions and increased parental age only partially account for this precipitous increase, suggesting that recent changes in environmental factors may also be responsible. One such factor could be the dramatic decrease in consumption of anti-inflammatory dietary omega-3 (n-3) polyunsaturated fatty acids (PUFAs) relative to the amount of pro-inflammatory omega-6 (n-6) PUFAs and saturated fats in the Western diet. Docosahexaenoic acid (DHA) is the principle n-3 PUFA found in neural tissue and is important for optimal brain development, especially during late gestation when DHA rapidly and preferentially accumulates in the brain. In this study, we tested whether supplementation of a low n-3 PUFA diet with DHA throughout development could improve measures related to autism in a mouse model of maternal immune activation. We found that dietary DHA protected offspring from the deleterious effects of gestational exposure to the viral mimetic polyriboinosinic-polyribocytidilic acid on behavioral measures of autism and subsequent adulthood immune system reactivity. These data suggest that elevated dietary levels of DHA, especially during pregnancy and nursing, may help protect normal neurodevelopment from the potentially adverse consequences of environmental insults like maternal infection.

Significance of antenatal glucocorticoid exposure for pressure injury prevalence in neonates

AIMS

Studies have highlighted that antenatal steroids could have an effect on neonatal skin maturation. This study examined if there was a relationship between the administration of antenatal glucocorticoids for mothers and the skin injuries in their neonates. Data from skin injury audit were extracted from the neonatal database and analyzed to determine differences in the prevalence of neonates with pressure injuries [cases] whose mothers had received antenatal steroids, compared to those without pressure injuries [control].

RESULTS

Of 247 neonates audited, 77 [31%], had documented pressure injuries, 170 [69%] had no documented injury. The median birth weight and gestation were 1400 g [IQR 893-2268 g] and 30.3 weeks [IQR 26.3-40.0 weeks] respectively. Of the neonates born less than 34 weeks, 80% were exposed to antenatal steroids and were equally distributed across patient genders. Within the 77 cases, 53 [66%] were exposed to antenatal steroids compared to controls in which 88 [53%] had not. The effect between cases and controls was not statistically significant [χ2 = 2.81, P = 0.09]. However a difference was noted between genders, as female neonates benefited from the exposure to steroids [OR = 0.317, 95% [CI 0.105-0.956], p value -0.041].

CONCLUSION

Antenatal glucocorticoids appear to be beneficial in reducing pressure injury prevalence in female neonates.

Transplacental passage of antimicrobial paraben preservatives

Parabens are widely used preservatives suspected of being endocrine disruptors, with implications for human growth and development. The most common paraben found in consumer products is methylparaben. To date, no study has examined whether these substances cross the human placenta. A total of 100 study subjects (50 mother-child pairs) were enrolled at two medical institutions, serving primarily African-American and Caucasian women, respectively. A maternal blood sample was drawn on admission and a paired cord blood sample was obtained at delivery. Of the 50 mothers, 47 (94%) showed methylparaben in their blood (mean level 20.41 ng/l), and 47 in cords bloods (mean level 36.54 ng/l). There were 45 mother-child pairs where methylparaben was found in both samples. Of these, the fetal level was higher than the maternal level in 23 (51%). For butylparaben, only 4 mothers (8%) showed detectable levels (mean 40.54 ng/l), whereas 8 cord blood samples (16%) were positive (mean 32.5 ng/l). African-American mothers and infants showed higher prevalence of detectable levels (P=0.017). Methylparaben and butylparaben demonstrate transplacental passage. Additional studies are needed to examine potential differences in exposure by geography and demographics, what products are used by pregnant women that contain these preservatives, as well as any potential long-term effects in the growth and development of exposed children.

Early Initiation of ARV During Pregnancy to Move towards Virtual Elimination of Mother-to-Child-Transmission of HIV-1 in Yunnan, China

Objective

To identify factors associated with mother-to-child-transmission and late access to prevention of maternal to child transmission (PMTCT) services among HIV-infected women; and risk factors for infant mortality among HIV-exposed infants in order to assess the feasibility of virtual elimination of vertical transmission and pediatric HIV in this setting.

Design

Observational study evaluating the impact of a provincial PMTCT program.

Methods

The intervention was implemented in 26 counties of Yunnan Province, China at municipal and tertiary health care settings. Log linear regression models with generalized estimating equations were used to identify unadjusted and adjusted correlates for late ARV intervention and MTCT. Cox proportional hazard models with robust sandwich estimation were applied to examine correlates of infant mortality.

Results

Mother-to-child- transmission rate of HIV was controlled to 2%, with late initiation of maternal ARV showing a strong association with vertical transmission and infant mortality. Risk factors for late initiation of maternal ARV were age, ethnicity, education, and having a husband not tested for HIV. Mortality rate among HIV-exposed infants was 2.9/100 person-years. In addition to late initiation of maternal ARV, ethnicity, low birth weight and preterm birth were associated with infant mortality.

Conclusions

This PMTCT program in Yunnan achieved low rates of MTCT. However the infant mortality rate in this cohort of HIV-exposed children was almost three times the provincial rate. Virtual elimination of MTCT of HIV is an achievable goal in China, but more attention needs to be paid to HIV-free survival.

Effect of maternal ketoacidosis on the ovine fetus

Ketoacidosis during pregnancy carries significant risk of intrauterine fetal demise, but little is known about the impact of ketoacids on the ovine fetus. We report a case series of maternal ketoacidosis in ewes. Maternal ketoacidosis may result in biochemical and acid-base fetal abnormalities associated with changes in feto-placental unit perfusion.

Is periconceptional opioid use safe?

QUESTION

A patient in my practice who takes buprenorphine for chronic pain would like to conceive. Is it safe for her to continue taking her medication?

ANSWER

The literature regarding periconceptional opioid use is conflicted as to whether opioids pose an elevated risk of birth defects. Confounding factors such as socioeconomic status, stress, and alcohol consumption might play a role. The first trimester of pregnancy is the critical period of development for many organ systems in the embryo. A chemical or environmental insult is more likely to produce major congenital malformations such as neural tube defects or mental retardation if it occurs within this window. Medical practitioners should judiciously consider a risk-benefit analysis before making their decisions.

Impaired cardiac energy metabolism in embryos lacking adrenergic stimulation

As development proceeds from the embryonic to fetal stages, cardiac energy demands increase substantially, and oxidative phosphorylation of ADP to ATP in mitochondria becomes vital. Relatively little, however, is known about the signaling mechanisms regulating the transition from anaerobic to aerobic metabolism that occurs during the embryonic period. The main objective of this study was to test the hypothesis that adrenergic hormones provide critical stimulation of energy metabolism during embryonic/fetal development. We examined ATP and ADP concentrations in mouse embryos lacking adrenergic hormones due to targeted disruption of the essential dopamine β-hydroxylase (Dbh) gene. Embryonic ATP concentrations decreased dramatically, whereas ADP concentrations rose such that the ATP/ADP ratio in the adrenergic-deficient group was nearly 50-fold less than that found in littermate controls by embryonic day 11.5. We also found that cardiac extracellular acidification and oxygen consumption rates were significantly decreased, and mitochondria were significantly larger and more branched in adrenergic-deficient hearts. Notably, however, the mitochondria were intact with well-formed cristae, and there was no significant difference observed in mitochondrial membrane potential. Maternal administration of the adrenergic receptor agonists isoproterenol or l-phenylephrine significantly ameliorated the decreases in ATP observed in Dbh-/- embryos, suggesting that α- and β-adrenergic receptors were effective modulators of ATP concentrations in mouse embryos in vivo. These data demonstrate that adrenergic hormones stimulate cardiac energy metabolism during a critical period of embryonic development.

Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario

OBJECTIVE

To document the management of and outcomes for patients receiving narcotic replacement and tapering with long-acting morphine preparations during pregnancy.

DESIGN

A prospective cohort study over 18 months.

SETTING

Northwestern Ontario.

PARTICIPANTS

All 600 births at Meno Ya Win Health Centre in Sioux Lookout, Ont, from January 1, 2012, to June 30, 2013, including 166 narcotic-exposed pregnancies.

INTERVENTION

Narcotic replacement and tapering of narcotic use with long-acting morphine preparations.

MAIN OUTCOME MEASURES

Prenatal management of maternal narcotic use, incidence of neonatal abstinence syndrome, and other neonatal outcomes.

RESULTS

The incidence of neonatal abstinence syndrome fell significantly to 18.1% of pregnancies exposed to narcotics (from 29.5% in a previous 2010 study, P = .003) among patients using narcotic replacement and tapering with long-acting morphine preparations. Neonatal outcomes were otherwise equivalent to those of the nonexposed pregnancies.

CONCLUSION

In many patients, long-acting morphine preparations can be safely used and tapered in pregnancy, with a subsequent decrease in observed neonatal withdrawal symptoms.

Orally administered melatonin prevents lipopolysaccharide-induced neural tube defects in mice

Lipopolysaccharide (LPS) has been associated with adverse pregnant outcomes, including fetal demise, intra-uterine growth restriction (IUGR), neural tube defects (NTDs) and preterm delivery in rodent animals. Previous studies demonstrated that melatonin protected against LPS-induced fetal demise, IUGR and preterm delivery. The aim of the present study was to investigate the effects of melatonin on LPS-induced NTDs. All pregnant mice except controls were intraperitoneally injected with LPS (25 µg/kg) daily from gestational day (GD)8 to GD12. Some pregnant mice were orally administered with melatonin (MT, 50 mg/kg) before each LPS injection. A five-day LPS injection resulted in 27.5% of fetuses with anencephaly, exencephaly or encephalomeningocele. Additional experiment showed that maternal LPS exposure significantly down-regulated placental proton-coupled folate transporter (pcft) and disturbed folate transport from maternal circulation through the placentas into the fetus. Interestingly, melatonin significantly attenuated LPS-induced down-regulation of placental pcft. Moreover, melatonin markedly improved the transport of folate from maternal circulation through the placentas into the fetus. Correspondingly, orally administered melatonin reduced the incidence of LPS-induced anencephaly, exencephaly or encephalomeningocele. Taken together, these results suggest that orally administered melatonin prevents LPS-induced NTDs through alleviating LPS-induced disturbance of folate transport from maternal circulation through the placenta into the fetus.

Synthetic glucocorticoid reduces human placental system a transport in women treated with antenatal therapy

CONTEXT

Synthetic glucocorticoids (sGCs) are routinely given to women with threatened preterm labor and have been linked to fetal growth restriction and developmental programming. Reductions in fetal growth are likely to be mediated by placental dysfunction, including altered nutrient transport. sGCs modify the system A neutral amino acid transporter in vitro, but there are no in vivo comparable data in human placenta.

OBJECTIVE

Because ∼ 30% of women who receive sGCs carry to term, our objective was to examine the short- and longer-term consequences of antenatal sGCs on placental system A transport.

METHODS AND PATIENTS

Placental tissue was collected from women treated with sGCs between 24 hours and 14 days before delivery (24h-14d), 14 days after treatment but before term (14d-term), or at term, compared with healthy term (control) deliveries to measure system A-mediated activity (Na(+)-dependent [(14)C]methylaminoisobutyric acid uptake per gram placenta) and mRNA expression.

RESULTS

After sGC treatment, system A activity was significantly reduced at term compared with both sGC placentas delivered 24h-14d and compared with controls. Placentae from women treated with sGCs who delivered between 14d-term also had significantly reduced system A activity compared with 24h-14d placentas. SLC38A1 and SLC38A2 mRNA expression was unaffected. However, SLC38A4 was significantly reduced by sGCs at term compared with placentas delivered between 14d-term.

CONCLUSION

We conclude that women who are at risk of preterm labor and receive sGCs but deliver at term have significantly reduced placental system A amino acid transporter activity. Altered placental transporter function could affect fetal growth and may contribute to developmental programming reported in both animal and clinical studies.

Safety of tacrolimus in pregnancy

QUESTION

I have a 30-year-old patient who had a kidney transplant 2 years ago. She is now planning a pregnancy. She has been treated with tacrolimus since her transplant. Will it be safe for the fetus if she continues to take it during the pregnancy or should she switch to a different antirejection medication?

ANSWER

If your patient is stable while taking tacrolimus, there is no reason to switch. The current available information does not suggest that tacrolimus increases the risk of major congenital malformations above the baseline risk in the general population. Premature birth and low birth weight are often reported in this population; however, these effects are frequently reported in pregnant transplant patients treated with other immunosuppressant agents and probably reflect the effects of the maternal condition. As there are some reports of hyperkalemia and renal impairment in infants exposed to tacrolimus in utero, kidney function and electrolytes should be monitored in exposed neonates.

Retardation of fetal dendritic development induced by gestational hyperglycemia is associated with brain insulin/IGF-I signals

Hyperglycemia is an essential risk factor for mothers and fetuses in gestational diabetes. Clinical observation has indicated that the offspring of mothers with diabetes shows impaired somatosensory function and IQ. However, only a few studies have explored the effects of hyperglycemia on fetal brain development. Neurodevelopment is susceptible to environmental conditions. Thus, this study aims to investigate the effects of maternal hyperglycemia on fetal brain development and to evaluate insulin and insulin-like growth factor-I (IGF-I) signals in fetal brain under hyperglycemia or controlled hyperglycemia. At day 1 of pregnancy, gestational rats were intraperitoneally injected with streptozocin (60 mg/kg). Some of the hyperglycemic gestational rats were injected with insulin (20 IU, two times a day) to control hyperglycemia; the others were injected with saline of equal volume. The gestational rats were sacrificed at days 14, 16, and 18 of embryo development. The dendritic spines of subplate cortex neurons in the fetal brain were detected by Golgi-Cox staining. The mRNA levels of insulin receptors (IRs) and IGF-IR in the fetal brain were measured using qRT-PCR. The protein levels of synaptophysin, IR, and IGF-IR in the fetal brain were detected by western blot. No significant difference in fetal brain formation was observed between the maternal hyperglycemic group and insulin-treated group. By contrast, obvious retardation of dendritic development in the fetus was observed in the maternal hyperglycemic group. Similarly, synaptophysin expression was lower in the fetus of the maternal hyperglycemic group than in that of the insulin-treated group. The mRNA and protein expression levels of IRs in the fetal brain were higher in the hyperglycemic group than in the insulin-treated group. By contrast, the levels of IGF-IR in the brain were lower in the fetus of the maternal hyperglycemic group than in that of the insulin-treated group. These results suggested that maternal hyperglycemia can retard dendritic development in the fetal brain and that these changes partially resulted from abnormal insulin/IGF-I signaling in the fetal brain.

Maternal and fetal insulin levels at birth in women with polycystic ovary syndrome: data from a randomized controlled study on metformin

CONTEXT

Metformin is suggested to reduce pregnancy complications in women with polycystic ovary syndrome (PCOS). Metformin crosses the placenta and therapeutic concentrations are measured in the fetal circulation. Whether metformin treatment in pregnant PCOS women affects maternal and fetal insulin concentrations at birth is not clarified.

OBJECTIVES

To investigate the possible effect of metformin on insulin concentrations in umbilical cord blood and the possible association between maternal and fetal insulin concentrations.

DESIGN

Post-hoc analysis of a subgroup of PCOS women participating in a double-blind randomized controlled trial.

SETTING

University hospital setting.

PARTICIPANTS

Women with PCOS (n=118), aged 19-39 years.

MAIN OUTCOME MEASURES

Maternal and umbilical cord insulin concentrations immediately after birth.

RESULTS

At delivery women randomized to metformin had lower insulin concentrations than those randomized to placebo (259±209 vs 361±261 pmol/l; P=0.020). No difference was found in insulin concentrations in umbilical venous (P=0.95) and arterial (P=0.39) blood between the metformin and placebo groups. The arteriovenous difference was also equal between the groups (P=0.38). Insulin concentrations were higher in the umbilical vein than in the umbilical artery independent of randomization (70±51 vs 45±48 pmol/l; P<0.0005).

CONCLUSIONS

In PCOS, metformin treatment during pregnancy resulted in lower maternal insulin concentrations at delivery. Metformin treatment did not affect fetal insulin concentrations. Higher insulin concentrations in the umbilical vein indicate that the placenta somehow secretes insulin to the fetus. The possibility of placental insulin secretion to the fetus deserves further investigations.

Antibiotic Therapy in Pregnancy and Lactation

When considering whether to administer drugs to women during pregnancy and lactation, we have to take into account that these substances may expose the fetus or neonate to multiple effects. This occurs because there is a unique situation where the maternal compartment is connected with the fetal or neonatal compartment through, respectively, the placental barrier or breast milk. The fetus in utero and the breast-fed neonate are to be considered as organisms exposed and sensitive to the effects of drugs that cross the placenta or enter the breast milk. This review focuses on the most frequently used antibiotics during pregnancy and lactation and presents useful suggestions for daily practice. Drugs that must be avoided are clearly underlined.

Pharmacokinetics of ethanol in the maternal-fetal unit

Due to its wide range of deleterious effects on the unborn baby, knowledge on the disposition of ethanol in the maternal-fetal unit is critical. This review summarizes and updates the existing evidence on ethanol disposition in the mother, the placenta and the fetus, and relates them to their potential fetal effects. 

Online training on fetal alcohol spectrum disorders for court-appointed special advocates volunteers

Fetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disabilities. Children within the child welfare system are five to 10 times more likely than other children to experience these symptoms. Court Appointed Special Advocates (CASA) volunteers are uniquely positioned to identify these children and refer them for assessment and services. This study used a one-group pretest-posttest design to assess the impact of a three-hour online FASDs training on CASA workers' knowledge of FASDs and their comfort and confidence in identifying children with FASDs for referral, advocating for them, and linking them to services. The training and assessment measures were completed by 338 CASA volunteers and staff from 55 CASA locations in Texas. Wilcoxon matched-pairs tests and paired t tests were used to assess change in each of the dependent measures. All comfort and confidence items showed significant improvement from pretest to posttest; there was also a significant improvement in knowledge. These results support the potential of this online training to enhance CASA volunteers' ability to help children with FASDs.

Iodine supplementation during pregnancy and infant neuropsychological development. INMA Mother and Child Cohort Study

Iodine supplementation during pregnancy is a common practice in developed countries. However, scant evidence is available regarding the safety and effectiveness of maternal iodine supplementation with regard to child neuropsychological development. We previously reported an inverse association between iodine supplementation and the psychomotor development of infants in a birth cohort from Valencia, Spain. In the present study, we assessed this association in a wider sample of mother and child pairs from 3 other regions in Spain. Neuropsychological development was assessed using the Bayley Scales of Infant Development in 1,519 infants (median age, 16 months) between 2006 and 2009. In multivariate analyses, maternal consumption of 150 μg/day or more of iodine from supplements was related to a 1.5-fold increase in the odds of a psychomotor score less than 85 (95% confidence interval: 0.8, 2.9) and to a 1.7-fold increase in the odds of a mental score less than 85 (95% confidence interval: 0.9, 3.0). Findings previously reported in the Valencia cohort were only partially verified. The results of the present study suggest that, at least in these regions, iodine supplementation does not improve infant neuropsychological development at 1 year of age. Further research is needed on the risks and benefits of supplementary iodine for both maternal thyroid function and child neurodevelopment.

A novel method of fetal cardioversion

The ideal treatment for fetal arrhythmias associated with hydrops is not known. This case report describes a novel approach to fetal cardioversion using oral maternal bolus dosing of flecainide.

Pre-placement risk and longitudinal cognitive development for children adopted from foster care

This study examined the trajectory of cognitive development over the first five years of adoptive placement among children adopted from foster care and how pre-adoption risk factors relate to this development. Overall, children's cognitive scores increased significantly, with the most rapid improvement occurring in the first year post-placement. By five years post-placement, children's mean cognitive and achievement scores were in the average range. Adoption is a positive intervention for children's cognitive development.

[Erythropoietin through the placenta barrier and fetal blood-brain barrier with transient uteroplacental ischemia]

OBJECTIVE

To observe the permeability of recombinant human erythropoietin through placenta barrier and fetal blood-brain barrier after transient uteroplacental ischemia.

METHODS

Rats on days 19 of pregnancy were divided into rhEPO treated group, ischemia-reperfusion group and sham operated group. Fetal ischemia in rhEPO treated group and ischemia-reperfusion group was induced by bilateral occlusion of the utero-ovarian artery for 20 minutes. Different dosage of 125I-rhEPO (2500 U/kg, 5000 U/kg, 7500 U/kg) was injected into the rats through caudal veins 30 min before injury in rhEPO treated group and sham-operated group. Saline was administered intravenously 30 min before the induction of hypoxic-ischemic injury in ischemia-reperfusion group. The amniotic fluid, placenta and fetal organs including brain, liver, heart, lung and kidney were collected to measure the radioactivity at 24h after injury.

RESULTS

125I-rhEPO was detected in amniotic fluid, placenta and fetal organs. The radioactivity of 125I-rhEPO in these tissues increased gradually with the increased dose injected in rhEPO treated group and sham-operated group. There were significant differences in the radioactivity of 125I-rhEPO between rhEPO treated group and sham-operated group (P < 0.05).

CONCLUSION

The permeability of rhEPO through placental barrier and blood-brain barrier increased under the condition of fetal ischemia and hypoxia.

[Optimization of antibiotic therapy in pregnancy--clinical implications]

The aim of the antibacterial therapy during pregnancy is to select a proper antibiotic and determine its effective dose, at the same time excluding the risk of potential teratogenic effect. Pregnancy is characterized by many physiological, disease-predisposing changes, particularly of bacterial etiology that have an influence on different pharmacokinetic of drugs. When determining an effective dose of an antibiotic, one should take into account changes in the pharmacokinetics (PK) of drugs in pregnant women, involving mainly the phase of distribution (increased volume of body fluids, cardiac output, reduced concentration of albumins), metabolism (induction of hepatic enzymes: CYP3A4, CYP2D6, CYP2C9, UGT1A4, UGT2B7, inhibition of CYP1A2, CYP2C19), and excretion (increased glomerular filtration rate). Results of few pharmacokinetic studies on pregnant patients point to the need of increasing the dose or reducing dosage intervals for some antibiotics (e.g. penicillin V ampicillin, piperacillin, imipenem, clindamycin). The aim of this study was to summarize current knowledge regarding the PK of antibiotics during pregnancy.