Applications of 2-dimensional matrix array for 3- and 4-dimensional examination of the fetus: a pictorial essay

OBJECTIVES

Two-dimensional (2D) matrix array is a new technology for the performance of 3-dimensional and 4-dimensional (4D) ultrasonography. In this study, we report the use of a 2D matrix array transducer for examination of fetal structures including the fetal heart.

METHODS

Thirty-four fetuses without abnormalities and 19 fetuses with congenital anomalies were examined with a 2D matrix array transducer (x3-1, IE-33; Philips Medical Systems, Bothell, WA). Median gestational age was 25 6/7 weeks (range, 13 0/7-40 1/7 weeks).

RESULTS

(1) A 360 degrees rotation and examination of selected structures was possible in the second trimester. (2) Structures were examined by maintaining the transducer in a fixed position and rotating the volume using the system trackball. (3) Dorsal and ventral parts of the hands and feet were visualized in a single volume data set, in real time, without moving the transducer. (4) Real-time en face visualization of atrioventricular valves was possible from the ventricular or atrial chambers. (5) Four-dimensional images of bones were obtained by decreasing gain settings only, with no need for cropping. (6) Four-dimensional reconstruction of vascular structures was possible with color Doppler imaging. Two limitations were identified: (1) lower resolution than mechanical volumetric transducers, and (2) narrow volume display.

CONCLUSIONS

Real-time direct 4D imaging with 360 degrees rotation for examination of fetal anatomic structures is feasible. This technology allows examination of fetal structures from multiple perspectives, in real time, without the need to move the transducer in the maternal abdomen. Further technological developments may overcome the limitations identified in this study.

Prenatal glucocorticoid exposure and physiological programming of adult disease

Compelling epidemiological evidence suggests that the early environment is an important determinant of later risk of disease. In particular, low birth weight has been associated with an increased risk of cardiovascular and metabolic disorders, including hypertension, Type 2 diabetes mellitus and ischemic heart disease, independent of classical adult lifestyle risk factors such as smoking, adult weight, social class, excess alcohol intake and sedentary lifestyle. These observations have led to a revolutionary concept of early life physiological programming. The molecular mechanisms that underlie this relationship remain unclear, but one major hypothesis implicates fetal overexposure to glucocorticoid stress hormones. This article will review evidence for this hypothesis.

Comparison of the number of spermatogonia and Sertoli cells in fetal and neonatal testes autopsied between 1958-1964 and 1989-1998 in Tokyo

Background:  Studies in several countries have reported a decline in human sperm quality similar to that observed in wild animals. To quantify whether the number of sperm in humans has decreased and whether humans are affected by similar environmental influences, we compared the number of spermatogonia and Sertoli cells in human fetal and neonatal testes autopsied at two institutions in Tokyo between 1958-1964 (term A) and 1989-1998 (term B), with special attention to chronological changes during gestation. Methods:  We used an immunohistochemical method with antibody against neuron-specific enolase to determine the percentage of seminiferous tubules containing spermatogonia in the formalin-fixed tissue samples, and a morphometrical method using a dissector to count the number of spermatogonia. Results:  There were no significant statistical differences between the two time periods in the regression parameters compared for the number of spermatogonia and Sertoli cells, nor was there a remarkable difference in the estimated number of Leydig cells. Conclusion:  The results indicate that even if there has been a deterioration in human semen quality, it is not necessarily caused by endocrine disruption of fetal testicular development. (Reprod Med Biol 2006; 5: 65-70).

Botulinum toxin A during pregnancy: a survey of treating physicians

Botulinum toxin A (btxA) is widely used for cosmetic purposes, headaches, dystonia, spasticity, pain and other on and off label uses. Despite the widespread use of btxA in women of childbearing potential, there are few data on the effects of this drug on pregnant women and the fetus. The goal of this study was to survey physicians who use btxA, to determine their experience with pregnant women. We surveyed 900 physicians who used commercially available btxA. The questionnaire asked treating physicians if they had knowingly or unknowingly injected pregnant women and what was the outcome of each pregnancy. In total, 396 physicians (44%) returned questionnaires, of whom only 12 physicians reported injecting pregnant women with btxA. Sixteen pregnant women were injected, mostly in the first trimester, and only one patient, who had prior spontaneous abortions, suffered a miscarriage. Another woman had a therapeutic abortion. All other pregnancies went to term and there were no fetal malformations. Based on this limited survey of treating physicians in the USA, btxA appears to be relatively safe for both expectant mother and fetus. We need further data, however, and we would recommend that physicians and patients carefully consider the risks and benefits before using btxA in pregnant women.

Selective type 5 phosphodiesterase inhibition alters pulmonary hemodynamics and lung liquid production in near-term fetal lambs

Nitric oxide causes dilation of the pulmonary circulation and reduction in net lung liquid production in the fetal lamb, two critical perinatal events. Phosphodiesterase inhibition alone causes similar changes and also enhances the effects of nitric oxide. To better define the cyclic guanosine 5'-monophosphate (GMP) pathway in these events, we studied the effects of a specific phosphodiesterase inhibitor, E4021, on pulmonary arteries and veins isolated from near-term fetal lambs, as well as in intact, chronically instrumented late-gestation fetal lambs. In the in vitro experiments, both pulmonary arteries and veins relaxed to E4021 in a dose-dependent manner, although pulmonary veins were significantly more sensitive to E4021. Pretreatment with N(G)-nitro-l-arginine (L-NNA) abolished this response in arteries but not in veins. In both arteries and veins, pretreatment with beta-phenyl-1,N2-etheno-8-bromoguanosine-3',5'-cyclic monophosphorothionate blunted relaxations to E4021. In the in vivo experiments, E4021 infusion into either the pulmonary artery or central venous circulation increased pulmonary blood flow and decreased pulmonary vascular resistance, and these responses were blunted by pretreatment with L-NNA. Net lung liquid production, measured by a dye-dilution technique using blue dextran, decreased when E4021 was infused directly into the pulmonary artery and this effect was not altered by L-NNA. There was no effect on lung liquid production when E4021 was infused into the central venous circulation. Taken together, these results suggest that the pulmonary hemodynamic effects of E4021 involve the cyclic GMP pathway and are primarily nitric oxide synthase dependent. In contrast, the effects on E4021 on net lung liquid production appear to be independent of nitric oxide synthase, suggesting that these two critical perinatal events might be modulated independently.

Maternal age, parity, and reproductive outcome in captive chimpanzees (Pan troglodytes)

As early as the 1970s, it was suggested that nonhuman primates may serve as models of human reproductive senescence. In the present study, the reproductive outcomes of 1,255 pregnancies in captive chimpanzees (Pan troglodytes) were examined in relation to parity and its covariate, maternal age. The results show that the percentage of positive pregnancy outcomes was negatively correlated with increasing parity. In addition, spontaneous abortions, stillbirths, and caesarian sections (C-sections) were positively correlated with increasing parity. Maternal age, rather than parity, was found to be the most important predictor of negative birth outcome. This study supports research demonstrating reproductive decline and termination in nonhuman primates, and is the first to quantitatively account for this phenomenon in captive female chimpanzees.

Biomarkers in maternal and newborn blood indicate heightened fetal susceptibility to procarcinogenic DNA damage

Polycyclic aromatic hydrocarbons (PAHs) such as benzo[a]pyrene (BaP) are widespread air contaminants released by transportation vehicles, power generation, and other combustion sources. Experimental evidence indicates that the developing fetus is more susceptible than the adult to carcinogenic effects of PAHs, although laboratory studies in rodents suggest that the dose to fetal tissues is an order of magnitude lower than that to maternal tissues. To assess fetal versus adult susceptibility to PAHs and environmental tobacco smoke (ETS), we compared carcinogen-DNA adducts (a biomarker associated with increased cancer risk) and cotinine (a biomarker of tobacco smoke exposure) in paired blood samples collected from mothers and newborns in New York City. We enrolled 265 nonsmoker African-American and Latina mother-newborn pairs in New York City between 1997 and 2001 (estimated average ambient air BaP concentrations < 0.5 ng/m3). Despite the estimated 10-fold lower fetal dose, mean levels of BaP-DNA adducts as determined by high-performance liquid chromatography-fluorescence were comparable in paired New York City newborn and maternal samples (0.24 adducts per 10(8) nucleotides, 45% of newborns with detectable adducts vs. 0.22 per 10(8) nucleotides, 41% of mothers with detectable adducts). However, by the Wilcoxon signed-rank test, the levels in newborns were higher (p = 0.02). Mean cotinine was higher in newborns than in mothers (1.7 ng/mL, 47% detectable vs. 1.28 ng/mL, 44% detectable). Consistent with our prior study in a Caucasian Polish population, these results indicate increased susceptibility of the fetus to DNA damage and reduced ability to clear ETS constituents. The findings have implications for risk assessment, given the need to protect children as a sensitive subset of the population.

Tricuspid regurgitation in the diagnosis of chromosomal anomalies in the fetus at 11-14 weeks of gestation

OBJECTIVE

To analyse patient data to elucidate the apparent association between an abnormal karyotype and tricuspid regurgitation found during fetal echocardiography at early gestations.

SETTING

Tertiary referral centre for fetal medicine and cardiology.

METHODS

Fetuses between 11 and 14 weeks' gestation were selected for detailed echocardiography. Referral reasons were increased nuchal translucency, a suspected cardiac or extracardiac malformation, and a family history of cardiac malformation.

INTERVENTION

The fetus was imaged transabdominally. The four chamber view, outflow tracts, arterial duct, and aortic arch were assessed on cross sectional imaging and colour flow mapping. Pulsed Doppler of the atrioventricular valves was recorded if possible. Subsequently, the fetal karyotype was ascertained by chorionic villous sampling.

RESULTS

Pulsed Doppler recording of the tricuspid valve was obtained for 262 fetuses. Tricuspid regurgitation was present in 70 (27%) of these, of whom 58 (83%) proved to have karyotype anomalies. In contrast, 68 (35%) of those without tricuspid regurgitation were found to have karyotype anomalies (95% confidence interval 36% to 59%, p < 0.001). Structural heart defects were detected in 34 of the 58 (59%) with tricuspid regurgitation and in 22 (32%) of those without. The chromosome defect most frequently found to be associated with tricuspid regurgitation was trisomy 21, but all types of karyotypic anomalies were seen in association.

CONCLUSION

A careful search for tricuspid regurgitation is an important aspect of the evaluation of the early fetus, as this is frequently a marker for chromosomal defects even in the absence of structural heart disease.

Review of diagnosis, treatment, and outcome of fetal atrial flutter compared with supraventricular tachycardia

OBJECTIVE

To review the diagnosis, treatment, and outcome of fetal atrial flutter compared with supraventricular tachycardia.

DESIGN

Retrospective review of published reports: 11 papers about fetal tachyarrhythmia published between 1991 and 2002 were selected for review.

MAIN OUTCOME MEASURES

All selected studies were analysed for the type of arrhythmia, degree of atrioventricular block in atrial flutter, occurrence of hydrops fetalis, gestational age at diagnosis, first and second line drug treatment, associated cardiac and extracardiac malformations, and mortality of the fetuses.

RESULTS

Atrial flutter accounted for 26.2% of all cases of fetal tachyarrhythmias, and supraventricular tachycardia for 73.2%. Hydrops fetalis was reported in 38.6% and 40.5% of fetuses with atrial flutter and supraventricular tachycardia, respectively (NS). Hydropic fetuses with atrial flutter had higher ventricular rates (median 240 beats/min, range 240-300) than non-hydropic fetuses (220 beats/min, range 200-310) (p = 0.02), whereas the atrial rates were not significantly different (median 450 beats/min, range 370-500). Digoxin treatment resulted in a higher conversion rate in non-hydropic fetuses with fetal tachyarrhythmias than in hydropic fetuses (p < 0.001). The overall mortality of atrial flutter was similar to that of supraventricular tachycardia, at 8.0% v 8.9% (p = 0.7).

CONCLUSIONS

The prevalence of hydrops fetalis did not differ in fetal atrial flutter and supraventricular tachycardia with 1:1 conduction. There was no difference between the response rate to digoxin in fetus with atrial flutter or supraventricular tachycardia. Mortality was similar in the two types of tachyarrhythmia.

Vitamin E sensitive genes in the developing rat fetal brain: a high-density oligonucleotide microarray analysis

Vitamin E (tocopherols and tocotrienols) is essential for normal neurological function. Recently we have reported that the neuroprotective properties of tocotrienols are much more potent than that of the widely studied tocopherols (Sen, C.K., Khanna, S., Roy, S. and Parker, L. (2000) J. Biol. Chem. 275, 13049-13055). The objective of this study was to evaluate whether (i) oral supplementation of tocotrienols during pregnancy is bioavailable to fetal and mother brains; (ii) short-term change in dietary vitamin E levels of pregnant rats influences gene expression profile of developing fetal brains. We report that dietary tocotrienol is bioavailable to both mother and fetal brains. The enrichment is more in fetal brain tissue. Using a GeneChip microarray expression profiling approach we have identified a specific set of vitamin E sensitive genes in the developing rat fetal brain.

Fetal musculoskeletal malformations with a poor outcome: ultrasonographic, pathologic, and radiographic findings

The early and accurate antenatal diagnosis of fetal musculoskeletal malfomations with a poor outcome has important implications for the management of a pregnancy. Careful ultrasonographic examination of a fetus helps detect such anomalies, and a number of characteristic features may suggest possible differential diagnoses. During the last five years, we have encountered 39 cases of such anomalies, and the typical prenatal ultrasonographic and pathologic findings of a number of those are described in this article.

Prenatal ultrasound findings of fetal neoplasms

A variety of neoplasms can develop in each fetal organ. Most fetal neoplasms can be detected by careful prenatal ultrasonographic examination. Some neoplasms show specific ultrasonographic findings suggesting the differential diagnosis, but others do not. Knowledge of the presence of a neoplasm in the fetus may alter the prenatal management of a pregnancy and the mode of delivery, and facilitates immediate postnatal treatment. During the last five years, we experienced 32 cases of fetal neoplasms in a variety of organs. We describe their typical ultrasonographic findings with correlating postnatal CT, MRI, and pathologic findings.

Early development of neuronal activity in the primate hippocampus in utero

Morphological studies suggest that the primate hippocampus develops extensively before birth, but little is known about its functional development. Patch-clamp recordings of hippocampal neurons and reconstruction of biocytin-filled pyramidal cells were performed in slices of macaque cynomolgus fetuses delivered by cesarean section. We found that during the second half of gestation, axons and dendrites of pyramidal cells grow intensively by hundreds of micrometers per day to attain a high level of maturity near term. Synaptic currents appear around midgestation and are correlated with the level of morphological differentiation of pyramidal cells: the first synapses are GABAergic, and their emergence correlates with the growth of apical dendrite into stratum radiatum. A later occurrence of glutamatergic synaptic currents correlates with a further differentiation of the axodendritic tree and the appearance of spines. Relying on the number of dendritic spines, we estimated that hundreds of new glutamatergic synapses are established every day on a pyramidal neuron during the last third of gestation. Most of the synaptic activity is synchronized in spontaneous slow ( approximately 0.1 Hz) network oscillations reminiscent of the giant depolarizing potentials in neonatal rodents. Epileptiform discharges can be evoked by the GABA(A) receptor antagonist bicuculline by the last third of gestation, and postsynaptic GABA(B) receptors contribute to the termination of epileptiform discharges. Comparing the results obtained in primates and rodents, we conclude that the template of early hippocampal network development is conserved across the mammalian evolution but that it is shifted toward fetal life in primate.

Enterocytic CYP3A4 in a paediatric population: developmental changes and the effect of coeliac disease and cystic fibrosis

AIMS

To investigate the effects of age and disease states on the expression and activity of intestinal CYP3A4 in a paediatric population.

METHODS

Duodenal biopsies and surgical sections were collected from 104 paediatric patients (age range 2 weeks to 17 years) and from 11 foetuses. An S9 fraction was prepared in each case. CYP3A4 expression was assessed by Western blotting and by immunohistochemistry; activity was measured by the rate of formation of 6beta-hydroxytestosterone from testosterone. Villin expression was used as a marker of enterocyte harvest to normalize CYP3A4 expression and activity data.

RESULTS

In the 74 histologically normal paediatric biopsies there were statistically significant increases in CYP3A4 expression (r2 = 0.19, P = 0.001) and activity (r2 = 0.17, P = 0.02) with age. CYP3A4 was practically absent in fetal duodenum and was expressed at relatively low levels in neonates (P < 0.05 between neonates and children > 5 years). Active coeliac disease resulted in significant (P < 0.001) decreases in CYP3A4 expression and activity.

CONCLUSIONS

Duodenal CYP3A4 is present at significantly lower levels in neonates and in patients with active coeliac disease. This may have clinical significance with respect to the oral bioavailability of CYP3A4 substrates.

Cocaine upregulates the dopamine transporter in fetal rhesus monkey brain

Cocaine is a highly addictive drug that binds to the dopamine transporter (DAT), inhibits the reuptake of dopamine, and initiates multiple actions within midbrain dopaminergic systems. Using the rhesus monkey, we have investigated the consequences of in utero cocaine exposure on the expression of DAT in the fetal brain. By using the selective DAT ligand [125I]RTI-121 and tyrosine hydroxylase (TH) immunocytochemistry, we found that DAT binding sites are highly developed by day 70 of gestation and show a distribution pattern similar to TH. The rank order of specific 3beta-(4-[125I]iodophenyl)tropane-2beta-carboxylic acid isopropyl ester ([125I]RTI-121) binding densities was substantia nigra-ventral tegmental area > putamen > caudate > lateral hypothalamus > accumbens > linear/interfascicular nuclei >/= globus pallidus > prefrontal cortex. Furthermore, we observed that DAT mRNA was differentially expressed within fetal midbrain dopamine neurons with the highest levels detected in the ventral tier of the substantia nigra pars compacta, and the lowest levels in the ventral tegmental area and the linear/interfascicular nuclei. In utero cocaine exposure between days 22 and 70 significantly increased DAT mRNA expression, and the density of [125I]RTI-121 binding sites within midbrain dopamine neurons in the 70-d-old fetus. This increased DAT expression is accompanied by other presynaptic and postsynaptic neuronal changes, which collectively suggest that midbrain dopamine neurons are hypoactive after prolonged cocaine exposure, a state that may be a contributing factor in the development of attention deficit disorders observed in subjects exposed prenatally to cocaine.

The hormonal effects of alcohol use on the mother and fetus

During pregnancy, the hormonal systems of the mother and fetus are intricately interconnected to ensure normal fetal development. Accordingly, maternal alcohol consumption during pregnancy can interfere with fetal development, not only directly, through adverse effects exerted by alcohol that crosses the placenta and enters the fetal bloodstream, but also indirectly, by disturbing the functions and interactions of maternal and fetal hormones. In both the mother and the fetus, alcohol exposure can impair the functioning of the hypothalamic-pituitary-adrenal axis, which regulates the body's response to stress; the hypothalamic-pituitary-gonadal axis, which controls reproductive functions; and the hypothalamic-pituitary-thyroid axis, which regulates the metabolism of almost all tissues. In addition, alcohol can interfere with the activities of growth hormone and insulin-like growth factors, which promote body growth and activity. Some of the effects of maternal alcohol consumption on fetal hormone systems may contribute to the adverse effects observed in children with fetal alcohol syndrome and related disorders.

Fetal alcohol syndrome: does alcohol withdrawal play a role?

Alcohol use by a pregnant woman may interfere with the development of her fetus. Newborns whose mothers are intoxicated during delivery can experience withdrawal symptoms, such as tremors and even seizures. It is likely that withdrawal also can occur during fetal development. Thus, the possibility exists that withdrawal by the pregnant woman may exacerbate alcohol's adverse effects on her fetus. One potential mechanism through which alcohol withdrawal might damage the fetus involves the receptor for the neurotransmitter glutamate (i.e., the N-methyl-D-aspartate [NMDA] receptor). This receptor plays a crucial role during neuronal development. Excessive activation of the NMDA receptor, which occurs during withdrawal, may lead to neuronal cell death. Animal studies suggest that these effects may contribute to behavioral deficits following prenatal exposure to alcohol.

Minimally traumatic techniques for in utero access and fetal surgery

BACKGROUND AND OBJECTIVES

Prenatal interventions may prevent some sequelae of congenital anomalies, yet open fetal surgery is limited by pre-term labor. We are developing amnioscopic strategies to reduce risks for in utero surgery.

METHODS

Seven fetal sheep were accessed percutaneously under ultrasound guidance, via maternal laparoscopy/transuterine trocars, or via laparoscopically assisted partial uterine exteriorization (mini-hysterotomy). Three fetal immobilization methods were investigated: 2 mm grasping forceps, 2-0 absorbable Roeder loop lasso, and detachable metal T-fasteners.

RESULTS

Percutaneous access with 2 mm trocars required accessible amniotic fluid pockets. The laparoscopically assisted method enabled 5 mm trocar placement under direct fetal visualization. Mini-hysterotomy avoided trocars and was leak-proof. 2 mm graspers enabled fetal manipulation with repeatable applications. Roeder loop sutures were not readily repositioned, and required two 3 mm or larger trocars. T-fasteners were easily deployed into fetal skin via the self-contained needle applicator with minimal hemorrhage. Cutaneous marks were present immediately from the grasper and T-fastener, but not at postoperative day 10. The Roeder loop produced no observable effects. All devices demonstrated adequate intrauterine performance.

CONCLUSIONS

Minimally invasive fetal surgery promises to lower maternal-fetal risks. All strategies permitted prolonged amnioscopy and fetal manipulation. The 2 mm grasper was easiest to use, producing no observable lasting trauma.

Effect of glucocorticoid treatment on biochemical and hormonal blood parameters in early pregnant gilts

Twenty Polish Landrace gilts were grouped immediately after mating as follows: Experiment I-- Group 1 (5 gilts), control animals and Group 2 (5 gilts), injected i.m. with dexamethasone (30 mg/kg) at 12-h intervals from day 13 to day 22 of pregnancy; Experiment II--Group 3 (5 gilts), injected i.m. with corn oil from day 13 to day 22 of pregnancy and Group 4 (5 gilts), injected i.m. with hydrocortisone acetate (250 mg) at 12-h intervals from day 11 to day 20 of pregnancy. Gilts were placed in metabolic cages on day 7. On days 34-36 of pregnancy gilts were slaughtered and blood samples were collected. Serum was used for analysis of aspartate aminotransferase (S-ASAT), alanine aminotransferase (S-ALAT), alkaline phosphatase (S-ALP), S-cholesterol, S-triglycerides, S-fructosamine, S-urea, S-total protein, and for electrophoretic fractionation of serum proteins, corticosteroid-binding globulin (CBG), cortisol, progesterone, thyroxine (T4) and free T4. There were no significant differences between groups in embryonic survival or in number of viable fetuses after treatment with glucocorticoids. The activity of S-ALP was lower (p < 0.05) in Group 4 than in Group 3 (0.5 vs 1.2 mukat/l). Group 4 had higher (p < 0.05) levels of S-triglycerides (1.17 vs 0.73 mmol/l), S-cholesterol (5.4 vs 2.7 mmol/l), S-total protein (110.5 vs 93.3 g/l), S-albumin (56.3 vs 43.3 g/l) and alpha 2-globulin concentrations (18.0 vs 14.3 g/l) than Group 3. The hydrocortisone-treated gilts had lower (p < 0.05) CBG (6.8 vs 21.3 nmol/l) and beta 1-globulin (3.25 vs 5.0 g/l) concentrations than the oil-treated ones. Concentrations of T4 were lower (p < 0.05) in Groups 2 (61.3 nmo/l) and 4 (49.0 nmol/l) compared with control Groups 1 and 3 (88.2 and 97.0 nmol/l, respectively). Overall, the treatment of early pregnant gilts with hydrocortisone acetate resulted in decreased levels of S-ALP, CBG, beta 1-globulin and T4, and in increased levels of S-cholesterol, S-triglycerides, S-total protein, S-albumin and alpha 2-globulin. The only effect of dexamethasone was a lowering of T4. There were no differences in free T4, S-fructosamine or S-urea between controls and treatments. Furthermore a negative correlation between triglycerides concentrations and the number of embryos (r = -0.76, p < 0.05) was found in control untreated and oil-treated pregnant gilts.

Antenatal assessment of the fetus

There is now a complex array of genetic, biochemical, and biophysical parameters to use in our assessment of the unborn. This article reviews these various parameters and discusses the indication for their use, as well as their limitations.

Alcohol and the fetus: a reasoned approach

Evidence relating adverse pregnancy outcome to maternal alcohol use seldom focuses on nonabusive levels of drinking, yet this is what the majority of patients seek information about. Outcomes of the hypothesized mechanisms of action appear related to pattern of exposure and timing during pregnancy. Methodological problems encountered in human studies include determination of exposure, method of analysis, and outcome measurement. Physicians should be aware of drinking habits of women in the childbearing years, and the reported adverse effects of moderate drinking. Guidelines for alcohol use in pregnancy are suggested.