Adenosine produces changes in cerebral hemodynamics and metabolism as assessed by near-infrared spectroscopy in late-gestation fetal sheep in utero

Rises in fetal adenosine during hypoxia may have a metabolic inhibitory role that helps the fetus adapt to periods of low arterial partial pressure of oxygen (P(a)O(2)). We examined the fetal cerebral hemodynamic and metabolic responses to exogenous adenosine infusion and compared this with previous studies. Six fetal sheep at ca. 125 d gestation were instrumented under general anesthesia with catheters, flow probes, and near-infrared optodes and allowed to recover. After 3 d, adenosine was infused at a level known to reproduce fetal levels during hypoxia. Fetal hemodynamics and cerebral near-infrared spectroscopic (NIRS) variables were monitored and paired blood samples taken for oxygen delivery and consumption calculation. Fetal heart rate, mean arterial pressure, and carotid flow showed no change during adenosine infusion. Cerebral oxyhemoglobin (HbO(2)), deoxyhemoglobin (Hb), and blood volume rose, suggesting venous pooling in the brain. Cerebral cytochrome oxidase (CcO) became more oxidized, indicating reduction in electron flow down the mitochondrial electron transfer chain and, thus, a fall in metabolic rate. Blood sample analysis revealed that there was no change in oxygen delivery to the head but that cerebral oxygen consumption fell during adenosine infusion. These data indicate that fetal cerebral metabolism fell during infusion of adenosine at a level known to reproduce fetal plasma concentrations during hypoxia.

[Biochemical parameters predictive of neuronal damage in childhood]

INTRODUCTION

Hypoxemia, hypoxia and ischemia may induce deletereous effects on both metabolism and cellular structure, particularly at neuronal level. Early estimation of the potential severity of an acute cerebral hypoxic ischemic injury or other pathological conditions would be useful on making preventive or therapeutic decisions. On the basis of the physiopathological mechanisms involved in the brain damage related to hypoxic ischemic encephalopathy of the newborn, a number of metabolic parameters had been studied in the aim to provide an early and reliable marker of tissue injury for both diagnostic and prognostic purposes.

OBJECTIVE

To provide a current revision about the diagnostic and prognostic value of various biochemical parameters determined in different body fluids and studied in the last years, the attention focusing in the hypoxic ischemic encephalopathy of the newborn. Design. For methodological purposes the exposition is structured in the following sections: 1. creatine kinase isoenzymes; 2. lactate; 3. lactate dehydrogenase, aspartate aminotransferase and hidroxybutirate dehydrogenase; 4. excitatory amino acids; 5. glial fibrillary acidic protein; 6. cytokines; 7. neuron specific enolase; 8. oxypurines; 9. cyclic adenosine monophosphate; 10. Others.

CONCLUSIONS

The current role of the above mentioned biochemical parameters as predictors of brain damage and the future perspectives on this topic are discussed.

Influence of mild hypothermia on delayed mitochondrial dysfunction after transient intrauterine ischemia in the immature rat brain

The aim of this study was to determine the effect of different maternal thermal conditions during transient intrauterine ischemia on the mitochondrial respiratory activities in the immature rat brain. On 17 days of gestation, transient intrauterine ischemia was induced by 30 min of right uterine artery occlusion under hypothermic (33.5-34.5 degrees C, n=6), normothermic (36.5-37.5 degrees C, n=6), and hyperthermic conditions (39.5-40.5 degrees C, n=6). All of the pups were delivered by cesarean section at 21 days of gestation and cerebral neocortical tissue was sampled 1 h after delivery. The mitochondrial respiration was measured polarographically in homogenates. In the ischemic uterine horn, ADP-stimulated respiration of the normothermia and the hyperthermia groups decreased significantly to 73 and 74% of the non-ischemic controls, respectively. Since non-stimulated respiration remained unchanged, the respiratory control ratio (RCR) of the normothermia and the hyperthermia groups decreased significantly to 59 and 54% of the non-ischemic levels, respectively. In contrast, the mitochondrial respiratory activities of the hypothermia group showed no differences between the non-ischemic and the ischemic uterine horns. The results demonstrate that mild maternal hypothermia ameliorates the cerebral mitochondrial dysfunction in neonatal rats after intrauterine ischemia due to transient uterine artery occlusion and suggest that maternal thermal conditions, particularly during uteroplacental insufficiency, have important implications for the neuropathological outcome of the newborn.

Hypoxia-ischemia in fetal rabbit brain increases reactive nitrogen species production: quantitative estimation of nitrotyrosine

Reactive nitrogen species (RNS) cause nitration of protein-bound tyrosine that is used as biomarker for detection. We hypothesized that RNS are formed in fetal rabbit brain following acute placental insufficiency. Near-term pregnant rabbits were randomized to either repetitive uterine ischemia or no ischemia, and fetal brains obtained. Only one electrochemical HPLC method (of three tested) was successful in detecting brain nitrotyrosine. Protein nitrotyrosine was significantly increased following cumulative 40 min ischemia and 20 min reperfusion compared to controls. Repetitive hypoxia-ischemia results in the increased formation of RNS in near-term fetal brains.

Acute hypoxia-induced alterations of calbindin-D28k immunoreactivity in cerebellar Purkinje cells of the guinea pig fetus at term

Purkinje cells (PCs) are vulnerable to hypoxic/ischemic insults and rich in calcium and calcium-buffering/sequestering systems, including calcium-binding proteins (CaBPs). Calbindin-D28k is an EF-hand CaBP, which is highly expressed in PCs where it acts primarily as a cellular Ca++ buffer. Elevation of [Ca++] in the cytosol and nuclei of PCs is pivotal in hypoxic/ischemic cell death. We hypothesize that hypoxia results in decreased concentration, or availability of calbindin-D28k in PCs, thereby decreasing their buffering capacity and resulting in increase of intracellular and intranuclear [Ca++]. Cerebellar tissues from normoxic fetuses were compared to fetuses obtained from term pregnant guinea pigs exposed to hypoxia [7% FiO2] for 60 min. The pregnant guinea pigs were either killed upon delivery immediately following hypoxia (Hx0h) or were subsequently allowed to recover for 24 h (Hx24h) or 72 h (Hx72h). Fetal brain hypoxia was documented biochemically by a decrease in brain tissue levels of ATP and phosphocreatine. Compared to normoxic fetuses, there is a predominantly somatodendritic loss or decrease of calbindin-D28k immunohistochemical staining in PCs of Hx0h (p < 0.005), Hx24h (p < 0.05), and Hx72h (p < 0.005) fetuses. Hypoxia-induced alterations of calbindin-D28k immunoreactivity are qualitatively similar at all time points and include a distinctive intranuclear localization in subpopulations of PCs. A similar trend is demonstrated by immunoblotting. Subpopulations of TUNEL+/calbindin-D28k- PCs lacking morphologic features of apoptosis or necrosis are demonstrated in Hx24h and Hx72h fetuses. The present study demonstrates an abrogating effect of perinatal hypoxia on calbindin-D28k immunoreactivity in cerebellar PCs. The perturbation of this Ca++ buffer protein in hypoxia-induced neuronal injury may herald delayed cell death or degeneration.

Increased urinary flow without development of polyhydramnios in response to prolonged hypoxia in the ovine fetus

OBJECTIVE

In the ovine fetus subjected to 24 hours of hypoxia, urinary flow is normal within a few hours from the onset of hypoxia and there is a maintained inhibition of swallowing. We hypothesized that 4 days of fetal hypoxia would lead to polyhydramnios.

STUDY DESIGN

Five late-gestation fetal sheep were subjected to hypoxia for 4 days and 7 other late-gestation fetal sheep served as time control animals. Fetal hypoxia was produced on postsurgical days 5 through 9 by continuous intratracheal nitrogen insufflation to the ewe. On days 3, 5, 7, and 9 after surgery, amniotic fluid volume, fetal urinary flow rate, and the compositions of maternal and fetal blood, amniotic fluid, and fetal urine were measured. A 3-factor analysis of variance was used for statistical analysis.

RESULTS

During the period of experimental hypoxia the mean (+/-SE) fetal PaO(2) was 16.0 +/- 0.6 mm Hg, versus 21.2 +/- 0.7 mm Hg in control sheep (P <.001). Fetal hypoxia was associated with increased urinary flow on days 7 and 9, averaging 1410 +/- 310 and 2101 +/- 345 mL/d, respectively, versus 585 +/- 92 and 699 +/- 78 mL/d, respectively, in control animals (P <.001). Amniotic fluid volume was unchanged with time and averaged 960 +/- 159 mL in hypoxic fetuses on postsurgical days 7 through 9 and 851 +/- 130 mL in control animals (P =.60). Fetal blood lactate increased in the hypoxic animals, averaging 3.4 +/- 2.1 mmol/L versus 1.6 +/- 0.3 mmol/L in control animals (P =.02). Fetal urinary excretions of sodium, potassium, chloride, and lactate increased significantly during hypoxia, by 170% to 400%.

CONCLUSION

Four days of nitrogen-induced hypoxia in the ovine fetus resulted in excess fetal urinary flow approximating 1000 mL/d greater than normal without the development of polyhydramnios. Because amniotic fluid volume did not change and hypoxia is a known inhibitor of fetal swallowing, we speculate that intramembranous absorption of amniotic water, electrolytes, and lactate increased.

Developmental regulation of corticotrophin receptor gene expression in the adrenal gland of the ovine fetus and newborn lamb: effects of hypoxia during late pregnancy

Responsiveness of the fetal sheep adrenal gland to adrenocorticotrophin (ACTH) increases in late pregnancy, resulting in increased glucocorticoid production. Development of this responsiveness is an important determinant of fetal hypothalamic-pituitary-adrenal function and depends, in part, on the potential for ACTH binding to adrenal tissue. In the present study, we have examined the developmental pattern of ACTH receptor (ACTH-R) expression during the latter half of pregnancy and in neonatal and adult life. As hypoxaemia induces increases in cortisol and ACTH secretion, in addition to increasing fetal adrenal responsiveness, a further aim of this study was to investigate whether hypoxaemia was associated with altered expression of the ACTH-R gene. Whole adrenal glands were removed from fetal sheep, lambs and adult sheep at different stages of development for measurement of ACTH-R mRNA. Moderate hypoxaemia was induced for 48 h beginning on days 124-128, or on days 132-134 of gestation, by decreasing the maternal fractional inspired oxygen. ACTH-R mRNA was detected by northern blotting using a cDNA cloned in our laboratory and by in situ hybridisation. ACTH-R mRNA (3.6 kb major transcript) was detected in adrenal tissue at day 63 of gestation. Its relative abundance increased significantly (P<0.05) between days 126-128 and 140-141 of pregnancy, increased further with the onset of spontaneous labour, and remained increased in newborn lambs at 7 h-7 days after birth. ACTH-R mRNA levels then decreased in adrenal tissue from lambs and adult sheep (P<0.05). Hypoxaemia for 48 h significantly increased ACTH-R mRNA expression in adrenals of the older fetuses (days 134-136) compared with that in controls (P<0.05), but was without effect in younger fetuses. We conclude that levels of ACTH-R mRNA in the fetal adrenal gland increase as term approaches, coincident with the endogenous prepartum surge in plasma ACTH and cortisol. Sustained hypoxaemia resulted in an upregulation of mRNA encoding for ACTH-R, but only in older fetuses and in association with a sustained increase in plasma cortisol. These results are consistent with cortisol, ACTH, or both, contributing to increased fetal adrenal responsiveness, by increasing expression of fetal adrenal receptors for ACTH.

Effect of the immunosuppressant drug FK506 on neonatal cerebral mitochondrial function and energy metabolism after transient intrauterine ischemia in rats

Mitochondrial respiratory activities and energy metabolism were measured in neonatal rat brains to evaluate the influence of transient intrauterine ischemia on the near-term fetus and to assess the effect of the immunosuppressant drug FK506 treatment. Transient intrauterine ischemia was induced by 30 min of right uterine artery occlusion at 17 days of gestation in Wistar rats. The vehicle or 1.0 mg/kg of FK506 was administered after 1 h of recirculation. All of the pups were delivered by cesarean section at 21 days of gestation and samples of cerebral cortical tissue were obtained from pups at 1 h after birth. The mitochondrial respiration was measured polarographically in homogenates. For the analysis of ATP, ADP, and AMP, neonatal brains were frozen in situ and fluorometric enzymatic techniques were used. In the neonatal cortical tissue exposed to ischemia, mitochondrial respiratory activities and ATP concentrations decreased significantly to approximately 59 and 67% of those in normoxic controls, respectively. The deterioration of both mitochondrial respiratory activities and high-energy phosphates was prevented by FK506, given 1 h after the start of recirculation. The present results indicate that transient intrauterine ischemia is accompanied by mitochondrial dysfunction and cellular bioenergetic failure in the neonatal rat brain and suggest that treatment with FK506 prevents the deterioration, even when administered after the ischemic periods.

Effects of maternal iron restriction in the rat on hypoxia-induced gene expression and fetal metabolite levels

The mechanism by which maternal Fe deficiency in the rat causes fetal growth retardation has not been clearly established. This study compared the effects on the fetuses from dams fed a control diet with two groups of dams fed Fe-restricted diets. One Fe-restricted group was fed the Fe-restricted diet for 1 week prior to mating and throughout gestation and the second Fe-restricted group was fed the Fe-restricted diet for 2 weeks prior to mating and throughout gestation. On day 21 of gestation Fe-restricted dams, and their fetuses, were anaemic. Fetal weight was reduced in both Fe-restricted groups compared with controls. Expression of hypoxia-inducible factor (HIF)-1alpha and vascular endothelial growth factor (VEGF) are induced by hypoxia. The levels of HIF-1alpha mRNA were highest in placenta, then in kidney, heart and liver but were not different between the groups. Levels of plasma VEGF were not different between the groups. Maternal plasma triacylglycerol was decreased in the 1-week Fe-restricted dams compared with controls. Maternal plasma cholesterol and free fatty acid levels were not different between the groups. In fetal plasma, levels of triacylglycerol and cholesterol were decreased in both Fe-restricted groups. In maternal plasma, levels of a number of amino acids were elevated in both Fe-restricted groups. In contrast, levels of a number of amino acids in fetal plasma were lower in both Fe-restricted groups. Fetal plasma lactate was increased in Fe-restricted fetuses but fetal plasma glucose and beta-hydroxybutyrate were not affected. These changes in fetal metabolism may contribute to fetal growth retardation in this model. This study does not support the hypothesis that the Fe-restricted fetus is hypoxic.

The effect of intermittent umbilical cord occlusion on insulin-like growth factors and their binding proteins in preterm and near-term ovine fetuses

Intermittent umbilical cord compression with resultant fetal hypoxia can have a negative impact on fetal growth and development. Insulin-like growth factors (IGFs) and their binding proteins (IGFBPs) are the most important regulators of fetal growth. In preterm (107-108 days of gestation) and near-term (128-131 days of gestation) ovine fetuses, we have determined the effect of intermittent umbilical cord occlusion (UCO) over a period of 4 days on the profile and expression of IGFs and IGFBPs. In experimental group animals (preterm n=7; near term n=7) UCOs were carried out by complete inflation of an occluder cuff (duration 90 s) every 30 min for 3-5 h each day, while control fetuses (preterm n=7; near term n=7) received no UCOs. Ewes were euthanized at the end of day 4, and fetal heart, lung, kidney, liver, skeletal muscle and placenta were collected. During UCOs, PO(2! ) fell (by approximately 13 mmHg), pH fell (by approximately 0.05) and PCO(2) increased (by approximately 7 mmHg), and changed to a similar extent in both preterm and near-term groups. In both preterm and near-term groups, there was no difference in fetal body or organ weight between UCO and control fetuses. No significant changes were observed in plasma IGF-I and -II concentrations or IGFBP-1, -2, -3 or -4 levels throughout the 4-day study at either gestational age. In the preterm group UCO fetuses, IGF-II mRNA (1.2-6.0 kb) levels were lower in fetal lung (33%, P<0.05), heart (54%, P<0.01) and skeletal muscle (29%, P<0.05), but there were no differences in IGF-I mRNA levels (7.3 kb); IGFBP-2 mRNA (1.5 kb) levels were lower in the right lobe of the liver (42%, P<0.05) and kidney (22%, P<0.01), but hig! her in the heart (72%, P<0.01), while IGFBP-4 (2.4 kb) levels were lower in skeletal muscle (21%, P<0.01). In the near-term group UCO fetuses, IGFBP-2 mRNA levels were greater in the placenta (39%, P<0.05). Thus, intermittent UCO as studied has a greater effect on the expression of genes encoding certain peptides of the fetal IGF system in selected tissues in preterm fetuses than that in near-term fetuses. Altered IGFBP-2 mRNA levels with reduced IGF-II mRNA levels in selected tissues may mediate changes in growth and/or differentiation that might become apparent if the length of the UCO study were extended.

In vivo electrical activity of brainstem neurons in fetal rats during asphyxia

To see changes in the activity and the sensitivity to glutamate of fetal brain neurons during asphyxia, the electrical activity of brainstem neurons was recorded extracellularly in fetal rats which were still connected with the dams by the intact umbilical cord. In urethan-anesthetized pregnant rats, fetal asphyxia (2-10 min) was induced by occluding the umbilical cord with a surgical clip, while reperfusion of the umbilical blood flow was performed by local application of a relaxant of blood vessels to the occlusion site. The spontaneous discharge of fetal brainstem neurons was suppressed for a long period of time by umbilical cord occlusion. The suppression of the firing occurred 48-150 (78+/-7) s after the start of umbilical cord occlusion, and lasted even after fetal cortical PO(2) recovered to control level after reperfusion. The changes occurred with a marked reduction in spike amplitude. A similar suppression was observed for the spikes induced by iontophoretic application of glutamate, although fetal brainstem neurons were extremely sensitive to glutamate before asphyxia. The suppression of the spontaneous spikes became more notable and longer when asphyxia was repeated. These findings suggest that the long-lasting suppression of fetal neurons during asphyxia may contribute to a reduction of cellular energy requirements in the fetal brain, thereby playing a role in the resistance of fetal neurons to brain damage caused by asphyxia. Furthermore, the reduced sensitivity of fetal neurons to glutamate during asphyxia may also contribute to prevent brain damage due to excitotoxity of glutamate.

Mechanisms of perinatal cerebral injury in fetus and newborn

Cerebral hypoxia in the fetus and newborn results in neonatal morbidity and mortality as well as long-term sequelae such as mental retardation, seizure disorders, and cerebral palsy. In the developing brain, determinants of susceptibility to hypoxia should include the lipid composition of the brain cell membrane, the rate of lipid peroxidation, the presence of antioxidant defenses, and the development and modulation of excitatory amino acid neurotransmitter receptors such as the N-methyl-D-aspartate (NMDA) receptor, the intracellular Ca2+, and the intranuclear Ca(2+)-dependent mechanisms. In addition to the developmental status of these cellular components, the response of these potential mechanisms to hypoxia determines the fate of the hypoxic brain cell in the developing brain. Using electron spin resonance spectroscopy of alpha-phenyl-N-tert-butyl-nitrone spin adducts, studies from our laboratory demonstrated that tissue hypoxia results in increased free radical generation in the cortex of fetal guinea pigs and newborn piglets. Pretreatment with MgSO4 significantly decreased the hypoxia-induced increase in free radical generation in the term fetal brain. We also showed that brain tissue hypoxia modifies the NMDA receptor ion-channel recognition and modulatory sites. Furthermore, a higher increase in NMDA receptor agonist-dependent Ca2+ in synaptosomes was demonstrated. The increase in intracellular Ca2+ may activate several enzymatic pathways such as phospholipase A2 and metabolism of archidonic acid by cyclooxygenase and lipoxygenase, conversion of xanthine dehydrogenase to xanthine oxidase by proteases, and activation of nitric oxide synthase. Using inhibitors of each of these enzymes such as cyclooxygenase (indomethacin), lipoxygenase (nordihydroguaiaretic acid), xanthine oxidase (allopurinol), and nitric oxide synthase (N-nitro-L-arginine), studies have shown that these enzyme reactions result in oxygen free radical generation, membrane peroxidation, and cell membrane dysfunction in the hypoxic brain. Specifically, generation of nitric oxide free radicals during hypoxia may lead to nitration and nitrosylation of specific membrane proteins and receptors, resulting in dysfunction of receptors and enzymes. We conclude that hypoxia-induced modification of the NMDA receptor leading to increased intracellular Ca2+ results in free radical generation and cell injury. We suggest that during hypoxia the increased intracellular Ca2+ may lead to increased intranuclear Ca2+ concentration and alter nuclear events including transcription of specific apoptotic genes and activation of endonucleases, resulting in programmed cell death.

Reduced nitric oxide is involved in prenatal ischemia-induced tolerance to neonatal hypoxic-ischemic brain injury in rats

To explore the role of nitric oxide (NO) in the hypoxic-ischemic (HI) tolerance phenomenon, NO production and brain injury following neonatal hypoxia-ischemia (induced by unilateral common carotid artery ligation followed by hypoxic exposure) were assessed in rat pups with or without HI preconditioning. A previously demonstrated prenatal HI rat model of preconditioning was used in this study. On G17, rat fetuses were subjected to either HI in utero (PreHI) for 30 min or a sham operation (SH). The PreHI treatment provided significant protection against neonatal HI-induced brain injury, as indicated by decreased ipsilateral brain weight reduction, less severe tissue damage, and decreased activation of caspase-3. Concomitant with the protective effect of prenatal HI preconditioning, elevation of nitrite/nitrate content in the ipsilateral cortex of the brain, as an indirect measure of NO production, was significantly lower in the PreHI group than in the SH group following neonatal HI. The protective effect of prenatal HI preconditioning could be reversed by sodium nitroprusside (SNP), a spontaneous NO donor, while SNP had no effect on neonatal HI-induced brain injury in the SH group. Intraperitoneal administration of SNP to pups from the PreHI group (2 mg/kg, 24 and 1.5 h before neonatal HI) increased neonatal HI-induced brain injury similar to that observed in the SH group. On the other hand, L-N(G)-nitro-arginine (2 mg/kg, i.p., 1.5 h before the hypoxic exposure), an NO synthase inhibitor, significantly attenuated neonatal HI-induced brain injury in the SH group. The overall results indicate that reduced NO production in the preconditioned rat brain contributes to prenatal HI-induced tolerance to neonatal HI brain injury.

A quantitative study on the effects of maternal smoking on placental morphology and cadmium concentration

The aim of this study was to quantify the effects of maternal cigarette smoking on placental morphology, paying particular attention to variables known to be influential in facilitating oxygen diffusion. Structural quantities were estimated by stereological analyses of placental samples drawn from non-smoking and smoking women whose smoking habits were assessed both subjectively (from volunteered cigarette consumption) and objectively (by determining levels of plasma cotinine, a major metabolite of nicotine). Concentrations of placental cadmium were also measured. In the smoking group, maternal and fetal haematocrits were elevated and mean birthweight was reduced. Within placentae, the most significant alterations were increases in cadmium levels, the relative volumes of maternal intervillous space, the relative surface areas of fetal capillaries and decreases in the relative and absolute volumes of fetal capillaries. Findings indicate that changes in capillary volume are the result of a decrease in mean capillary diameter rather than total length. The mean thickness of the trophoblast component of the villous membrane was also increased in the smoking group. Although increased haematocrits suggest that fetuses of smoking mothers suffer hypoxic stress, these morphological changes are likely to compromise, rather than assist, transplacental oxygen transfer. This is in marked contrast to the adaptive changes seen in pregnancies associated with preplacental hypoxia and suggests that other factors might be compromising the fetoplacental unit. Finally, although the morphological changes associated with maternal smoking seem to be the result of an all-or-none, rather than dose-dependent, effect, the available evidence is not conclusive.

Cooling the newborn after asphyxia - physiological and experimental background and its clinical use

Many years of experimental work on hypoxic-ischaemic injury have supported the hypothesis that cooling the body and brain after the primary injury offers permanent neuroprotection. Clinically, the question of how late cooling can start after the insult and still have a protective effect is important and not fully investigated. Pilot studies in human adults initiated cooling after 10-18 h (trauma, stroke), however animal data suggest cooling is not effective if started later than 6 h. There might be a threshold for 'cooling dose' - by depth or duration - to achieve permanent protection. Hypothermia must be administered with understanding of the extensive physiological effects. Different enzymes have different sensitivity to changes in temperature, hence some effects may be beneficial and some deleterious. Hypothermia and cardiovascular responses and coagulation needs careful monitoring.

Novel treatments after experimental brain injury

Perinatal hypoxic-ischaemic encephalopathy(HIE) is being studied in laboratory models that allow the delayed cascade of events triggered by the energetic insult to be examined in detail. The concept of the 'excitotoxic cascade' provides a conceptual framework for thinking about the pathogenesis of HIE. Major events in the cascade triggered by hypoxia-ischaemia include overstimulation of N-methyl-D-aspartate type glutamate receptors, calcium entry into cells, activation of calcium-sensitive enzymes such as nitric oxide synthase, production of oxygen free radicals, injury to mitochondria, leading in turn to necrosis or apoptosis. New experimental approaches to salvaging brain tissue from the effects of HIE include inhibition of neuronal nitric oxide synthase, administration of neuronal growth factors, and inhibition of the caspase enzymes that execute apoptosis. Recent experimental work suggests that these approaches may be effective during a longer 'therapeutic window' after the insult, because they are acting on events that are relatively delayed. Application of modest hypothermia may allow these agents to be neuroprotective at even longer intervals after hypoxia-ischaemia.

Selection of babies for intervention after birth asphyxia

Based on animal experiments, the therapeutic window for neonates with signs of perinatal hypoxia-ischaemia is probably less than 6 h, and early selection of patients is of utmost importance. In term neonates, fetal heart rate and blood flow patterns, the Apgar score, and other clinical scoring systems are insufficient to select patients for intervention, whereas umbilical artery pH<7.0 combined with umbilical arteriovenous differences in PCO(2), lactate/pyruvate ratios in cord blood, and CSF interleukin-1beta have a better predictive value. At present, neurophysiological methods such as (amplitude-integrated) EEG and evoked potentials have the best predictive value. In preterm neonates, lactate/pyruvate and uric acid measurements in cord blood, as well as neurophysiology appear to be helpful to predict brain injury, and might be used to select patients for intervention.

Hemodynamic and metabolic responses to moderate asphyxia in brain and skeletal muscle of late-gestation fetal sheep

The purpose of this study was to investigate metabolic and hemodynamic responses in two fetal tissues, hindlimb muscle and brain, to an episode of acute moderate asphyxia. Near-infrared spectroscopy was used to measure changes in total hemoglobin concentration ([tHb]) and the redox state of cytochrome oxidase (COX) simultaneously in the brain and hindlimb of near-term unanesthetized fetal sheep in utero. Oxygen delivery (DO(2)) to, and consumption (VO(2)) by, each tissue was derived from the arteriovenous difference in oxygen content and blood flow, measured by implanted flow probes. One hour of moderate asphyxia (n = 11), caused by occlusion of the maternal common internal iliac artery, led to a significant fall in DO(2) to both tissues and to a significant drop in VO(2) by the head. This was associated with an initial fall in redox state COX in the leg but an increase in the brain. [tHb], and therefore blood volume, fell in the leg and increased in the brain. These data suggest the presence of a fetal metabolic response to hypoxia, which, in the brain, occurs rapidly and could be neuroprotective.

Hypoxia, the subsequent systemic metabolic acidosis, and their relationship with cerebral metabolite concentrations: An in vivo study in fetal lambs with proton magnetic resonance spectroscopy

OBJECTIVE

The relationship among decreased fetal arterial oxygen saturation, the subsequent systemic metabolic acidosis, and changes in cerebral metabolite concentrations in the fetal lamb brain was investigated by means of quantitative proton magnetic resonance spectroscopy.

STUDY DESIGN

Fetal hypoxia was induced in 6 fetal lambs by gradual reduction of the oxygen supply to the anesthetized pregnant ewe. In vivo proton magnetic resonance spectroscopy was performed on the fetal lamb brain simultaneously with repeated measurements of fetal arterial oxygen saturation and acid-base balance.

RESULTS

Proton magnetic resonance spectra showed metabolites such as inositol, choline compounds, creatine, and N-acetylaspartate. A signal for cerebral lactate was below the detection level under normoxic conditions and increased during hypoxia to indicate concentrations varying from 2.8 to 11.1 mmol/kg wet weight brain tissue. N -Acetylaspartate signals decreased during hypoxia, whereas signals of inositol, choline compounds, and creatine remained constant.

CONCLUSION

These results support the view that fetal cerebral anaerobic metabolism in fetal lambs does not start under hypoxic conditions if the arterial blood pH is >7.28 or the base excess is >-8 mmol/L.

Effects of vaginal birth versus caesarean section birth with general anesthesia on blood gases and brain energy metabolism in neonatal rats

Using a rat model, several laboratories have demonstrated long-term effects of Caesarean section (C-section) birth or of global hypoxia during C-section birth on a variety of central nervous system (CNS) parameters. These studies used C-section delivery from rapidly decapitated dams, to avoid confounding anesthetic effects, or from dams anesthetized with halothane or ether under unspecified conditions. Systemic oxygenation or cerebral energy metabolites in the pups at birth have not been systematically measured in this model. To develop and characterize a C-section model with relevance to the human situation, the present study measured arterial/venous blood gases and pH and brain ATP and lactate, a widely accepted measure of CNS hypoxia, in pups born either vaginally, by C-section from decapitated dams, or by C-section from dams anesthetized with nitrous oxide (N2O) and increasing concentrations of isoflurane under well-defined conditions. Immediately after birth, pups born vaginally, by C-section with maternal decapitation, or by C-section with 2.5% isoflurane showed no group differences in systemic pO2 or pH or brain ATP levels, but pCO2 was elevated in the C-section/2.5% isoflurane group. Pups born by C-section with 3.0, 3.5, or 4.0% isoflurane, showed progressive reductions in blood pO2 and increases in pCO2 and blood pH was reduced with 3.5% isoflurane. Relative to vaginal birth, brain lactate levels were unchanged in pups born by C-section with any concentration (2.5-4.0%) of isoflurane, but reduced in pups born by C-section from decapitated dams. At 1 h (and 4 h) after birth, in both vaginally born controls and the 2.5% isoflurane group, brain lactate fell while blood pO2 and brain ATP remained stable. In the 3.0, 3.5, or 4.0% isoflurane groups, blood gases and pH and brain lactate also normalized to control values. In conclusion, rat neonates show minimal signs of systemic or CNS hypoxia following C-section birth under 2.5% isoflurane with N2O. However, there is a rather narrow window of isoflurane concentrations which produces effective maternal anesthesia without producing respiratory compromise in the neonate. Thus the results indicate that the level of maternal anesthesia employed is an important factor influencing neonatal systemic and CNS oxygenation during C-section birth.

Hypoxic response of synaptosomal proteins in term guinea pig fetuses

Early events in the hypoxia-induced response trigger tyrosine phosphorylation cascades involving a large number of enzymes and substrates. The resolving power of advanced two-dimensional gel electrophoresis, followed by immunoblotting with specific antibodies to phosphotyrosine, has been used to analyze hypoxia-induced modifications in guinea pig brain synaptosomes. These procedures, in conjunction with computer-aided image analysis, are useful in the differential display of gene products, providing comparison at the level of posttranslationally modified products. Studies were performed in cerebral cortical synaptosomes from three normoxic and three hypoxic newborn guinea pigs. To filter off background noise consisting of nonreproducible migrating protein spots, only reproducible features of electrophoretic patterns were considered. Immunoreactivity patterns obtained with anti-phosphotyrosine antibodies proved to be different in normoxic and hypoxic synaptosomes: of a total of 130 immunoreactive spots, 49 were tyrosine-phosphorylated in hypoxic synaptosomes only and 20 in the normoxic ones only. Our data suggest that hypoxia extensively remodels the signaling pathway by switching off tyrosine phosphorylation of some cellular components (i.e., alpha-internexin) and switching on tyrosine phosphorylation of some other proteins (i.e., heat shock cognate 70, aconitase, 2',3'-cyclic nucleotide 3'-phosphodiesterase, and pyruvate kinase).

[Study on the relationship between perinatal hypoxia and concentration of endothelin-1 in amniotic fluid]

OBJECTIVE

To investigate the relationship between endothelin-1 (ET-1) concentration in amniotic fluid (AF) and perinatal hypoxia.

METHODS

161 cases were measured for amniotic fluid(AF) ET-1 levels by radioimmunoassay. 110 cases of normal pregnancy were included in control group among which 30 term pregnancies were simultaneously measured for maternal and umbilical plasma ET-1. 51 cases of intrauterine hypoxia were the study group.

RESULTS

(1) The AF ET-1 levels showed increasing trend after 14 weeks (P < 0.01). (2) Fetal plasma ET-1 levels were significantly higher than that of maternal plasma ET-1 levels, but lower than those of AF ET-1 (P < 0.01). The ET-1 levels of umbilical plasma had positive correlation with those of AF ET-1 (r = 0.952, P < 0.01), but there is no correlation with levels of maternal plasma ET-1 (r = 0.338, P < 0.05). (3) In study group, the level of AF ET-1 was elevated with severity of hypoxia, the average level of AF ET-1 in cases of intrauterine hypoxia was (30.654 +/- 5.832) ng/L. In cases of severe neonatal asphyxia it was (960.650 +/- 236.698) ng/L.

CONCLUSIONS

The ET-1 exists in AF and gradually increases while pregnancy advanced. AF ET-1 levels can be served as a marker to predict perinatal hypoxia.

Nitric oxide and nitric oxide synthase in the early phase of perinatal asphyxia of the rat

The role of nitric oxide, a compound involved in neurotransmission and regulation of cerebral blood flow, in cerebral ischemia is still not fully elucidated yet. Although well studied in adult systems of cerebral ischemia/hypoxia, information on nitric oxide in perinatal asphyxia is limited and, in particular, no direct evidence for its generation has been provided. We therefore decided to study nitric oxide generation in brain of asphyctic rat pups by biophysical and biochemical methods. We used a simple, non-invasive rat model resembling the clinical situation in perinatal asphyxia: rat pups delivered by Caesarean section were placed into a water bath at 37 degrees C still in patent membranes for various asphyctic periods (up to 20 min). Brain pH, cerebral blood flow, neuronal nitrix oxide synthase messenger RNA (by northern and dot blot analysis), immunoreactive protein (by western blot analysis) and nitric oxide synthase activity were determined; generation of nitric oxide was evaluated directly by electron paramagnetic resonance spectroscopy. Neuronal nitric oxide synthase messenger RNA activity and nitric oxide generation were unaffected, whereas neuronal nitric oxide synthase-immunoreactive protein of 150,000 mol. wt was decreased and of 136,000 mol. wt was increased with the length of the asphyctic period. This is the first report on direct evidence for the generation of nitric oxide in perinatal asphyxia and we demonstrate that nitric oxide production remains unaffected even by 20 min of asphyxia, at a time-point when cerebral blood flow was increased four-fold and severe acidosis was present. However, it was found that levels of immunoreactive neuronal nitric oxide synthase of 136,000 mol. wt were increased paralleling the length of asphyxia. Levels of the 150,000 mol. wt immunoreactive neuronal nitric oxide synthase protein decreased, suggesting a different regulation pattern. Thus, the present biochemical and biophysical results form the basis for further investigations on nitric oxide in perinatal asphyxia.

Hypoxia during early developmental period induces long-term changes in the dopamine content and release in a mesencephalic cell culture

The present study was conducted to elucidate the long-term effects of exposure to hypoxia of dopaminergic neurons during the early developmental period. Primary mesencephalic cell cultures prepared from fetal rats and containing 0.5-2% of dopaminergic neurons were exposed to hypoxia between in vitro days 1 and 6, the putative critical developmental period. Changes in the content, release and uptake of dopamine were found to depend on the degree of hypoxia and on the duration of exposure. Following moderate hypoxia (7 h, 5% O2) on two consecutive days between in vitro days 1 and 3, the cultures showed a small increase in the dopamine levels, by 16%. After severe hypoxia (0% O2/95% N2 for 24 h), during the same time window, the cellular dopamine content was elevated by 100%. Moreover, severe hypoxia produced long-lasting modulations of the dopaminergic system. On in vitro day 14, cells exhibited increased levels of 3,4-dihydroxyphenylacetic acid and homovanillic acid (by 34% and 55%, respectively), and elevations of both the spontaneous and potassium-stimulated dopamine release by 70%. The dopamine transport and metabolism of cells exposed to hypoxia between in vitro days 4 and 6 remained unchanged with regard to long-term effects. The present study provides strong evidence for the induction of long-term changes in dopaminergic cells due to hypoxia during the critical developmental period in mesencephalic culture. The developmental period capable of inducing long-lasting changes in dopamine metabolism is restricted to in vitro days 1-3.

Kynurenic acid in brain and cerebrospinal fluid of fetal, newborn, and adult sheep and effects of placental embolization

Concentrations of the endogenous glutamate receptor antagonist kynurenic acid (KA) were measured in various brain regions and in cisternal cerebrospinal fluid of fetal, newborn, and adult sheep. KA concentrations were significantly higher in the fetal brain and cerebrospinal fluid at 90 and 140 d gestation compared with postnatal ages. In fetuses of 132-139 d gestation, KA concentrations in cerebrospinal fluid collected by drainage from an indwelling cisternal catheter increased significantly after infusion of the organic acid transport inhibitor probenecid (100 or 200 mg/kg, i.v.) indicating active transport of KA out of the fetal brain. In fetuses in which the umbilical circulation had been chronically restricted from 120 to 140 d gestation by partial embolization of the placenta, plasma concentrations of the KA precursor kynurenine were significantly lower than in control fetuses, and KA concentrations in the hypothalamus and hippocampus were significantly reduced; other brain regions were not affected. These results indicate that the production of KA is higher in the fetal brain compared with the newborn and adult brain. Because KA diminishes the risk of excitotoxic neuronal damage under hypoxic-ischemic conditions, the high levels of KA in the brain before birth may have a neuroprotective function. The decrease of KA concentrations in the hypothalamus and hippocampus after umbilical embolization suggests that, after chronic hypoxia in utero, these regions of the brain may become more vulnerable to subsequent episodes of acute hypoxia or ischemia encountered in late gestation or during parturition.