Maternal hypothalamic-pituitary-adrenal axis in pregnancy and the postpartum period. Postpartum-related disorders

Caregiving behavior and interactions of prenatally depressed mothers (antidepressant-treated and non-antidepressant-treated) during newborn acute pain

This exploratory study aimed to examine time-based measures of the behaviors and interactions of prenatally depressed serotonin reuptake inhibitors (SRI)-medicated mothers to their infant's pain (n = 10) by comparing them with similar measures obtained from prenatally depressed nonmedicated mothers and their infants (n = 10), and nondepressed mothers and their infants (n = 10). During the second trimester of their pregnancy, the 30 study mothers were assessed for depression and anxiety, with no further measures of maternal mood taken. Maternal and infant interactions were continuously videorecorded while the infant underwent a scheduled heel lance for routine blood screening that occurred when study infants were between the ages of 24 and 60 hr. Maternal behavior and infant cry, for all 30 cases, were coded second-by-second for the full duration of each infant's heel lance using a reliable coding system and analyzed using odds ratio and regression analyses. Infants exposed to prenatal SRIs and depressed maternal mood were more likely to have lower Apgar scores and to exhibit weak and absent cry. Even when duration of the heel lance was controlled for, women with depression during the second trimester were more likely to exhibit depressed behavior at 2 days' postpartum despite sustained SRI antidepressant treatment. Both groups of prenatally depressed mothers were more likely to exhibit diminished response to their infants' pain cue although nonmedicated mothers' expressions of depressed behavior were more similar to healthy controls. Comprehensive understanding is essential to optimize the clinical care of mothers and their infants in this complex setting. This study contributes preliminary new findings that warrant prospective and longitudinal studies to clarify further the impacts of prenatal SRI and maternal mental mood (e.g., chronic depression and anxiety) effects on the mother-infant interaction and infant pain and stress reactivity.

No stress please! Mechanisms of stress hyporesponsiveness of the maternal brain

The time around birth is accompanied by behavioural and physiological adaptations of the maternal brain, which ensure reproductive functions, maternal care and the survival of the offspring. In addition, profound neuroendocrine and neurobiological adaptations have been described with respect to behavioural and neuroendocrine stress responsiveness in rodents and human mothers. Thus, the hormonal response of the hypothalamo-pituitary-adrenal (HPA) axis and the response of the sympathetic nervous system to emotional and physical stressors are severely attenuated. Moreover, anxiety-related behaviour and emotional responsiveness to stressful stimuli are reduced with the result of general calmness. These complex adaptations of the maternal brain are likely to be a consequence of an increased activity of brain systems with inhibitory effects on the HPA axis (such as the oxytocin and prolactin systems) and of a reduced activity of excitatory pathways (noradrenaline (norepinephrine), corticotrophin-releasing factor and opioids). Experimental manipulation of these systems using complementary approaches indeed demonstrates their importance in these maternal brain adaptations. Maternal stress adaptations are not only important for the healthy prenatal development of the offspring by preventing excessive glucocorticoid responses and in the promotion of postnatal maternal behaviour, but are also vital for the well-being of the mother and her mental health.

Regulation of anxiety during the postpartum period

Healthy mother-infant interactions are critical for the physical, cognitive, and psychological development of offspring. Such interactions rely on numerous factors, including a positive maternal emotional state. However, many postpartum women experience emotional dysregulation, often involving elevated anxiety. Neuroendocrine factors contributing to the onset of postpartum anxiety symptoms are mostly unknown, but irregularities in hypothalamic-pituitary-adrenal axis function, reduced prolactin and oxytocin signaling, or parturitional withdrawal of ovarian, placental and neural steroids could contribute to anxiety in susceptible women. Although the causes of initial onset are unclear, postpartum anxiety can be mitigated by recent contact with infants. Numerous neurochemical systems, including oxytocin, prolactin, GABA, and norepinephrine mediate this anxiolytic effect of infant contact. Insight into the etiology of postpartum anxiety disorders, and how contact with infants helps counter existing anxiety dysregulation, will surely facilitate the diagnosis and treatment of postpartum women at risk for, or experiencing, an anxiety disorder.

Serotonin 1A receptor reductions in postpartum depression: a positron emission tomography study

OBJECTIVE

To measure brain serotonin-1A (5HT1A) receptor binding potential (BP) in healthy and depressed postpartum women.

DESIGN

5HT1A receptor BP was measured with positron emission tomography by using [(11)C]WAY100635 a single time. Multivariate analysis of variance was used to determine depression effects on 5HT1A receptor BP in relevant brain regions.

SETTING

An academic research environment.

PATIENT(S)

Seven postpartum healthy controls and nine postpartum depressed (PD) subjects with perinatal (antepartum or postpartum) depression onset. Of the nine PD subjects, five had unipolar depression, and four had bipolar disorder.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

5HT1A receptor BP.

RESULT(S)

Age, time since delivery, and reproductive hormones did not differ between groups. Postsynaptic 5HT1A receptor binding in postpartum depression was reduced 20%-28% relative to controls, with most significant reductions in anterior cingulate and mesiotemporal cortices.

CONCLUSION(S)

Postsynaptic 5HT1A receptor binding is reduced in PD women by a similar magnitude as has been shown in other depression samples. The postpartum hormonal milieu and the large proportion of bipolar spectrum subjects in the PD group may have accentuated this finding in this small sample. Recognition of this neurobiological deficit in postpartum depression may be useful in the development of treatments and prevention strategies for this disabling disorder.

"Reproductive" corticotropin-releasing hormone

Corticotropin-releasing hormone (CRH), a 41 amino acid peptide, is an important regulatory molecule synthesized by neurons of the parvocellular and magnocellular hypothalamic paraventricular nuclei. It acts as the major physiologic corticotropin (ACTH) secretagogue. The CRH gene is located in humans on chromosome 8. The CRH hormone family has at least four ligands, two receptors (CRH-R1 and CRH-R2), and a binding protein (CRHbp). CRH is the principal regulator of the hypothalamic-pituitary-adrenal axis. Furthermore, CRH has been identified in most female reproductive tissues including the uterus, the placenta, and the ovary. CRH produced in the endometrium may participate in decidualization, implantation, and early maternal tolerance to semiallograft embryo. Placental CRH may participate in the physiology of pregnancy, in late pregnancy complications such as preterm labor and preeclampsia, and also in the onset of parturition. Ovarian CRH is involved in follicular maturation, ovulation, and luteolysis. Increased levels of unbound placental CRH may be responsible for the hypercortisolism of the second half of pregnancy. This hypercortisolism is followed by a transient suppression of hypothalamic CRH secretion in the postpartum period. This may explain the depressive states frequently observed in the postpartum period.

Prenatal stress increases HPA axis activity and impairs maternal care in lactating female offspring: implications for postpartum mood disorder

Early life stress is believed to constitute a risk factor for the development of mood disorders later in life. In the present study, we hypothesized that prenatal stress (PS) exerts long-lasting effects in female rat offspring, resulting in impaired adaptations to stress during lactation and, as such, may be a contributory factor to postpartum mood disorders. PS increased anxiety in adult virgin females compared with controls. During lactation, PS dams nursed significantly less and spent less time with pups compared with controls, whereas dams did not differ in pup retrieval or maternal aggression. HPA axis reactivity was elevated in response to a mild stressor in PS dams compared to their controls, but not in virgins, with the delta corticosterone response returning to the higher level seen in virgins. Moreover, corticotropin-releasing hormone (CRH) mRNA expression within the parvocellular region of the paraventricular nucleus (PVN) was increased in both virgins and dams exposed to PS compared with the relative controls, while the attenuation in expression in lactating controls was abolished following PS. In addition, arginine vasopressin (AVP) mRNA was increased in the parvocellular, but not magnocellular part of the PVN, in both PS-exposed virgins and lactating dams compared with their relative controls; although expression was also higher in controls during lactation compared with virgins. Thus, the present study demonstrates that exposure to PS results in long-lasting behavioural and neuroendocrine alterations in the female offspring, which are manifested during the lactation period. Furthermore, it implicates PS as a potential risk factor for the development of postpartum mood disorders, and that alterations in the HPA axis reactivity, at least partially, are involved.

Psychological stressors as a model of maternal adversity: diurnal modulation of corticosterone responses and changes in maternal behavior

Maternal adversity is associated with long-lasting consequences on cognitive development, behavior and physiological responses in rat offspring. Few studies have examined whether repeated maternal stress produces repeated activation of the hypothalamus-pituitary-adrenal (HPA) axis in mothers and whether it modifies maternal behavior. Here, we tested a novel model of perinatal stress using repeated exposure to "purely" psychological stressors throughout the gestation and lactation periods in rats. We first tested the diurnal influences of repeated 1-h strobe light exposure on maternal corticosterone secretion. Despite the hyporesponsiveness to stress documented in late pregnant and lactating mothers, we observed an enhanced response to strobe light in the afternoon compared to the morning in stressed mothers during lactation. Next, dams were exposed to 24-h forced foraging followed by 10-h wet bedding during the diurnal peak of corticosterone secretion. Although no corticosterone responses to forced foraging and wet bedding were observed, the combination of both stressors had a significant effect on maternal behavior. Mother-pup interactions were significantly altered during the first 8 days of lactation. Taken together, these findings suggest that lactating mothers maintain responsiveness to specific and repeated psychological stressors, in particular at the time of the diurnal peak in corticosterone secretion. Depending on the stressor applied, either neuroendocrine activation or changes in maternal behavior might be important determinants of the long-term consequences in the offspring. The combination of forced foraging, wet bedding and strobe light might represent a novel model of mild maternal adversity using "purely" psychological stressors.

Assessment of adrenal reserve in pregnancy: defining the normal response to the adrenocorticotropin stimulation test

CONTEXT

Normal pregnancy is a state of hypercortisolism, making adrenal insufficiency difficult to diagnose.

OBJECTIVE

We sought to identify a normative, minimum-response threshold for the ACTH stimulation test in pregnancy. We hypothesized that salivary free cortisol (SaFC) would prove a more physiological and less variable measure of adrenal reserve in pregnancy than serum cortisol (SC).

DESIGN

This is a prospective study of normal controls.

SETTING

The study was conducted in an obstetrical clinic in a tertiary care hospital.

PATIENTS

Patients included 36 healthy ambulatory pregnant women (aged 18-37 yr) with singleton pregnancies.

INTERVENTION

The 250-microg ACTH stimulation test was performed in the healthy pregnant volunteers. Based on their gestational age at the time of recruitment, women were studied in one of the trimesters and were restudied at 11-14 wk postpartum.

MAIN OUTCOME MEASURES

Total SC, aldosterone, and SaFC concentrations were measured before and after ACTH. The response in pregnancy was compared with postpartum values.

RESULTS

Basal SC (P = 0.01), aldosterone (P = 0.001), and SaFC (P = 0.01) values progressively increased during the trimesters of pregnancy and decreased postpartum, confirming that pregnant women have increased basal glucocorticoid and mineralocorticoid production. There was enhanced responsiveness of the maternal adrenal glands to ACTH stimulation as pregnancy progressed, as measured by peak stimulated SaFC (P = 0.009) and aldosterone (P = 0.01). In the milieu of altered binding globulins, SaFC is a more consistent, binding-globulin-independent measure of stimulated adrenal function than total SC. Minimum criteria for the normal SaFC response to ACTH stimulation in the second and third trimesters of pregnancy and postpartum have been generated based on a predominantly African-American group of subjects.

CONCLUSIONS

Reliable data are available for the evaluation of the adrenal axis in pregnancy with a noninvasive, outpatient measure of SaFC. Glucocorticoid therapy in pregnancy should take into account that adrenal reserve increases as pregnancy progresses.

Maternal psychological distress, prenatal cortisol, and fetal weight

OBJECTIVE

The objective of this study was to examine the effects of maternal psychological distress on estimated fetal weight during midgestation and explore the maternal hypothalamic-pituitary axis and sympathoadrenal dysregulation as potential risk factors for these effects.

METHODS

Fetal ultrasound biometry measurements and maternal sociodemographic characteristics, emotional distress symptoms, and first morning urine samples were collected during a clinical ultrasound examination for a cross-sectional sample of 98 women who were between 16 and 29 weeks pregnant. Fetal weight was estimated from ultrasound biometry measurements; maternal emotional distress was assessed using the daily hassles (stress), Center for Epidemiologic Studies-Depression (depression), and State-Trait Anxiety Inventory (anxiety) scales; and urine samples were assayed for cortisol and norepinephrine levels.

RESULTS

Correlation analyses revealed that both maternal psychological (daily hassles, depression, and anxiety) and biochemical (cortisol and norepinephrine) variables were negatively related to fetal biometry measurements and estimated fetal weight. A structural equation model further revealed that when the independent variance of maternal sociodemographic, psychological distress, and biochemistry measures were accounted for, prenatal cortisol was the only significant predictor of fetal weight.

CONCLUSIONS

Women exhibiting psychological distress during pregnancy exhibit elevated cortisol levels during midgestation that are in turn related to lower fetal weight.

Augmentation and proliferation of T lymphocytes and Th-1 cytokines by Withania somnifera in stressed mice

Stress has been associated with reports of both greater severity and prolongation of diseases in patients with the infectious origin as well as other immune-mediated diseases. Withania somnifera, an Indian medicinal plant used widely in the treatment of many clinical conditions in India, was investigated for its anti-stress properties using BALB/c mice subjected to chronic stress. The study aimed to investigate chronic stress-induced alterations on Th1 lymphocyte subset distribution and corresponding cytokine secretion patterns. Oral administration of chemically standardized and identified aqueous fraction of W. somnifera root (WS) at the graded doses of 25, 50, 100 and 200 mg/kg p.o. caused significant increase in the stress-induced depleted T-cell population and increased the expression of Th1 cytokines in chronically stressed mice.

Effect of Triphala on oxidative stress and on cell-mediated immune response against noise stress in rats

Stress is one of the basic factors in the etiology of number of diseases. The present study was aimed to investigate the effect of Triphala (Terminalia chebula, Terminalia belerica and Emblica officinalis) on noise-stress induced alterations in the antioxidant status and on the cell-mediated immune response in Wistar strain male albino rats. Noise-stress employed in this study was 100 dB for 4 h/d/15 days and Triphala was used at a dose of 1 g/kg/b.w/48 days. Eight different groups of rats namely, non-immunized: control, Triphala, noise-stress, Triphala with noise-stress, and corresponding immunized groups were used. Sheep red blood cells (5 x 10(9) cells/ml) were used to immunize the animals. Biochemical indicators of oxidative stress namely lipid peroxidation, antioxidants superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), ascorbic acid in plasma and tissues (thymus and spleen) and SOD, GPx and corticosterone level in plasma were estimated. Cell-mediated immune response namely foot pad thickness (FPT) and leukocyte migration inhibition (LMI) test were performed only in immunized groups. Results showed that noise-stress significantly increased the lipid peroxidation and corticosterone level with concomitant depletion of antioxidants in plasma and tissues of both non-immunized and immunized rats. Noise-stress significantly suppressed the cell-mediated immune response by decreased FPT with an enhanced LMI test. The supplementation with Triphala prevents the noise-stress induced changes in the antioxidant as well as cell-mediated immune response in rats. This study concludes that Triphala restores the noise-stress induced changes may be due to its antioxidant properties.

The neurobiology of postpartum depression

Postpartum psychiatric changes can range from maternity blues to psychosis. Causality is still undetermined, but explanations for these disturbances often focus on hormonal changes and dysregulation. Researchers have begun the process of delineating what neurobiological factors may be associated with depressive disorders in pregnancy and the postpartum. This article reviews the current literature on the roles of gonadal and pituitary hormones in the psychopathophysiology of postpartum mood disorders. Other biological factors, such as biogenic amines, neuroactive steroids, cholesterol, and fatty acids, are also discussed. The potential benefits of neuroimaging to aid in understanding neuropsychiatric changes that occur in the context of postpartum depression are also considered.

Factors involved in the inflammatory events of cervical ripening in humans

BACKGROUND

Cervical ripening is an inflammatory reaction. The glucocorticoid receptor (GR) mediates glucocorticoid anti-inflammatory reactions, whereas nuclear factor (NF)kappaB is a key pro-inflammatory transcription factor. Prostaglandins as well as platelet activating factor (PAF) are inflammatory mediators. Inducible nitric oxide synthase (iNOS) regulates the level of nitric oxide (NO) in response to various inflammatory stimuli. We hypothesize that a changed biological response to glucocorticoids could be a mechanism regulating the inflammatory events resulting in cervical ripening.

METHODS

We monitored GR and NFkappaB, prostaglandin synthases cyclooxygenase (COX)-1 and -2, iNOS, as well as the PAF-receptor (PAF-R) in the uterine cervix from term pregnant women (with unripe cervices) before the onset of labor (TP), immediately after parturition (PP), as compared to non-pregnant (NP), using immunohistochemistry and RT-PCR.

RESULTS

The GR protein was detected by immunohistochemistry in the nuclei of stroma and squamous epithelium (SQ). Stromal GR staining was increased in TP as compared to the NP group and decreased again after parturition. GR staining in SQ was decreased after parturition as compared to term. NFkappaB was present in SQ and glandular epithelium (GE), stroma and vascular endothelium. Increased nuclear NFkappaB staining was observed postpartum as compared to term pregnancy in stroma and GE. Stromal immunostaining for COX-1 as well as COX-2 was increased in the TP and PP groups as compared to the NP, and GE displayed an intensely increased COX-2 immunostaining at term and postpartum. Stromal PAF-R immunostaining was highest at term, while it was greatly increased in GE postpartum. No difference in the immunostaining for iNOS was found between the groups. RT-PCR showed a predominance of GRalpha to GRbeta mRNA in cervical tissue. The COX-2 mRNA level was increased in the PP group as compared to the TP group.

CONCLUSIONS

There is a decrease in GR levels in human cervix at parturition. Concomitantly there is an increase of factors such as NFkappaB, PAF-R, COX-1 and COX-2, suggesting that they may participate in the sequence of events leading to the final cervical ripening.

Effects of adrenocorticotropin stimulation on cortisol dynamics of pregnant gilts and their fetuses: implications for prenatal stress studies

The effect of adrenocorticotropic hormone (ACTH) administration on plasma cortisol concentrations was determined in pregnant gilts and their fetuses. In a first experiment, 100 IU ACTH (Synacthen Depot) was administered intramuscularly to the gilts every second day from Days 49 to 75 of gestation. ACTH injections were carried out at 08:00 h and, thereafter, 10 blood samples were taken within the following 8h via jugular catheters. Blood samples were analysed for plasma cortisol concentrations, and results were compared with values from animals which were treated with physiological saline and untreated animals (blood sampling only). The values for plasma cortisol concentrations increased until 3h after ACTH applications to a mean maximum level of 276.5+/-17.2 nmol/l in the whole 4-week stimulation period. Plasma cortisol levels did not return to pre-treatment values within the 8 h post-injection. No differences in cortisol levels were found between the physiological saline and untreated control, and no habituation of the adrenocortical response to ACTH was found during the 4-week stimulation period. In a second experiment, 100 IU ACTH were administered to pregnant gilts at gestation Day 65. After 3 h, fetuses were recovered under general anaesthesia and blood samples were taken from the umbilical vein, artery, and, after decapitation, from periphery. Application of ACTH to the sows significantly increased their plasma cortisol concentrations (P<0.001), and also increased plasma cortisol concentrations in peripheral blood samples from the fetuses (P=0.09) and in the umbilical vein (P<0.001) and artery (P<0.01), respectively. Plasma ACTH concentrations did not differ in fetuses from ACTH-treated or control sows. The results show that in gilts the adrenocortical response to an exogenous application of Synacthen Depot is consistent over time during mid-gestation. Furthermore, cortisol but not ACTH levels were increased in fetuses from ACTH-treated sows, indicating that maternal cortisol can cross the placenta during mid-gestation. The stimulation of maternal cortisol release through exogenous ACTH with subsequent elevation of fetal cortisol levels is, therefore, a useful approach for studying effects of elevated maternal glucocorticoids in prenatal stress studies in pigs.

Cortisol levels and conduct disorder in adolescent mothers

OBJECTIVE

To examine the association between cortisol levels and conduct disorder (CD) in adolescent mothers. Past research has shown that low levels of cortisol were associated with CD, particularly with its aggressive symptoms. The authors tested the hypothesis that adolescent mothers with CD would show lower levels of salivary cortisol compared to mothers without CD at 4 and 9 months postpartum.

METHOD

Midmorning salivary cortisol levels were measured in 228 adolescent mothers (age at delivery 16.9 +/- 1 years [mean +/- SD]) during a laboratory visit at 4 and 9 months postpartum. CD was diagnosed during pregnancy according to the CD subsection on the criteria for antisocial personality disorder (DSM-III-R).

RESULTS

Results did not confirm the hypothesis. Lower cortisol levels were not significantly associated with a CD diagnosis, the number of CD symptoms, or aggressive symptoms.

CONCLUSIONS

Despite valid measures and strong statistical power, this study failed to find an association between cortisol levels and CD in a sample of adolescent mothers. The results may have been influenced by the fact that participants were 4 and 9 months postpartum and by comparisons of mothers with CD to mothers living in stressful circumstances.

Maternal and fetal hypothalamic-pituitary-adrenal axes during pregnancy and postpartum

The principal modulators of the hypothalamic-pituitary-adrenal (HPA) axis are corticotropin-releasing hormone (CRH) and arginine-vasopressin (AVP). Corticotropin-releasing hormone is not exclusively produced in the hypothalamus. Its presence has been demonstrated at peripheral inflammatory sites. Ovulation and luteolysis bear characteristics of an aseptic inflammation. CRH was found in the theca and stromal cells as well as in cells of the corpora lutea of human and rat ovaries. The cytoplasm of the glandular epithelial cells of the endometrium has been shown to contain CRH and the myometrium contains specific CRH receptors. It has been suggested that CRH of fetal and maternal origin regulates FasL production, thus affecting the invasion (implantation) process through a local auto-paracrine regulatory loop involving the cytotrophoblast cells. Thus, the latter may regulate their own apoptosis. During pregnancy, the plasma level of circulating maternal immunoreactive CRH increases exponentially from the first trimester of gestation due to the CRH production in the placenta, decidua, and fetal membranes. The presence in plasma and amniotic fluid of a CRH-binding protein (CRHbp) that reduces the bioactivity of circulating CRH by binding is unique to humans. Maternal pituitary ACTH secretion and plasma ACTH levels rise during pregnancy-though remaining within normal limits-paralleling the rise of plasma cortisol levels. The maternal adrenal glands during pregnancy gradually become hypertrophic. Pregnancy is a transient, but physiologic, period of hypercortisolism. The diurnal variation of plasma cortisol levels is maintained in pregnancy, probably due to the secretion of AVP from the parvicellular paraventricular nuclei. CRH is detected in the fetal hypothalamus as early as the 12th week of gestation. CRH levels in fetal plasma are 50% less than in maternal plasma. The circulating fetal CRH is almost exclusively of placental origin. The placenta secretes CRH at a slower rate in the fetal compartment. AVP is detected in some neurons of the fetal hypothalamus together with CRH. AVP is usually detectable in the human fetal neurohypophysis at 11 to 12 weeks gestation and increases over 1000-fold over the next 12 to 16 weeks. The role of fetal AVP is unclear. Labor appears to be a stimulus for AVP release by the fetus. The processing of POMC differs in the anterior and intermediate lobes of the fetal pituitary gland. Corticotropin (ACTH) is detectable by radioimmunoassay in fetal plasma at 12 weeks gestation. Concentrations are higher before 34 weeks gestation, with a significant fall in late gestation. The human fetal adrenal is enormous relative to that of the adult organ. Adrenal steroid synthesis is increased in the fetus. The major steroid produced by the fetal adrenal zone is sulfoconjugated dehydroepiandrosterone (DHEAS). The majority of cortisol present in the fetal circulation appears to be of maternal origin, at least in the nonhuman primate. The fetal adrenal uses the large amounts of progesterone supplied by the placenta to make cortisol. Another source of cortisol for the fetus is the amniotic fluid where cortisol converted from cortisone by the choriodecidua, is found. In humans, maternal plasma CRH, ACTH, and cortisol levels increase during normal labor and drop at about four days postpartum; however, maternal ACTH and cortisol levels at this stage are not correlated. In sheep, placental CRH stimulates the fetal production of ACTH, which in turn leads to a surge of fetal cortisol secretion that precipitates parturition. The 10-day-long intravenous administration of antalarmin, a CRH receptor antagonist, significantly prolonged gestation compared to the control group of animals. Thus, CRH receptor antagonism in the fetus can also delay parturition. The HPA axis during the postpartum period gradually recovers from its activated state during pregnancy. The adrenals are mildly suppressed in a way analogous to postcure Cushing's syndrome. Provocation testing has shown that hypothalamic CRH secretion is transiently suppriently suppressed at three and six weeks postpartum, normalizing at 12 weeks.

Prepartum, postpartum, and chronic depression effects on newborns

In order to assess the effects of the onset and chronicity of maternal depression on neonatal physiology, eighty pregnant women were assessed for depression during mid-pregnancy (M gestational age = 25.9 weeks) and shortly after delivery. The women were classified as reporting depressive symptoms 1) only during the prepartum assessment; 2) only during the postpartum assessment; 3) during both the prepartum and postpartum assessments; or 4) reporting no depressive symptoms at either the prepartum or the postpartum assessment. Maternal mood and biochemistry were assessed during pregnancy, and the EEG and biochemical characteristics of their 1-week-old infants were assessed shortly after birth. As predicted, the newborns of the mothers with prepartum and postpartum depressive symptoms had elevated cortisol and norepinephrine levels, lower dopamine levels, and greater relative right frontal EEG asymmetry. The infants in the prepartum group also showed greater relative right frontal EEG asymmetry and higher norepinephrine levels. These data suggest that effects on newborn physiology depend more on prepartum than postpartum maternal depression but may also depend on the duration of the depressive symptoms.

A case of ACTH-producing pheochromocytoma associated with pregnancy

Ectopic ACTH syndrome is rarely caused by pheochromocytoma. We report a case of a 28-year-old woman with Cushing's syndrome due to ACTH-producing adrenal pheochromocytoma. She had delivered preterm baby at 32nd week of gestation with 'severe preeclampsia'. After delivery, persistent hypertension accompanied by severe headache led her to being misdiagnosed as Cushing's syndrome due to right adrenal adenoma (normal plasma ACTH level) and cerebral vasculitis of unknown etiology. She was referred to our hospital for surgical treatment. Repeated biochemical studies suggested coexistence of ectopic ACTH syndrome and pheochromocytoma. To reverse her clinical deterioration, right total and left subtotal adrenalectomy was performed with presumptive diagnosis of 1) right adrenal pheochromocytoma causing ectopic ACTH syndrome or 2) coexistence of ACTH-dependent Cushing's syndrome and right adrenal pheochromocytoma. Pathologic examination of right adrenal mass revealed pheochromocytoma which showed strong immunostaining for ACTH. Plasma ACTH and urinary cortisol excretion normalized after surgery, but she succumbed to multiple cerebral infarcts and disseminated intravascular coagulation. Pregnancy and inappropriately low plasma ACTH at initial evaluation might have hampered early diagnosis. To our knowledge, this is the first description of a case with ectopic ACTH syndrome due to pheochromocytoma associated with pregnancy.

Pituitary and adrenal disorders complicating pregnancy

PURPOSE OF REVIEW

Confidential enquiries of maternal deaths in the UK for 1997-1999 revealed that the number of indirect deaths from medical conditions exacerbated by pregnancy was greater than deaths from conditions directly caused by pregnancy. Indirect maternal deaths accounted for 36% of all deaths. Although neoplastic disorders of the pituitary and adrenal glands are very rare during pregnancy, they can be potentially fatal. The rarity of these disorders may pose difficulty in formulating an optimum plan of management. Biochemical tests that can be performed in the non-pregnant state may be of little value during pregnancy. The presence of a fetus may also influence the type and timing of intervention.

RECENT FINDINGS

A few case reports have been reported in the literature, but unfortunately no large series to develop guidelines or protocols. However, endoscopic surgical procedures have recently been used in their management with good outcomes. New drugs such as octreotide and lanreotide are increasingly being used during pregnancy. Although too soon to assess the safety of these new treatments, results so far have been very encouraging.

SUMMARY

Awareness of these potentially fatal neoplastic disorders of the pituitary and adrenal glands, coupled with early diagnosis and appropriate treatment, may help improve maternal and fetal outcomes. Advances in imaging techniques and endoscopic procedures are also likely to change clinical practice. Various new treatment options are being reported in the literature, but they are not supported by randomized, controlled trials. Further research is needed to determine their safety and efficacy during pregnancy.

Blunted ACTH and cortisol responses to systemic injection of corticotropin-releasing hormone (CRH) in fibromyalgia: role of somatostatin and CRH-binding protein

Thirteen female patients suffering from fibromyalgia (FM) and thirteen female age-matched controls were intravenously injected with a bolus dose of 100 microg corticotropin-releasing hormone (CRH), and the evoked secretion pattern of ACTH, cortisol, somatostatin, and growth hormone (GH) was followed up for two hours, together with the plasma levels of CRH. The increases of ACTH and cortisol following CRH were not significantly different between controls and FM patients. The increase of plasma CRH following its injection was significantly higher in FM patients and lasted about 45 min, paralleled by an increase of somatostatin with a similar time course. Basal GH levels were significantly lower in FM patients. GH increased in FM patients 90 min after injection of CRH, coincident with decreasing CRH and somatostatin levels, while GH levels in controls rather decreased with the lowest values occurring 90 min after CRH. The results support the concept that the hormonal secretion pattern frequently observed in FM patients is primarily caused by CRH, possibly as a response to chronic pain and stress. The elevated levels of CRH in the circulation of FM patients suggest elevated levels of CRH-binding protein, which could explain why the levels of ACTH and cortisol between controls and FM following CRH do not differ.

Alterations induced by chronic stress in lymphocyte subsets of blood and primary and secondary immune organs of mice

BACKGROUND

The immune system is particularly sensitive to stress. Although acute stress generally has positive effects, chronic stress typically provokes immunosuppression. The elucidation of the mechanisms involved in immunosuppression are of interest for the design of therapeutic approaches to avoid the appearance of stress disorders. This study aimed to investigate chronic stress-induced alterations on lymphocyte subset distribution and percentages. The experiments were performed with C57BL/6 mice subjected to chronic immobilization stress.

RESULTS

Stress caused a marked increase in apoptosis inside the thymus, and a reduction in the total number of thymocytes. Furthermore, the proportion of immature thymocytes declined significantly suggesting that the increased apoptosis mainly affected cells of immature phenotype. In blood, the total number of lymphocytes diminished but not all lymphocyte populations showed the same tendency: while the relative proportion of B cells declined slightly, the relative proportion of circulating CD3+ cells, and particularly some T cell subsets showing an immature phenotype (CD3+PNA+), increased under stress. The spleen and lymph nodes show a marked reduction in cellularity, but the relative proportion of T cells increased, while no change or only a slight reduction was observed in the relative proportion of B cells. Similarly, the relative proportion of T cells increased in bone marrow.

CONCLUSIONS

Detailed data on the alterations of lymphoid cell subsets occurring under immobilization stress, both in the bloodstream and in different lymphoid tissues, are obtained. In general, T cells are more affected than B cells and, in particular, a marked increase in the percentage of a subset of circulating PNA+CD3+ T cells is observed.