Teratogen update: vitamin A congeners

Face-to-face: isotretinoin use and pregnancy outcome

Isotretinoin has been used to treat severe acne for more than 40 years. There are no accurate data on the absolute risk of potential teratogenicity to all fetuses exposed to isotretinoin. According to current guidelines, isotretinoin should be discontinued at least 1 month before pregnancy. This study enrolled pregnant women who contacted the Clinical Pharmacology and Toxicology Unit for individual drug risk assessment between 2016 and 2020. Data on maternal characteristics and isotretinoin exposures were obtained at first consultation. After delivery, follow-up calls were conducted using a structured questionnaire. Of 2,323 pregnant women consulted, 1.3% (31/2,323) had systemic isotretinoin exposure during and before pregnancy. Of 31 prospectively followed pregnancies, eight terminated electively. Most elective terminations (7/8) were performed because of the fear of fetal malformation. The majority of continued pregnancies (16/23) resulted in healthy live birth. There were no major birth defects. In six pregnancies, intrauterine deaths (three first trimester, three second trimester) were reported. Cesarean section was performed in 70.5% (12/17) of all deliveries. The median gestational age at birth was 39, and no preterm births were reported. Local isotretinoin treatments in six cases were evaluated and presented additionally, and all babies were born healthy. Based on the results of this study, there was no evidence of major birth defect, mental disorder, or retinoid embryopathy associated with the use of isotretinoin in pregnancy. Not local use, but systemic exposure to isotretinoin is of great concern that results in pregnancy termination.

Review of Dermatologic Medications and Impact on Male Fertility, Sexual Dysfunction and Teratogenicity

BACKGROUND

Dermatologic medications have been linked to issues with safety during pregnancy and lactation. Despite this, limited research, often with conflicting findings, has been published on the association between dermatologic medications, male infertility, sexual dysfunction, and teratogenicity following paternal exposure.

OBJECTIVE

This review seeks to provide evidence-based guidance for physicians who are prescribing dermatologic medications to male patients who are trying to conceive.

METHODS

Common medications used in the largest outpatient specialist dermatologic centre in Singapore were the focus of this review. A PubMed search using MeSH terms from inception to April 22, 2021, was conducted. A secondary search was conducted to include common non-dermatologic medications. Drug information from various online clinical resources and the Tenth Edition of Drugs in Pregnancy and Lactation were also used as a reference.

RESULTS

In this review of 234 studies, 131 medications were covered. A total of 34 medications were associated with male infertility and sexual dysfunction, while 16 medications were implicated with concerns of teratogenicity.

DISCUSSION AND CONCLUSION

Physicians are advised to discuss the potential impact on male fertility and teratogenicity with males who are trying to conceive, while taking into consideration the clinical efficacy and tolerability of these medications and alternative treatments. This article is protected by copyright. All rights reserved.

Craniofacial Phenotypes and Genetics of DiGeorge Syndrome

The 22q11.2 deletion is one of the most common genetic microdeletions, affecting approximately 1 in 4000 live births in humans. A 1.5 to 2.5 Mb hemizygous deletion of chromosome 22q11.2 causes DiGeorge syndrome (DGS) and velocardiofacial syndrome (VCFS). DGS/VCFS are associated with prevalent cardiac malformations, thymic and parathyroid hypoplasia, and craniofacial defects. Patients with DGS/VCFS manifest craniofacial anomalies involving the cranium, cranial base, jaws, pharyngeal muscles, ear-nose-throat, palate, teeth, and cervical spine. Most craniofacial phenotypes of DGS/VCFS are caused by proximal 1.5 Mb microdeletions, resulting in a hemizygosity of coding genes, microRNAs, and long noncoding RNAs. TBX1, located on chromosome 22q11.21, encodes a T-box transcription factor and is a candidate gene for DGS/VCFS. TBX1 regulates the fate of progenitor cells in the cranial and pharyngeal apparatus during embryogenesis. Tbx1-null mice exhibit the most clinical features of DGS/VCFS, including craniofacial phenotypes. Despite the frequency of DGS/VCFS, there has been a limited review of the craniofacial phenotypes of DGC/VCFS. This review focuses on these phenotypes and summarizes the current understanding of the genetic factors that impact DGS/VCFS-related phenotypes. We also review DGS/VCFS mouse models that have been designed to better understand the pathogenic processes of DGS/VCFS.

Identification of a novel CYP26A1 mutation in a Chinese family with congenital microtia

OBJECTIVES

Microtia is defined as a congenital malformation characterized by a small, abnormally shaped auricle, with atresia or stenosis of the auditory canal. This study investigated a mutation of the cytochrome P450, family 26, subfamily A, polypeptide 1(CYP26A1) gene, which is considered important in craniofacial development, in a family affected with microtia.

METHODS

Whole-exome sequencing (WES) was performed on the proband and his family members to identify disease-associated variants. Computational predictions of the altered protein were analyzed using several bioinformatics tools. The wild-type (WT) and mutant forms of CYP26A1 cDNA were transfected into human embryonic kidney cells, and the mRNA and protein levels were compared using quantitative polymerase chain reaction (qPCR) and Western blot analyses.

RESULTS

In this two-generation family, the proband and his mother were diagnosed with unilateral microtia. Unilateral microtia and ipsilateral accessory ear were observed in one of the twins, who were sisters of the proband. The father and the other twin showed no abnormal clinical features. A heterozygous mutation of a C to T in the CYP26A1 gene, which leads to truncation of the CYP26A1 protein, was identified in this family. The nonsense mutation cosegregated with patients and was absent in normal members of the family. The prediction software indicated that it was a possibly pathogenic mutation. The structure of the protein varied significantly between the WT and mutant proteins. Functional analysis showed that this mutation caused a significant decrease in both the mRNA and protein levels.

CONCLUSIONS

Our findings suggest that this mutation of CYP26A1 may be a pathogenic factor leading to the phenotypes of microtia and accessory ear in this family. Further studies are needed to prove the function of this mutation and to explore the possible mechanism by which this variant is involved in the occurrence of microtia.

Variations in maternal vitamin A intake modifies phenotypes in a mouse model of 22q11.2 deletion syndrome

BACKGROUND

Vitamin A regulates patterning of the pharyngeal arches, cranial nerves, and hindbrain that are essential for feeding and swallowing. In the LgDel mouse model of 22q11.2 deletion syndrome (22q11DS), morphogenesis of multiple structures involved in feeding and swallowing are dysmorphic. We asked whether changes in maternal dietary Vitamin A intake can modify cranial nerve, hindbrain and pharyngeal arch artery development in the embryo as well as lung pathology that can be a sign of aspiration dysphagia in LgDel pups.

METHODS

Three defined amounts of vitamin A (4, 10, and 16 IU/g) were provided in the maternal diet. Cranial nerve, hindbrain and pharyngeal arch artery development was evaluated in embryos and inflammation in the lungs of pups to determine the impact of altering maternal diet on these phenotypes.

RESULTS

Reduced maternal vitamin A intake improved whereas increased intake exacerbated lung inflammation in LgDel pups. These changes were accompanied by increased incidence and/or severity of pharyngeal arch artery and cranial nerve V (CN V) abnormalities in LgDel embryos as well as altered expression of Cyp26b1 in the hindbrain.

CONCLUSIONS

Our studies demonstrate that variations in maternal vitamin A intake can influence the incidence and severity of phenotypes in a mouse model 22q11.2 deletion syndrome.

Heparin mimics and fibroblast growth factor-2 fabricated nanogold composite in promoting neural differentiation of mouse embryonic stem cells

The replacement therapy or transplantation using neural cells, which differentiated from stem cells, has emerged as a promising strategy for repairing damaged neural tissues and helping functional recovery in the treatment of neural system diseases. The challenge, however, is how to control embryonic stem cell fate so that neural differentiation can be efficiently directed to enrich a neuron cell population, and meanwhile to maintain their bioactivities. This is a key question and has a very significant impact in regenerative medicine. Here we proposed a new neural-differentiation inductive nanocomposite, containing gold nanoparticles (AuNPs), poly(2-methacrylamido glucopyranose-co-3-sulfopropyl acrylate) (PMS), and basic fibroblast growth factor (FGF2), for the high efficient directional neural-specific differentiation of mouse embryonic stem cells (mESCs). In this AuNP-PMS/FGF2 composite, PMS, playing as the high-active mimic of heparin/heparan sulfate (HS), is covalently anchored to AuNPs and bound with FGF2 on the surface of nanoparticles, forming a HS/FGF2 complex nanomimics to facilitate its binding to FGF receptor (FGFR) and promote high neural-inductive activity of mESCs. The stability, bioactivity and biocompatibility of the composite are investigated in this study. The results showed that the AuNP-PMS/FGF2 composite could maintain a long-term stability at room temperature for at least 8 days, and greatly promote the neural differentiation of mESCs. Compared with the other materials, the AuNP-PMS/FGF2 composite could significantly stimulate the expression of the specific neural differentiation markers (nestin and β3-tubulin), while obviously down-regulate the mRNA production of pluripotency marker Oct-4 in mESCs. Moreover, the promotion effect of the composite on neuronal maturation marker β3-tubulin expression achieved maximally at the low concentration of FGF2 (4 ng/mL), which suggested the high efficiency of AuNP-PMS/FGF2 composite in neural differentiation of mESCs. Meanwhile, both mESCs and L929 cells showed desirable growth during the incubation with AuNP-PMS/FGF2 composite. The AuNP-PMS/FGF2 system presents a new way to achieve HS/FGF2 complex nanomimics efficiently for the neural differentiation of mESCs.

Regulating Retinoic Acid Availability during Development and Regeneration: The Role of the CYP26 Enzymes

This review focuses on the role of the Cytochrome p450 subfamily 26 (CYP26) retinoic acid (RA) degrading enzymes during development and regeneration. Cyp26 enzymes, along with retinoic acid synthesising enzymes, are absolutely required for RA homeostasis in these processes by regulating availability of RA for receptor binding and signalling. Cyp26 enzymes are necessary to generate RA gradients and to protect specific tissues from RA signalling. Disruption of RA homeostasis leads to a wide variety of embryonic defects affecting many tissues. Here, the function of CYP26 enzymes is discussed in the context of the RA signalling pathway, enzymatic structure and biochemistry, human genetic disease, and function in development and regeneration as elucidated from animal model studies.

Rubella Virus Infection, the Congenital Rubella Syndrome, and the Link to Autism

Rubella is a systemic virus infection that is usually mild. It can, however, cause severe birth defects known as the congenital rubella syndrome (CRS) when infection occurs early in pregnancy. As many as 8%-13% of children with CRS developed autism during the rubella epidemic of the 1960s compared to the background rate of about 1 new case per 5000 children. Rubella infection and CRS are now rare in the U.S. and in Europe due to widespread vaccination. However, autism rates have risen dramatically in recent decades to about 3% of children today, with many cases appearing after a period of normal development ('regressive autism'). Evidence is reviewed here suggesting that the signs and symptoms of rubella may be due to alterations in the hepatic metabolism of vitamin A (retinoids), precipitated by the acute phase of the infection. The infection causes mild liver dysfunction and the spillage of stored vitamin A compounds into the circulation, resulting in an endogenous form of hypervitaminosis A. Given that vitamin A is a known teratogen, it is suggested that rubella infection occurring in the early weeks of pregnancy causes CRS through maternal liver dysfunction and exposure of the developing fetus to excessive vitamin A. On this view, the multiple manifestations of CRS and associated autism represent endogenous forms of hypervitaminosis A. It is further proposed that regressive autism results primarily from post-natal influences of a liver-damaging nature and exposure to excess vitamin A, inducing CRS-like features as a function of vitamin A toxicity, but without the associated dysmorphogenesis. A number of environmental factors are discussed that may plausibly be candidates for this role, and suggestions are offered for testing the model. The model also suggests a number of measures that may be effective both in reducing the risk of fetal CRS in women who acquire rubella in their first trimester and in reversing or minimizing regressive autism among children in whom the diagnosis is suspected or confirmed.

What's retinoic acid got to do with it? Retinoic acid regulation of the neural crest in craniofacial and ocular development

Retinoic acid (RA), the active derivative of vitamin A (retinol), is an essential morphogen signaling molecule and major regulator of embryonic development. The dysregulation of RA levels during embryogenesis has been associated with numerous congenital anomalies, including craniofacial, auditory, and ocular defects. These anomalies result from disruptions in the cranial neural crest, a vertebrate-specific transient population of stem cells that contribute to the formation of diverse cell lineages and embryonic structures during development. In this review, we summarize our current knowledge of the RA-mediated regulation of cranial neural crest induction at the edge of the neural tube and the migration of these cells into the craniofacial region. Further, we discuss the role of RA in the regulation of cranial neural crest cells found within the frontonasal process, periocular mesenchyme, and pharyngeal arches, which eventually form the bones and connective tissues of the head and neck and contribute to structures in the anterior segment of the eye. We then review our understanding of the mechanisms underlying congenital craniofacial and ocular diseases caused by either the genetic or toxic disruption of RA signaling. Finally, we discuss the role of RA in maintaining neural crest-derived structures in postembryonic tissues and the implications of these studies in creating new treatments for degenerative craniofacial and ocular diseases.

Crossed looks on the dermatologist's position and the patient's preoccupations as to psoriasis and pregnancy: preliminary results of the PREGNAN-PSO study

BACKGROUND

While some information on psoriasis impact on pregnancy is available, very little is known on the preoccupations of women afflicted by the disease or on the dermatologists' (D) positioning as to psoriasis and pregnancy. The 'Objectifs Peau' project demonstrated a 4.7% prevalence of psoriasis in women aged 18-45 years in France.

OBJECTIVE

This project sought to further address these issues in view of a targeted action plan.

METHODS

A questionnaire was made available to 361 D of different types.

RESULTS

Overall, 152 D answered the questionnaire, 50.7% working in private or mixed practice and 49.3% in hospitals, with 63% females (DF) and 37% males (DM). Over the last 3 months, the mean percentage of women of child-bearing age seen by these D was 28.6%. The main issue addressed by D upon psoriasis diagnosis was the patient's wish to become pregnant in the short-term (84%), while the compatibility of drug treatment with pregnancy was the issue prioritized by patients (64%). Among DM and DF, 46% and 29% reported having been confronted with an unplanned pregnancy, with their reaction mainly dependent on the treatment taken in 66%. Regarding follow-up, 26% D declared having shared their decision-making with gynaecologists, while 56% considered the first pregnancy trimester to be the highest-risk period. Only 28% D were familiar with existing recommendations, with only 21% of them considering them appropriate.

CONCLUSION

Overall, 26.2% of French psoriasis women are of child-bearing potential, in line with our dataset (28.6%). Only 56% D considered the 1st pregnancy trimester to be the highest-risk period, with only one-third familiar with existing recommendations. The gap between recommendations and actual practices must be addressed through policies that take women's preoccupations better into account.

Retinoic Acid Maintains Function of Neural Crest-Derived Ocular and Craniofacial Structures in Adult Zebrafish

Purpose

Retinoic acid (RA) is required for embryonic formation of the anterior segment of the eye and craniofacial structures. The present study further investigated the role of RA in maintaining the function of these neural crest–derived structures in adult zebrafish.

Methods

Morphology and histology were analyzed by using live imaging, methylacrylate sections, and TUNEL assay. Functional analysis of vision and aqueous humor outflow were assayed with real-time imaging.

Results

Both decreased and increased RA signaling altered craniofacial and ocular structures in adult zebrafish. Exogenous treatment with all-trans RA for 5 days resulted in a prognathic jaw, while inhibition of endogenous RA synthesis through treatment with 4-diethylaminobenzaldehyde (DEAB) decreased head height. In adult eyes, RA activity was localized to the retinal pigment epithelium, photoreceptors, outer plexiform layer, inner plexiform layer, iris stroma, and ventral canalicular network. Exogenous RA increased apoptosis in the iris stroma and canalicular network in the ventral iridocorneal angle, resulting in the loss of these structures and decreased aqueous outflow. DEAB, which decreased RA activity throughout the eye, induced widespread apoptosis, resulting in corneal edema, cataracts, retinal atrophy, and loss of iridocorneal angle structures. DEAB-treated fish were blind with no optokinetic response and no aqueous outflow from the anterior chamber.

Conclusions

Tight control of RA levels is required for normal structure and function of the adult anterior segment. These studies demonstrated that RA plays an important role in maintaining ocular and craniofacial structures in adult zebrafish.

Human Pluripotent Stem Cells to Assess Developmental Toxicity in the Osteogenic Lineage

Musculoskeletal birth defects are frequent, yet their causes remain insufficiently investigated. Aside from genetic factors, exposure to environmental toxicants is suspected to contribute to the etiology of skeletal malformations. However, most chemicals in the environment are insufficiently characterized for their potential to cause harm to the differentiation of osteoblasts, the bone-forming cells and thereby the development of the skeleton.This lack of information primarily stems from animal testing being prohibitively expensive and time-consuming, which has prompted the development of predictive in vitro alternative methods. With the advent of mouse embryonic stem cells, which represent cells with the potential to become any of the 200 cell types in the body, among them osteoblasts, the past 15 years have borne suitable opportunities to assess chemicals in vitro. However, with an increasing understanding of the differences between mouse and human embryonic development, a need for human-specific developmental toxicity testing has risen. This chapter provides a detailed protocol on how to differentiate human embryonic stem cells into the osteogenic lineage, how to assess differentiation inhibition and how to evaluate such findings in relation to the mitochondrial activity of human embryonic stem cells and human fibroblasts, while exposed to a potential toxicant. Together, these endpoints allow for a human-specific screening of developmental toxicity specifically related to the osteogenic lineage.

Perturbation of Retinoid Homeostasis Increases Malformation Risk in Embryos Exposed to Pregestational Diabetes

Pregestational diabetes is highly associated with an increased risk of birth defects. However, factors that can increase or reduce the expressivity and penetrance of malformations in pregnancies in women with diabetes remain poorly identified. All-trans retinoic acid (RA) plays crucial roles in embryogenesis. Here, we find that Cyp26a1, which encodes a key enzyme for catabolic inactivation of RA required for tight control of local RA concentrations, is significantly downregulated in embryos of diabetic mice. Embryonic tissues expressing Cyp26a1 show reduced efficiency of RA clearance. Embryos exposed to diabetes are thus sensitized to RA and more vulnerable to the deleterious effects of increased RA signaling. Susceptibility to RA teratogenesis is further potentiated in embryos with a preexisting genetic defect of RA metabolism. Increasing RA clearance efficiency using a preconditioning approach can counteract the increased susceptibility to RA teratogenesis in embryos of diabetic mice. Our findings provide new insight into gene-environment interactions that influence individual risk in the manifestation of diabetes-related birth defects and shed light on environmental risk factors and genetic variants for a stratified medicine approach to screening women with diabetes who are of childbearing age and assessing the risk of birth defects during pregnancy.

Enzymatic Metabolism of Vitamin A in Developing Vertebrate Embryos

Embryonic development is orchestrated by a small number of signaling pathways, one of which is the retinoic acid (RA) signaling pathway. Vitamin A is essential for vertebrate embryonic development because it is the molecular precursor of the essential signaling molecule RA. The level and distribution of RA signaling within a developing embryo must be tightly regulated; too much, or too little, or abnormal distribution, all disrupt embryonic development. Precise regulation of RA signaling during embryogenesis is achieved by proteins involved in vitamin A metabolism, retinoid transport, nuclear signaling, and RA catabolism. The reversible first step in conversion of the precursor vitamin A to the active retinoid RA is mediated by retinol dehydrogenase 10 (RDH10) and dehydrogenase/reductase (SDR family) member 3 (DHRS3), two related membrane-bound proteins that functionally activate each other to mediate the interconversion of retinol and retinal. Alcohol dehydrogenase (ADH) enzymes do not contribute to RA production under normal conditions during embryogenesis. Genes involved in vitamin A metabolism and RA catabolism are expressed in tissue-specific patterns and are subject to feedback regulation. Mutations in genes encoding these proteins disrupt morphogenesis of many systems in a developing embryo. Together these observations demonstrate the importance of vitamin A metabolism in regulating RA signaling during embryonic development in vertebrates.

Vitamin A and Carotenoid Toxicity

Large differences in time and dose needed to induce hypervitaminosis A have been observed. High doses of vitamin A in food and oily solutions are well tolerated, whereas emulsified preparations have higher toxicity. Chronic hypervitaminosis seems to be induced following daily doses of 300,000 to 600,000 IU of vitamin A (90–180 mg of retinol) in oily preparations for many months or years, whereas teratogenicity may be induced by daily doses as low as 40,000 IU of vitamin A (12 mg of retinol) in oil during the first trimester. for the provitamin A, β-carotene, serious adverse effects have been reported in large-scale prospective randomized trials: four years of supplementation with 20 to 30 mg β-carotene per day was associated with increased risk of lung cancer and cardiovascular disease among smokers and workers exposed to asbestos. These results strongly suggest that high doses of β-carotene should not be recommended for any group until the safety of such doses can be established.

Safety and Toxicity of Vitamin A Supplements in Pregnancy

Vitamin A plays an essential role during fetal development; however, if consumed at high doses it can produce teratogenic effects. Synthetic retinoids are potent teratogens and are contraindicated during pregnancy. β-Carotene is free of toxic effects. Intakes of vitamin A less than 10,000 IU per day during pregnancy have not been associated with birth defects. However, there are conflicting results for intakes of 10,000 IU to 30,000 IU per day. Intakes of vitamin A greater than 10,000 IU per day are not recommended for well-nourished pregnant women. Intakes of 30,000 IU per day of vitamin A in nonpregnant women produce only minor increases in the primary teratogen of vitamin A embryopathy. in vitamin A–deficient populations, doses of vitamin A less than 10,000 IU per day or 25,000 IU per week are considered beneficial to pregnant women without risk to the fetus. in these populations, the risks of teratogenicity from high vitamin A intake may need to be balanced against those from a deficiency.

A Retrospective Appraisal of the Ability of Animal Tests To Predict Reproductive and Developmental Toxicity in Humans

The reproductive and developmental toxicology areas have undergone numerous changes in the 30 years since the thalidomide tragedy. It would be comforting if such changes have resulted in a greatly decreased likelihood that human conceptuses will develop malformations. However, there is little evidence that such testing has better enabled us to identify human reproductive or developmental toxicants. Although there may be justification for performing animal testing on drugs and pesticides, a simple acute toxicity test may be just as predictive as currently employed reproductive and developmental toxicity tests for other synthetic chemicals. Support for this premise is provided by comparing available acute toxicity information on many compounds, identified as (potential) human developmental or reproductive toxicants, with their respective likely human threshold doses. Acute LD50 values of other potential human reproductive or developmental toxicants, not documented as being a threat to humans, also were compared with their time-weighted averages or their lowest teratogenic dose in the same species. The data generated support the premise that most reproductive or developmental toxicants are a potential threat to humans only if exposure levels approach those that are lethal in the rat or mouse. In contrast, unequivocal evidence of developmental toxicity for drugs, such as thalidomide and isotretinoin, to which the human embryo is highly sensitive, were not apparent in the screens used now for routine developmental toxicology testing. Thus, requirements that all chemicals be tested for reproductive and developmental toxicity should await the development of testing methodology capable of better assessing human risk.

Thyroid hormone and retinoic acid interact to regulate zebrafish craniofacial neural crest development

Craniofacial and ocular morphogenesis require proper regulation of cranial neural crest migration, proliferation, survival and differentiation. Although alterations in maternal thyroid hormone (TH) are associated with congenital craniofacial anomalies, the role of TH on the neural crest has not been previously described. Using zebrafish, we demonstrate that pharmacologic and genetic alterations in TH signaling disrupt cranial neural crest migration, proliferation, and survival, leading to craniofacial, extraocular muscle, and ocular developmental abnormalities. In the rostral cranial neural crest that gives rise to the periocular mesenchyme and the frontonasal process, retinoic acid (RA) rescued migratory defects induced by decreased TH signaling. In the caudal cranial neural crest, TH and RA had reciprocal effects on anterior and posterior pharyngeal arch development. The interactions between TH and RA signaling were partially mediated by the retinoid X receptor. We conclude that TH regulates both rostral and caudal cranial neural crest. Further, coordinated interactions of TH and RA are required for proper craniofacial and ocular development.

Micronutrient status in phenylketonuria

Patients with phenylketonuria (PKU) encompass an 'at risk' group for micronutrient imbalances. Optimal nutrient status is challenging particularly when a substantial proportion of nutrient intake is from non-natural sources. In PKU patients following dietary treatment, supplementation with micronutrients is a necessity and vitamins and minerals should either be added to supplement phenylalanine-free l-amino acids or given separately. In this literature review of papers published since 1990, the prevalence of vitamin and mineral deficiency is described, with reference to age of treatment commencement, type of treatment, dietary compliance, and dietary practices. Biological micronutrient inadequacies have been mainly reported for zinc, selenium, iron, vitamin B12 and folate. The aetiology of these results and possible clinical and biological implications are discussed. In PKU there is not a simple relationship between the dietary intake and nutritional status, and there are many independent and interrelated complex factors that should be considered other than quantitative nutritional intake.

Pregnancy outcomes and factors associated with voluntary pregnancy termination in women who had been treated for acne with isotretinoin

OBJECTIVE

We aimed to study the pregnancy outcomes of women exposed to isotretinoin and to identify the factors influencing their decision to request an abortion.

METHODS

The study prospectively identified 79 women who had been treated for acne with isotretinoin during the periconceptional period, and who were followed up until completion of their pregnancy. Characteristics of exposure and doses were self-reported by participants.

RESULTS

Of the 56 participants who decided to continue their pregnancy, there were 11 spontaneous abortions and 44 women who delivered healthy full-term babies of which 19 had been exposed to isotretinoin <1 month before conception or during pregnancy. In a nominal logistic regression analysis including 68 patients who provided adequate information for analysis, exposure to isotretinoin >2 weeks post-conception and pregnancy termination recommended by the first-contact physician were found to be significantly associated with patients' decision to undergo elective abortion: adjusted OR = 9.87 (95% CI 1.18-82.34) and 12.51 (95% CI 2.36-66.29), respectively.

CONCLUSIONS

Our study reports an elevated rate of babies born without evidence of gross malformation or neurofunctional abnormality even tough exposure occurred during the teratogenic risk period. However, caution is recommended since a substantial risk of congenital malformations has been reported with low doses of isotretinoin and at exposures limited to early pregnancy. We also found that primary-care physicians may influence patients' decision to request pregnancy termination independently of their timing of exposure to isotretinoin.

Comparative studies on effects of all-trans-retinoic acid and all-trans-retinoyl-beta-d-glucuronide on the development of foetal mouse thymus in an organ culture system

The thymus is a target organ of retinoid teratogens. Retinoids with a generally reduced teratogenic potency should therefore also exert reduced adverse effects on thymus development. The effects of all-trans-retinoic acid (a-tRA) and all-trans-retinoyl-beta-glucuronide (a-tRAG) on the in vitro development of thymic lobes of 15-day-old mouse foetuses were compared in an organ culture system. Both compounds were added to the medium at concentrations ranging from 10(-7) to 10(-5)m. The culture period was 6 days. The investigations showed a concentration-dependent effect of both substances on the proliferation of the lymphatic cells. At 10(-5)m the number of thymocytes was significantly reduced to values of about 70% of the controls by either of the retinoids (P 0.05). Results of flow cytometry showed significant differences concerning the differentiation markers CD4 and CD8 after the culture period. The presence of 10(-6)m a-tRA induced a significant increase in the percentages of CD4(+)CD8(-) cells and a significant decrease of CD4(+)CD8(+) cells. At 10(-5)m a-tRA an additional significant increase in the percentages of CD4(-)CD8(-) cells was found. In contrast, after treatment with a-tRAG, percentages of these populations were in the same range as the controls. Light and electron microscopic investigations revealed a depletion of lymphatic cells and an increase of intracytoplasmic vacuoles in the thymic epithelial cells at 10(-6) and 10(-5)m of either retinoid. HPLC analyses revealed a remarkable degree of retinoid isomerization and (in the case of a-tRAG) of hydrolysis. Compared with the culture medium, retinoids were accumulated in the thymic lobes. Possibly a-tRAG acts by way of limited hydrolysis to retinoic acid.

A comparison of gene expression responses in rat whole embryo culture and in vivo: time-dependent retinoic acid-induced teratogenic response

The whole embryo culture (WEC) model serves as a potential alternative for classical in vivo developmental toxicity testing. In the WEC, cultured rat embryos are exposed during neurulation and early organogenesis and evaluated for morphological effects. Toxicogenomic-based approaches may improve the predictive ability of WEC by providing molecular-based markers associated with chemical exposure, which can be compared across multiple parameters (e.g., exposure duration, developmental time, experimental model). Additionally, comparisons between in vitro and in vivo models may identify objective relevant molecular responses linked with developmental toxicity endpoints in vivo. In this study, using a transcriptomic approach, we compared all-trans retinoic acid (RA)-exposed and nonexposed Wistar rat embryos derived using WEC (RA, 0.5 μg/ml) or in vivo (RA, 50 mg/kg, oral gavage) to identify overlapping and nonoverlapping effects of RA on RNA expression in parallel with morphological changes. Across six time points (gestational day 10 + 2-48 h), we observed strong similarities in RA response at the gene (directionality, significance) and functional (e.g., embryonic development, cell differentiation) level which associated with RA-induced adverse morphological effects, including growth reduction as well as alterations in neural tube, limb, branchial, and mandible development. We observed differences between models in the timing of RA-induced effects on genes related to embryonic development and RA metabolism. These observations on the gene expression level were associated with specific differential morphological outcomes. This study supports the use of WEC to examine compound-induced molecular responses relative to in vivo and, furthermore, assists in defining the applicability domain of the WEC in determining complementary windows of sensitivity for developmental toxicological investigations.

A zebrafish model of axenfeld-rieger syndrome reveals that pitx2 regulation by retinoic acid is essential for ocular and craniofacial development

PURPOSE

The homeobox transcription factor PITX2 is a known regulator of mammalian ocular development, and human PITX2 mutations are associated with Axenfeld-Rieger syndrome (ARS). However, the treatment of patients with ARS remains mostly supportive and palliative.

METHODS

The authors used molecular genetic, pharmacologic, and embryologic techniques to study the biology of ARS in a zebrafish model that uses transgenes to mark neural crest and muscle cells in the head.

RESULTS

The authors demonstrated in vivo that pitx2 is a key downstream target of retinoic acid (RA) in craniofacial development, and this pathway is required for coordinating neural crest, mesoderm, and ocular development. pitx2a knockdown using morpholino oligonucleotides disrupts jaw and pharyngeal arch formation and recapitulates ocular characteristics of ARS, including corneal and iris stroma maldevelopment. These phenotypes could be rescued with human PITX2A mRNA, demonstrating the specificity of the knockdown and evolutionary conservation of pitx2a function. Expression of the ARS dominant negative human PITX2A K50E allele also caused ARS-like phenotypes. Similarly, inhibition of RA synthesis in the developing eye (genetic or pharmacologic) disrupted craniofacial and ocular development, and human PITX2A mRNA partially rescued these defects.

CONCLUSIONS

RA regulation of pitx2 is essential for coordinating interactions among neural crest, mesoderm, and developing eye. The marked evolutionary conservation of Pitx2 function in eye and craniofacial development makes zebrafish a potentially powerful model of ARS, amenable to in vivo experimentation and development of potential therapies.

Phenothiourea sensitizes zebrafish cranial neural crest and extraocular muscle development to changes in retinoic acid and IGF signaling

1-Phenyl 2-thiourea (PTU) is a tyrosinase inhibitor commonly used to block pigmentation and aid visualization of zebrafish development. At the standard concentration of 0.003% (200 µM), PTU inhibits melanogenesis and reportedly has minimal other effects on zebrafish embryogenesis. We found that 0.003% PTU altered retinoic acid and insulin-like growth factor (IGF) regulation of neural crest and mesodermal components of craniofacial development. Reduction of retinoic acid synthesis by the pan-aldehyde dehydrogenase inhibitor diethylbenzaldehyde, only when combined with 0.003% PTU, resulted in extraocular muscle disorganization. PTU also decreased retinoic acid-induced teratogenic effects on pharyngeal arch and jaw cartilage despite morphologically normal appearing PTU-treated controls. Furthermore, 0.003% PTU in combination with inhibition of IGF signaling through either morpholino knockdown or pharmacologic inhibition of tyrosine kinase receptor phosphorylation, disrupted jaw development and extraocular muscle organization. PTU in and of itself inhibited neural crest development at higher concentrations (0.03%) and had the greatest inhibitory effect when added prior to 22 hours post fertilization (hpf). Addition of 0.003% PTU between 4 and 20 hpf decreased thyroxine (T4) in thyroid follicles in the nasopharynx of 96 hpf embryos. Treatment with exogenous triiodothyronine (T3) and T4 improved, but did not completely rescue, PTU-induced neural crest defects. Thus, PTU should be used with caution when studying zebrafish embryogenesis as it alters the threshold of different signaling pathways important during craniofacial development. The effects of PTU on neural crest development are partially caused by thyroid hormone signaling.

Low levels of alitretinoin in seminal fluids after repeated oral doses in healthy men

BACKGROUND

Alitretinoin, like all retinoids, is teratogenic, and can only be given to women of childbearing potential if pregnancy is excluded and a strict contraceptive programme is followed.

AIM

This study was designed to determine whether alitretinoin in the semen of men treated with alitretinoin poses a teratogenic risk to their female partners.

METHODS

In total, 24 healthy men aged 18-45 years received alitretinoin 20 mg (n = 12) or 40 mg (n = 12), once daily for 14 days. Subjects in the 40 mg dose group provided ejaculate at baseline, on day 1, before and approximately 4 h after dosing on day 2, and at follow-up on study day 21 (± 2).

RESULTS

Alitretinoin and 4-oxo-alitretinoin were detected in 11 of the 12 semen samples. The highest level of alitretinoin in semen was 7.92 ng/mL. Assuming an ejaculate volume of 10 mL, the amount of drug transferred in semen would be about 80 ng, 1/375,000 of a single 30 mg capsule. Complete absorption of 80 ng of alitretinoin from semen, presuming a volume of distribution confined to 5 L of circulating blood in the partner, would lead to an increase in plasma alitretinoin concentration of 0.016 ng/mL, which appears to be negligible compared with measured endogenous plasma levels. Increases in plasma levels of related retinoids are also negligible.

CONCLUSIONS

Alitretinoin in the semen of men receiving up to 40 mg of oral alitretinoin per day is unlikely to be associated with teratogenic risk in their female partners. Barrier contraception is therefore not required for men taking alitretinoin.

The 9-cis retinoic acid signaling pathway and its regulation of prostaglandin-endoperoxide synthase 2 during in vitro maturation of pig cumulus cell-oocyte complexes and effects on parthenogenetic embryo production

The addition of 9-cis retinoic acid to the oocyte maturation culture medium has a beneficial effect on in vitro fertilized embryos. However, the mechanism of this activity is not known. Therefore, this study was done to elucidate the effect of 9-cis retinoic acid on parthenogenetic embryo production and its signaling pathway and molecular function during in vitro maturation of porcine cumulus cell-oocyte complexes (COCs). Concentrations of 0, 5, 50, and 500 nM 9-cis retinoic acid were added to the in vitro maturation medium, and the embryos were assessed after parthenogenetic activation. Cumulus cells and oocytes from the in vitro matured COCs were separated and subjected to RT-PCR and real-time RT-PCR for detecting retinoic acid receptors and measuring expression of prostaglandin-endoperoxide synthase1 and 2. The addition of 5 nM 9-cis retinoic acid to the maturation medium was beneficial for parthenogenetic embryo production. The effect of 9-cis retinoic acid was exerted directly through the oocytes via the retinoic acid receptor alpha and retinoid X receptor gamma signaling pathways and indirectly through the cumulus cells by the retinoic acid receptor beta and gamma and retinoid X receptor alpha and beta signaling pathways. The addition of 5 nM 9-cis retinoic acid-stimulated cumulus cells reaches full expansion by suppressing their excessive expression of prostaglandin-endoperoxide synthase 2. This study shows that 9-cis retinoic acid can exert its beneficial effect on parthenogenetic embryo production in pigs by multidimensional pathways affecting oocyte maturation.

Gene-environment interactions, folate metabolism and the embryonic nervous system

Formation of brain and spinal cord requires the successful closure of neural ectoderm into an embryonic neural tube. Defects in this process result in anencephaly or spina bifida, which together constitute a leading cause of mortality and morbidity in children, affecting all ethnic and socioeconomic groups. The subject of intensive research for decades, neural tube defects (NTDs), are understood to arise from complex interactions of genes and environmental conditions, though systems-level details are still elusive. Despite the variety of underlying causes, a single intervention, folic acid supplementation given in the first gestational month, can measurably reduce the occurrence of NTDs in a population. Evidence for and the scope of gene-environment interactions in the genesis of NTDs is discussed. A systems-based approach is now possible toward studies of genetic and environmental influences underlying NTDs that will enable the assessment of individual risk and personalized optimization of prevention.

Exercise and pregnancy

Exercise is an important component of a healthy lifestyle and, as such, is recommended during pregnancy. However, the response to exercise of both the expectant mother and fetus varies depending on the fitness level of the woman. The response to exercise is also affected by the known musculoskeletal and physiologic changes associated with pregnancy, such as increased ligament laxity, weight gain, change in the center of gravity, and carpal tunnel syndrome. Although the physiologic responses of the pregnant woman and fetus have been well studied, the literature contains comparatively few studies investigating response to exercise. When performed properly, activities such as aerobics, impact and nonimpact activities, resistance training, and swimming may be beneficial during pregnancy.

Genetic modifiers of the physical malformations in velo-cardio-facial syndrome/DiGeorge syndrome

Velo-cardio-facial syndrome/DiGeorge syndrome (VCFS/DGS), the most common micro-deletion disorder in humans, is characterized by craniofacial, parathyroid, and thymic defects as well as cardiac outflow tract malformations. Most patients have a similar hemizygous 3 million base pair deletion on 22q11.2. Studies in mouse have shown that Tbx1, a T-box containing transcription factor present on the deleted region, is likely responsible for the etiology of the syndrome. Furthermore, mutations in TBX1 have been found in rare non-deleted patients. Despite having the same sized deletion, most VCFS/DGS patients exhibit significant clinical variability. Stochastic, environmental and genetic factors likely modify the phenotype of patients with the disorder. Here, we review mouse genetics studies, which may help identify possible genetic modifiers for the physical malformations in VCFS/DGS.

Retinoic acid downregulates microRNAs to induce abnormal development of spinal cord in spina bifida rat model

OBJECTS

MicroRNAs have been found in the developing central nervous system, but little is known about their functions in development, especially in the abnormal development of spinal cord in spina bifida. To this end, we have studied the mechanism of microRNAs involved in the morphogenesis of the spinal cord in all-trans-retinoic acid (RA)-treated spina bifida rat fetus.

MATERIALS AND METHODS

Timed-pregnant rats were gavage-fed RA, and embryos were obtained on 13.5, 15.5, 17.5, and 19.5 days. MicroRNAs' expression profile was analyzed by Northern blot. In situ apoptosis detection and microRNA in situ hybridization methods on sections of paraffin-embedded tissues were employed to explore the mechanism.

CONCLUSION

Administration of RA reduced the size of the spinal cord, probably as a consequence of increased cell death. There is a dramatic decrease in the expression of miR-9/9*, miR-124a and miR-125b, and Bcl2 and P53 as well in the sacral cord from E13.5 to E19.5 days post coitum. Our data showed that expression of these microRNAs was dysregulated in RA-treated spinal cord during embryonic development, suggesting that they may be involved in the development of the spinal cord.

Management of psoriasis in pregnancy

Many treatments for this chronic skin disease are harmful to the developing fetus, so careful pre-conception planning and management adjustment are crucial for the pregnant patient

Involvement of apoptotic cell death and cell cycle perturbation in retinoic acid-induced cleft palate in mice

Retinoic acid (RA), a metabolite of vitamin A, plays a key role in a variety of biological processes and is essential for normal embryonic development. On the other hand, exogenous RA could cause cleft palate in offspring when it is given to pregnant animals at either the early or late phases of palatogenesis, but the pathogenetic mechanism of cleft palate caused by excess RA remains not fully elucidated. The aim of the present study was to investigate the effects of excess of RA on early palatogenesis in mouse fetuses and analyze the teratogenic mechanism, especially at the stage prior to palatal shelf elevation. We gave all-trans RA (100 mg/kg) orally to E11.5 ICR pregnant mice and observed the changes occurring in the palatal shelves of their fetuses. It was found that apoptotic cell death increased not only in the epithelium of the palatal shelves but also in the tongue primordium, which might affect tongue withdrawal movement during palatogenesis and impair the horizontal elevation of palatal shelves. In addition, RA was found to prevent the G(1)/S progression of palatal mesenchymal cells through upregulation of p21(Cip1), leading to Rb hypophospholylation. Thus, RA appears to cause G(1) arrest in palatal mesenchymal cells in a similar manner as in various cancer and embryonic cells. It is likely that apoptotic cell death and cell cycle disruption are involved in cleft palate formation induced by RA.

Acceleration of Lung Maturation in a Human Fetus following Maternal Isotretinoin Intake

The viability of the human fetus increases significantly beyond 25 weeks' gestation as the lung development progresses towards the 'saccular' stage. We report on a fetus of 22 weeks' gestation whose lung maturation was accelerated by 4 weeks, most likely due to the unintentional exposure to the retinoid isotretinoin (13-cis-retinoic acid) during pregnancy. Although retinoids are known to be stored within the lungs and to play a key role in lung differentiation and growth, their storage within the lung is limited during this critical developmental period. Even though glucocorticosteroids are used clinically to enhance lung maturation in the face of impending preterm birth, there are no data yet which demonstrate that glucocorticosteroids, when given alone, are effective in promoting lung maturation prior to 24 weeks' gestation. Strong evidence however, indicates that glucocorticosteroids promote the utilization of lung retinoids immediately before birth. Our observation of increased lung maturation, in conjunction with the above information suggests that retinoids alone or in combination with glucocorticosteroids might promote lung maturation more effectively than glucocorticosteroids alone when birth seems inevitable at a very early gestational age.

Retinoids have differing efficacies on alveolar regeneration in a dexamethasone-treated mouse

We have investigated the relative efficacy of a range of natural and synthetic retinoids on the induction of alveolar regeneration in a dexamethasone-treated mouse model. The aim was to explore the roles of the different retinoic acid receptors using receptor-selective agonists and to determine whether other natural retinoids in addition to all-trans-retinoic acid (tRA) were effective. Dexamethasone treatment of newborn pups led to a reduced lung surface area and increased mean chord length. Subsequently, tRA induced alveolar repair, improved mean chord length, and improved the lung surface area to volume ratio. We found that 4-oxo-RA and a retinoic acid receptor (RAR) alpha-selective compound were as effective as tRA at inducing alveolar regeneration, with neither showing a significantly better efficacy. An RARbeta-selective compound was also effective, whereas a RARgamma-selective compound was not. Other retinoids, such as 9-cis-RA, 13-cis-RA, retinol, and a pan retinoid X receptor (RXR) agonist, do not induce significant responses. Neither did granulocyte colony-stimulating factor. We also showed that an RARbeta-null mutant mouse line responded to dexamethasone by failing to develop alveoli appropriately and that tRA induced alveolar regeneration, suggesting that RARbeta was not required for the regenerative response.