Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque (Macaca fascicularis): I. Neonatal/infant observations

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Evaluation of the thermal effects of prenatal ultrasound on hematological analysis of young Oryctolagus Cuniculus

Elevated temperatures can induce changes in red blood cell (RBC), white blood cell (WBC) and platelet (PLT) counts. Ultrasound heating during obstetric scans has the potential to increase body temperature owing to the phenomenon of absorption. We conducted a study to determine the thermal effects of prenatal ultrasound on RBCs, hemoglobin concentration (Hb), WBCs and PLTs in young rabbits. We selected 69 rabbits that were 1 month of age and 73 that were 5 months of age, and allocated them to four groups. The control group consisted of four pregnant does that were allowed to have a full term delivery without any ultrasound exposure. The experimental groups were subjected to one-time ultrasound exposure for 30, 60 and 90 min in the middle of each gestational stage accordingly. RBCs and Hb showed significant reductions in the experimental groups of 1- and 5-month-old rabbits (P<0.05). In addition, WBCs and PLTs yielded significant differences in the 1-month group that were not observed in the 5-month group (P>0.05). The highest values recorded were those of the WBCs of 1-month-old subjects that received 90 min of exposure at the second stage of gestation. The PLTs were the lowest values recorded in 1-month-old subjects following 90 min of ultrasound exposure at the third stage of gestation. These findings suggest that hematological fluctuations during the early stages of postnatal life persisted until 1 month of age and recovered thereafter, as the subjects progressed into adulthood. Therefore, ultrasound heating can cause significant, yet reversible effects on the hematological parameters of rabbits.

Severity of ASD symptoms and their correlation with the presence of copy number variations and exposure to first trimester ultrasound

Current research suggests that incidence and heterogeneity of autism spectrum disorder (ASD) symptoms may arise through a variety of exogenous and/or endogenous factors. While subject to routine clinical practice and generally considered safe, there exists speculation, though no human data, that diagnostic ultrasound may also contribute to ASD severity, supported by experimental evidence that exposure to ultrasound early in gestation could perturb brain development and alter behavior. Here we explored a modified triple hit hypothesis [Williams & Casanova, ] to assay for a possible relationship between the severity of ASD symptoms and (1) ultrasound exposure (2) during the first trimester of pregnancy in fetuses with a (3) genetic predisposition to ASD. We did so using retrospective analysis of data from the SSC (Simon's Simplex Collection) autism genetic repository funded by the Simons Foundation Autism Research Initiative. We found that male children with ASD, copy number variations (CNVs), and exposure to first trimester ultrasound had significantly decreased non-verbal IQ and increased repetitive behaviors relative to male children with ASD, with CNVs, and no ultrasound. These data suggest that heterogeneity in ASD symptoms may result, at least in part, from exposure to diagnostic ultrasound during early prenatal development of children with specific genetic vulnerabilities. These results also add weight to on-going concerns expressed by the FDA about non-medical use of diagnostic ultrasound during pregnancy. Autism Res 2017, 10: 472-484. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.

Reassessment of teratogenic risk from antenatal ultrasound

Science has shown that risk of cavitation and hyperthermia following prenatal ultrasound exposure is relatively negligible provided intensity, frequency, duration of exposure, and total numbers of exposures are safely limited. However, noncavitational mechanisms have been poorly studied and occur within what are currently considered “safe” levels of exposure. To date, the teratogenic capacity of noncavitational effectors are largely unknown, although studies have shown that different forms of ultrasound-induced hydraulic forces and pressures can alter membrane fluidity, proliferation, and expression of inflammatory and repair markers. Loose regulations, poor end user training, and unreliable ultrasound equipment may also increase the likelihood of cavitation and hyperthermia during prenatal exposure with prolonged durations and increased intensities. The literature suggests a need for tighter regulations on the use of ultrasound and further studies into its teratogenicity.

Ultrasonic imaging: safety considerations

Modern ultrasound imaging for diagnostic purposes has a wide range of applications. It is used in obstetrics to monitor the progress of pregnancy, in oncology to visualize tumours and their response to treatment, and, in cardiology, contrast-enhanced studies are used to investigate heart function and physiology. An increasing use of diagnostic ultrasound is to provide the first photograph for baby's album-in the form of a souvenir or keepsake scan that might be taken as part of a routine investigation, or during a visit to an independent high-street 'boutique'. It is therefore important to ensure that any benefit accrued from these applications outweighs any accompanying risk, and to evaluate the existing ultrasound bio-effect and epidemiology literature with this in mind. This review considers the existing laboratory and epidemiological evidence about the safety of diagnostic ultrasound and puts it in the context of current clinical usage.

Craniorachischisis and omphalocele in a stillborn cynomolgus monkey (Macaca fascicularis)

Nonhuman primates have been a common animal model to evaluate experimentally induced malformations. Reports on spontaneous malformations are important in determining the background incidence of congenital anomalies in specific species and in evaluating experimental results. Here we report on a stillborn cynomolgus monkey (Macaca fascicularis) with multiple congenital anomalies from the colony maintained at the Southwest National Primate Research Center at the Texas Biomedical Research Institute, San Antonio, Texas. Physical findings included low birth weight, craniorachischisis, facial abnormalities, omphalocele, malrotation of the gut with areas of atresia and intussusception, a Meckel diverticulum, arthrogryposis, patent ductus arteriosus, and patent foramen ovale. The macaque had normal male external genitalia, but undescended testes. Gestational age was unknown but was estimated from measurements of the limbs and other developmental criteria. Although cytogenetic analysis was not possible due to the tissues being in an advanced state of decomposition, array Comparative Genomic Hybridization analysis using human bacterial artificial chromosome clones was successful in effectively eliminating aneuploidy or any copy number changes greater than approximately 3-5 Mb as a cause of the malformations. Further evaluation of the animal included extensive imaging of the skeletal and neural tissue defects. The animal's congenital anomalies are discussed in relation to the current hypotheses attempting to explain the frequent association of neural tube defects with other abnormalities.

Safety assurance in obstetrical ultrasound

Safety assurance for diagnostic ultrasound in obstetrics began with a tacit assumption of safety allowed by a federal law enacted in 1976 for then-existing medical ultrasound equipment. The implementation of the 510(k) pre-market-approval process for diagnostic ultrasound resulted in the establishment of guideline upper limits for several examination categories in 1985. The obstetrical category has undergone substantial evolution from initial limits (ie, 46 mW/cm2 spatial peak temporal average [SPTA] intensity) set in 1985. Thermal and mechanical exposure indices, which are displayed onscreen according to an Output Display Standard, were developed for safety assurance with relaxed upper limits. In 1992, with the adoption of the Output Display Standard, the allowable output for obstetrical ultrasound was increased in terms of both the average exposure (eg, to a possible 720 mW/cm2 SPTA intensity) and the peak exposure (via the Mechanical Index). There has been little or no subsequent research with the modern obstetrical ultrasound machines to systematically assess potential risks to the fetus using either relevant animal models of obstetrical exposure or human epidemiology studies. The assurance of safety for obstetrical ultrasound therefore is supported by three ongoing means: (1) review of a substantial but uncoordinated bioeffect research literature; (2) the theoretical evaluation of diagnostic ultrasound exposure in terms of thermal and nonthermal mechanisms for bioeffects; and (3) the skill and knowledge of professional sonographers. At this time, there is no specific reason to suspect that there is any significant health risk to the fetus or mother from exposure to diagnostic ultrasound in obstetrics. This assurance of safety supports the prudent use of diagnostic ultrasound in obstetrics by trained professionals for any medically indicated examination.

Effect of diagnostic ultrasound during the fetal period on learning and memory in mice

BACKGROUND

An experiment was conducted to find out whether in utero exposure to diagnostic ultrasound leads to changes in postnatal behavior in adult mice.

METHODS

A total of 15 pregnant Swiss albino mice were exposed to diagnostic levels of ultrasound (3.5 MHz, 65 mW/cm(2), intensity((spatial peak-temporal peak)) (I(SPTP))=1 mW/cm(2), intensity((spatial average-temporal average)) (I(SATA))=240 mW/cm(2)) for 30 min on day 14 or 16 of gestation. All exposed as well as control animals were left to complete gestation and parturition. Their offspring were used in our further studies. They were monitored during early postnatal life for standard developmental markers (such as pinna detachment, eye opening and fur development) and postnatal mortality was recorded up to 6 weeks of age. The litters were subjected to behavioral tests for learning and memory at 4 months of age. Representative animals from each group were sacrificed and the hippocampal region of the brain was assayed for biogenic amines, noradrenaline, dopamine, serotonin (5-HT) and 5-HT's metabolite, 5-hydroxy indoleacetic acid (5-HIAA), in order to determine whether ultrasound exposure produced any biochemical changes in the hippocampal region of the brain. Coronal sections from the dorsal hippocampus from the representative animals from each group were processed for staining and the number of neurons was counted.

RESULTS

Neither the standard developmental markers (such as pinna detachment, eye opening and fur development) nor the postnatal mortality was affected by ultrasound exposure. However, there was a significant impairment in learning (hole board test) and memory functions (shuttle box test) in both the exposure groups. Significant reductions in the biogenic amines and the decrease in the neuronal density were found only in day 14th pc ultrasound-exposed group compared with the control animals. The 16th day exposure group is relatively resistant to ultrasound-induced impairment of brain functions.

CONCLUSIONS

The results suggest that the early fetal brain is highly susceptible to induction of neurobehavioral changes by ultrasound exposure.

Fetal Gene Transfer Using Lentiviral Vectors:In VivoDetection of Gene Expression by microPET and Optical Imaging in Fetal and Infant Monkeys

Fetal intraperitoneal administration of human immunodeficiency virus (HIV)-l-derived lentiviral vectors (10(7) infectious particles/fetus) has consistently shown high levels of transduction and gene expression in the omentum, peritoneum, and diaphragm when assessed by polymerase chain reaction (PCR) and whole tissue fluorescence. In vivo imaging techniques were explored with early-gestation long-tailed macaques that were administered the vesicular stomatitis virus-glycoprotein (VSV-G)-pseudotyped HIV-1-derived lentiviral vector expressing a mutant herpes simplex virus type 1 thymidine kinase (HSV-1-sr39tk) and firefly luciferase under the control of the cytomegalovirus (CMV) promoter. Fetuses were monitored sonographically and twice during gestation 9-[4-[18F]Fluoro-3-(hydroxymethyl)butyl]guanine (18F-FHBG) was injected into the fetal circulation under ultrasound guidance in preparation for microPET imaging. All newborns were delivered at term by cesarean section and raised in the nursery for postnatal studies. At 2 months postnatal age, animals were imaged and biodistribution was assessed. Optical imaging for firefly luciferase expression was also performed every 2 months postnatal age. Under all imaging conditions gene expression was observed in the abdominal region, and closely paralleled findings from prior studies based on whole tissue fluorescence. These investigations have shown that HSV-1-sr39tk and firefly luciferase can be used to safely detect transgene expression at multiple time points in fetal and infant monkeys in vivo and without evidence of adverse effects.

Intrapulmonary and intramyocardial gene transfer in rhesus monkeys (Macaca mulatta): safety and efficiency of HIV-1-derived lentiviral vectors for fetal gene delivery

Fetal gene transfer was studied using intrapulmonary and intramyocardial transfer of SIN HIV-1-derived lentiviral vectors expressing EGFP in rhesus monkeys. Fetuses were monitored sonographically during gestation and tissue analyses performed at term or 3 months postnatal age. Animals remained healthy during the study period as evidenced by normal growth, development, hematology, clinical chemistry, echocardiography, and pulmonary function tests. Strong pulmonary fluorescence was observed postnatally after fetal intrapulmonary delivery of lenti-CMV, but not lenti-SP-C, and compared to nontransferred controls. High EGFP copy numbers were found by quantitative PCR with both vector constructs in lung lobes (<or=15%) and EGFP copies were also detected in the diaphragm, pericardium, and thorax. No differences were found in lung:body weight ratios, percentage lung parenchyma, or overall morphology when compared to controls. For intramyocardial gene delivery, strong transgene expression was found within the myocardium and pericardium, and high EGFP copy numbers were found by quantitative PCR (3-36%). EGFP was also detected in the aorta, thorax, and diaphragm. These studies indicate that postnatal heart and lung development and function were not altered after fetal intraorgan gene transfer and subsequent transgene expression prenatally and postnatally, and gene transfer was restricted to the thoracic cavity with intrapulmonary and intramyocardial lentiviral vector-mediated gene delivery.

Gestational stage sensitivity to ultrasound effect on postnatal growth and development of mice

BACKGROUND

An experiment was conducted to find out whether ultrasound exposure leads to changes in postnatal growth and development in the mouse.

METHODS

A total of 15 pregnant Swiss albino mice were exposed to diagnostic levels of ultrasound (3.5 MHz, 65 mW/cm2, I(SPTP) = 1 mW/cm2 Intensity(Spatial Peak-Temporal Peak), I(SATA) = 240 mW/cm2 Intensity(Spatial Average-Temporal Average)) for 30 min for a single day between days 10 and 18 of gestation (GD 10-18). Virgin female mice were placed with same age group males for mating in the ratio 2 females : 1 male and examined the next morning for the presence of vaginal plug, a sign of successful copulation. The females with vaginal plugs were separated and labeled as 0-day pregnant. Maternal vaginal temperature was also measured. A sham exposed control group of 15 pregnant mice was maintained for comparison. All exposed as well as control animals were left to complete gestation and parturition. Their offspring were used in our further studies. They were monitored during early postnatal life for standard developmental markers, postnatal mortality, body weight, body length, head length, and head width, and growth restriction was recorded up to 6 weeks of age.

RESULTS

An exposure to ultrasound induced nonsignificant deviations in the maternal vaginal temperature or developmental markers. Significant low birth weight was observed in the present study, after exposure at GD 11, 12, 14, and 16. However, 14 and 16 days postcoitus during the fetal period appears to be the most sensitive to the ultrasound effect, in view of the number of different effects as well as severity of most of the observed effects when exposed on these gestation days.

CONCLUSIONS

The results indicate that diagnostic ultrasound can induce harmful effects on mouse growth and development when given at certain critical periods of gestation.

Effects of repeated prenatal ultrasound examinations on childhood outcome up to 8 years of age: follow-up of a randomised controlled trial

BACKGROUND

Despite the widespread use of prenatal ultrasound studies, there are no published data from randomised controlled trials describing childhood outcomes that might be influenced by repeated ultrasound exposures. We previously undertook a randomised controlled trial to assess the effects of multiple studies on pregnancy and childhood outcomes and reported that those pregnancies allocated to receive multiple examinations had an unexplained and significant increase in the proportion of growth restricted newborns. Our aim was to investigate the possible effects of multiple prenatal ultrasound scans on growth and development in childhood. Here, we provide follow-up data of the childrens' development.

METHODS

Physical and developmental assessments were done on children whose pregnant mothers had been allocated at random to a protocol of five studies of ultrasound imaging and umbilical artery Doppler flow velocity waveform between 18 and 38 weeks' gestation (intensive group n=1490) or a single imaging study at 18 weeks' gestation (regular group n=1477). We used generalised logistic and linear regression models to assess the group differences in developmental and growth outcomes over time. Primary data analysis was done by intention-to-treat.

FINDINGS

Examinations were done at 1, 2, 3, 5, and 8 years of age on children born without congenital abnormalities and from singleton pregnancies (intensive group n=1362, regular group n=1352). The follow-up rate at 1 year was 85% (2310/2714) and at 8 years was 75% (2042/2714). By 1 year of age and thereafter, physical sizes were similar in the two groups. There were no significant differences indicating deleterious effects of multiple ultrasound studies at any age as measured by standard tests of childhood speech, language, behaviour, and neurological development.

INTERPRETATION

Exposure to multiple prenatal ultrasound examinations from 18 weeks' gestation onwards might be associated with a small effect on fetal growth but is followed in childhood by growth and measures of developmental outcome similar to those in children who had received a single prenatal scan.

Dopplerfluxometria no estudo da circulação fetal: revisão do aspecto segurança

Os autores apresentam os métodos Doppler e sua evolução no estudo da circulação fetal, dando ênfase à segurança e aos bioefeitos. Os aparelhos de ultra-sonografia utilizados correntemente funcionam com índice térmico máximo e índice mecânico automaticamente mantidos em níveis inferiores a 1,0. Até os dias atuais, não foi descrita lesão biológica em fetos humanos submetidos ao Doppler diagnóstico. Portanto, o Doppler pulsado, o colorido e o "power" Doppler são seguros na exposição ultra-sonográfica do pré-natal.

Long-term effects of diagnostic ultrasound during fetal period on postnatal development and adult behavior of mouse

Pregnant Swiss albino mice were exposed to diagnostic levels of ultrasound (3.5 MHz, intensity 65 mW, I(SPTP) = 1 W/cm(2), I(SATA) = 240 W/cm(2)) for 10, 20 and 30 minutes on day 14 of gestation. Sham exposed controls were maintained for comparison. Fifteen pregnant mice were exposed for each group. Exposed as well as control animals were left to complete gestation and parturition. Ultrasound induced changes in maternal vaginal temperature was recorded. The changes in the physiological reflexes and postnatal mortality up to 6 weeks of age were recorded. The litters were subjected to behavioral tests for locomotor activity, learning and memory at 4 month and 1 year of age. Neither the physiological reflexes nor the postnatal mortality was affected by ultrasound exposure. However, there was a noticeable impairment in both locomotor and learning behavior even after a 10 min exposure, which further increased with increases in exposure time. Thus the present study demonstrates the neurotoxicity of diagnostic ultrasound and the high susceptibility of early fetal brain to induction of lasting detrimental changes by ultrasound exposure.

Rhesus monkey model for fetal gene transfer: studies with retroviral- based vector systems

Many life-threatening conditions that can be diagnosed early in gestation may be treatable in utero using gene therapy. In order to determine in utero gene transfer efficiency and safety, studies were conducted with fetal rhesus monkeys as a model for the human. Included in these studies were Moloney murine leukemia virus (MLV)-based amphotropic retrovirus, vesicular stomatitis virus-G (VSV-G) pseudotyped MLV, and a VSV-G pseudotyped HIV-1-based vector, all expressing the enhanced green fluorescent protein (EGFP) as a reporter gene and driven by a cytomegalovirus-immediate early promoter (N = 16). Rhesus monkey fetuses were administered viral vector supernatant preparations by the intraperitoneal (ip) (N = 14) or intrahepatic (ih) (N = 2) routes via ultrasound guidance at 55 +/- 5 days gestation (late first trimester; term 165 +/- 10 days). Fetuses were monitored sonographically, specimens were collected prenatally and postnatally, and tissue harvests were performed at birth or 3 or 6 months postnatal age (3-10 months post-gene transfer). PCR analyses demonstrated that transduced cells were present at approximately 1.2% in peripheral blood mononuclear cells from fetuses administered amphotropic MLV, <0.5% in fetuses receiving MLV/VSV-G, and approximately 4.2% for the lentiviral vector, which decreased to 2% at birth. Hematopoietic progenitors showed that overall (mean of all time points assessed), approximately 25% of the collected colonies were positive for the EGFP transgene with the lentiviral vector, which was significantly greater than results achieved with the MLV-based vector systems (4-9%; P < or = 0.001-0.016). At necropsy, 0.001-10% of the total genomic DNA was positive for EGFP in most tissues for all groups. EGFP-positive fluorescent cells were found in cell suspensions of thymus, liver, spleen, lymph nodes, cerebral cortex, and bone marrow (0.5-6%). Overall, the results of these studies have shown: (1) healthy infants expressing vector sequences up to 10 months post-gene transfer, (2) fetal primate administration of retroviral vectors results in gene transfer to multiple organ systems, (3) the highest level of gene transfer to hematopoietic progenitors was observed with the lentiviral vector system, and (4) there was no evidence of transplacental transfer of vector sequences into the dams. The rhesus monkey is an important preclinical primate model system for exploring gene transfer approaches for future applications in humans.

Transplantation of human peripheral blood stem cells into fetal rhesus monkeys (Macaca mulatta)

BACKGROUND

Methods for assessing engraftment efficiency have been explored in a primate xenogeneic model of in utero hematopoietic stem cell transplantation.

METHODS

Human peripheral blood stem cells (PBSC) were obtained by leukapheresis from a human male donor after 4 days of administration of recombinant human granulocyte-colony stimulating factor (5 microg/kg/ day). PBSC were enriched for the CD34+ population with and without T-cell depletion. The resulting mononuclear cells consisted of two cell populations, one that was stem cell enriched (0.83% CD3+ cells, 95% CD34+; group 1) and one that was stem cell enriched and T-cell depleted (<0.03% CD3+ cells, 98% CD34+; group 2). Four fetal monkeys (two per group) received either two or four i.p. injections (approximately 5x10(6) cells/injection) via ultrasound guidance every other day over a 7-day period (gestational days 50, 52, 54, and 56). One fetus in each group also received i.p. recombinant human stem cell factor (25 microg/kg) and recombinant human granulocyte-colony stimulating factor (10 microg/kg) posttransplant every 10 days from gestational day 60-150.

RESULTS

Four healthy newborns were delivered at term, and specimens were analyzed by polymerase chain reaction for the human Y chromosome (birth, monthly to 6 months; blood, marrow, progenitor assays). Polymerase chain reaction results were positive for all four newborns in all specimens assessed, and flow cytometric analysis for human CD45 in marrow showed engraftment ranging from 0.1-1.7%. There was no evidence of graft-versus-host disease in any of the animals.

CONCLUSION

These studies show that (1) multilineage engraftment of human PBSC can be achieved in the fetal rhesus recipient, (2) the rhesus fetus appears to tolerate relatively high numbers of human CD3+ cells, and (3) healthy chimeric rhesus infants can be delivered at term after multiple in utero procedures.

Pharmacokinetics, pharmacodynamics, and safety of administering pegylated recombinant megakaryocyte growth and development factor to newborn rhesus monkeys

Thrombocytopenia is common among sick neonates. Certain groups of thrombocytopenic adults respond favorably to the administration of recombinant thrombopoietin or to pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF), a recombinant human polypeptide that contains the receptor-binding N-terminal domain of thrombopoietin. The effectiveness and safety of such treatment in neonates, however, have not been reported. The purpose of the present study was to determine the biologic activity and safety of PEG-rHuMGDF administration to newborn rhesus monkeys. Eight monkeys were divided into four groups and treated subcutaneously with 0.00, 0.25, 1.00, or 2.50 microg/kg once daily for 7 d. Complete blood counts, serum chemistries, clotting panels, and MGDF levels were followed serially, and hematopoietic progenitor cell assays were performed on bone marrow aspirates before the first dose and again on d 8. Pharmacokinetic evaluations were performed on the animals that received the highest dose of PEG-rHuMGDF. All monkeys had normal growth during the study period, and all chemistries, clotting studies, and blood pressure measurements were normal. The peak serum MGDF concentration occurred at 3 h, and the half-life was 8.4 to 13.0 h. As in adult rhesus monkeys, platelet counts in the treated neonates began to rise on d 6, peaked on d 11, and returned to baseline by d 23. The two highest doses generated an 8- to 12-fold increase in platelets, whereas those treated with 0.25 microg/kg had a 6-fold increase. Other hematologic parameters measured were unaffected. Thus, newborn monkeys responded to doses of PEG-rHuMGDF that were similar to or smaller than (per kilogram body weight) those that are effective in adult animals and did so without obvious short-term toxicity.

Ultrasound during pregnancy and birthweight, childhood malignancies and neurological development

The present paper summarizes some of the epidemiological studies of in utero ultrasound exposure and subsequent childhood development. Emphasis is placed on birthweight, childhood malignancies and neurological development. A meta-analysis, including neurological outcomes such as handedness, speech development, motor development, hearing and vision, is presented. The epidemiological evidence does not indicate any association between diagnostic ultrasound exposure during pregnancy and reduced birthweight, childhood malignancies or neurological maldevelopment. The possible association between ultrasound and nonrighthandedness among boys needs further evaluation.

Administration of 9-[2-(R)-(phosphonomethoxy)propyl]adenine (PMPA) to gravid and infant rhesus macaques (Macaca mulatta): safety and efficacy studies

9-[2-(R)-(phosphonomethoxy)propyl]adenine (PMPA) significantly inhibits viral reverse transcription and has been reported to sustain low virus load in SIV-infected rhesus monkeys. Based on these findings, studies were conducted to assess the safety, efficacy, and placental transfer of PMPA when administered once daily subcutaneously to gravid rhesus monkeys during the second and third trimesters and their offspring (30 mg/kg/day). Fetuses (SIV-infected, N = 6; noninfected, N = 6) were monitored sonographically, and maternal/fetal blood samples were collected at select time points for hematologic, clinical chemical, virologic, immunologic, and pharmacologic assessments. Newborns were delivered by cesarean section at term and nursery reared for postnatal studies. Infants were administered PMPA once daily beginning on day 2 of life until 9 months postnatal age. Results of these studies have shown significant placental transport of PMPA, with peak fetal levels at 1 to 3 hours post-maternal administration; a significant and sustained reduction in viral load in SIV-infected fetuses and infants; and marked improvements in outcome (e.g., survival, growth, health) in SIV-infected offspring. However, decreased infant body weights and alterations of select serum biochemical parameters (e.g., decreased phosphorus levels, elevated alkaline phosphatase) have been shown to occur in approximately 67% of PMPA-treated infants, with severe growth restriction and bone-related toxicity in approximately 25% of animals studied. These data suggest that although PMPA holds great promise for HIV-infected patients, there is the potential for bone-related toxicity at chronic, high dosages, particularly in infants.

Intrauterine effects of ultrasound: animal studies

During the past several decades, the use of ultrasound technology in the clinical setting has greatly increased. Because nearly every pregnant woman receives at least one sonographic procedure today, there has been developing concern about the safety of such procedures. Since ultrasound exposure can result in hyperthermia and other physiological effects, the determination of a threshold or no-effect exposure has become a high-priority goal. Animal research has been important to the study of the effects of various exposures at all stages of pregnancy, since the clinical use of ultrasonography can occur during the preimplantation, organogenic, and fetal stages. Animal experiments using various mammalian species have been able to determine no-effect exposure levels for embryonic loss, congenital malformations and neurobehavioral effects. The preponderance of evidence from these studies indicates that, in the absence of a thermal effect, ultrasonography represents no measurable risk when used at recommended intensity levels.

Direct administration of insulin-like growth factor to fetal rhesus monkeys (Macaca mulatta)

A potential treatment for the amelioration of fetal growth failure is insulin-like growth factor-I (IGF-I). To address concerns of safety and efficacy, IGF-I (80 microg/kg; GroPep Pty.) was administered i.p. to healthy rhesus monkey fetuses via ultrasound guidance every other day between gestational days (GD) 110-120 and 130-140 (third trimester; term = approximately GD 165 +/- 10; n = 6). Pregnancies were monitored sonographically, and fetal/maternal blood samples were collected for complete blood counts, immunophenotyping, and biochemical analyses. Blood samples, external measures of the fetus and newborn, and tissue and organ weights were collected at fetal necropsy (GD 150; n = 2) or at term delivery of neonates (GD 160; n = 4). The results of these investigations have shown no evidence of hypoglycemia in the fetus or dam during the course of treatment. Circulating concentrations of fetal, but not maternal, IGF-I increased with treatment (approximately 80 to approximately 1015 ng/ml), and there was no evidence of a change in serum IGF-II or an increase in IGF binding protein-3 compared with historical control values. Fetal lymphocytes and select red cell parameters increased, and a significant elevation in circulating B cells and CD4/CD8 ratios in fetal lymph nodes was shown. Although no changes were detected in body weights, increases in thymic, splenic, and kidney weights and small intestine lengths occurred. Thus, administration of IGF-I to the fetal monkey is safe and results in 1) transient increases in circulating IGF-I, 2) a significant effect on fetal hematopoietic and lymphoid tissues, and 3) an increase in select fetal organ weights and measures. These data suggest that IGF-I may represent a potential candidate for therapeutic treatment of growth-compromised human fetuses in utero.

The sensitivity of biological tissue to ultrasound

Mammalian tissues have differing sensitivities to damage by physical agents such as ultrasound. This article evaluates the scientific data in terms of known physical mechanisms of interaction and the impact on pre- and postnatal tissues. Actively dividing cells of the embryonic and fetal central nervous system are most readily disturbed. As a diagnostic ultrasound beam envelopes a small volume of tissue, it is possible that the effects of mild disturbance may not be detected unless major neural pathways are involved. There is evidence that ultrasound can be detected by the central nervous system; however, this does not necessarily imply that the bioeffect is hazardous to the fetus. Biologically significant temperature increases can occur at or near to bone in the fetus from the second trimester, if the beam is held stationary for more than 30 s in some pulsed Doppler applications. In this way, sensory organs that are encased in bone may be susceptible to heating by conduction. Reports in animals and humans of retarded growth and development following frequent exposures to diagnostic ultrasound, in the absence of significant heating, are difficult to explain from the current knowledge of ultrasound mechanisms. There is no evidence of cavitation effects occurring in the soft tissues of the fetus when exposed to diagnostic ultrasound; however, the possibility exists that such effects may be enhanced by the introduction of echo-contrast agents.

Effects of two antiprogestins on early pregnancy in the long-tailed macaque (Macaca fascicularis)

The abortifacient effects of mifepristone and HRP 2000 were compared in gravid long-tailed macaques. Thirty-six animals were studied with treatment administered either by the oral (0.5 or 5.0 mg/kg; N = 5 per antiprogestin per dose) or intramuscular (i.m.) routes (0.5 mg/kg; N = 5 per antiprogestin) on gestational days (GD) 23-26; six vehicle controls were included. Blood samples were collected for assay of progesterone (P4) and each of the antiprogestins (pre-treatment, daily GD 23-28, every other day GD 30-40), and animals were monitored sonographically throughout gestation. Results of these studies indicated high rates of abortion with i.m. administration (3/5 mifepristone, 4/5 HRP 2000) and 5.0 mg/kg oral route (4/5, 2/5, respectively), with less effects noted at oral doses of 0.5 mg/kg (2/5, 0/5, respectively). No early abortions were observed in the control groups. Following daily i.m. treatment, peak levels of 8-16 ng/ml mifepristone were detected whereas 6-10 ng/ ml of HRP 2000 were noted (GD 26-27). No serum levels of mifepristone were detected following either of the oral doses whereas serum levels of 2-6 ng/ml HRP 2000 were noted with high dose oral administratation. Results of these studies suggest: (1) both antiprogestins are roughly comparable in terminating early pregnancy although HRP 2000 may be more efficacious when administered i.m. whereas mifepristone may be more effective when administered orally; (2) similar levels of biological activity are seen with the i.m. and high dose oral dosing regimens, with little or no activity with the oral low dose; and (3) infants resulting from surviving pregnancies were not affected by early gestation exposure.

Characterisation of the possible effect on birthweight following frequent prenatal ultrasound examinations

The objective of this study was to evaluate and characterise by study of newborn biometry a possible effect on birthweight which we observed previously in a randomised controlled trial of multiple prenatal ultrasound examinations. A total of 2743 women with single pregnancies had been allocated at random to either a protocol of ultrasound imaging and continuous wave Doppler studies at 18, 24, 28, 34 and 38 weeks gestation (intensive group), or to a protocol of a single imaging examination at 18 weeks and further imaging scans only as clinically indicated (regular group). When compared with those in the regular group, and adjusted for other confounding variables, normally formed babies of term gestational age in the intensive group tended to be shorter when measured at birth (P = 0.123) and on day 2-3 of age (P = 0.068). There were statistically insignificant reductions in the circumferences of the chest, abdomen and mid-arm; and in the skinfold thicknesses of the triceps, parascapular and subscapular regions. Principal component analysis showed a trend for a reduction for the skeletal component (P = 0.085) but not for the soft tissue component (P = 0.332). Comparison of the neonatal biometry in the two groups is not conclusive, but the differential effects on the various growth parameters suggest that if multiple scans do indeed restrict fetal growth, the mechanism is more likely to be an effect on bone growth rather than a reduction in nutrient supply from the placenta.

Patterns of prenatal survival in the common marmoset (Callithrix jacchus)

Fifty common marmoset pregnancies were monitored using ultrasound. The objective was to ascertain if fetal mortality was related to litter size. Prior to analysis we determined abortion rate and litter size were not influenced by repeated ultrasound. Mortality was unrelated to litter size and occurred fairly late in gestation. All singletons born in this study began gestation as twins. It is hypothesized that marmosets may be able to adjust litter size late in pregnancy in response to proximate environmental factors.

Teratogenic effects of repeated exposures to X-rays and/or ultrasound in mice

Pregnant Swiss mice were exposed to 9 mGy of 70 kVp X-rays or 10 min of ultrasound (3.5 MHz, approximately 65 mW, ISPTP = 1 W/cm2, ISATA = 240 mW/cm2) on Days 6.5 and 11.5 of gestation in four combinations: X-rays on both days (X + X), ultrasound on both days (U + U), X-rays on Day 6.5 postcoitus (PC) and ultrasound on day 11.5 PC(X + U) and ultrasound at 6.5 days PC and X-rays on day 11.5 PC(U + X). Sham-treated controls were maintained for comparison. Effects on prenatal development, postnatal growth and adult behavior were studied. U + U group showed an increase in percent growth retarded fetuses and a nonsignificant increase was seen in the U + X group. Transient growth retardation was observed in all the exposure groups. This is less likely to be of any biological significance as the animals recovered during postweaning period. The postnatal mortality was significantly higher only in the U + U group. In the X + U group, the exploratory activity was affected at 6 months of age. There was a significant change in the locomotor activity with a reduction in the total activity as 3 and 6 months of age in the U + U group. Latency in learning capacity was also noticed in this group. The results indicate that repeated exposures to ultrasound or its combination with X-rays could be detrimental to the embryonic development and can impair adult brain function when administered at certain stages of organogenesis.

Hematologic and growth-related effects of frequent prenatal ultrasound exposure in the long-tailed macaque (Macaca fascicularis)

Prior investigations have shown that reduced birth weights and transient neutropenias result from frequent exposure of monkey fetuses to ultrasound. To further explore these findings, 26 animals were studied (16 exposed, 10 controls; "triple mode"; ATL Ultramark 9 with HDI; ISPTAd approximately 645 to 714 mW/cm2). Exposures were performed daily for 5 days each week from gestational days (GD) 21 to 35 (5 min), three times weekly from GD 36 to 60 (5 min), then weekly from GD 61 to 153 +/- 1 (10 min). Fetal blood samples (FBS) were collected for complete blood counts (CBCs), hematopoietic progenitor assay, circulating insulin-like growth factors (IGF-I, IGF-II) and binding proteins (IGFBP-3) (GD 120, 140, 153 +/- 1). Animals were delivered by Cesarean section at term (GD 153 +/- 1), and body weights, morphometrics, CBCs, and bone marrow aspirates assessed at delivery and postnatally for 3 months. Fetal neutropenias were noted in exposed animals in addition to reduced circulating progenitors (colony forming unit-granulocyte-macrophage [CFU-GM]). Growth of CFU-GM from bone marrow was exuberant at term, whereas circulating levels were diminished comparable to prenatal samples. Exposed animals were smaller at birth; marked reductions in IGFBP-3 were noted prenatally. These data suggest that frequent prenatal ultrasound exposure can transiently alter the neutrophil lineage, although these findings may be the result of enhanced margination and organ sequestration. Data also suggest that transient, altered growth patterns may be due to perturbations of the IGF axis.

Glycoprotein and ganglioside changes in human trophoblasts after exposure to pulsed Doppler ultrasound

Changes in glycoprotein and ganglioside composition in human trophoblasts (eighth week of gestation) after in vitro exposure to pulsed Doppler ultrasound (pulse duration 1.22 microseconds; repetition frequency 11.1 kHz; center frequency 4 MHz; ISPPA = 175.5 W/cm2; ISPTA = 0.59 W/cm2) were investigated. Evacuated trophoblasts were divided in two halves and insonated for 10 min on top of a 6-cm layer of 5% gelatin in 50-mL tubes (Falcon) at 37 degrees C. One half of each trophoblast was sham insonated and served as an internal control. After insonation trophoblasts were maintained at 37 degrees C for 24 h. Glycoproteins were detected using alpha-D-mannose specific lectins from Galanthus nivalis and Narcissus pseudonarcissus. A decrease in the expression of mannose containing glycoprotein mgp47 and an increase in expression of mgp54 were observed. Ganglioside composition was also significantly altered. Concentrations of two gangliosides migrating similarly to GM2, and one similarly to GQ1, decreased by more than 75%. At the same time, concentrations of one ganglioside migrating similarly to GM3, and two other unidentified gangliosides increased two- to fourfold.

The effect of ultrasound exposure in utero on the development of the fetal mouse testis: adult consequences

The effects of exposure in utero to 1 MHz, continuous-wave ultrasound on adult growth and testicular development in the mouse was investigated. The spatial peak temporal average intensity (ISPTA) employed ranged from 1 to 10 W/cm2, with exposure durations (t) of 200 s to 20 s. Exposures were made on days 9, 12 or 15 of gestation. Results showed an increase in postpartum deaths, an increase in the number of stillbirths, and a decrease in litter size when I2 t > or = 1125 W2 s/cm4, such that there was significant loss of pups. Birthweights of pups from nearly all dosage groups was significantly lower than that of the sham or cage control groups. Results also showed that males exposed to ultrasound in utero had decreased testis size and decreased daily sperm production ranging from 9% to 30%. This study showed that ultrasound exposure in utero is capable of disrupting fetal development and having potential subsequent effects on fertility in the adult male.

Behavioral teratologic effects of prenatal exposure to continuous-wave ultrasound in unanesthetized rats

While there are no known risks associated with diagnostic ultrasound, uncertainty about the safety of prenatal ultrasound exposure remains. The purpose of the present experiment was to evaluate the behavioral teratogenic potential of continuous-wave (cw) ultrasound in rats, in the absence of maternal anesthesia or restraint. Pregnant CD rats, trained to remain immobile in a water-filled ultrasound exposure tank, were scanned with 3 MHz cw ultrasound at levels of 0, 2, 10, 20, or 30 W/cm2 ISPTA (spatial peak, temporal average intensity) on gestational days 4-20 for approximately 10 min/day. Offspring were examined postnatally for survival, growth, physical landmarks of development, behavioral development, and the adult functions of locomotor activity, learning and memory, and startle reactivity. No effects of prenatal ultrasound were found on maternal characteristics, offspring survival or growth, physical or behavioral landmarks of development, or adult tests of passive avoidance or startle. Effects at the highest intensity were obtained on corner and side locomotor activity and in a multiple-T water maze on measures of errors of commission and time spent finding the goal. The results showed that prenatal cw ultrasound in rats can induce effects on some postnatal neurobehavioral functions at high exposure intensities (30 W/cm2), but at lower intensities (2-20 W/cm2) no consistent evidence of neurobehavioral effects was observed.

Teratologic evaluation of rats prenatally exposed to pulsed-wave ultrasound

While there are no known risks associated with diagnostic ultrasound, uncertainty about the safety of prenatal ultrasound exposure remains. The purpose of the present experiment was to evaluate the teratogenic potential of pulsed-wave (pw) ultrasound in rats, in the absence of maternal anesthesia or restraint. Pregnant CD rats, trained to remain immobile in a water-filled ultrasound exposure tank, were scanned with 3-MHz pw ultrasound at levels of 0, 2, 20 or 30 W/cm2 ISPTA (spatial peak, temporal average intensity) on gestational days 4-19 for approximately 10 min/day. Examination of fetuses on E20 revealed no increase in skeletal or visceral malformations in groups exposed to pw ultrasound in utero. The number of implantations/dam was significantly increased in all pw ultrasound exposure groups compared to sham-exposed animals and, in a possibly related finding, resorptions were increased in the two highest exposure groups. Although significantly increased compared to controls, resorption frequencies in these groups were low (< 10%). No exposure-related changes in fetal weights were observed in offspring of rats scanned with pw ultrasound during gestation. The results indicate that, under the conditions described, no overt embryotoxicity is associated with gestational exposure to pw ultrasound intensities of up to 30 W/cm2.

Ultrasound-induced lung hemorrhage in the monkey

Studies with the mouse have shown that lung hemorrhage can result from exposure to ultrasound at a peak pressure of approximately 1 MPa at 4 MHz (Mechanical Index [MI] approximately 0.5). In order to determine whether a comparable outcome could occur in a larger animal with characteristics similar to humans, studies were performed with monkeys using a clinical scanner under maximum output conditions (imaging + pulsed and color Doppler; derated pr of 3.7 MPa [4.5 MPa, measured in water], 4 MHz; MI approximately 1.8) (N = 57). Monkeys ranged in age from 1 day of life to 16 years with exposures limited to the right lung lobes (5 min cranial, 5 min caudal; N = 41 exposed, N = 12 sham-exposed controls, N = 4 colony controls). Results showed that animals ranging in age from 3 months to 5 years (mean age of 2.5 years) had a greater propensity for the occurrence of multiple well-demarcated circular hemorrhagic foci (0.1-1.0 cm), which were not observed in either control group. These lesions were characterized by marked congestion of alveolar capillaries with accumulation of red blood cells within the alveolar spaces, and were unassociated with major vessels or respiratory bronchioles. Further studies will be required in order to determine the relevance of these findings to the human, although it was concluded that ultrasound-induced lung hemorrhage in the monkey is of a significantly lesser degree when compared to the mouse.

Effect of in utero exposure to diagnostic ultrasound on the postnatal survival and growth of mouse

Pregnant Swiss albino mice were exposed to 3.5 MHz diagnostic ultrasound for 10 min (upper limit for ISPTP = 1 W/cm2 and for ISATA = 240 mW/cm2, acoustic power = approximately 65 mW) on day 3.5 (preimplantation period), 6.5 (early organogenesis period), 11.5 (late organogenesis period), or 14.5 (early fetal period) of gestation. The offspring were observed for changes in litter size at birth, and sex ratio at 4 weeks of age, and postnatal mortality and growth retardation up to 6 weeks of age. No significant difference from control in litter size or sex ratio was observed in the offspring exposed to ultrasound on any of the gestation days studied. Exposure at the early organogenesis period produced a marginally significant increase in the postnatal mortality. A significant number of ultrasound exposed animals showed lesser body weights than the control group. However this growth retardation was transient and the normal growth pattern was restored by 6 weeks of age. It is concluded that the early stages in mouse gestation may be sensitive to the lethal effects of ultrasound than the later stages of pregnancy. Even though a small increase in the postnatal mortality was observed in the ultrasound exposed animals, the normal growth was not affected in the surviving animals except for a transient growth retardation. Low birth weight may be a characteristic effect of exposure only at the preimplantation period.

Effects of frequent ultrasound during pregnancy: a randomised controlled trial

Despite widespread application of ultrasound imaging and Doppler blood flow studies, the effects of their frequent and repeated use in pregnancy have not been evaluated in controlled trials. From 2834 women with single pregnancies at 16-20 weeks gestation, 1415 were selected at random to receive ultrasound imaging and continuous-wave Doppler flow studies at 18, 24, 28, 34, and 38 weeks gestation (the intensive group) and 1419 to receive single ultrasound imaging at 18 weeks (the regular group). Outcome data was obtained from 99% of women who entered the study. The only difference between the two groups was significantly higher intrauterine growth restriction in the intensive group, when expressed both as birthweight < 10th centile (relative risk 1.35; 95% confidence interval 1.09 to 1.67; p = 0.006) and birthweight < 3rd centile (relative risk 1.65; 95% confidence intervals 1.09 to 2.49; p = 0.020). While it is possible that this finding was a chance effect, it is also plausible that frequent exposure to ultrasound may have influenced fetal growth. Repeated prenatal ultrasound imaging and Doppler flow examinations should be restricted to those women to whom the information is likely to be of clinical benefit.

Tamoxifen as an antifertility agent in the long-tailed macaque (Macaca fascicularis)

The potential use of tamoxifen, a nonsteroidal antiestrogen, as an antifertility agent was studied in the long-tailed macaque (Macaca fascicularis). Twenty-six cycling females were bred, then treated with a single oral dose of tamoxifen (5 mg/kg) (N = 13) or vehicle (N = 13) on day 4 post-ovulation. Serum progesterone (P4) and tamoxifen concentrations were evaluated on post-ovulation days 4, 8, 12, 16, and 18. No effects of treatment were observed on P4 concentrations or on the fertility rate--pregnancy was achieved in 4/13 controls (31%) and 6/13 treated females (46%). Analysis for serum tamoxifen concentrations in samples collected during the fertility and a supplemental pharmacokinetic study (N = 3; single oral dose of 10 mg/kg; urine and serum evaluated) failed to reveal any detectable tamoxifen levels. It was concluded that (1) absorption of tamoxifen may be negligible under the described treatment regimens or (2) tamoxifen metabolism/clearance occurs at a rapid rate.

Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque (Macaca fascicularis): III. Developmental and hematologic studies

The multiple applications of diagnostic ultrasound in obstetrics have resulted in a continued rise in the prenatal population exposed each year. Although human epidemiologic and experimental studies with various animal models have not consistently documented any significant, reproducible findings related to clinically relevant exposures, technologic changes in scanning equipment and gaps in our knowledge regarding the interaction(s) of ultrasound with tissues emphasize the need to pursue safety issues. Studies with nonhuman primates have provided information on the potential for pre and postnatal effects on offspring exposed repeatedly during gestation (ATL MK 600, 7.5 MHz, ISPTA = 27 mW/cm2; ISPPA = 85 W/cm2; Estimated power = 12 mW--scanned for 10 min 5 times weekly gestational day [GD] 20-35; 3 times weekly GD 36-60; once weekly for 20 min GD 60-150). These studies have indicated transient effects on body weight, white blood cell counts (WBCs), and muscle tone postnatally. In an effort to confirm these findings and focus on hematologic changes, a second series of studies was initiated using the same exposure conditions (N = 22; 11 exposed, 11 sham controls). Data derived from both studies were combined and confirmed transient reductions in body weights for infants up through 4 months of age (P < or = 0.03); no statistically significant differences in muscle tone were noted. Similar to the original findings, WBCs were transiently reduced on days 3 (P < or = 0.02) and 21 (P < or = 0.05); prenatal sampling indicated a significant difference between the groups on GD 140 (P < or = 0.04). No direct effects were evident in bone marrow aspirates collected on postnatal days 3, 9, and 21 +/- 1. Although animals were able to compensate for these observed changes and remained unaffected by their occurrence, additional studies will be required to further our understanding of this phenomenon.

A teratologic evaluation of continuous-wave, daily ultrasound exposure in unanesthetized pregnant rats

Pregnant Sprague-Dawley rats were trained to remain immobile when placed in water in an ultrasound exposure tank and exposed to 0, 0.1, 2.0, or 30.0 W/cm2 ISPTA (spatial peak, temporal average), 3.0-MHz continuous wave (cw) ultrasound on embryonic (E) days 4-19 for approximately 15 min/day. On E20 fetuses were removed; weighed; examined for external, skeletal, and visceral malformations; and uteri were examined for resorptions. Analyses revealed no increase in pre-implantation loss and no effects on maternal body weight, food, or water consumption. No increase in skeletal or visceral malformations was found, in fact exposed groups had a lower incidence of defects than controls. A significant increase in resorptions in the lowest exposure group (0.1 W/cm2) was obtained, but the effect was isolated, non-dose dependent and not credible as a treatment-related effect. No reduction in fetal weight was obtained, in fact the lowest (0.1-W/cm2) and middle (2.0-W/cm2) exposure level groups weighed slightly more than controls. The immobility procedure succeeded in avoiding anesthetization or forced restraint of the dams, thereby eliminating these factors as potential confounders. The results demonstrated that in unanesthetized, unrestrained rats in utero exposure to incident intensities of ultrasound of up to 30.0 W/cm2 cw ultrasound (or estimated internal exposures of 4-21 W/cm2, depending on body orientation to the incident beam) produced no evidence of embryotoxicity based on fetal necropsy data.

Medical sonography: reproductive effects and risks

While it is clear that the levels and types of medical sonography that have been used in the past have no measurable risks, it would be inaccurate to label the modality of ultrasound as totally safe regardless of exposure. Most agents have reproductive risks and even teratogenic risks if the exposure is raised sufficiently. Thus the prudent use of sonography means that clinicians and designers of equipment have to maintain exposures far below the risks that have been demonstrated in animal studies and from the knowledge obtained about the physical changes that can be produced in humans as the absorbed dose is elevated. The reproductive risks were evaluated using five criteria: 1) human epidemiology, 2) secular trend data, 3) animal experiments, 4) dose response relationships, and 5) biologic plausibility. The analysis reveals that the human epidemiology does not indicate that diagnostic ultrasound presents a measurable risk to the developing embryo or fetus. Animal studies also indicate that diagnostic levels of ultrasound are safe and do not elevate the fetal temperature into the region where deleterious embryonic and fetal effects will occur. Because higher exposures of ultrasound can elevate the temperature of the embryo, the use of diagnostic procedures and the design of sonographic equipment should take into consideration the hyperthermic potential of higher exposures of ultrasound and the hypothetical additional risk of performing sonography on pregnant patients who are febrile. It would appear that if the embryonic temperature never exceeds 39 degrees C, then there is no measurable risk. We suggest that sonography (the field) and sonogram (the procedure) are the most appropriate and least anxiety provoking terms.

Effects of pulsed ultrasound and temperature on the development of rat embryos in culture

Rat embryos in culture were exposed to pulsed ultrasound at SPTA intensity of 1.2 W/cm2 for 5, 15, and 30 min on day 9.5 of development. The whole embryo culture system allowed precise temperature control for directly examining the effects of ultrasound on the developing neural plate. After exposure, embryos were maintained in culture for a further 48 hr. No major morphological abnormalities were observed but a reduction in somite number occurred in the group insonated for 30 min, which was equivalent to a 2 hr delay in embryonic development. Similar delay in growth and "blistering" in the prosencephalon region of some embryos were observed after insonation for 15 min at 40.0 degrees C, an elevation of 1.5 degrees C over the temperature used for controls. Exposure to ultrasound for 15 min at 40 degrees C caused significant reduction in the growth of the head compared with that of control embryos. Heat shock genes for hsps 71/73 and 88 kD were induced after insonation for 30 min at 38.5 degrees C. Insonation did not cause any temperature changes in the culture medium. However, when the temperature of the culture medium was increased during insonation, defective development occurred. The results of these in vitro experiments suggest that ultrasound if resulting in significant hyperthermia could affect the development during early organogenesis of the neural plate and in particular they suggest that the embryo is at greater risk of damage during hyperthermic conditions. These results should provoke discussion of the concept that ultrasound in the febrile patient may present an increased embryonic risk which should be considered when deliberating on the use of diagnostic ultrasound procedures in the pregnant patient.

Developmental exposure of mice to pulsed ultrasound

Exposure of pregnant mice on gestation day (gd) 8 to 1 MHz continuous-wave ultrasound (0, 0.05, 0.50, or 1.00 W/cm2) was reported previously to result in a slight (nonsignificant) increase in malformations. The present study was conducted in a similar fashion using pulsed ultrasound but was designed to maximize the likelihood of finding effects of gd 8 ultrasound exposure on prenatal development. Pregnant ICR mice (approximately 60 animals/group) were exposed on gd 8 to pulsed ultrasound with a center frequency of 1 MHz at levels of 0 (sham control), 0.05, 0.50, or 1.00 W/cm2 (spatial average, temporal average intensities; ISATA) with a spatial peak, pulse average intensity (ISPPA) of 90 W/cm2 and pulse duration of 6.5 microseconds. Anesthetized animals were placed in a degassed water bath (30 degrees C) and exposed for two 10 min intervals during which the beam was centered 1 cm on either side of the abdominal midline. On gd 17, dams were killed; the uterus and its contents were weighed and examined; and live fetuses were weighed and examined for external, visceral, and skeletal malformations. Although one female in the 0.50 W/cm2 group and seven animals in the 1.00 W/cm2 group died following exposure, no other significant change from controls was seen in any maternal or fetal parameter evaluated. Thus the results of this study indicate that there was no detectable effect on prenatal development of mice following exposure to ultrasound on gd 8 (a time of maximal sensitivity), even at exposure intensities that were lethal to some maternal animals.

Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque (Macaca fascicularis): II. Growth and behavior during the first year

The extensive use of ultrasonography for the prenatal assessment of growth and development continues to present questions regarding biological effects. We are currently evaluating a nonhuman primate model (Macaca fascicularis) exposed to ultrasound from gestational day (GD) 21 to 152 +/- 2. Exposures were performed with a commercial real-time sector scanner (ATL, MK 600); animals were scanned five times weekly on GD 21-35 +/- 2, three times weekly on GD 36-60 +/- 2, and once weekly on GD 61-150 +/- 2. The length of exposure was approximately the same as human exposure (GD 21-60 +/- 2 = 10 min/exam and GD 61-150 +/- 2 = 20 min/exam) although the frequency of the examinations was considerably greater. Initial reports indicated differences between control and treated animals including lower birth weight, higher simian Apgar scores, and changes in select hematologic parameters. Follow-up evaluations of growth during the first year included measurements of body weight, hand and foot lengths, humerus and femur lengths, biparietal and occipitofrontal diameters, head circumference, arm circumference, chest circumference, skinfold thickness, and crown-rump length. Results indicated a significant reduction in body weight in treated animals during the first three months, with nonsignificant differences during the following nine months. Hematologic analysis including complete blood counts (CBC) and clinical biochemistry at 6, 9, and 12 months of age were not significantly different. A series of behavioral evaluations including a neurobehavioral test battery (NBT) and tests assessing motor and cognitive skills were included. The NBT revealed increased muscle tone in treated animals at one, two, and four days. In an observation cage (week 1-14) more quiet activities were displayed by treated animals. Group differences in performance of motor and cognitive tasks were observed and may be attributable to agitation and difficulties in adjusting to test environments. There were no group differences observed in discrimination learning. When considering the possible implications to the human population, it is important to consider the amount of exposure these animals received, and the fact that most of the effects observed appeared to be transitory. Although human epidemiological studies have not revealed any significant bioeffects, the "prudent use" of diagnostic ultrasound should still be kept in mind. This is especially significant with the current rise in the use of endovaginal scanning and pulsed Doppler.