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Asztalos EV, Murphy KE, Matthews SG. A Growing Dilemma: Antenatal Corticosteroids and Long-Term Consequences. Am J Perinatol 2022; 39:592-600. [PMID: 33053595 DOI: 10.1055/s-0040-1718573] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A single course of synthetic antenatal corticosteroids is standard care for women considered to be at risk for preterm birth before 34 weeks of gestation. While the intended target is the fetal lung, the fetal brain contains remarkably high levels of glucocorticoid receptors in structures critical in the regulation of behavior and endocrine function. Negative programming signals may occur which can lead to permanent maladaptive changes and predispose the infant/child to an increased risk in physical, mental, and developmental disorders. METHODS Framed around these areas of concerns for physical, mental, and developmental disorders, this narrative review drew on studies (animal and clinical), evaluating the long-term effects of antenatal corticosteroids to present the case that a more targeted approach to the use of antenatal corticosteroids for the betterment of the fetus urgently needed. RESULTS Studies raised concerns about the potential negative long-term consequences, especially for the exposed fetus who was born beyond the period of the greatest benefit from antenatal corticosteroids. The long-term consequences are more subtle in nature and usually manifest later in life, often beyond the scope of most clinical trials. CONCLUSION Continued research is needed to identify sufficient safety data, both short term and long term. Caution in the use of antenatal corticosteroids should be exercised while additional work is undertaken to optimize dosing strategies and better identify women at risk of preterm birth prior to administration of antenatal corticosteroids. KEY POINTS · A single-course ACS is a remarkable therapy with substantial benefits.. · There is a potential of long-term neurodevelopmental consequences in the ACS-exposed fetus.. · There is a need to improve dosing strategies and identification of appropriate at risk women..
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Affiliation(s)
- Elizabeth V Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynecology, Sinai Health Systems, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G Matthews
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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Hermes M, Antonow-Schlorke I, Hollstein D, Kuehnel S, Rakers F, Frauendorf V, Dreiling M, Rupprecht S, Schubert H, Witte OW, Schwab M. Maternal psychosocial stress during early gestation impairs fetal structural brain development in sheep. Stress 2020; 23:233-242. [PMID: 31469022 DOI: 10.1080/10253890.2019.1652266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Maternal stress, especially during early pregnancy, predisposes offspring to neuropsychiatric disorders. We hypothesized that maternal psychosocial stress (MPS) during pregnancy affects fetal structural neurodevelopment depending on the gestational age of exposure. Fetal sheep brains were harvested at 130 days gestation (dG, term 150 dG) from ewes frequently isolated from flock-mates during early gestation (first and second trimester; n = 10) or late gestation (third trimester; n = 10), or from control flock-mates (n = 8). Immunohistochemistry for formation of neuronal processes, myelination, synaptic density, cell proliferation and programed cell death was performed on brain tissue sections. Sections of the cortical gray matter, the hippocampal CA3 region and the superficial, subcortical and deep white matter were examined morphometrically. Stress effects depended on the brain region and time of exposure. Stress during early gestation but not during late gestation reduced the amount of neuronal processes in the cerebral cortex and hippocampus by 36.9 ± 10.1% (p < 0.05, mean ± SEM) and 36.9 ± 15.8% (p < 0.05), respectively, accompanied by a decrease in synaptic density in the cerebral cortex and hippocampus by 39.8 ± 23.1% (p < 0.05) and 32.9 ± 13.4% (p < 0.01). Myelination was decreased in white matter layers on average by 44.8 ± 11.7% (p < 0.05) accompanied by reduced (glial) cell proliferation in the deep white matter by 83.6 ± 12.4% (p < 0.05). In contrast, stress during the third trimester had no effect in any brain region. Chronic MPS during the first and second trimester induced prolonged effects on neuronal network and myelin formation which might contribute to disturbed neurobehavioral, cognitive and motor development in offspring of stressed mothers.Lay summaryMany women are exposed to stressful events during pregnancy. Maternal stress especially during early pregnancy predisposes for offspring's neuropsychiatric disorders. In our sheep study, we show that disturbance of fetal brain development is a potential mechanism and is worst during 1st and 2nd trimester.
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Affiliation(s)
- Markus Hermes
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Dorothea Hollstein
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sarah Kuehnel
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Florian Rakers
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Vilmar Frauendorf
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michelle Dreiling
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
- Else Kröner-Forschungskolleg AntiAge, Bad Homburg, Germany
| | - Harald Schubert
- Institute of Lab Animal Sciences and Welfare, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Kuypers E, Jellema RK, Ophelders DRMG, Dudink J, Nikiforou M, Wolfs TGAM, Nitsos I, Pillow JJ, Polglase GR, Kemp MW, Saito M, Newnham JP, Jobe AH, Kallapur SG, Kramer BW. Effects of intra-amniotic lipopolysaccharide and maternal betamethasone on brain inflammation in fetal sheep. PLoS One 2013; 8:e81644. [PMID: 24358119 PMCID: PMC3866104 DOI: 10.1371/journal.pone.0081644] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 10/15/2013] [Indexed: 01/16/2023] Open
Abstract
Rationale Chorioamnionitis and antenatal glucocorticoids are common exposures for preterm infants and can affect the fetal brain, contributing to cognitive and motor deficits in preterm infants. The effects of antenatal glucocorticoids on the brain in the setting of chorioamnionitis are unknown. We hypothesized that antenatal glucocorticoids would modulate inflammation in the brain and prevent hippocampal and white matter injury after intra-amniotic lipopolysaccharide (LPS) exposure. Methods Time-mated ewes received saline (control), an intra-amniotic injection of 10 mg LPS at 106d GA or 113d GA, maternal intra-muscular betamethasone (0.5 mg/kg maternal weight) alone at 113d GA, betamethasone at 106d GA before LPS or betamethasone at 113d GA after LPS. Animals were delivered at 120d GA (term=150d). Brain structure volumes were measured on T2-weighted MRI images. The subcortical white matter (SCWM), periventricular white matter (PVWM) and hippocampus were analyzed for microglia, astrocytes, apoptosis, proliferation, myelin and pre-synaptic vesicles. Results LPS and/or betamethasone exposure at different time-points during gestation did not alter brain structure volumes on MRI. Betamethasone alone did not alter any of the measurements. Intra-amniotic LPS at 106d or 113d GA induced inflammation as indicated by increased microglial and astrocyte recruitment which was paralleled by increased apoptosis and hypomyelination in the SCWM and decreased synaptophysin density in the hippocampus. Betamethasone before the LPS exposure at 113d GA prevented microglial activation and the decrease in synaptophysin. Betamethasone after LPS exposure increased microglial infiltration and apoptosis. Conclusion Intra-uterine LPS exposure for 7d or 14d before delivery induced inflammation and injury in the fetal white matter and hippocampus. Antenatal glucocorticoids aggravated the inflammatory changes in the brain caused by pre-existing intra-amniotic inflammation. Antenatal glucocorticoids prior to LPS reduced the effects of intra-uterine inflammation on the brain. The timing of glucocorticoid administration in the setting of chorioamnionitis can alter outcomes for the fetal brain.
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Affiliation(s)
- Elke Kuypers
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Reint K. Jellema
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Daan R. M. G. Ophelders
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeroen Dudink
- Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands
| | - Maria Nikiforou
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tim G. A. M. Wolfs
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ilias Nitsos
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
- The Ritchie Centre, Monash Institute of Medical Research, Melbourne, Australia
| | - J. Jane Pillow
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Australia
| | - Graeme R. Polglase
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
- The Ritchie Centre, Monash Institute of Medical Research, Melbourne, Australia
| | - Matthew W. Kemp
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
| | - Masatoshi Saito
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
| | - John P. Newnham
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
| | - Alan H. Jobe
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Suhas G. Kallapur
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Australia
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Boris W. Kramer
- Department of Pediatrics, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- * E-mail:
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Antenatal steroids and the IUGR fetus: are exposure and physiological effects on the lung and cardiovascular system the same as in normally grown fetuses? J Pregnancy 2012; 2012:839656. [PMID: 23227338 PMCID: PMC3512319 DOI: 10.1155/2012/839656] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 09/06/2012] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids are administered to pregnant women at risk of preterm labour to promote fetal lung surfactant maturation. Intrauterine growth restriction (IUGR) is associated with an increased risk of preterm labour. Hence, IUGR babies may be exposed to antenatal glucocorticoids. The ability of the placenta or blood brain barrier to remove glucocorticoids from the fetal compartment or the brain is compromised in the IUGR fetus, which may have implications for lung, brain, and heart development. There is conflicting evidence on the effect of exogenous glucocorticoids on surfactant protein expression in different animal models of IUGR. Furthermore, the IUGR fetus undergoes significant cardiovascular adaptations, including altered blood pressure regulation, which is in conflict with glucocorticoid-induced alterations in blood pressure and flow. Hence, antenatal glucocorticoid therapy in the IUGR fetus may compromise regulation of cardiovascular development. The role of cortisol in cardiomyocyte development is not clear with conflicting evidence in different species and models of IUGR. Further studies are required to study the effects of antenatal glucocorticoids on lung, brain, and heart development in the IUGR fetus. Of specific interest are the aetiology of IUGR and the resultant degree, duration, and severity of hypoxemia.
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Church MW, Adams BR, Anumba JI, Jackson DA, Kruger ML, Jen KLC. Repeated antenatal corticosteroid treatments adversely affect neural transmission time and auditory thresholds in laboratory rats. Neurotoxicol Teratol 2011; 34:196-205. [PMID: 21963399 DOI: 10.1016/j.ntt.2011.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 12/12/2022]
Abstract
Antenatal corticosteroid (AC) treatment is given to pregnant women at risk for preterm birth to reduce infant morbidity and mortality by enhancing lung and brain maturation. However, there is no accepted regimen on how frequently AC treatments should be given and some studies found that repeated AC treatments can cause growth retardation and brain damage. Our goal was to assess the dose-dependent effects of repeated AC treatment and estimate the critical number of AC courses to cause harmful effects on the auditory brainstem response (ABR), a sensitive measure of brain development, neural transmission and hearing loss. We hypothesized that repeated AC treatment would have harmful effects on the offspring's ABRs and growth only if more than 3 AC treatment courses were given. To test this hypothesis, pregnant Wistar rats were given either a high regimen of AC (HAC), a moderate regimen (MAC), a low regimen (LAC), or saline (SAL). An untreated control (CON) group was also used. Simulating the clinical condition, the HAC dams received 0.2mg/kg Betamethasone (IM) twice daily for 6 days during gestation days (GD) 17-22. The MAC dams received 3 days of AC treatment followed by 3 days of saline treatment on GD 17-19 and GD 20-22, respectively. The LAC dams received 1 day of AC treatment followed by 5 days of saline treatment on GD 17 and GD 18-22, respectively. The SAL dams received 6 days of saline treatment from GD 17 to 22 (twice daily, isovolumetric to the HAC injections, IM). The offspring were ABR-tested on postnatal day 24. Results indicated that the ABR's P4 latencies (neural transmission time) were significantly prolonged (worse) in the HAC pups and that ABR's thresholds were significantly elevated (worse) in the HAC and MAC pups when compared to the CON pups. The HAC and MAC pups were also growth retarded and had higher postnatal mortality than the CON pups. The SAL and LAC pups showed little or no adverse effects. In conclusion, repeated AC treatment had harmful effects on the rat offspring's ABRs, postnatal growth and survival. The prolonged ABR latencies reflect slowed neural transmission times along the auditory nerve and brainstem auditory pathway. The elevated ABR thresholds reflect hearing deficits. We concluded that repeated AC treatment can have harmful neurological, sensory and developmental effects on the rat offspring. These effects should be considered when weighing the benefits and risks of repeated AC treatment and when monitoring and managing the prenatally exposed child for possible adverse effects.
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Affiliation(s)
- M W Church
- Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Church MW, Wapner RJ, Mele LM, Johnson F, Dudley DJ, Spong CY, Peaceman AM, Moawad AH, O’Sullivan MJ, Miodovnik M. Repeated courses of antenatal corticosteroids: are there effects on the infant's auditory brainstem responses? Neurotoxicol Teratol 2010; 32:605-10. [PMID: 20553856 PMCID: PMC2955992 DOI: 10.1016/j.ntt.2010.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 05/04/2010] [Accepted: 05/20/2010] [Indexed: 11/17/2022]
Abstract
Our objective was to assess the effects of repeated antenatal corticosteroid treatments on the neonatal auditory brainstem response (ABR), a sensitive measure of neonatal brain maturity and auditory function. To achieve this, we performed and blindly evaluated neonatal ABRs on a subset of infants delivering within a multicenter randomized placebo-controlled clinical trial comparing single versus repeated courses of antenatal corticosteroid treatments for women at 23-31 weeks gestation who remained at increased risk for preterm birth. The women were randomly assigned to either the single or the repeated antenatal corticosteroid treatment group. Women in the repeated antenatal corticosteroid group received weekly antenatal corticosteroid treatments until 34 weeks gestation or until they reached a study-determined limited number of courses, whereas women in the single antenatal corticosteroid group received an initial course of corticosteroid followed by weekly placebo injections. We performed ABR testing on their infants prior to discharge. The latencies of waves I, III and V and the peak-to-trough amplitudes of waves I and V were compared between those in the single (n=27) and repeated antenatal corticosteroid treatment (n=24) groups. The majority of repeated antenatal corticosteroid infants (20 of 24) were exposed to ≥ 4 antenatal corticosteroid treatments. Even though gestational age was similar between our subset of single and repeated antenatal corticosteroid treatment groups, infant birth weight and length and head circumference were significantly smaller in the repeated antenatal corticosteroid group (p <0.05). Despite these differences in birth sizes, there were no significant group differences in the ABR wave latencies or amplitudes. We concluded that our repeated antenatal corticosteroid treatments, in comparison to a single treatment, did not significantly benefit or harm the neonatal ABR despite significant effects on birth size.
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Affiliation(s)
- Michael W. Church
- Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Ronald J. Wapner
- Obstetrics & Gynecology, Drexel University College of Medicine, Philadelphia, PA 19103, USA
| | - Lisa M. Mele
- The George Washington University Biostatistics Center, Rockville, MD 20852, USA
| | - Francee Johnson
- Obstetrics & Gynecology, Ohio State University, Columbus, OH 43210, USA
| | - Donald J. Dudley
- Obstetrics & Gynecology, University of Utah, Salt Lake City, UT 84132, USA
| | - Catherine Y. Spong
- National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Alan M. Peaceman
- Obstetrics & Gynecology, Northwestern University, Chicago, IL 60611, USA
| | - Atef H. Moawad
- Obstetrics & Gynecology, University of Chicago, Chicago, IL 60637, USA
| | | | - Menachem Miodovnik
- Obstetrics & Gynecology, University of Cincinnati, Cincinnati, OH 45267, USA
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Abstract
OBJECTIVE To determine in fetal sheep the effect of betamethasone on myelination in relation to stage of myelination, number of treatment courses, dose, and route of administration. METHODS Fetal expression of myelin basic protein (MBP), a marker of mature oligodendrocytes and myelin, was determined between 0.27 and 0.93 gestation. Short-term betamethasone effects were examined 24 hours after one maternal intramuscular treatment course (weight adjusted to equal the clinical dose of 2 x 8 mg betamethasone to a 70-kg woman) at 0.63, 0.75, and 0.87 gestation or after continuous 48-hour fetal intravenous infusion at 0.75 and 0.87 gestation. Lasting effects were examined 20 days after one and two treatment courses weight-adapted to the clinical dose of 2 x 8 mg or 2 x 12 mg betamethasone at 0.75 gestation. RESULTS Myelin basic protein immunoreactivity was first detected in the internal capsule at 0.53 gestation, followed by the centrum semiovale, the superficial white matter, and corpus callosum at 0.63 gestation. Within 24 hours after treatment, betamethasone reduced the number of mature oligodendrocytes and MBP immunoreactivity. The effect decreased with gestational age. Maternal and fetal betamethasone administration had similar effects. Loss of MBP immunoreactivity was not reversed 20 days after two treatment courses, independent of dose. CONCLUSION Betamethasone-induced delayed cerebral myelination is dependent on the stage of brain development in sheep. Betamethasone-related disturbances in myelination and any potential contribution to childhood behavior deficits need to be confirmed in clinical studies.
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