Urinary compound W in pregnant women is a potential marker for fetal thyroid function

A Homogeneous Time-Resolved Fluorescence Immunoassay Method for the Measurement of Compound W

OBJECTIVE

Using compound W (a 3,3'-diiodothyronine sulfate [T2S] immuno-crossreactive material)-specific polyclonal antibodies and homogeneous time-resolved fluorescence immunoassay assay techniques (AlphaLISA) to establish an indirect competitive compound W (ICW) quantitative detection method.

METHOD

Photosensitive particles (donor beads) coated with compound W or T2S and rabbit anti-W antibody were incubated with biotinylated goat anti-rabbit antibody. This constitutes a detection system with streptavidin-coated acceptor particle. We have optimized the test conditions and evaluated the detection performance.

RESULTS

The sensitivity of the method was 5 pg/mL, and the detection range was 5 to 10 000 pg/mL. The intra-assay coefficient of variation averages <10% with stable reproducibility.

CONCLUSIONS

The ICW-AlphaLISA shows good stability and high sensitivity and can measure a wide range of compound W levels in extracts of maternal serum samples. This may have clinical application to screen congenital hypothyroidism in utero.

3,3'-Diiodothyronine sulfate cross-reactive material (compound W) in human newborns

BACKGROUND

Thyrosulfoconjugation appears to facilitate fetal-to-maternal transfer of 3,3'-diiodothyronine-sulfate (T(2)S). Elevated maternal levels of T(2)S cross-reactive material (compound W) are found in humans, with higher levels found in venous cord blood than in arterial samples. These findings are consistent with the postulate that the placenta plays an essential role in compound W production.

METHODS

Serum compound W levels were measured by a T(2)S-specific radioimmunoassay in 60 serum samples from newborns with hyperbilirubinemia, age 1-30 d. In addition, 59 maternal serum samples, from day 1 to day 7 after uneventful deliveries, were studied.

RESULTS

As compared with day 1, at day 5, the mean (±SE) compound W level fell to 43.5 ± 6.8% (decay half-life (t(1/2)) = 4.12 d) and to 33.7 ± 4.6% (decay t(1/2) = 2.82 d) in the newborn and maternal groups, respectively. In the mothers, the level continued to decline along the same slope through day 7. In the newborns, however, the mean compound W level entered a slower phase of decay after the fifth day with a decay t(1/2) = 10.9 d.

CONCLUSION

Compound W is cleared at similar rates in newborn and postpartum maternal sera. This is consistent with the postulate that compound W is produced in the placenta.

Alternate pathways of thyroid hormone metabolism

The major thyroid hormone (TH) secreted by the thyroid gland is thyroxine (T(4)). Triiodothyronine (T(3)), formed chiefly by deiodination of T(4), is the active hormone at the nuclear receptor, and it is generally accepted that deiodination is the major pathway regulating T(3) bioavailability in mammalian tissues. The alternate pathways, sulfation and glucuronidation of the phenolic hydroxyl group of iodothyronines, the oxidative deamination and decarboxylation of the alanine side chain to form iodothyroacetic acids, and ether link cleavage provide additional mechanisms for regulating the supply of active hormone. Sulfation may play a general role in regulation of iodothyronine metabolism, since sulfation of T(4) and T(3) markedly accelerates deiodination to the inactive metabolites, reverse triiodothyronine (rT(3)) and T(2). Sulfoconjugation is prominent during intrauterine development, particularly in the precocial species in the last trimester including humans and sheep, where it may serve both to regulate the supply of T(3), via sulfation followed by deiodination, and to facilitate maternal-fetal exchange of sulfated iodothyronines (e.g., 3,3'-diiodothyronine sulfate [T(2)S]). The resulting low serum T(3) may be important for normal fetal development in the late gestation. The possibility that T(2)S or its derivative, transferred from the fetus and appearing in maternal serum or urine, can serve as a marker of fetal thyroid function is being studied. Glucuronidation of TH often precedes biliary-fecal excretion of hormone. In rats, stimulation of glucuronidation by various drugs and toxins may lead to lower T(4) and T(3) levels, provocation of thyrotropin (TSH) secretion, and goiter. In man, drug induced stimulation of glucuronidation is limited to T(4), and does not usually compromise normal thyroid function. However, in hypothyroid subjects, higher doses of TH may be required to maintain euthyroidism when these drugs are given. In addition, glucuronidates and sulfated iodothyronines can be hydrolyzed to their precursors in gastrointestinal tract and various tissues. Thus, these conjugates can serve as a reservoir for biologically active iodothyronines (e.g., T(4), T(3), or T(2)). The acetic acid derivatives of T(4), tetrac and triac, are minor products in normal thyroid physiology. However, triac has a different pattern of receptor affinity than T(3), binding preferentially to the beta receptor. This makes it useful in the treatment of the syndrome of resistance to thyroid hormone action, where the typical mutation affects only the beta receptor. Thus, adequate binding to certain mutated beta receptors can be achieved without excessive stimulation of alpha receptors, which predominate in the heart. Ether link cleavage of TH is also a minor pathway in normal subjects. However, this pathway may become important during infections, when augmented TH breakdown by ether-link cleavage (ELC) may assist in bactericidal activity. There is a recent claim that decarboxylated derivates of thyronines, that is, monoiodothyronamine (T(1)am) and thyronamine (T(0)am), may be biologically important and have actions different from those of TH. Further information on these interesting derivatives is awaited.

A radioimmunoassay for measurement of 3,3'-diiodothyronine sulfate: Studies in thyroidal and nonthyroidal diseases, pregnancy, and fetal/neonatal life

Data suggesting that (1) sulfation of the phenolic hydroxyl of iodothyronines plays an important role in thyroid hormone metabolism and (2) maternal serum 3,3'-diiodothyronone sulfate (3,3'-T(2)S) may reflect on the status of fetal thyroid function stimulated us to develop a radioimmunoassay (RIA) for measurement of T(2)S. Our T(2)S RIA is highly sensitive, practical, and reproducible. T(4)S, T(3)S, and T(1)S crossreacted 3.1%, 0.81%, and 5.3%, respectively; thyroxine (T(4)), triiodothyronine (T(3)), and reverse (r)T(3), 3,3'-T(2) and 3'-T(1) crossreacted <0.1%. Although rT(3) sulfate (rT(3)S) crossreacted 55% in 3,3'-T(2)S RIA, its serum levels are very low and have little influence on serum T(2)S values reported here. T(2)S was measured in ethanol extracts of serum, amniotic fluid, and urine. Recovery of nonradioactive T(2)S added to serum was 96%. The dose-response curves of inhibition of binding of (125)I-T(2)S to anti-T(2)S by serial dilutions of ethanol extracts of serum or urine were essentially parallel to the standard curve. The detection threshold of the RIA varied between 0.17 and 0.50 nmol/L (or 10 and 30 ng/dL). The coefficient of variation (CV) averaged 9% within an assay and 13% between assays. The serum concentration of T(2)S was [mean +/- SE, nmol/L] 0.86 +/- 0.59 in 36 normal subjects, 2.2 +/- 0.06 in 10 hyperthyroid patients (P <.05), 0.73 +/- 0.10 in 11 hypothyroid patients (not significant [NS]), 6.0 +/- 1.5 in 16 patients with systemic nonthyroidal illness (P <.001), 18 +/- 2.5 in 16 newborn cord blood sera (P <.02), 2.7 +/- 0.32 in 25 pregnant women [15 to 40 weeks gestation, P <.001], 0.94 +/- 0.10 in 10 hypothyroid women receiving T(4) replacement therapy (NS), and 2.0 +/- 0.38 in 11 hypothyroid women treated with T(4) replacement and oral contraceptives (P <.02); serum T(2)S levels in the third trimester of pregnancy were similar to those in the second trimester of pregnancy. T(2)S concentration in amniotic fluid was 12.5 +/- 2.7 nmol/L (n = 7) at 15 to 20 weeks gestation, and it decreased markedly to 3.3 +/- 1.3 nmol/L (n = 3) at 35 to 38 weeks gestation. Urinary excretion of T(2)S in random urine samples of 19 normal subjects was 10.9 +/- 1.3 nmol/g creatinine. (1) T(2)S is a normal component of human serum, urine, and amniotic fluid, and serum T(2)S levels change substantially in several physiologic and pathologic conditions; (2) high serum T(2)S in pregnancy may signify increased transfer of T(2)S from fetal to maternal compartment, estrogen-induced increase in T(2)S production, decreased clearance, or a combination of these factors. The data do not support the notion that fetal thyroid function is the only or the predominant factor responsible for high serum T(2)S in pregnant women.

3,3'-Diiodothyronine sulfate excretion in maternal urine reflects fetal thyroid function in sheep

We have shown that there is significant fetal-to-maternal transfer of sulfated metabolites of thyroid hormone after fetal infusion of a pharmacologic amount of 3,3',5-triiodothyronine (T(3)) or sulfated T(3) in late pregnancy in sheep (Am J Physiol 277:E915, 1999). The transferred iodothyronine sulfoconjugate, i.e. 3,3'-diiodothyronine sulfate (T(2)S), of fetal origin appears in maternal sheep urine. The present study was carried out to assess the contribution of T(2)S of fetal origin to the urinary pool in ewes. Eighteen date-bred ewes (mean gestational age of 115 d) and their twin fetuses were divided into four groups. In group I (control, n = 5), both ewes (M) and their fetuses (F) were sham operated for thyroidectomy (Tx). In group II, the ewes (MTx, n = 4) and, in group III, the fetuses (FTx, n = 4) were subjected to Tx. In group IV (MTx.FTx, n = 5), both the ewe and fetus had Tx. After 10-12 d, fetal and/or maternal hypothyroidism were confirmed by serum thyroxine (<15 nmol/L) measurements. In addition, we infused radioactive T(3) without disturbing the T(3) pool in three singleton near-term fetuses and assessed the amount of radioactive iodothyronine that appeared in maternal urine (MU). After infusing [(125)I-3'],3,5-T(3) via fetal vein to the near-term normal fetuses, radioactive T(2)S was identified as the major metabolite in MU by HPLC and T(2)S-specific antibody. MU T(2)S excretion (pmol/mmol creatinine) was significantly reduced by FTx and MTx.FTx but not by MTx. In addition, positive correlations (p < 0.01) were found between MU T(2)S excretion and fetal serum thyroxine and T(3) concentrations but not with maternal serum thyroxine or T(3) levels. T(2)S of fetal origin contributes significantly to the MU pool.

Fetal-to-maternal transfer of 3,3',5-triiodothyronine sulfate and its metabolite in sheep

Earlier studies have shown that sulfoconjugation is a major pathway of thyroid hormone metabolism in fetal mammals. To assess the placental transfer of sulfoconjugates in the pregnant sheep model, we measured 3,3',5-triiodothyronine (T(3)) sulfate (T(3)S), 3, 3'-diiodothyronine sulfate (T(2)S), and T(3) concentrations in fetal serum and in maternal serum and urine after T(3)S infusion to the fetus (n = 5) or the ewe (n = 6). Maternal infusion of T(3)S did not increase fetal serum T(2)S, T(3)S, or T(3) concentrations. In contrast, fetal infusion of T(3)S produced significant increases in maternal serum T(2)S and T(3)S but not T(3) concentrations. Fetal T(3)S infusion also increased maternal urine excretion of T(3)S. However, the 4-h cumulative maternal urinary excretion of T(2)S and T(3)S after fetal T(3)S infusion was less than the excretion observed after fetal infusion of equimolar amounts of T(3) in our previous study. It is concluded that fetal serum T(2)S and T(3)S can be transferred to maternal compartments. However, compared with T(3), these sulfoconjugates may be less readily transferred.

A T2S cross-reactive material (compound W) in hyperthyroid patients with trophoblastic disease

In a previous study we observed increased serum levels of a 3,3'-diiodothyronine sulfate (T2S)-like material (compound W) in women who received human chorionic gonadotropin (hCG) treatment. In the present study we assessed serum compound W values in 113 women (total serum sample: 190) with trophoblastic disease, in 7 normal nonpregnant women during the menstrual cycle and 7 women given hCG treatment in the course of in vitro fertilization. Fifty-three women with trophoblastic disease had serum free thyroxine (FT4) concentrations greater than 3.0 ng/dL with suppressed serum thyrotropin (TSH) levels; 61 had FT4 values less than 3.0 ng/dL with a mean TSH of 0.83 mU/L. Mean (+/- SE) compound W concentrations in the high FT4 group were significantly higher than in the low FT4 group (76 +/- 8.1 vs. 21 +/- 1.7 ng T2S equivalent, p < 0.001) There were significant correlations between serum hCG and compound W concentrations (r = 0.472, p < 0.001), serum FT4 and hCG (r = 0.503, p < 0.0001) and serum FT4 and compound W (r = 0.585, p < 0.0001). In nonpregnant women serum compound W levels increased from 7.5 +/- 8 ng/dL at the end of the menstrual period to 15 +/- 1.7 ng/dL 21 days after the last menstrual period. Finally, a single dose of hCG (10,000 USP units, intramuscularly) increased mean (+/- SE) serum compound W levels from 12.8 +/- 2.3 to 64 +/- 9.7 ng/dL and 54 +/- 12 ng/dL at 9 and 16 days, respectively. These results indicate that hCG and perhaps luteinizing hormone (LH) increase serum compound W concentrations in women. The mechanism and significance presently are unclear.

Regulation of thyroid hormone metabolism during fetal development

Compared with adults, plasma T3 concentrations in the human fetus are decreased, whereas levels of rT3 and the different iodothyronine sulfates, T4S, T3S, rT3S and 3,3'-T2S, are increased. The low T3 and high rT3 concentrations reflect the preponderance of inner ring versus outer ring deiodinase activity due to high type III iodothyronine deiodinase (D3) expression in fetal tissues, such as liver and brain, the placenta, and perhaps also the uterus, in combination with still incomplete expression of hepatic type I iodothyronine deiodinase (D1) expression. In contrast to humans, D3 is hardly expressed in the fetal rat liver. However, high D3 expression is observed in the embryonic chicken liver which decreases dramatically towards the end of incubation, resulting in a marked increase in plasma T3. Thyroid hormone is essential for the development of the brain, in which local conversion of the prohormone T4 to the active hormone T3 by the type II iodothyronine deiodinase (D2) plays a very important role. In contrast to the rat, however, little is known about the ontogeny of D2 in different human brain areas. The cause of the high concentrations of sulfated iodothyronines in fetal plasma is unknown. In adults, the liver is an important site for the clearance of these conjugates, where they are rapidly degraded by D1. Although fetal human liver expresses significant D1 activity, clearance of iodothyronine sulfates may be defective due to the lack of transporters mediating their hepatic uptake. However, production of iodothyronine sulfates may also be increased in the human fetus, although the responsible sulfotransferases and their location remain to be identified. Sulfation may be a reversible pathway of thyroid hormone inactivation, depending on the recovery of free hormone by sulfatases. However, little is known at present about the characteristics and regulation of these enzymes in fetal human tissues. Further studies are required to increase our understanding of the tissue-specific and stage-dependent regulation of thyroid hormone bioactivity during human development.

Diagnosis and management of maternal and fetal thyroid disorders

Thyroid diseases in pregnancy are a group of disorders with different clinical manifestations which require a rational approach in their diagnosis and management. In many cases, this involves a team approach including different specialties. Several topics have received particular attention in recently published reports. The syndrome of transient hyperthyroidism of hyperemesis gravidarum, more frequently recognized and considered to be caused by inappropriate concentrations of human chorionic gonadotropin in plasma, has been reported for the first time to be secondary to a mutation in the thyrotropin-releasing hormone receptor. Mutations in the thyrotropin-releasing hormone receptor have also being found in cases, most of them familiar, of congenital hypothyroidism caused by resistance to thyrotropin-releasing hormone. However, other cases of congenital hypothyroidism with resistance to thyrotropin-releasing hormone were not caused by mutations in the thyrotropin-releasing hormone receptor. This is a fascinating new field in molecular medicine, stimulated by clinical observations in infants born with congenital hypothyroidism that did not fulfill the classical clinical descriptions. New studies in the metabolism and transfer of anti-thyroid drugs from mother to fetus have indicated no differences between propylthiouracil and methimazole. Finally, changes in titers and the biological action of thyrotropin-releasing hormone receptors antibodies appear to explain the clinical observation of improvement in Graves' hyperthyroidism during the second half of pregnancy and its recurrence during the postpartum period.