Letter: Congenital abnormalities and first-trimester exposure to progestagen/oestrogen

Association between the 2d:4d and cardiovascular risk factors: Body mass index, blood pressure and body fat

OBJECTIVES

To examine the relationship between the cardiovascular risk factors such as obesity as measured by Body mass index (BMI), body fat and blood pressure with the second to fourth digit ratio (2d:4d); a prenatal testosterone exposure marker.

METHODS

The 2d:4d for both hands were measured for the Indian male subjects' (n = 1217). Subject's anthropometric parameters such as height, weight, skinfold thicknesses at various regions and blood pressure measurements were collected in a cross-sectional study with a convenient sampling approach. The association between digit ratio and the other variables were examined using analysis of variance, Pearson's correlation test and linear regression methods.

RESULTS

The study included 1193 subjects and all were males aged 19.69 ± 5.38 years (range 13 to 40 years). The subjects' body mass index (BMI) was 19.45 ± 3.82 and right and left hand 2d:4d were 0.958 ± 0.054, and 0.958 ± 0.061 respectively. The systolic blood pressure (SBP) and BMI significantly differed between the higher and lower half of right 2d:4d. The left hand 2d:4d was significantly correlated with SBP (r = 0.075, p = 0.028) and significantly differed between different hypertensive groups (p < 0.003, F = 3.552, df = 5).

CONCLUSION

The study observed an association between 2d:4d with hypertension and BMI among young Indian population, emphasizing the effect of prenatal testosterone on late life cardiovascular risk factor.

EUROmediCAT signal detection: an evaluation of selected congenital anomaly-medication associations

AIMS

To evaluate congenital anomaly (CA)-medication exposure associations produced by the new EUROmediCAT signal detection system and determine which require further investigation.

METHODS

Data from 15 EUROCAT registries (1995-2011) with medication exposures at the chemical substance (5th level of Anatomic Therapeutic Chemical classification) and chemical subgroup (4th level) were analysed using a 50% false detection rate. After excluding antiepileptics, antidiabetics, antiasthmatics and SSRIs/psycholeptics already under investigation, 27 associations were evaluated. If evidence for a signal persisted after data validation, a literature review was conducted for prior evidence of human teratogenicity.

RESULTS

Thirteen out of 27 CA-medication exposure signals, based on 389 exposed cases, passed data validation. There was some prior evidence in the literature to support six signals (gastroschisis and levonorgestrel/ethinylestradiol (OR 4.10, 95% CI 1.70-8.53; congenital heart disease/pulmonary valve stenosis and nucleoside/tide reverse transcriptase inhibitors (OR 5.01, 95% CI 1.99-14.20/OR 28.20, 95% CI 4.63-122.24); complete absence of a limb and pregnen (4) derivatives (OR 6.60, 95% CI 1.70-22.93); hypospadias and pregnadien derivatives (OR 1.40, 95% CI 1.10-1.76); hypospadias and synthetic ovulation stimulants (OR 1.89, 95% CI 1.28-2.70). Antipropulsives produced a signal for syndactyly while the literature revealed a signal for hypospadias. There was no prior evidence to support the remaining six signals involving the ordinary salt combinations, propulsives, bulk-forming laxatives, hydrazinophthalazine derivatives, gonadotropin releasing hormone analogues and selective serotonin agonists.

CONCLUSION

Signals which strengthened prior evidence should be prioritized for further investigation, and independent evidence sought to confirm the remaining signals. Some chance associations are expected and confounding by indication is possible.

Environmental factors in the etiology of isolated and nonisolated esophageal atresia in a Chinese population: A case-control study

BACKGROUND

Esophageal atresia (EA) is a common birth defect that occurs with tracheoesophageal fistula (TEF), although etiological studies on EA/TEF have produced inconsistent results.

METHODS

The aim of this study was to examine the association between environmental factors during pregnancy and the risk of EA/TEF in a Chinese population. Cases of isolated EA and nonisolated EA and unaffected controls were identified between July 2005 and November 2015, and face-to-face questionnaires concerning exposure to environmental factors were administered to the birth mothers of 130 cases and 400 controls. The adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the association between environmental factors and the risk of EA/TEF.

RESULTS

The results of this case-control study suggest that lower maternal education (p < 0.0001), maternal binge drinking (OR = 2.63; 95% CI, 1.05-6.6) and pickled food consumption (OR = 2.04; 95% CI, 1.31-3.71) during pregnancy increase the risk of EA in offspring, while maternal folic acid supplementation (OR = 0.45; 95% CI, 0.29-0.71) is significantly associated with a decreased risk of EA.

CONCLUSION

These results suggest a role for environmental exposures in the etiology of EA/TEF; however, further studies are needed to replicate the observed associations. Birth Defects Research (Part A) 106:840-846, 2016. © 2016 Wiley Periodicals, Inc.

Respiratory Care of Infants and Children with Congenital Tracheo-Oesophageal Fistula and Oesophageal Atresia

Despite acute respiratory and chronic respiratory and gastro-intestinal complications, most infants and children with a history of oesophageal atresia / trachea-oesophageal fistula [OA/TOF] can expect to live a fairly normal life. Close multidisciplinary medical and surgical follow-up can identify important co-morbidities whose treatment can improve symptoms and optimize pulmonary and nutritional outcomes. This article will discuss the aetiology, classification, diagnosis and treatment of congenital TOF, with an emphasis on post-surgical respiratory management, recognition of early and late onset complications, and long-term clinical outcomes.

The ratio of second to fourth digit length (2D:4D) and coronary artery disease in a Han Chinese population

BACKGROUND

The association between index finger to ring finger length ratio (2D:4D) and cardiac disorders has been reported, however it has not been discussed in terms of coronary artery disease (CAD). We investigated whether 2D:4D could be used as a marker for predisposition to CAD as assessed by coronary angiography in Chinese men and women.

METHODS

This study included 1764 persons divided into 4 groups, 441 cases with CAD and 441 persons without CAD as control in each sex of the same age. Finger lengths were measured twice for both hands using electronic calipers. Student t test was used to detect the difference of 2D:4D among groups. The receiver operator characteristic curves (ROCs) were used to detect the diagnostic effect of 2D:4D for CAD.

RESULTS

There were no significant differences in age among the four groups. A significant difference of 2D:4D ratios between right and left hand were observed only in men in both control and CAD groups. On the right hand in the control group and on both hands in the CAD group, the 2D:4D ratios were higher in women than in men (all, P < 0.001). In men with CAD, mean 2D:4D was higher than mean 2D:4D in control men (right hand 0.962±0.042:0.927±0.038; left hand 0.950±0.044:0.934±0.048; both hands, P < 0.001), but this was not observed in women. No relationship was found between 2D:4D and age (all, P >0.05). The area under the curve of right hand 2D:4D in male was 0.72 (95% CI 0.683-0.753, p<0.001), while it was 0.602 (95% CI 0.565-0.639, p<0.001) in left hand.

CONCLUSIONS

The present study showed an association between high 2D:4D ratio and CAD in both hands in men. There were no significant differences in mean 2D:4D between women with CAD and controls.

Digit ratios and relation to myocardial infarction in Greek men and women

BACKGROUND

Digit ratios, such as the second to fourth digit ratio (2D:4D), are biometric markers that are influenced by estrogen and testosterone concentrations in utero and are determined genetically by HOX genes (homeodomain-containing homeotic genes). Sex steroids also play a crucial role in the occurrence of myocardial infarction (MI), which is considered to be gender dependent and related to testosterone. Additionally, first-trimester exposure to excess levels of estrogens and progesterone has been linked to cardiovascular anomalies.

OBJECTIVE

The aim of this work was to study digit ratios in a Greek population and assess their clinical importance as markers of predisposition to MI.

METHODS

Two samples were used: a group of Greek men and women hospitalized with MI, and a control group of healthy Greek men and women of the same age. Finger lengths were measured twice for both hands using electronic calipers. In the results, digits were designated as 2D (second digit), 3D (third digit), 4D (fourth digit), and 5D (fifth digit).

RESULTS

A total of 50 Greek men and 50 Greek women with MI were recruited (mean [SD] age, 69.3 [11.2] years for men; 69.7 [11.0] years for women). The control group consisted of 40 healthy Greek men and 40 healthy Greek women (mean age, 68.0 [11.8] years for men; 66.8 [10.7] years for women). In the control group, 2D:4D, 2D:3D, and 2D:5D ratios were significantly higher in women than in men (2D:4D: right hand, P < 0.001; left hand, P = 0.002; 2D:3D: right hand, P < 0.001; left hand, P = 0.003; 2D:5D: right hand, P < 0.001; left hand, P < 0.05). The mean values of 2D:4D ratios appeared to increase in the following order: healthy men < men with MI < healthy women < women with MI, although this difference was not statistically significant. In men with MI, 2D:4D and 3D:4D ratios were significantly higher than the respective ratios in healthy men (2D:4D: right hand, P = 0.001; left hand, P < 0.05; 3D:4D: right hand, P < 0.05; left hand, P = 0.001), but no significant differences were observed in the ratios between women with MI and healthy women.

CONCLUSIONS

Digit ratios that include ring-finger length (ie, 4D) may be useful biomarkers for predisposition to MI in Greek men, but not in Greek women. Sexual dimorphism of digit ratios was present in both groups and was independent of the individuals' health status.

Etiology of esophageal atresia and tracheoesophageal fistula: "mind the gap"

Esophageal atresia and tracheoesophageal fistula (EA/TEF) are major congenital malformations affecting 1:3500 live births. Current research efforts are focused on understanding the etiology of these defects. We describe well-known animal models, human syndromes, and associations involving EA/TEF, indicating its etiologically heterogeneous nature. Recent advances in genotyping technology and in knowledge of human genetic variation will improve clinical counseling on etiologic factors. This review provides a clinical summary of environmental and genetic factors involved in EA/TEF.

How does a physician avoid prescribing drugs and medical procedures that have reproductive and developmental risks?

The medicolegal climate in the United States has changed considerably in the past 50 years. This article provides practical tips that obstetricians and perinatologists can use to reduce the likelihood of being a defendant in malpractice litigation.

Nongenital malformations following exposure to progestational drugs: The last chapter of an erroneous allegation

In the late 1960s and 1970s, a number of epidemiological studies were published indicating that pregnant women who were exposed to an array of sex steroids delivered infants with an increased incidence of nongenital congenital malformations. Because of these publications, the Food and Drug Administration (FDA), in conjunction with various pharmaceutical companies, labeled the therapeutic exposure of progestational drugs and contraceptives in pregnant women as a risk factor for limb-reduction defects (LRDs) and congenital heart defects (CHDs). Subsequently there was a rapid decrease in the exposure of pregnant women to these drugs and the initiation of numerous lawsuits alleging that a particular progestational drug was responsible for a child's nongenital congenital malformation. Wilson and Brent (1981) published an article indicating that epidemiological and animal studies of these drugs, and basic science did not support the package insert's warnings. Many new and previous animal and epidemiological studies did not support the FDA box warning. In 1987 the FDA held a hearing in which the FDA, the Teratology Society, the Centers for Disease Control and Prevention, the American College of Obstetrics and Gynecology, and other organizations supported the position that progestational agents did not result in nongenital malformations. An editorial appeared in Teratology congratulating the FDA for removing the warning label on oral contraceptives regarding nongenital malformations. In 1999 the FDA published new wording for package inserts that removed warnings for nongenital malformations for all progestational agents. In spite of the recent changes in the package inserts, lawsuits have alleged that progestational drugs cause nongenital malformations. It took 22 years from the time a box warning was required by the FDA until the warnings were removed in 1999. The 1999 FDA publication, which is a scholarly and objective document, should put an end to 2 decades of concern and anxiety for pregnant women or women of reproductive age. Could scientists, the pharmaceutical companies, or the FDA have prevented the mislabeling of progestational drugs with regard to their teratogenic risks? Was the epidemiological or teratology community at fault because they did not critique and respond to the early publications? Did the FDA act too slowly? The epidemiologic analyses, animal studies, and basic science principles have been reviewed, and it is obvious that clinically utilized progestational drugs do not cause nongenital malformations (i.e., LRDs and CHDs).

The ratio of second- and fourth-digit lengths and congenital adrenal hyperplasia due to 21-hydroxylase deficiency

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency results in excessive androgen exposure in the gestational period and various degrees of masculinization of the external genitalia in female foetuses. Intrauterine gonadal steroids are not only essential for the development of the genital organs but also affect some other extragenital organ development. The second to fourth digit (2D/4D) ratio shows a sexually dimorphic pattern with longer fourth digit from second digit in men compared to women. A low 2D/4D ratio is associated with high sperm count, testosterone levels and reproductive success in men. A high 2D/4D ratio is associated with high oestrogen levels in women. Second and fourth digit ratio has also found to be correlated with sexual orientation, left hand preference autism and some adult onset diseases such as breast cancer and myocardial infarction. We found lower 2D/4D ratio in female patients with 21-hydroxylase deficiency compared to healthy girls (p=0.000) and equal 2D/4D ratio for female patients when compared to male controls. Male patients with 21-hydroxylase deficiency had significantly lower 2D/4D ratio than female and male controls in the right hand. Healthy boys had lower 2D/4D ratio than healthy girls. It is concluded that 2D/4D ratio established by intrauterine androgen levels influences the sexually dimorphic digit pattern.

The ratio of 2nd to 4th digit length: a new predictor of disease predisposition?

The ratio between the length of the 2nd and 4th digits is: (a) fixed in utero; (b) lower in men than in women; (c) negatively related to testosterone and sperm counts; and (d) positively related to oestrogen concentrations. Prenatal levels of testosterone and oestrogen have been implicated in infertility, autism, dyslexia, migraine, stammering, immune dysfunction, myocardial infarction and breast cancer. We suggest that 2D:4D ratio is predictive of these diseases and may be used in diagnosis, prognosis and in early life-style interventions which may delay the onset of disease or facilitate its early detection.

The 2nd:4th digit ratio, sexual dimorphism, population differences, and reproductive success. evidence for sexually antagonistic genes?

The ratio between the length of the 2nd and 4th digit (2D:4D) is sexually dimorphic, with mean male 2D:4D lower than mean female 2D:4D. It recently was suggested that 2D:4D is negatively correlated with prenatal testosterone and positively correlated with prenatal estrogen. It is argued that high prenatal testosterone and low estrogen (indicated by low 2D:4D) favors the male fetus and low prenatal testosterone and high estrogen (indicated by high 2D:4D) favors the female fetus. The patterns of expression of 2D:4D are interpreted in terms of sexually antagonistic genes.We report data on the following. (a) reproductive success and 2D:4D from England, Germany, Spain, Hungary (ethnic Hungarians and Gypsy subjects), Poland, and Jamaica (women only). Significant negative associations were found between 2D:4D in men and reproductive success in the English and Spanish samples and significant positive relationships between 2D:4D in women and reproductive success in the English, German, and Hungarian samples. The English sample also showed that married women had higher 2D:4D ratios than unmarried women, suggesting male choice for a correlate of high ratio in women, and that a female 2D:4D ratio greater than male 2D:4D predicted high reproductive success within couples. Comparison of 2D:4D ratios of 62 father:child pairs gave a significant positive relationship. This suggested that genes inherited from the father had some influence on the formation of the 2D:4D ratio. Waist:hip ratio in a sample of English and Jamaican women was negatively related to 2D:4D. (b) Sex and population differences in mean 2D:4D in samples from England, Germany, Spain, Hungary (including ethnic Hungarians and Gypsy subjects), Poland, Jamaica, Finland, and South Africa (a Zulu sample). Significant sex and population differences in mean 2D:4D were apparent.

Effect of gestational sex steroid exposure on limb development and endochondral ossification in the pregnant C57Bl/6J mouse: I. Medroxyprogesterone acetate

Although data supporting the teratogenic potential of intrauterine progestin exposure is lacking, concern persists among some individuals within the scientific community that these drugs have the potential for nongenital teratogenesis, especially with regard to limb reduction defects. Our laboratory has been interested in the ontogeny of steroid receptors in the developing embryo and in the role of steroid-receptor interactions in limb development, particularly the process of endochondral ossification. Since limb reduction defects can be produced from abnormal processes that are operative during organogenesis or during midgestation (vascular disruption) we have designed an animal study whereby embryos were exposed to sex steroids throughout organogenesis and fetal development. The present study assesses the effects of medroxyprogesterone acetate (MPA) on intrauterine endochrondral bone development specifically, as well as overall embryo-fetal development. Primagravid C57Bl/6J mice were treated via subdermal pellets which deliver MPA at dosages of 5.0, 50.0, and 500.0 mg/kg/day on gestational days 7 through 19. These doses were 25-, 250-, and 2,500-fold higher on a mg/kg basis than the human dose equivalent (HDE). No increases in nongenital malformations were noted at any evaluated MPA dosage level. At 25 X the HDE, MPA did not influence endochondral bone development as evidenced by a lack of significant effects on assessed bone growth parameters. In the 250- and 2,500-fold HDE dosage groups, MPA was shown to exert an embryotoxic effect inducing 48 and 100% resorptions respectively. Mean embryo weights/litter were significantly reduced by MPA exposure at 250 X the HDE. Intrauterine exposure to 250 X the MPA HDE induced reductions in humeral and femoral diaphyseal length in proportion to a reduction in overall growth. The data demonstrate that MPA, administered at dosages of up to several orders of magnitude in excess of the HDE and which permitted embryo survival, did not induce increases in the frequency of nongenital teratogenesis at any dose or gestational stage. Importantly, limb reduction defects were not noted even in instances where the dosage of MPA induced an inhibition of endochondral bone growth.

Neuroendocrine consequences of alcohol abuse in women

Alcohol abuse and alcoholism are associated with a broad spectrum of reproductive system disorders. Amenorrhea, anovulation, luteal phase dysfunction, and ovarian pathology may occur in alcohol-dependent women and alcohol abusers. Luteal phase dysfunction, anovulation and persistent hyperprolactinemia have also been observed in social drinkers studied under clinical research ward conditions. The mechanisms underlying alcohol-related disruptions of the hypothalamic-pituitary-ovarian-adrenal axis are unknown. The reproductive consequences of alcohol abuse and alcoholism range from infertility and increased risk for spontaneous abortion to impaired fetal growth and development. Recent studies of alcohol's effects on pituitary gonadotropins and on gonadal, steroid and adrenal hormones in women are reviewed. Research on the acute effects of alcohol on opioid antagonist and synthetic LHRH-stimulated pituitary gonadotropins is summarized. The implications of alcohol's effects on reproductive hormones for impairment of fetal growth and development are discussed.

Association of tracheoesophageal anomalies with visceral and parietal malformations in a human embryo (Carnegie stage 21)

A human embryo (Carnegie stage 21) with tracheoesophageal malformations (esophageal atresia and tracheoesophageal fistula) and anomalies at the caudal end of the embryo (anorectal atresia, rectovesical fistula, vertebral and notochordal defects, and agenesis of the metanephros) was studied. Other anomalies observed were: absence of right umbilical artery, fusion of spinal ganglia, and absence of cloacal outlet of mesonephric ducts. The possible pathogenesis of these associated malformations is discussed.

Exogenous sex hormone exposure and the risk for VACTERL association

In several studies investigators have suggested that maternal use of exogenous sex hormones during early pregnancy may be associated with various congenital malformations. A group of malformations, the VACTERL (vertebral, anal, cardiac, trachea, esophageal, renal, limb-acronym) association, has been statistically associated with maternal exposure to exogenous sex hormones during the first trimester of pregnancy. The VACTERL association is a nonrandom group of major malformations that occur together more often than would be expected on the basis of chance. To assess this association, we conducted a case-control study of first-trimester exposure to sex hormones among mothers of 34 infants with the VACTERL association and of 1,024 comparison infants with one or more of ten major malformations or Down syndrome. The study subjects were malformed infants born between July 1970 and June 1979 and registered in a population-based birth defects registry. Information concerning the use of exogenous sex hormones during pregnancy was obtained by systematically interviewing the mothers of the malformed infants. Most of the mothers were interviewed within 6 months of their children's births. Each mother was interviewed within a year of her child's birth. We found an odds ratio of 0.98 (90% confidence limits 0.40, 2.38) for the relationship between VACTERL association and use of any sex hormone in the first trimester of pregnancy. Our study had adequate statistical power to detect a true relative risk of 2.8 or greater.

Congenital heart disease and extracardiac anomalies: associations and indications for fetal echocardiography

Fetal echocardiography is a well-established technique for the prenatal identification of congenital heart disease. One of the indications for its use is the presence of extracardiac anomalies, as such coexistent defects may have important implications for obstetric and neonatal management. We have reviewed the obstetric and pediatric literature to examine reported associations. If a fetus is suspected to have hydrocephalus, microcephaly, holoprosencephaly, agenesis of the corpus callosum, Meckel-Gruber syndrome, esophageal atresia, duodenal atresia, diaphragmatic hernia, omphalocele, or renal dysplasia, cardiac evaluation should be pursued. Furthermore, echocardiography may be of help in differential diagnosis of some anomalies (for instance, skeletal dysplasias). Maternal diabetes and phenylketonuria, as well as exposure to phenytoin, trimethadione, or isotretinoin, may result in multiple systemic defects, including congenital heart disease.

Cardiovascular birth defects and antenatal exposure to female sex hormones: a reevaluation of some base data

A re-evaluation of the base data as reported by Heinonen et al. from the Drug Epidemiology Unit of the Boston Collaborative Perinatal Project (CPP) was undertaken in order to examine particularly three matters which were not fully considered in the publication. These were, first, the timing of administration of sex hormones during the index pregnancy, which is relevant to determining whether any statistical association reported between sex hormone exposure and malformations could be causal; second, the incidence of serious maternal vaginal bleeding in early pregnancy, which could be an indication of threatened abortion, which in turn is associated with an increased malformation rate, and in addition is an indication for sex hormone administration; and third, the incidence of malformations or other adverse outcome in previous pregnancies, which, if present, might play a material role in the risk of malformation in the index pregnancy. Examination of the records of the 19 cases described by Heinonen et al. as hormone-exposed/cardiac-malformed revealed that no preparation containing hormone was administered in two patients, that five cases were given hormones too late in the index pregnancy to have any effect on cardiac organogenesis (which by general consensus begins on day 19 and ends at the latest on day 50 of gestation), that two cases were given hormones too early and two cases had Down's Syndrome. Thus eight children were exposed to hormones during the critical period of cardiac organogenesis, out of 17 actual hormone takers (47%). The description of vaginal bleeding did not allow any conclusions regarding differential rates of threatened abortion. It was found that the incidence of major malformations was 17% in the index group and 4% in the non-malformed group. This suggests that the hormone-exposed patients who gave rise to children with cardiac malformations were a highly selected group. The re-evaluation therefore reveals that the incidence of exposure to sex hormones during the critical period of cardiac organogenesis was not significantly different statistically in those women whose children had cardiac lesions as compared to those without such lesions. It is suggested that the result of this re-evaluation should direct the attention of epidemiologists to the quality of their base data. Re-examination of the base data of the Boston CPP does not support their reported association between the exposure to female sex hormones during pregnancy and the occurrence of cardiac malformations.

Embryotoxicity of Norlestrin, a combined synthetic oral contraceptive, in rhesus macaques (Macaca mulatta)

Thirty timed-mated pregnant rhesus monkeys received Norlestrin (Norethindrone acetate, 2.5 mg, and ethinyl estradiol, 0.05 g per tablet, Parke-Davis) orally at four different dose levels. The dose levels were 5, 10, 25 and 50 mg/day/monkey and the doses were administered during early (days 21-35), late (days 33-46), and throughout (days 21-46) organogenesis, except for the 50-mg-dose-group animals, which were treated only during early organogenesis (days 21-35). All except the animals in the 60-mg-dose group were allowed to go to term (165 days gestation). Pregnancy for the animals in the 50-mg-dose group was terminated by cesarean section on day 50 of gestation and the fetuses were fixed, serially sectioned, and examined histologically. No teratogenicity was observed. However, the prenatal mortality rate (38.5%) was higher for the Norlestrin-treated animals than in the control colony (21%). Eight animals aborted between days 40 and 78 of gestation and two other cases resulted in stillbirths at 139 and 165 days of gestation. There was a higher incidence of abortion (44.4%) in the 25-mg-dose group. Norlestrin treatment during early organogenesis also resulted in a higher abortion rate (37.5%) compared to treatment during late organogenesis (22.2%) abortions). No morphological abnormalities were found in infants observed at birth or in juvenile monkeys which died of natural causes or in those that were sacrificed over a period of two years. No histopathology was observed in the 50-day-old fetuses examined by serial section. Examination of endogenous maternal serum estrogen and progesterone levels in Norlestrin-treated monkeys (25 mg/day, days 21-35) suggested that placental steroidogenesis was not affected; however, the lower levels of estrogen in maternal serum suggested that the ovarian steroidogenesis was affected. Although the precise pathogenesis of this selective embryolethality is not known, several observations in this study suggest a direct generalized embryotoxic effect. Thus, this study for the first time has demonstrated that, while Norlestrin may be embryolethal at 100 times the human contraceptive dose equivalent (25 mg/day) in the rhesus monkey, nevertheless it does not affect the offspring which survive the exposure.

Evaluation of the use of Proluton-Depot (hydroxyprogesterone hexanoate) in early pregnancy

This study evaluates the effect of treatment with Proluton-Depot (hydroxyprogesterone hexanoate) in early pregnancy, and the final outcome of pregnancy and fetal status. One hundred and fifty patients received intramuscular injection of Proluton-Depot from 6 weeks to 8 weeks to 16 weeks to 18 weeks gestation. The outcome of this treated group was compared with a similar number of 150 patients with similar problems, but the second group received no hormonal treatment. There was no evidence to suggest that Proluton-Depot had any adverse effect on the infant or the final outcome of pregnancy.

Congenital abnormalities and hormones during pregnancy: a clinical review

A review of the extensive literature on the subject indicates that sex hormones have been associated with a wide variety of adverse clinical conditions following usage during pregnancy. About 230 cases of female pseudohermaphroditism have been reported following use of hormones with androgenic potency, but masculinization observed with estrogens in a few females may represent only adrenal-stimulated pseudohermaphroditism. Feminization of males, mostly by progestogens in some 45 cases, is unproven at present. Realizing the limitations of the published studies when all present data are considered, there seems no justification for undue concern over the induction of nongenital congenital malformations through hormone use in pregnancy. The available data on the association to cardiac, limb, and CNS defects, and to several malformative syndromes, are not convincing: the effects appear to be remarkably nonspecific, the studies are contradicted by a large number of negative reports, and an increased incidence of defects with increased usage has not materialized. A possible exception are the CNS malformations associated with the use of the antifertility agent clomiphene, and careful surveillance is warranted at present. While a reasonable interpretation from this review would be that hormones present no major teratogenic hazard, elimination of hormonal exposure whenever possible during pregnancy is suggested.

Binary developmental commitments in normal and abnormal human morphogenesis

An hypothesis is presented to account for the occurrence of overlapping patterns of anomalies in various malformation syndromes. According to this proposal, normal human morphogenesis occurs by means of a series of sequential commitments by neighboring groups of cells to alternative developmental programs.

Teratoepidemiology

A review of the field of human teratoepidemiology—the epidemiology of congenital malformations—is presented here along with a discussion of the importance of international collaboration in monitoring congenital malformations. Studies implicating various environmental teratogens such as drugs, industrial and agricultural chemicals, intrauterine infections, radiation and nutritional factors are discussed at some length as well as problems encountered in detecting human teratogenic agents.

Oral contraceptives and birth defects

We reviewed the birth certificates and hospital records of 7723 infants those mothers had reported using oral contraceptives. The overall frequency of malformation was 4.3 per cent for infants whose mothers terminated use of oral contraceptives shortly before conception, as compared with 3.3 per cent for infants whose mothers did not take oral conceptives diring the three years before conception. The 90 per cent confidence limits for the prevalence ratio were 1.0 and 1.7. No difference was apparent for major malformations. For specific malformations the most notable difference was for undescented testis, but this excess, like the overall excess, could be explained by sampling variability. Despite the slightly greater rate of minor malformations in the short-interval group, a reasonable interpretation of these data would be that oral contraceptives present no major teratogenic hazard.

Are hormonal contraceptives teratogenic?

The widespread use of hormonal contraceptives for a prolonged time in women during the child-bearing period necessitates that appropriate precautions be taken to ensure safety for the patient as well as for her progeny. Hormonal administration during or prior to pregnancy may be potentially teratogenic. Although there have been many reports during the last decade, it has been very difficult to document conclusively such a relationship. Over-all, it seems that hormonal use prior to pregnancy does not lead to an increase in the frequency of chromosomal aberrations or of congenital malformations. The use of certain hormones during pregnancy, on the other hand, may lead to an increase in the incidence of congenital malformations, probably in the genetically predisposed fetus. In view of this concept hormonal contraceptives should not be used to treat threatened abortion, and their use as a pregnancy test should be abandoned. Since the question of the safety of the inadvertent administration of pills during early pregnancy has not been resolved, the mother should be informed of the potential risks.

Cardiovascular birth defects and antenatal exposure to female sex hormones

In a cohort of 50,282 pregnancies 19 children with cardiovascular defects were born to 1042 women who received female hormones during early pregnancy (18.2 per 1000). Among 49,240 children not exposed in utero to these agents there were 385 with cardiovascular malformations (7.8 per 1000). Six children with cardiovascular defects were born to a sub-group of 278 women who used oral contraceptives during early pregnancy (21.5 per 1000). After the data were controlled for a wide variety of potentially confounding factors by multivariate methods, the association between in utero exposure to female hormones and cardiovascular birth defects was statistically significant.