Endocrine studies in anencephaly

The etiopathogenic and morphological spectrum of anencephaly: a comprehensive review of literature

Anencephaly is a severe malformation of the central nervous system (CNS), being one of the most common types of neural tube defects. It is defined as total or partial absence of the calvarium, with absence of the brain. Anencephaly has an incidence of 1 to 5 in every 1000 births, and the mortality rate is 100% during intrauterine life or within hours or days after birth. The etiology of anencephaly remains unclear, but various maternal-related environmental and genetic risk factors have been reported, which include diabetes, obesity, exposure to different drugs or toxins, genetic polymorphisms and mutations, as well as positive family history for neural tube defects. One of the most important nutritional factors in the development of anencephaly is folate deficiency. Methylenetetrahydrofolate reductase (MTHFR) gene codes the enzyme involved in the intracellular metabolism of folic acid; the 677C-T polymorphism of this gene causes the thermolability of the enzyme and decreased enzymatic activity, which is also dependent of folate plasmatic level. Etiopathogenesis of anencephaly includes several mutations in various other genes, such as: platelet-derived growth factor receptor alpha (PDGFRA), cadherin epidermal growth factor (EGF) laminin G (LAG) seven-pass G-type receptor 1 (CELSR1), Vang-like 1 (VANGL1) and Vang-like 2 (VANGL2), the last two being involved in the process of neurulation. Screening tests include maternal serum alpha-fetoprotein level and ultrasound (US) examination. During the first trimester US screening, anencephaly is now detected in all cases, but in order to decrease the complication rate of pregnancy termination, the diagnosis should be established as soon as possible, during the pregnancy confirmation US. We conclude that given that anencephaly is a severe malformation of the CNS, morphological characterization could improve the screening by US that is mandatory in the first trimester in order to plan the best, safe and early management.

Immunocytochemical study of the GH cells in the anterior pituitary gland of human fetus II. Anencephalic fetus

In order to elucidate the effects of hypothalamic regulation on the morphology of GH cells, light and electron microscopic immunocytochemical examinations were carried out comparing GH cells in the anterior pituitary gland of anencephalic fetus with those of normal fetuses. Three types of GH cells were identified in the anterior pituitary gland of anencephalic fetus as well as in the normal fetus. Type-I is a small, round cell containing a few small secretory granules. Type-III is a large, polygonal cell with numerous large secretory granules. Type-II is a polygonal cell with medium-sized secretory granules. The Type-II GH cell was predominant in both anencephalic and normal fetuses. The most striking difference between anencephalic and normal fetuses was the presence of atypical forms of the Type II cell. These were polygonal cells containing secretory granules, which were either immunopositive or immunonegative to anti-human GH (anti-hGH) serum. Furthermore, two other types of GH cells were identified. The somatomammotroph (SM cell) contained GH and PRL in different granules within the same cell. Also, a different type of the GH cell was noted containing two varieties of secretory granules; one was immunolabeled only with anti-hGH and the other was not immunolabeled to either anti-hGH or anti-human PRL (anti-hPRL). From these results, we suggest that an absence of hypothalamic regulation in the anencehpalic does not seriously modify GH cell morphology but induces an altered GH storage pattern in some of the cells.

Development and differentiation of pituitary cells

Classically, it was thought that the adenohypophyseal gland originated from the oral ectoderm. Its development has been the object of numerous studies over many years. However, several questions are still raised about its origin, differentiation, and commitment. The adenohypophyseal gland could originate from the anterior ridge of the neural plate. Glandular adenohypophyseal cells are committed very early in embryonic life. Interactions between adenohypophyseal presumptive territory and neighboring tissues can exist very soon, as early as at the open neural stage. The expression of a given phenotype by the committed cells seems to be controlled by a number of differentiation and/or transcription factors. In view of all these studies, performed with the use of different in vivo and in vitro models, classical concepts of the embryology of the adenohypophyseal gland need to be reevaluated. Indeed, many questions remain unanswered concerning the molecular mechanisms of known and unknown factors controlling development of the adenohypophyseal gland.

Circulating levels of growth hormone, insulin-like growth factor-I and prolactin in normal, growth retarded and anencephalic human fetuses

We measured growth hormone (GH), insulin-like growth factor-I (IGF-I), and both total and glycosylated prolactin (PRL) levels in 131 blood samples obtained by cordocentesis in normal and abnormal fetuses from 19 to 40 weeks of gestation. In normal fetuses, IGF-I and PRL levels showed a positive correlation and GH a negative correlation with gestational age. A negative relation between GH and IGF-I levels was observed, while PRL did not show any correlation with both GH and IGF-I concentrations. IGF-I increased from 5.6 +/- 3 (at 19-22 weeks) to 10.7 +/- 5 nmol/l at term; GH decreased from 31 +/- 10 to 7.7 +/- 4 micrograms/l and PRL increased from 16 +/- 18 to 139 +/- 76 micrograms/l. Glycosylated PRL accounted for about 15% of total PRL, a value similar to that found in normal adults. In 27 fetuses of 27-37 weeks with intra-uterine growth retardation, GH and PRL levels were higher and IGF-I levels lower than in normal fetuses matched for week of gestation. In 8 anencephalic fetuses of 19-26 weeks of gestation, both GH and IGF-I levels were lower, and PRL levels were higher than in matched controls. Altogether these data support the views that a) both GH and PRL secretion are under the hypothalamic control during fetal development, b) the serum GH decrease from midgestation to the end of pregnancy is mediated by the negative feed-back mechanism of increasing IGF-I levels and c) IGF-I production is mainly regulated by fuel supply and only partially by GH.

Fetal development and regulation of pituitary cell types

The ontogenesis of the pituitary gland is considered from anatomical and functional points of view. Embryogenesis of the hypothalamo-pituitary unit involving development of the hypothalamo-hypophyseal portal system is complete during early life as shown in several mammalian species. The ultrastructural characteristics of the different cell types during development are described according to observations made by using immunochemical techniques. The patterns of differentiation of the cell types are reviewed according to studies of pituitary glands from human anencephalic fetuses and encephalectomized rat fetuses as well as in vitro studies of cultured pituitary primordia in synthetic media. The maturation of the neuroendocrine mechanisms controlling the secretion of fetal hormones is also analyzed. During fetal life, the factors implicated in the regulation of pituitary hormone secretion are generally the same as in adults, but the intensity of the response of pituitary cells to their action is variable according to the species, thus reflecting an immaturity in the functioning of certain cell types.

Plasma prolactin and clinical outcome in preterm infants

Plasma prolactin was measured weekly in 280 preterm infants. The complex gestational age dependent pattern of postnatal prolactin release has been defined and reference standards provided. Plasma prolactin was higher in girls, with increasing divergence between the sexes from the third week onwards, and higher after two weeks, in infants of mothers with pregnancy related hypertension. Diet, assigned randomly, exerted a major effect on plasma prolactin, with significantly higher values in infants fed donor breast milk or standard formula than in those fed a protein, energy, and mineral enriched preterm formula. After adjusting for confounding factors, infants with the lowest plasma prolactin concentrations (less than 1000 mU/l, 32.9 micrograms/l) occurring usually at a nadir between days 5 and 12, showed a 120% increase in the duration of ventilatory assistance required, a 20% increase in the number of days to attain full enteral feeds, and a 30% decrease in length gain. We suggest preterm birth disrupts the normal perinatal pattern of prolactin release and that those infants who develop relatively low plasma concentration have an adverse outcome. Our data add to the broader debate on whether preterm infants require multiple endocrine replacement treatment.

Growth hormone deficiency in the Rothmund-Thomson syndrome

We describe the first proven occurrence of growth hormone deficiency in an individual with the Rothmund-Thomson syndrome. This was suspected because of the patient's severely retarded growth and bone age and her failure to respond normally to growth hormone stimulation testing with l-DOPA, arginine, and growth hormone releasing factor. In addition, we have briefly reviewed other genetic and malformation syndromes that have been found associated with growth hormone deficiency. We recommend that growth hormone deficiency be considered in these syndromes, especially when the growth failure is more marked than expected.

Anatomical and ontogenetic studies of the human paraventriculo-infundibular corticoliberin system

In human fetus, newborn, infant and adult hypothalami, antibodies to ovine corticoliberin-41 stain a paraventriculo-infundibular neuroglandular pathway. The perikarya are located in the paraventricular nucleus, they mainly project to the ventral and lateral areas of the median eminence. Eminential corticoliberin-positive fibres appear during the 16th week of fetal life, and increase in number during the following weeks. Perikarya were first revealed in the 19th week. In some areas of the median eminence, corticoliberin-, vasopressin- or [Met]enkephalin-immunoreactive terminals are similarly distributed. Sequential stainings or staining comparison of contiguous semi-thin sections failed to prove the coexpression of corticoliberin and [Met]enkephalin immunoreactivities in fibres, but indicated that corticoliberin and vasopressin immunoreactivities may be coexpressed in a few fibres. Those methods enabled us to observe, in the paraventricular nucleus, perikarya revealed by corticoliberin and vasopressin antisera. Our results suggest a possible release of corticoliberin in portal vessels of the median eminence beginning in the 16th week of fetal life, i.e. 8 weeks later than appearance of the corticotrophs in the pituitary. Establishment of a corticoliberin hypothalamic control of pituitary corticotrophs at mid gestation agrees with previous physiological and teratological studies. Abundance, as well as immunostaining intensity of the corticoliberin processes, in the infant and adult median eminence attest to the physiological importance of this system. Close vicinity of corticoliberin, vasopressin and [Met]enkephalin fibres, in some eminential areas and coexpression of corticoliberin and vasopressin immunoreactivities in some neurons, are morphological correlates of functional relations which were reported.

Sexual maturation of the hypothalamus: pathophysiological aspects and clinical implications

Sexual maturation in humans begins early in fetal life and culminates in adulthood when the gonads have acquired a full capacity for reproduction. It is remarkable that during this long process, the pituitary gonadal function, hence its hypothalamic control presents an alternative of activation and inhibition periods, during which the interrelations of the 3 components of the hypothalamic-pituitary-gonadal axis change gradually and inversely. The ontogeny of the hypothalamic-pituitary system, the varying activity of the reproductive endocrine system throughout sexual maturation and the developmental changes in the interrelations of the hypothalamic-pituitary-gonadal axis are reviewed: the most striking feature of human sexual development is the long inhibition of hypothalamo-pituitary function during childhood. Much indirect evidence points to the determining role of the CNS in the maturation of hypothalamic function: the occurrence of rhythms of secretion, the amplitude of secretions and peripubertal specific sleep-related nycthemeral rhythm of secretion at the onset of puberty. Despite the reality of a negative feedback control, these changes do occur independently of gonadal secretions since they are observed (qualitatively if not strictly quantitatively) in agonadal children. It is likely that neurotransmitters (dopamine, serotonine) and opiates have an inhibitory effect on Gn-RH release. But we still don't know their evolution during sexual maturation. It does not appear that melatonine plays any determinant role in the onset of human puberty. The clinical implications of our present understanding of the physiological events occurring during sexual maturation are several. Considering the major problems related to abnormal sexual maturation we will discuss successively: (1) diagnosis of hypogonadotrophic hypogonadism in early infancy; (2) differential diagnosis between premature thelarche and true sexual precocity; (3) the usefulness of endocrine investigations in the evaluation of hypothalamic-pituitary function; and (4) the new developments in the treatment of precocious puberty, delayed puberty or hypogonadism.

Effect of metoclopramide on maternal and fetal hyperprolactinemia

To investigate the effect of metoclopramide (MET), a dopaminergic antagonist drug, on serum PRL concentration in maternal and cord blood (CB) serum, the drug was injected in 94 at term pregnant women whereas 28 mothers received saline. Maternal serum (MS) samples were obtained before MET injection and at the parturition time. According to the interval of time between MET administration and birth, MS specimens were grouped in 7 groups. CB was obtained from neonates whose mothers were injected with saline, group 0 and from newborns whose mothers were treated with MET, groups 1 to 7. In the 7 groups of women the mean PRL concentration before MET ranged between 307 and 439 ng/ml. After MET injection a significant increase has been observed in all groups with a minimum and maximal mean value of 639 and 931 ng/ml. The highest net increment of PRL has been measured in group 1 sampled at 5 to 30 minutes after MET. CB PRL concentration in group 0, saline treated, was not different from the values measured in group 1 to 7, treated groups, with a range between 504 and 703 ng/ml. These findings suggest that maternal lactotropes are still responsive to MET. On the opposite, fetal pituitary does not release PRL after MET injection probably because PRL secretory activity is maximal or because the dopaminergic receptors' system is still immature.

Acceleration of pulmonary surfactant maturation in stresses pregnancies: a study of neonatal lung effluent

To determine the maturation of pulmonary surfactant at birth, phospholipid patterns in tracheal or pharyngeal aspirates of 54 newborn infants were analyzed by two-dimensional thin-layer chromatography. The compositions of phospholipids and their surface tension-lowering abilities were assessed after gestations with various complications. Preterm infants with respiratory distress syndrome (RDS) lacked phosphatidylglycerol and had lower lecithin/sphingomyelin ratios than infants without RDS. An acceleration of both phosphatidylcholine (lecithin) and phosphatidylglycerol concentrations was observed in 21 preterm infants born after prolonged rupture of the membranes and treatment with isoxuprine. In these infants, the phospholipid pattern of lung effluent was similar to that of term infants even at gestational ages less than or equal to 30 weeks. Biochemical lung maturation was delayed in aneccephalic infants, infants of diabetic mothers, and one infant of a mother with hypothyroidism.

Influence of bromocriptine on plasma levels of prolactin and steroid hormones in the 20th week of pregnancy

The influence of bromocriptine, a prolactin antagonist, on maternal plasma and amniotic fluid prolactin (PRL) was investigated in two pregnancies at the 20th week with medical indication for abortion. Voluntary consensus of the patients was obtained. Blood sample determinations demonstrated that bromocriptine inhibits the secretion of PRL both in plasma and amniotic fluid. Since no changes were observed in peripheral maternal steroid concentrations of dehydroepiandrosterone, dehydroepiandrosterone-sulfate, delta 4-androstene-3, 17-dione, testosterone, estradiol, estriol, and cortisol, it is concluded that PRL does not seem to affect maternal and fetal adrenal cortex as supposed in amenorrhoic patients with hyperprolactinemia.

The ontogenesis of human fetal hormones. III. Prolactin

The synthesis and release of human prolactin (hPRL) in the human fetus was assessed by radioimmunoassay analysis of the content and concentration of hPRL in 82 pituitary glands and the concentration of serum hPRL in 47 fetuses of gestational age 68 days to term. Fetal hPRL exhibited parallelism with the reference standard (Lewis 203-1). hPRL was detected by 68 days of gestation (10 wk), the earliest fetal pituitary gland studied; 8 out of 33 pituitaries had a prolactin (PRL) content above 2.0 ng between 10-15 wk gestation. The mean ocntent of PRL in the pituitary gland increased sharply from 14.8 plus or minus 4.6 ng at 15-19 wk to 405 plus or minus 142 ng at 20-24 wk and 542 plus or minus ng at 25-29 wk gestation. By term, the mean content was 2,039 plus or minus 459 (range 493-3,689) and the mean concentration 15.9 plus or minus 2.4 ng/mg (range 7-20). There was a significant positive correlation (P less than 0.001) between the hPRL and human growth hormone (hGH) content of fetal pituitary glands; at term the hPRL/hGH ratio was 1/290. The concentration of serum hPRL between 12 and 24 wk ranged from 2.9 to 67 ng/ml, mean 19.5 plus or minus 2.5 ng/ml )n = 21); by 26 wk fetal serum hPRL increased sharply and attained levels of 300-500 ng/ml in late gestation. At delivery, the mean plasma concentration of hPRL was 167 plus or minus 14.2 ng/ml in 36 umbilical venous specimens and 111.8 plus or minus 12.3 ng/ml in the matched maternal venous specimens. No correlation between serum hPRL and the pituitary content or concentration of hPRL was demonstrable in 12 matched fetal specimens. In five anencephalic infants, umbilical venous hPRL levels were between 65 and 283 ng/ml. In two anencephalic infants, thyrotropin releasing factor (TRF) (200 mug IV) evoked a rise in serum hPRL in one patient from 43 to 156 ng/ml at 30 min, and in the other from 65 to 404 ng/ml at 120 min. In both patients, plasma thyroid-stimulating hormone (TSH) rose from undetectable base-line levels to peak levels of 97 and 380 muU/ml, respectively. The pattern of change in serum hPRL in the human fetus contrasts sharply with that of serum hGH, luteinizing hormone, or follicle-stimulating hormone. These observations in the fetus and in anencephalic infants suggest that the striking elevation of serum PRL in the fetus is neither mediated by a putative PRL releasing factor or by TRF, nor is a consequence of suppression or absence of PRL release inhibiting factor alone, as a functional hypothalamus is not required to attain the high PRL concentration at term. Several lines of evidence support the view that high plasma estrogen levels characteristic of gestation act directly on the fetal anterior hypophysis to stimulate PRL secretion or to sensitize the secretory mechanism of the lactotrope, increasing its responsiveness to other stimuli.

Neontal hypoglycaemia in infants of insulin-dependent diabetic mothers

Neonatal hypoglycaemia (blood glucose smaller than 20 mg/100 ml) occurred in the first 6 hours of life in 25 of 34 infants born to diabetic mothers receiving insulin. Despite severe hypoglycaemia (blood glucose smaller than 10 mg/100 ml) in 17, clinical features of hypoglycaemia were absent in all but 2. Hypoglycaemia was not related either to the level of plasma insulin in cord blood, determined as nonextracted immunoreactive insulin, or to the degree of control of maternal blood glucose during pregnancy. The frequent occurrence of severe neonatal hypoglycaemia in the infants born to diabetic mothers receiving insulin appears to be due rather to failure to maintain basal glucose homoeostasis after birth than to hyperinsulinism.