Update on new developments in the study of human teratogens.

BACKGROUND AND METHODS: The purpose of this annual article is to highlight and briefly review new and significant information on agents that may be teratogenic in pregnant women. Various sources of on-line and printed information are given. RESULTS: The following topics have been discussed: 1) lithium medication: decreased estimate of risk; 2) cigarette smoking and genotype as contributors to oral-facial clefts and clubfoot; 3) trimethoprim; 4) methimazole syndrome?; 5) glucocorticoids and oral-facial clefts; 6) binge drinking; 7) fetal valproate syndrome; and 8) carbamazepine. CONCLUSIONS: We have highlighted several maternal exposures during pregnancy that are associated with small but increased rates of birth defects, generally only a few cases per 1,000 infants. These exposures include cigarette smoking, and treatment with lithium, trimethoprim, methimazole, or corticosteroids. This weak teratogenic effect was usually identified by the linkage of an uncommon treatment with an unusual birth defect outcome. The use of modern epidemiologic techniques, especially prospective multicenter studies that provide increased numbers, has helped to strengthen the evidence for these associations. We discuss how teratogenic risks that are small in comparison to the background risk can be presented to at-risk women and their doctors. We have briefly listed some elements that might be used in prioritizing further studies of suspected teratogenic exposures. Various existing methods for expressing the strength of evidence for human teratogenicity are also given.

Utilization of developmental basic science principles in the evaluation of reproductive risks from pre- and postconception environmental radiation exposures.

The subject of the reproductive toxicity of various forms of radiation can be anxiety provoking to the public on two accounts, since reproductive failure engenders an unusual level of guilt and anger in the affected families, and radiation effects are misunderstood and feared by the public. Reproductive problems include an array of genetic and acquired diseases affecting parents and their offspring. Many of these problems are associated with the risk of being induced by preconception and/or postconception exposures to environmental agents. For the various forms of radiation, namely, ionizing radiation, ultrasound, low-frequency electromagnetic fields (EMF), and microwaves, the potential for producing reproductive effects varies considerably with the form of "radiation" and, of course, the dose. Whether the exposure occurs preconceptionally or postconceptionally is another major consideration. In evaluating the actual reproductive risks, we rely on accurate dosimetry and information obtained in epidemiological studies and animal studies. Epidemiological studies must demonstrate consistency of the reproductive finding, and animal studies should be designed to add to the findings of the epidemiological studies. Most importantly, the conclusions must not contradict the basic principles of teratology, genetics, and reproductive biology, and they should be biologically plausible. But frequently important basic science principles are ignored in the evaluation process. Yet developmental basic science principles can be instrumental in refuting or supporting the concern about possible risks. Although there is some overlap with regard to the preconception and intrauterine effects of ionizing radiation, there are significant differences. Preconception effects are mainly stochastic effects, while intrauterine effects are mainly deterministic effects. The stochastic genetic risks are lower than the deterministic risks at equivalent exposures. Thus, it is frequently difficult to demonstrate the occurrence of stochastic effects in populations that have received low preconception exposures to ionizing radiation. The reproductive effects from preconception and intrauterine exposures to electromagnetic fields (low-frequency EMF, video display terminals, microwaves) and ultrasound represent much different problems, since the main effects of microwaves and ultrasound occur because of their hyperthermic effects at high exposures. Low-frequency EMF does not have the capacity to produce hyperthermia, and none of these forms of nonionizing radiation has the specificity to damage the DNA comparable to the specificity of ionizing radiation. Not only do they not have targeted mutagenic effects at the usual exposures that populations receive, they are not cytotoxic at these exposure levels as well. From the viewpoint of biological plausibility, these other forms of radiation are much less likely to have the potential for producing reproductive toxicity at the usual population exposures.

Reproductive and teratologic effects of low-frequency electromagnetic fields: a review of in vivo and in vitro studies using animal models.

In order to evaluate the reproductive risks of low-frequency electromagnetic fields (EMF), it is important to include epidemiological and animal studies in the evaluation, as well as the appropriate basic science information in developmental biology and teratology. This review presents a critical review of in vivo animal studies and in vitro tests, as well as the biological plausibility of the allegations of reproductive risks. In vitro or in vivo studies in nonhuman species can be used to study mechanisms and the effects that have been suggested by human investigations. Only well designed whole-animal teratology studies are appropriate when the epidemiologists and clinical teratologists are uncertain about the environmental risks. Even the inference of teratogenesis cannot be drawn from culture experiments, because the investigator is not in a position to know whether any of his observations will be manifested in living organisms at term. Other aspects of reproductive failure such as abortion, infertility, stillbirth, and prematurity, cannot be addressed by in vitro or culture experiments. In fact, they are very difficult to design and interpret in nonprimate in vivo models. The biological plausibility some of the basic mechanisms involved in reproductive pathology were evaluated, concentrating primarily on the mechanisms involved in the production of birth defects. The studies dealing with mutagenesis, cell death and cell proliferation using in vitro systems do not indicate that EMFs have the potential for deleteriously affecting proliferating and differentiating embryonic cells at the exposures to which populations are usually exposed. Of course, there is no environmental agent that has no effect, deleterious or not, at very high exposures. The animal and in vitro studies dealing with the reproductive effects of EMF exposure are extensive. There are >70 EMF research projects that deal with some aspect of reproduction and growth. Unfortunately, a large proportion of the embryology studies used the chick embryo and evaluated the presence or absence of teratogenesis after 48-52 h of development. This is not a stage of development at which an investigator could determine whether teratogenesis occurred. The presence of clinically relevant teratogenesis can only be determined at the end of the gestational period. The chick embryo studies are also of little assistance to the epidemiologist or clinician in determining whether EMF represents a hazard to the human embryo, and the results are, in any event, inconsistent. On the other hand, the studies involving nonhuman mammalian organisms dealing with fetal growth, congenital malformations, embryonic loss, and neurobehavioral development were predominantly negative and are therefore not supportive of the hypothesis that low-frequency EMF exposures result in reproductive toxicity.

Contribution of clinical teratologists and geneticists to the evaluation of the etiology of congenital malformations alleged to be caused by environmental agents: ionizing radiation, electromagnetic fields, microwaves, radionuclides, and ultrasound.

Analysis of these six clinical problems demonstrates the value of a complete clinical evaluation of a child with congenital malformations by an experienced and well-trained physician who is familiar with the fields of developmental biology, teratology , epidemiology, and genetics. Too often, the entire emphasis is placed on epidemiological data that may be meager or insufficient for a rational conclusion when clinical findings that are readily available can provide definitive answers with regard to the etiology of a child's malformations or the merits of an environmental etiology.

Limb reduction defects in the A/J mouse strain associated with maternal blood loss.

We previously described a high incidence of digit/limb anomalies in the offspring of A/J mice subjected to surgery on day 12.5 postconception (p.c.), but not in the offspring of untreated control mice. To investigate the cause of these defects, we compared the offspring of mice in experimental groups involving adrenalectomy, sham adrenalectomy, blood sampling, and anesthesia with the offspring of control mice. All treatments significantly reduced fetal weight and increased resorptions as compared with the controls. The highest incidence of digit anomalies occurred in the offspring of dams from which blood samples had been drawn on days 12.5, 14.5, and 15.5 p.c. The incidence of isolated cleft palate was also increased in the offspring of mice that had been subjected to blood sampling. We conclude that digit anomalies in the offspring of A/J mice result from fetal vascular disruptive phenomena subsequent to maternal blood loss induced hypovolemia and hypoperfusion to the uterus and placenta as has been suggested for uterine vascular clamping, misoprostol, chorionic villus sampling, and cocaine teratogenesis. The etiology for cleft lip in these mice may involve mechanisms unrelated to uterine/placental hypoperfusion.

Reproductive and teratologic effects of electromagnetic fields.

The reproductive risks of electromagnetic fields (EMF) were evaluated based on an extensive review of the scientific literature pertaining to human epidemiologic studies, secular trend data, in vivo animal studies and in vitro studies, and biologic plausibility. The epidemiologic studies involving the reproductive effects of EMF exposures to human populations have included populations exposed to: (1) video display terminals (VDTs), and (2) power lines and household appliances. The clinical use of diagnostic MRI (magnetic resonance imaging) has been increasing, but there are few reports or studies of pregnant women or individuals of reproductive age who have been exposed to MRI, and whose reproductive performance has been evaluated. The population that has been studied most frequently are women exposed to VDTs, but their EMF exposures are extremely low and frequently are at the level of the ambient EMF in a house or office. The results of epidemiologic studies involving VDTs are generally negative for the reproductive effects that have been studied. Based on the number of studies, the exposure levels, and the fairly consistent results, it can be argued that VDT epidemiologic studies should no longer be given priority. There have been fewer studies concerned with the reproductive risks of power lines, electric substations, and home appliances. In some publications, positive findings for reproductive risks were reported, but the more consistent findings indicate that EMF, even at these higher exposures, do not generate a measurable increase in reproductive failures in the human population. When compared to other fields of human epidemiology, it is obvious that these studies have many difficulties. Exposures are rarely determined. Studies frequently involve small sample sizes and the investigators rarely have a combined expertise in EMF physics, engineering, and reproductive biology. Because of the allegation that there may be particular windows of frequency, wave shape, and intensity that may be deleterious, it is impossible to disregard low frequency EMF exposures as having no deleterious reproductive effects. Yet the epidemiologic data that are available would point in that direction. Secular trend data analysis of birth defect incidence data indicate that increasing generation of electric power during this century is not associated with a concomitant rise in the incidence of birth defects. There are over 70 EMF research projects dealing with animal and in vitro studies that are concerned with some aspect of reproduction and growth. Unfortunately, a large proportion of the embryology studies utilized the chick embryo and evaluated the presence or absence of teratogenesis after 48 to 52 hours of development.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical teratology.

Genetic causes account for 20% to 25% of human birth defects, but the largest proportion of birth defects have no definitive etiology and some of these malformations may be due to intrinsic, "nonpreventable" spontaneous errors of development. Environmental causes, which include maternal disease states, maternal infection, mechanical factors, problems of constraint, chemicals, drugs, and physical agents, are responsible for only about 10% of human birth defects. The scientific basis for understanding the risk of congenital malformations from exposure to environmental agents is based on several tenets of toxicology and embryology dogma. The first tenet is that essentially all teratogens that have been studied have a typical toxicologic dose response relationship and a no-effect dose. Secondly, the stage of gestation is critical to the effects that are expected, and all stages of embryogenesis and fetogenesis can have vulnerability to environmental toxicants. Thirdly, the response of the embryo and fetus is characteristic for each teratogenic agent, although there is some similarity in the effect of certain teratogens. Appropriately designed developmental toxicology studies and basic embryologic and biologic concepts are all used to estimate the potential reproductive hazard for embryonic death, growth retardation, congenital malformation, and functional deficit.

Experimental manipulation of the rodent visceral yolk sac.

The visceral yolk sac (VYS) is an especially important placental organ in the rodent because it is the primary source of exchange between the embryo and mother during early organogenesis before the chorioallantoic placenta circulation is established. The VYS is involved with nutritional, endocrine, metabolic, immunologic, secretory, excretory, and hematopoietic functions. The VYS also plays a role in steroid metabolism and interacts with a variety of blood-borne factors: parathyroid hormone, glucocorticoids, insulin, and vitamin D metabolites. The importance of the VYS during development is emphasized by the embryotoxicity resulting from exposure to agents which cause VYS dysfunction when administered to the pregnant animal during organogenesis. Several experimental procedures have provided useful information concerning a variety of VYS functions from early organogenesis to term: Culture of the Embryo, Fetal Incubation, Culture of the Fetus, Giant Yolk Sac, Short- and Long-Term Culture of the Yolk Sac, Modified Ussing's Chamber, Single or Double Diffusion Chamber, and the use of Heterologous Rodent Visceral Yolk Sac Antibodies. Since human yolk sac pathology has been associated with developmental toxicity and spontaneous abortion, it is important to discover whether there are some common functional roles among different mammalian species and to determine if other experimental animal models can be used to study the possible contribution of human yolk sac dysfunction to some human reproductive problems.

Characterization of cytosolic glucocorticoid receptor of fetal rat epiphyseal chondrocytes.

The cytosolic glucocorticoid receptor of 21st gestational day rat epiphyseal chondrocytes has been evaluated. The receptor, a single class of glucocorticoid binding component approached saturation, utilizing [3H]triamcinolone acetonide ([3H]TA) as the radiolabeled ligand, at approximately 1.8-2.0 x 10(-8) M. The dissociation constant (Kd) reflected high-affinity binding, equaling 4.0 +/- 1.43 x 10(-9) M (n = 7) for [3H]TA. The concentration of receptor estimated from Scatchard analysis was approximately 250 fmol/mg cytosolic protein and when calculated on a sites/cell basis equalled 5800 sites/cell. The relative binding affinities of steroid for receptor were found to be triamcinolone acetonide greater than corticosterone greater than hydrocortisone greater than progesterone greater than medroxyprogesterone acetate much greater than 17 alpha-hydroxyprogesterone much greater than testosterone greater than 17 beta-estradiol. Cytosolic preparations activated in vitro by warming (25 degrees C for 20 min) were shown to exhibit an increased affinity for DNA-cellulose. 46% of the total specifically bound activated ligand-receptor complex was bound to DNA-cellulose. Cytosol maintained at 0-4 degrees C in the presence of 10 mM molybdate or activated in vitro in the presence of molybdate, bound to DNA-cellulose at 8 and 10% respectively. DEAE-Sephadex elution profiles of the nonactivated receptor were indicative of a single binding moiety which eluted from the columns at 0.4 M KCl. Elution profiles of activated receptor were suggestive of an activation induced receptor lability. The 0.4 M KCl peak was diminished, while a concomitant increase in the 0.2 M KCl peak was only modestly discernible. Evaluation of endogenous proteolytic activity in chondrocyte cytosol using [methyl-14C]casein as substrate show a temperature-dependent proteolytic activity with a pH optimum of 5.9-6.65. The proteolytic activity was susceptible to heat inactivation and was inhibitable, by 20 mM EDTA. The sedimentation coefficient of the nonactivated receptor was 9.3s (n = 6) on sucrose density gradients and exhibited steroid specificity and a resistance to activation induced molecular alterations when incubated in the presence of 10 mM molybdate. Receptor activation in vitro, in the absence of molybdate induced an increased receptor susceptibility to proteolytic attack and/or enhanced ligand receptor dissociation as evidenced by a diminution of the 9.3s binding form without a concomitant increase in 5s or 3s receptor fragments.

The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks.

The term radiation evokes emotional responses both from lay persons and from professionals. Many spokespersons are unfamiliar with radiation biology or the quantitative nature of the risks. Frequently, microwave, ultrasound, and ionizing radiation risks are confused. Although it is impossible to prove no risk for any environmental hazard, it appears that exposure to microwave radiation below the maximal permissible levels present no measurable risk to the embryo. Ultrasound exposure from diagnostic ultrasonographic-imaging equipment also is quite innocuous. It is true that continued surveillance and research into potential risks of these low-level exposures should continue; however, at present ultrasound not only improves obstetric care, but also reduces the necessity of diagnostic x-ray procedures. In the field of ionizing radiation, we have a better comprehension of the biologic effects and the quantitative maximum risks than for any other environmental hazard. Although the animal and human data support the conclusion that no increases in the incidence of gross congenital malformations, IUGR, or abortion will occur with exposures less than 5 rad, that does not mean that there are definitely no risks to the embryo exposed to lower doses of radiation. Whether there exists a linear or exponential dose-response relationship or a threshold exposure for genetic, carcinogenic, cell-depleting, and life-shortening effects has not been determined. In establishing maximum permissible levels for the embryo at low exposures, refer to Tables 4, 5, 6, 8, and 9. It is obvious that the risks of 1-rad (.10Gy) or 5-rad (.05Gy) acute exposure are far below the spontaneous risks of the developing embryo because 15% of human embryos abort, 2.7% to 3.0% of human embryos have major malformations, 4% have intrauterine growth retardation, and 8% to 10% have early- or late-stage onset genetic disease. The maximal risk attributed to a 1-rad exposure, approximately 0.003%, is thousands of times smaller than the spontaneous risks of malformations, abortion, or genetic disease. Thus, the present maximal permissible occupational exposures of 0.5 rem for pregnant women (see Table 10) and 5 rem for medical exposure, are extremely conservative. Medically indicated diagnostic roentgenograms are appropriate for pregnant women, and there is no medical justification for terminating a pregnancy in women exposed to 5 rad or less because of a radiation exposure.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of prenatal X-irradiation on postnatal testicular development and function in the Wistar rat: development/teratology/behavior/radiation.

It is evident that significant permanent tissue hypoplasia can be produced following radiation exposure late in fetal development. Because two organs, brain and testes, are developmentally and functionally interrelated, it was of interest to determine whether fetal testicular hypoplasia was a primary or a secondary effect of fetal brain irradiation. Twenty-four pregnant Wistar strain rats were randomly assigned to one of four groups, and a laparotomy was performed on day 18 of gestation. The fetuses received sham irradiation, whole body irradiation, or only head/thorax or pelvic body irradiation at a dosage level of 1.5 Gy. Mothers were allowed to deliver and raise their offspring until postnatal day 30, when the offspring were weaned. At 60 days of age, 74 male offspring were allowed to mate with colony control females of similar age until successful insemination or until the males reached 90 days of age, when they were killed. Testes were weighed and processed for histologic examination. Direct radiation of testes, due to whole body or pelvic exposure, resulted in testicular growth retardation and significantly reduced spermatogenesis. Breeding activity of the males and the percent of positive inseminations were also slightly reduced. However, a significant percentage of male offspring receiving direct testicular radiation did produce offspring. Head/thorax-only irradiation did not adversely affect testicular growth or spermatogenesis. Therefore, the use of histologic analysis as the sole determinant of infertility may be misleading. This study indicates that testicular growth retardation and an increased infertility rate result from direct prenatal exposure of rat testes to X-radiation and are not necessarily mediated via X-irradiation effects on the central nervous system.

The effects of embryonic and fetal exposure to x-ray, microwaves, and ultrasound.

The term radiation evokes emotional responses both from lay persons and from professionals. Many spokespersons are unfamiliar with radiation biology or the quantitative nature of the risks. Frequently, microwave, ultrasound, and ionizing radiation risks are confused. Although it is impossible to prove no risk for any environmental hazard, it appears that exposure to microwave radiation below the maximal permissible levels present no measurable risk to the embryo. Ultrasound exposure from diagnostic ultrasonographic imaging equipment also is quite innocuous. It is true that continued surveillance and research into potential risks of these low-level exposures should continue, but at present ultrasound not only improves obstetric care but also reduces the necessity of diagnostic x-ray procedures. In the field of ionizing radiation, we have as good a comprehension of the biologic effects and the quantitative maximum risks as of any other environmental hazard. Although the animal and human data support the conclusion that no increases in the incidence of gross congenital malformations, intrauterine growth retardation, or abortion will occur with exposures less than 5 rad, that does not mean that there are definitely no risks to the embryo exposed to lower doses of radiation. Whether there exists a linear or exponential dose-response relationship or a threshold exposure for genetic, carcinogenic, cell-depleting, and life-shortening effects has not been determined. In establishing maximum permissible levels for the embryo at low exposures, refer to Tables 4, 5, 6, 8, and 9. It is obvious that the risks of 1-rad or 5-rad acute exposure are far below the spontaneous risks of the developing embryo because 15 per cent of human embryos abort, 2.7 to 3.0 per cent of human embryos have major malformations, 4 per cent have intrauterine growth retardation, and 8 to 10 per cent have early- or late-onset genetic disease. The maximal risk attributed to a 1-rad exposure, approximately 0.003 per cent, is thousands of times smaller than the spontaneous risks of malformations, abortion, or genetic disease. Thus, the present maximal permissible occupational exposures of 0.5 rem for pregnant women (see Table 10) and 5 rem for medical exposure, are extremely conservative. Medically indicated diagnostic roentgenograms are appropriate for pregnant women, and there is no medical justification for terminating a pregnancy in women exposed to 5 rad or less because of a radiation exposure.(ABSTRACT TRUNCATED AT 400 WORDS)

Mechanism of known environmental teratogens: drugs and chemicals.

Basic principles of teratology and mechanisms of teratogenesis applicable to human exposures to environmental drugs and chemicals are discussed. The available clinical and experimental animal literature on environmental agents alleged or known to cause human malformations is critically reviewed and summarized.