Prediction and evaluation of fetal toxicity induced by NSAIDs using transplacental kinetic parameters obtained from human placental perfusion studies.

AIM: The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in full-term pregnant women leads to fetal or neonatal toxicity, such as constriction of the ductus arteriosus (DA) and persistent pulmonary hypertension in the newborn. The aim of this study was to predict quantitatively the fetal toxicity of three NSAIDs (antipyrine, salicylic acid and diclofenac) using the transplacental pharmacokinetic parameters obtained from our previous placental perfusion studies. METHODS: Human fetal plasma concentration profile after oral administration of each NSAID to the mother was estimated using the transplacental pharmacokinetic parameters and pharmacokinetic parameters in adult women. The fetal plasma concentration-response relationship for the three NSAIDs was estimated by pharmacokinetic/pharmacodynamic analysis of the results of previous studies investigating the effects of NSAIDs on the ratio of inner diameter of the DA to that of the pulmonary artery (DA/PA) in rats and the plasma concentration profiles of NSAIDs in pregnant rats. RESULTS: The risk of constriction of the DA was well predicted by the model. Mean DA/PA ratio after oral administration of diclofenac to the mother was estimated to be 39.0%, whereas both of the corresponding values after oral administration of antipyrine and salicylic acid were estimated to be 5.9%. These results suggest that the fetal risk of diclofenac is higher than those of salicylic acid and antipyrine. CONCLUSIONS: This study presents a novel approach to predict quantitatively the fetal risk of NSAIDs administered to the mother. Human placental perfusion study and pharmacokinetic/pharmacodynamic analysis may provide basic data for predicting human fetal toxicity of drugs.

Transplacental pharmacokinetics of diclofenac in perfused human placenta.

The aims of this study were to evaluate the transplacental transfer properties of diclofenac and to determine the effect of L-lactic acid on the transplacental transfer of diclofenac. The maternal and fetal vessels of human placenta were perfused in a single-pass mode with a solution containing diclofenac and antipyrine. The transplacental pharmacokinetic model was fitted to the time profiles of the drug concentrations in the effluent and placenta to obtain transplacental pharmacokinetic parameters. In addition, chloride ion in the perfusate was partially replaced with L-lactic acid to see the change in the transplacental transfer properties of diclofenac. The TPT(ss) value (ratio of the rate of amount transferred across the placenta to that infused in the steady state) of diclofenac was 2.22%, which was approximately one-third that of antipyrine and was significantly reduced in the presence of L-lactic acid. The transplacental pharmacokinetic model could adequately explain the transplacental transfer of diclofenac with influx clearances from maternal and fetal perfusates to placental tissue of 0.276 and 0.0345 ml/min/g cotyledon and efflux rate constants from placental tissue to maternal and fetal perfusates of 0.406 and 0.0337 min(-1), respectively. By taking into account protein binding, the placental tissue/plasma concentration ratio in humans for diclofenac was estimated to be 0.108 ml/g of cotyledon and was smaller than that of antipyrine. In conclusion, human placental perfusion and transplacental pharmacokinetic modeling allowed us to determine the transplacental transfer properties of diclofenac quantitatively. Diclofenac may share transplacental transfer system(s) with L-lactic acid.

Long-term effects of polychlorinated biphenyls and dioxins on pregnancy outcomes in women affected by the Yusho incident.

BACKGROUND: Maternal exposure to polychlorinated biphenyls (PCBs) is associated with increased proportions of spontaneous abortion and stillbirth in animal studies. In Japan in 1968, accidental human exposure to rice oil contaminated with PCBs and other dioxin-related compounds, such as polychlorinated dibenzofurans (PCDFs), led to the development of what was later referred to as Yusho oil disease. OBJECTIVE: The aim of this study was to investigate the association of maternal PCB and dioxin exposure with adverse pregnancy outcomes in Yusho women. METHODS: In 2004, we interviewed 214 Yusho women (512 pregnancies) about their pregnancy outcomes over the past 36 years. Pregnancy outcomes included induced abortion, spontaneous abortion, preterm delivery, and pregnancy loss. RESULTS: In pregnancy years 1968-1977 (within the first 10 years after exposure), the proportions of induced abortion [odds ratio adjusted for age at delivery (ORadj) = 5.93; 95% confidence interval (CI), 2.21-15.91; two-tailed p < 0.001) and preterm delivery (ORadj = 5.70; 95% CI, 1.17-27.79; p = 0.03) were significantly increased compared with the proportions in pregnancy years 1958-1967 (10 years before the incident). Spontaneous abortion (ORadj = 2.09; 95% CI, 0.84-5.18), and pregnancy loss (ORadj = 2.11; 95% CI, 0.92-4.87) were more frequent (OR = 2.18; 95% CI, 1.02-4.66), but these were not significant (p = 0.11 and p = 0.08, respectively) in pregnancy years 1968-1977. We found no significant increases in the proportions of these adverse pregnancy outcomes in pregnancies occurring during 1978-1987 or 1988-2003 compared with those in pregnancies before 1968. CONCLUSION: High levels of PCB/PCDF exposure had some adverse effects on pregnancy outcome in Yusho women.

Neutrophil-derived reactive oxygen species can modulate neutrophil adhesion to endothelial cells in preeclampsia.

BACKGROUND: Neutrophil activation has been implicated in the pathophysiology of preeclampsia. The aim of this study was to investigate whether neutrophil-derived reactive oxygen species (ROS) modulate adhesion to endothelial cells in preeclampsia. METHODS: We first assessed neutrophil superoxide production and neutrophil-endothelial cell adhesion in normal nonpregnant women (n = 8), normal pregnant women (n = 10), and preeclamptic pregnant women (n = 8). We then examined the effects of neutrophil-derived ROS on neutrophil-endothelial adhesion. The release of neutrophil superoxide was measured using cytochrome C reduction. RESULTS: N-formyl-methionyl-leucyl-phenylalanine (FMLP)-stimulated superoxide production by neutrophils was significantly increased in women with preeclampsia when compared with the other two groups. Neutrophils from women with preeclampsia were more likely to adhere to endothelial cells, than were those from the other two groups (mean adhesion rate +/- s.d. (%); 20.6 +/- 2.7 in preeclampsia, 10.2 +/- 1.2 in normal pregnancy, 11.0 +/- 0.9 in normal nonpregnancy, P < 0.01). Superoxide dismutase (SOD), which dismutates the excess superoxide to hydrogen peroxide, did not affect neutrophil-endothelial adhesion. In contrast, catalase, which catalyzes the conversion of hydrogen peroxide to oxygen and water, inhibited neutrophil-endothelial adhesion in the preeclamptic group (8.1 +/- 0.5%, P < 0.01). CONCLUSION: Neutrophils from women with preeclampsia demonstrate increased CD11b expression and adhesion to endothelial cells. This is likely caused by elevations in superoxide and its derivative, hydrogen peroxide.

Inhibition of nitric oxide synthetase at mid-gestation in rats is associated with increases in arterial pressure, serum tumor necrosis factor-alpha, and placental apoptosis.

BACKGROUND: Reduced uteroplacental perfusion and maternal cardiovascular dysfunction have been considered to be the main pathophysiological features of preeclampsia. In order to determine whether inhibition of nitric oxide synthetase (NOS) during the initial stage of placentation is associated with impaired placental development and maternal cardiovascular dysfunction, we studied the effect of N-nitro-arginine methyl ester (L-NAME), a NOS inhibitor, on morphological changes in the placenta, maternal blood pressure, and serum tumor necrosis factor-alpha (TNF-alpha) in pregnant rats during the initial stage of placentation. METHODS: Pregnant Wister rats were treated during mid-gestation (days 8-14) with either L-NAME or saline. On day 20 of pregnancy the rats were killed, and maternal blood and placentas were extracted and examined. RESULTS: In comparison with pregnant saline-treated control rats (blood pressure 119 +/- 9 mm Hg), pregnant rats treated with L-NAME displayed significant hypertension (blood pressure 178 +/- 7 mm Hg), which continued even after the withdrawal of L-NAME administration (P < 0.01). In L-NAME-treated pregnant rats, morphological examination showed decreased populations of placental trophoblast lineages, and a significant increase in placental trophoblast apoptosis. Serum TNF-alpha levels at day 20 of pregnancy were significantly higher in treated pregnant rats (21.2 +/- 9.6 pg/ml) than in control pregnant rats (3.3 +/- 2.8 pg/ml) (P < 0.01). CONCLUSIONS: Inhibition of NOS at mid-gestation in pregnant rats is associated with increases in arterial pressure, placental apoptosis, and serum TNF-alpha, all of which have been implicated as being pathophysiological features of preeclampsia.

Developmental change in fetal response to repeated low-intensity sound.

The aim of this study was to investigate developmental changes in heart rate response to repeated low-intensity (85 dB) sound stimulation in fetuses between 32 and 37 weeks of gestation. We measured amplitude changes in heart rate as our index of fetal response. At 35 to 37 weeks of gestation, the majority of fetuses showed a deceleratory response at the first trial. Amplitude decreased with further trials using the same stimulus before recovering when exposed to another type of stimulation. In contrast, responses in fetuses at 32 to 34 weeks of gestation were variable across trials and there was no recovery with exposure to another type of stimulation. Our results suggest that fetal habituation of cardiac response changes with developmental age.

B-cell lymphoma during pregnancy associated with hemophagocytic syndrome and placental involvement.

We report a case of B-cell lymphoma during pregnancy associated with hemophagocytic syndrome and placental involvement. A 33-year-old Japanese woman developed pancytopenia, hepatosplenomegaly, and a high-grade fever for 2 weeks at 23 weeks of gestation. The demonstration of hemophagocytes in her bone marrow confirmed the diagnosis of hemophagocytic syndrome. She was referred at 25 weeks of gestation for evaluation of hemophagocytic syndrome. The screening for infection and autoimmune disease was negative. Clinical manifestation suggested malignant lymphoma as the underlying cause of hemophagocytic syndrome, but we could not confirm any lymphoma involvement in the bone marrow aspiration. Glucocorticoid therapy did not arrest the hemophagocytic process. Her general status worsened, and reduction of amniotic fluid was noted. At 28 weeks of gestation, we performed a Cesarean section because of fetal distress. Microscopic examination of placental specimen revealed diffuse infiltration of large, atypical lymphoid cells involving the intervillous space. Using immunohistochemical study, we made the diagnosis of B-cell lymphoma. R-CHOP (rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy was administered on the eighth postpartum day. After 2 cycles of R-CHOP chemotherapy, hematopoiesis became normal and hepatosplenomegaly almost completely disappeared. After 6 cycles of R-CHOP, the patient received autologous peripheral-blood stem cell transplantation, and she is currently in complete remission 1 year after diagnosis. The infant did well, without clinical or laboratory manifestations of malignant lymphoma. In cases with suspected malignancy associated with hemophagocytic syndrome during pregnancy, it is important to verify placental microscopic examination for evaluating the causative disease of hemophagocytic syndrome.

Fulminant type 1 diabetes during pregnancy: A case report and review of the literature.

Fulminant type 1 diabetes, classified as a subtype of nonautoimmune type 1 diabetes, may result in severe complications for both mother and fetus due to the sudden onset of diabetic ketoacidosis. Little is known about the clinical features of pregnancy with fulminant type 1 diabetes. We present a case of fulminant type 1 diabetes during pregnancy, along with a review of the published literature. A 31-year-old Japanese woman presented with sudden onset of nausea and vomiting at 36 weeks' gestation and was provisionally diagnosed with acute gastroenteritis. She was referred to us for investigation of exaggerated general fatigue and intrauterine fetal death. Based on blood and urinary examinations, she was diagnosed with diabetic ketoacidosis, caused by fulminant type 1 diabetes. Although her ketoacidosis was improved, insulin therapy was needed. Awareness of this disease can lead to prompt diagnosis and treatment and consequently, improved maternal and fetal prognosis.

Increased inflammatory markers are associated with early periventricular leukomalacia.

The aim of the study was to investigate whether inflammatory markers are associated with the occurrence of periventricular leukomalacia (PVL). Superoxide (O(2) (-)) production of neutrophils and plasma antioxidative superoxide dismutase (SOD) activity in umbilical cord blood were studied. Participants were preterm infants with early PVL (n=6; three males, three females; mean birthweight 1458g [SD 517], range 620-2040g; mean gestational age 29.8wks [SD 2.9], range 27-34wks); and preterm control infants without PVL (n=10; five males, five females; mean birthweight 1838g [SD 664], range 925-2748g; mean gestational age 30.6wks [SD 3.1], range 26-34wks). In addition, pro-inflammatory cytokine levels were measured in the umbilical cord blood. N-formyl-methionyl-leucyl-phenylalanine-induced O(2) (-) production by neutrophils in infants with early PVL was significantly higher than that in the control group. In contrast, there was no significant difference in concentrations of copper/zinc-SOD and SOD activity between groups. Concentrations of interleukin (IL)-1beta and tumour necrosis factor-alpha (but not IL-6, IL-8, or granulocyte-colony stimulating factor) were significantly higher in infants with early PVL than in control infants. The excess O(2) (-) produced by activated neutrophils with increased pro-inflammatory cytokine production could play a role in the molecular cascade leading to white matter damage in PVL.

The influence of thermal environment on pulmonary hemodynamic acclimation to extrauterine life in normal full-term neonates.

OBJECTIVE: To assess chronological changes of pulmonary blood flow in response to ambient temperature load in normal full-term neonates. METHODS: Group I (n=8) neonates were maintained at 25-26 degrees C for the first 24 h after birth, with Group II (n=7) at 32-33 degrees C. Left pulmonary artery flow volume (Vp) and ductus arteriosus diameter were measured at 2, 4, 6, 12, and 24 h using Doppler ultrasound. Core and peripheral temperatures, as a marker for cold stress, were also evaluated over the same time frame. RESULTS: For Group I, Vp was steady for the first 6 h after birth before gradually decreasing. In contrast, Vp for Group II significantly decreased from 2-6 h, without later changes. At 6 h after birth in Group II, mean values of both Vp and ductus arteriosus diameter were significantly lower, whereas mean value of peripheral temperature was significantly higher than values in Group I (P<0.05). CONCLUSION: Pulmonary blood flow in neonates placed at neutral ambient temperature stabilizes earlier than that of neonates placed at room temperatures. Changes of peripheral flow in response to ambient temperature load may be associated with decreased pulmonary blood flow through a left-to-right ductal shunt.

Japanese midwives as psychiatric diagnosticians: application of criteria of DSM-IV mood and anxiety disorders to case vignettes.

It is believed in Japan that only psychiatrists are capable of providing reliable psychiatric diagnosis. However, more awareness of mental health issues related to perinatal care means that midwives are now required to have psychiatric diagnostic skills. The purpose of the present paper was to examine how well Japanese midwives agreed with a psychiatrist on diagnoses of different psychiatric disorders. Vignettes of 29 cases including DSM-IV mood disorders (major depressive disorder and bipolar disorder) and anxiety disorders (generalized anxiety disorder, panic disorder, phobic disorders, and obsessive-compulsive disorder) were distributed to 12 Japanese midwives. They decided the DSM-IV diagnoses independently and compared them with those made by an expert. The kappa coefficients of the diagnoses with a base rate of 0.1 or more were moderate to almost perfect (0.64-0.83). The accuracy of symptom assessment was also satisfactory. Appropriately trained Japanese midwives can use the diagnostic criteria for psychiatric disorders reliably. It is therefore feasible to dispatch midwives who are trained in psychiatric diagnosis to antenatal clinics.

Changes in aortic distension waveforms in acute hypoxemia and acidosis: fetal lamb study.

The objective was to investigate the relationship between fetal aortic distension waveforms and fetal hypoxemia and/or acidosis. Aortic distension waveforms were recorded using an echo-tracking system in nine late-gestation catheterized fetal lambs. Under hypoxic conditions induced by inhalation of gas mixture, fetal blood pressure and aortic distension waveforms were recorded. Four parameters, namely peak systolic and end diastolic diameter, amplitude (DeltaD) and ratio of DeltaD to end diastolic diameter (%DeltaD), were obtained, and correlations between these parameters and partial arterial oxygen tension (PaO(2)) and pH of fetal blood gas were analyzed. These four parameters were compared between the control, hypoxemic and asphyxic groups. The DeltaD and %DeltaD were significantly correlated with PaO(2) and pH using linear regression analysis. Both the DeltaD and %DeltaD decreased significantly, in a stepwise fashion, in the hypoxemic and asphyxiated groups compared with controls using repeated measured analysis of variance. It was concluded that fetal aortic distension waveforms proved to be a useful tool to detect the deterioration in the fetal circulation secondary to intrauterine hypoxemia/asphyxia.

Difference in neutrophil superoxide generation during pregnancy between preeclampsia and essential hypertension.

This study investigated whether production of reactive oxygen species by neutrophils differs between women with preeclampsia and those with essential hypertension. First, we assessed superoxide production by neutrophils during pregnancy and 4 weeks after delivery in 15 healthy pregnant women, 12 women with preeclampsia, and 7 pregnant women with essential hypertension. We then examined effects of serum from each subject on superoxide production by neutrophils obtained from healthy nonpregnant women. Neutrophil superoxide production was measured by cytochrome C reduction. N-formyl-methionyl-leucyl-phenylalanine-stimulated superoxide production was significantly increased in neutrophils from women with preeclampsia and women with essential hypertension compared with normal pregnant women. Four weeks postpartum, the level of superoxide production was significantly decreased in women with preeclampsia but not in women with either normal pregnancy or essential hypertension. When neutrophils obtained from nonpregnant women were preincubated with predelivery sera from each group, sera from women with preeclampsia significantly enhanced superoxide production compared with sera from the other 2 groups. When postpartum serum was used, enhancement of neutrophil superoxide production by serum from women with preeclampsia was significantly decreased compared with that by predelivery serum. In conclusion, increased neutrophil superoxide production resolved after delivery in preeclampsia, whereas activation persisted postpartum in women with essential hypertension. The different transition of neutrophil superoxide production in response to pregnancy appears to be that preeclampsia is characterized by the presence of serum factors that enhance neutrophil superoxide production. Thus, in preeclampsia, serum factors bear a more essential role producing superoxide than a behavior of neutrophils.

Clinical significance of RCAS1 as a biomarker of ovarian cancer.

Expression of RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) is associated with advanced disease of various malignancies including ovarian cancer. Proteolytic cleavage of RCAS1 at extracellular domains (ectodomain shedding) yields soluble RCAS1. Although RCAS1 can induce apoptosis in normal peripheral lymphocytes, its clinical significance and biologic function in ovarian cancer patients are unclear. Here, we evaluated serum RCAS1 concentrations to clarify its clinical significance and biologic activity in ovarian cancer. Via ELISA, we measured serum RCAS1 concentrations in samples from 75 healthy blood donors and 97 patients, 36 with ovarian benign tumor and 61 with ovarian cancer. We correlated via statistical means the RCAS1 values with patients' clinicopathologic variables. We assessed inhibition of growth of K562 cells, which express the putative RCAS1 receptor, via WST-1 assay of serum samples to clarify RCAS1's biologic activity. Ovarian cancer patients had significantly higher serum RCAS1 concentrations than did healthy blood donors and ovarian tumor patients (P<0.05). RCAS1 level was significantly different according to histologic subtype for both ovarian tumor and cancer patients (P=0.0266 and 0.0074, respectively). RCAS1 values were also significantly associated with response to treatment (P<0.001). The WST-1 assay showed that patients' serum induced K562 cell growth inhibition, but this effect partially recovered after immunodepletion of RCAS1 (P=0.0074). RCAS1 may be a biomarker of ovarian cancer by virtue of its ability to predict results of treatment and inhibit immune cell growth.

Kinetic analysis of the transport of salicylic acid, a nonsteroidal anti-inflammatory drug, across human placenta.

The aim of this study was to develop a pharmacokinetic model to describe the transplacental transfer of drugs, based on the human placental perfusion study. The maternal and fetal sides of human placentas were perfused with salicylic acid together with antipyrine, a passive diffusion marker. The drug concentration in the placental tissue was determined at the end of perfusion. A compartment model consisting of maternal space, fetal intravascular space, and placental tissue was fitted to the observed concentration profiles of salicylic acid in the maternal and fetal effluents. The developed model could adequately explain the concentration profiles of salicylic acid in the effluents with influx clearances from maternal and fetal perfusates to placental tissue of 0.0407 and 0.0813 ml/min/g cotyledon and efflux rate constants from placental tissue to maternal and fetal perfusates (k2 and k3) of 0.0238 and 0.176 min(-1), respectively. The kinetics of antipyrine was adequately described by assuming rapid equilibrium between fetal perfusate and placental tissue compartments. The influx plasma clearance from the maternal side (K''1) in humans was estimated by taking into account the protein binding. The K''1/k2 value of salicylic acid was 1.07 ml/g cotyledon and was larger than that of antipyrine (0.642 ml/g cotyledon). We evaluated the transplacental transfer kinetics of salicylic acid by human placental perfusion study with various perfusion protocols. Based on the data obtained, we developed a pharmacokinetic model, which should enable us to estimate the influx profile of drugs into umbilical arterial blood from the maternal plasma concentration profile.

Simplified ultrasound screening for fetal brain function based on behavioral pattern.

Despite the longstanding conclusion that behavior can reveal aspects of underlying anatomy and function, no generalized antenatal behavior screening has been developed to identify fetuses that may have central nervous system defects requiring further evaluation. We devised a brief ultrasound examination to distinguish fetuses with compromised central nervous system function from the general population and evaluated it with this study. The study design compared behavioral findings obtained by retrospectively reviewing the ultrasound examinations of 5 fetuses that had abnormal behavior with prospectively obtained findings of 29 normal fetuses. Median time for brief examination criteria was 50 min (range, 30-60 min). The only case undetectable by this brief ultrasound examination has an eye-movement period significantly longer than the normal upper limit. Using this method as a screening test may make it possible to include assessment of fetal brain function as part of routine antenatal care.

Long-term outcome of infants with twin-to-twin transfusion syndrome.

OBJECTIVE: To clarify the long-term neurodevelopmental outcome of twin-to-twin transfusion syndrome (TTTS) survivors. METHODS: From January 1994 to December 2003, 33 newborns with TTTS who were derived from 18 monochorionic twin gestations were enrolled for the study. The development and growth at 3 or 6 years of age were compared between TTTS survivors and weight-matched singleton controls. RESULTS: The mortality in TTTS (8/33: 24%) was significantly higher than that of the controls (7/80: 9%). Of all 12 TTTS patients who were diagnosed before 25 weeks and born before 28 weeks of gestation, in 10 (83%) it led to neonatal or intrauterine death. The morbidity of cerebral palsy, epilepsy, and mental retardation did not differ between TTTS and control patients. The morbidity and severity of neurological deficits at school age were similar in both groups. No growth parameters at 3 or 6 years of age differed between TTTS and controls. CONCLUSIONS: Morbidity, growth and development of TTTS survivors attained comparable levels of weight-matched controls, despite the higher neonatal mortality. These results suggest that the early management of TTTS is critical for refining the total outcome of the affected twins.

Noninvasive measurement of isovolumetric contraction time by Doppler cardiography can be substituted for fetal cardiac contractility: evaluation of a fetal lamb study.

OBJECTIVE: The objective of this study is to clarify whether the isovolumetric contraction time obtained from Doppler cardiography (Doppler ICT) can be an index substituted for fetal cardiac contractility. MATERIALS AND METHODS: In 10 pregnant ewes, fetal hypoxemia was induced by giving a variable mixture of gases. Through experiment, the Doppler ICT, pre-ejection period (PEP), and the maximum first derivative of the left ventricular pressure waveform (Max dp/dt) were simultaneously recorded every 10min. The relationship between both the Doppler ICT and PEP, and the Max dp/dt were analyzed. RESULTS: A significant negative linear regression was founded between the Doppler ICT and the Max dp/dt. A significant negative linear regression was also shown between PEP and the Max dp/dt. Moreover, the regression of Max dp/dt on ICT had significantly less residual variance than the regression of Max dp/dt on PEP (p=0.0004). CONCLUSION: In contrast to PEP, Doppler ICT is a reliable, and non-invasive index which can be substituted for fetal cardiac contractility.