Teratogenic Mechanisms Research Articles

Drugs associated with teratogenic mechanisms. Part I: dispensing rates among pregnant women in the Netherlands, 1998–2009

What are the dispensing rates of drugs suspected to be associated with teratogenic mechanisms among pregnant Dutch women? In a substantial proportion of pregnancies in our study population at least one drug associated with a teratogenic mechanism was dispensed in the first trimester of pregnancy. The main teratogenic mechanisms of medical drugs that may affect fetal development in the first trimester of pregnancy have been described previously. However, information on the dispensing rate of such drugs among women at all stages of pregnancy is lacking. To determine how often medications suspected to be associated with a teratogenic mechanism are used by pregnant women, we studied 32 016 pregnancies included in the IADB.nl database between 1998 and 2009. We estimated dispensing rates of medical drugs suspected to be associated with teratogenic mechanisms in our study population. The IADB.nl database includes all pharmacy dispensings for an estimated population of 220 000 in 1994-1998 and c.500 000 since 1999. In addition, trends in first trimester dispensing rates over time and patterns of receiving multiple drugs associated with teratogenic mechanisms were evaluated. In addition, we determined the number of pregnancies in which multiple prescription drugs from one or more teratogenic categories were dispensed in the first trimester, and we evaluated the numbers of different medications dispensed that could be grouped within a specific teratogenic mechanism. In 175 per 1000 pregnancies [95% confidence interval (CI), 171-179] at least one drug associated with a teratogenic mechanism was dispensed in the first trimester. The total dispensing rate was 236 per 1000 pregnancies (95% CI 232-241) in the 3 months before pregnancy and an increasing trend was seen in the second [214 per 1000 (95% CI 209-218)] and third [327 per 1000 (95% CI 322-332)] trimesters. The first trimester dispensing rates increased between 1998 and 2009 for selective serotonin-reuptake inhibitors (P < 0.001) and serotonin receptor agonists/antagonists (P < 0.001). In 71.8% of pregnancies in which drugs associated with teratogenic mechanisms were dispensed in the first trimester, women received drugs related to only one mechanism. Of the pregnancies in which drugs from multiple teratogenic categories were dispensed in the first trimester, 1148 (72.6%) women received drugs from 2 categories, 317 (20.0%) from three categories, 88 (5.6%) from 4 categories, 28 (1.8%) from 5 categories and 1 from 6 categories. Several women received multiple prescription medications grouped within a single teratogenic mechanism in the first trimester, ranging between 13.3% for cyclo-oxygenase inhibitors and 41.8% for serotonin receptor agonists/antagonists. We used a dispensing database, therefore actual use of the medication prescribed is unknown and non-compliance could have led to overestimation of exposure prevalences. Owing to the uncertainties concerning the safety of medication use during pregnancy, the results of this study stress the need for cautious prescription of medication associated with teratogenic mechanisms to women of reproductive age. This is further supported by our finding that women received multiple prescription medications grouped within a single teratogenic mechanism in the first trimester, which would theoretically increase strongly the risk of birth defects. Marleen van Gelder was supported by the Netherlands Organisation for Scientific Research/NWO (grant no. 021.001.008). No competing interests are declared. N/A.

Polymorphisms in the endothelial nitric oxide synthase gene in thalidomide embryopathy

Thalidomide is one of the most potent teratogens known to humans. It is currently used for many clinical situations such as treatment of leprosy reactions and multiple myeloma. However, the teratogenic mechanisms by which it produces morphological defects still remain unclear. One of the hypotheses is the blockage of angiogenesis by reduction of nitric oxide (NO). In this study, we evaluated two functional polymorphisms of the endothelial nitric oxide synthase (eNOS) gene which is a constitutively expressed enzyme responsible for production of NO. The promoter −786T>C exon 7 (896G>T) polymorphisms were genotyped using real-time PCR for 28 individuals with thalidomide embryopathy (TE), 27 first-degree relatives of these individuals, and 68 individuals from the general population. Their allele, genotypic, and haplotypic frequencies were compared. A significant difference was observed in the −786T>C polymorphism genotypes (p=0.03) between the groups affected by TE and those unaffected (non-relatives). The TT genotype of the 896G>T polymorphism was observed in 10.7% of those affected and 2.9% of those unaffected, but the difference was not statistically significant (p=0.09). The haplotypic analysis indicated that the wild haplotype −786T/896G was distributed differently in the affected and unaffected groups (p=0.004). These results indicate that the individuals with TE have a higher frequency of alleles associated with lower expression of eNOS, indicating that this may be a genotype susceptible to TE.

Nuanced but significant: How ethanol perturbs avian cranial neural crest cell actin cytoskeleton, migration and proliferation

Children with fetal alcohol syndrome (FAS) display striking craniofacial abnormalities. These features are proposed to result from perturbations in the morphology and function of cranial neural crest cells (cNCCs), which contribute significantly to the craniofacial complex. While certain pathways by which this may occur have been suggested, precise teratogenic mechanisms remain intensely investigated, as does the question of the teratogenic dose. The present study focused on examining how avian cNCC actin cytoskeleton, migratory distance, and proliferation are affected ex vivo by exposure to ethanol concentrations that simulate maternal intoxication. Chick cNCCs were cultured in 0.2% and 0.4% v/v ethanol. Distances migrated by both ethanol-treated and control cells at 24 and 48 h were recorded. Following phalloidin immunocytochemistry, treated and control cNCCs were compared morphologically and quantitatively. Apoptosis and proliferation in control versus treated cNCCs were also studied. Chick cNCCs cultured in ethanol lost their spindle-like shapes and their ordered cytoskeleton. There was a significant stage-dependent effect on cNCC migration at 24 h (p = 0.035), which was greatest at stage 10 (HH). Ethanol treatment for 48 h revealed a significant main effect for ethanol, chiefly at the 0.4% level. There was also an interaction effect between ethanol dose and stage of development (stage 9 HH). Actin microfilament disruption was quantitatively increased by ethanol at the doses studied while cNCC proliferation was increased but not significantly. Ethanol had no effect on cNCC apoptosis. At ethanol levels likely to induce human FAS, avian cNCCs exhibit various subtle, potentially significant changes in morphology, migration, and proliferation, with possible consequences for fated structures.

Fetal valproate syndrome in a 14-month-old child: A case report

Anti-epileptic drugs administered during pregnancy can cause structural defects in the growing fetus and result in adverse neurodevelopmental outcome later in life. Fetal valproate syndrome (FVS) results from teratogenic effects of valproic acid exposure in the prenatal period. It is characterised by a distinctive dysmorphic facies and a cluster of minor and major anomalies, as well as developmental and behavioural abnormalities. We describe a 14-month-old boy with the typical dysmorphic facies and other congenital abnormalities characteristic of FVS. There was a history of maternal intake of sodium valproate during pregnancy. The mechanism of teratogenicity and methods for prevention are discussed.

A scientific review: mechanisms of valproate-mediated teratogenesis

Living with epilepsy, for the majority of patients, is a continuous cycle of careful monitoring and attention to health. When coupled with pregnancy, safety becomes the primary focus. Epileptic women with reproductive intentions are confronted with a dilemma to either continue or discontinue current medication. Remaining on medication incurs the possibility of foetal abnormalities. However, discontinuation of medication could result in an uncontrolled condition that is potentially life threatening for both mother and child. Valproic acid (VPA) is a monocarboxylic acid with unclear mechanism of action and this is widely prescribed for epilepsy, bipolar disorder, migraine, Alzheimer's disease and recently, cancer and HIV polytherapies. Originally, low incidences of toxicity were reported; however, emerging teratogenic properties warranted further investigation. This paper examines the major contraindications that VPA facilitates during pregnancy and proposes the degree of teratogenic influence each may inflict upon the developing foetus. The relevant aspects addressed are drug accumulation within the foetus, oxidative stress, folate antagonism and histone deacetylase (HDAC) inhibition. Review of the literature has shown vast numbers of investigations proving and disproving various proposed mechanisms of VPA-induced teratogenicity; these are still largely undefined. Based on the evidence presented, HDAC inhibition provided the strongest association with teratogenicity, followed closely by the formation of reactive oxygen species. Both were particularly influential in the first trimester of pregnancy when DNA dysregulation has the largest impact on foetal organ development. In comparison, drug accumulation posed a lower risk as VPA is not the primary substrate for the majority of drug transporters across the placenta and lastly, folate inhibition was considered the lowest risk as new evidence has highlighted that the natural progression of gestation increases folate deficiency irrespective of VPA. All the suggested mechanisms (and possibly many more) may be contributing factors, together with inter-patient variability, environmental and lifestyle factors, each of which is also undefined, and lead to an increased risk of the teratogenic effects of VPA.

Wiring the developing heart: a serious matter for adulthood

This editorial refers to ‘Exploration of human, rat and rabbit embryonic cardiomyocytes suggests K-channel block as a common teratogenic mechanism’ by C. Danielsson et al ., pp. 23–32, this issue. The normal functioning of the heart resides in its coordinated and effective pumping capacity. Contraction of the heart is provided by the ordered and intricate design of the contractile apparatus, the sarcomere, while the coordination of contraction is accomplished by the cardiac conduction system.1 At the cellular level, the electrical properties of the contracting cardiomyocytes are governed by a complex array of inward and outward ion currents that configure the cardiac action potential. If we take as a paradigm the human cardiomyocyte, upstroke sodium current ( I Na) is responsible for depolarization of the cardiomyocyte plasma membrane,2 whereas a variety of outward potassium currents ( I Kur, I Kr, I Ks, I K1, I TO) provide the means to repolarize the cell membrane as well as to keep constant the resting membrane potential.3,4 Electrical coupling—that is to say from conduction to contraction—is provided mainly by calcium currents ( I Ca).5 It is important to acknowledge the nature of the regulation of the cardiac action potential, since limited variability is observed within the sodium currents in atrial and ventricular cardiomyocytes, a situation that similarly applies to the electrical coupling governed by calcium currents. However, a large variability is observed for the repolarization and resting membrane potential.6,7 For example, distinct resting membrane potential and cardiac action potential morphologies are observed for atrial and ventricular myocytes, and even within ventricular …

Exploration of human, rat, and rabbit embryonic cardiomyocytes suggests K-channel block as a common teratogenic mechanism

Several drugs blocking the rapidly activating potassium (K(r)) channel cause malformations (including cardiac defects) and embryonic death in animal teratology studies. In humans, these drugs have an established risk for acquired long-QT syndrome and arrhythmia. Recently, associations between cardiac defects and spontaneous abortions have been reported for drugs widely used in pregnancy (e.g. antidepressants), with long-QT syndrome risk. To investigate whether a common embryonic adverse-effect mechanism exists in the human, rat, and rabbit embryos, we made a comparative study of embryonic cardiomyocytes from all three species. Patch-clamp and quantitative-mRNA measurements of K(r) and slowly activating K (K(s)) channels were performed on human, rat, and rabbit primary cardiomyocytes and cardiac samples from different embryo-foetal stages. The K(r) channel was present when the heart started to beat in all species, but was, in contrast to human and rabbit, lost in rats in late organogenesis. The specific K(r)-channel blocker E-4031 prolonged the action potential in a species- and development-dependent fashion, consistent with the observed K(r)-channel expression pattern and reported sensitive periods of developmental toxicity. E-4031 also increased the QT interval and induced 2:1 atrio-ventricular block in multi-electrode array electrographic recordings of rat embryos. The K(s) channel was expressed in human and rat throughout the embryo-foetal period but not in rabbit. This first comparison of mRNA expression, potassium currents, and action-potential characteristics, with and without a specific K(r)-channel blocker in human, rat, and rabbit embryos provides evidence of K(r)-channel inhibition as a common mechanism for embryonic malformations and death.

A paradoxical teratogenic mechanism for retinoic acid

Retinoic acid, an active metabolite of vitamin A, plays essential signaling roles in mammalian embryogenesis. Nevertheless, it has long been recognized that overexposure to vitamin A or retinoic acid causes widespread teratogenesis in rodents as well as humans. Although it has a short half-life, exposure to high levels of retinoic acid can disrupt development of yet-to-be formed organs, including the metanephros, the embryonic organ which normally differentiates into the mature kidney. Paradoxically, it is known that either an excess or a deficiency of retinoic acid results in similar malformations in some organs, including the mammalian kidney. Accordingly, we hypothesized that excess retinoic acid is teratogenic by inducing a longer lasting, local retinoic acid deficiency. This idea was tested in an established in vivo mouse model in which exposure to excess retinoic acid well before metanephric rudiments exist leads to failure of kidney formation several days later. Results showed that teratogen exposure was followed by decreased levels of Raldh transcripts encoding retinoic acid-synthesizing enzymes and increased levels of Cyp26a1 and Cyp26b1 mRNAs encoding enzymes that catabolize retinoic acid. Concomitantly, there was significant reduction in retinoic acid levels in whole embryos and kidney rudiments. Restoration of retinoic acid levels by maternal supplementation with low doses of retinoic acid following the teratogenic insult rescued metanephric kidney development and abrogated several extrarenal developmental defects. This previously undescribed and unsuspected mechanism provides insight into the molecular pathway of retinoic acid-induced teratogenesis.

Drug induced embryonic cardiac arrhythmia: A teratogenic mechanism of human relevance

Drug induced embryonic cardiac arrhythmia: A teratogenic mechanism of human relevance

Oxidation of retinoic acids in hepatic microsomes of wild bullfrogs Lithobates catesbeianus environmentally-exposed to a gradient of agricultural contamination

Agricultural contaminants are suspected of contributing to the increased incidence of deformities and the decline of amphibians populations worldwide. Many authors have further suggested that a retinoid effect could be implicated in teratogenic mechanisms since the reported deformities resemble those caused by abnormal levels of retinoic acid (RA). We previously reported altered retinoid concentrations in male bullfrogs from the Yamaska River basin (Québec, Canada) associated with moderate-to-high agricultural activity, and the findings were consistent with a possible effect on hepatic RA oxidation. An in vitro assay was therefore optimized and hepatic microsomal RA oxidation in bullfrogs was found to be quite different from that of other vertebrates. With either all-transRA (atRA) or 13cisRA as the substrate, the major metabolite generated was at4-oxo-RA. The reaction with 13cisRA as substrate, markedly greater compared with atRA, was enhanced in the presence of a reducing agent and inhibited by cytochrome P450 inhibitors in a dose-dependent manner. Hepatic RA oxidation in male bullfrogs showed significant differences between sites with no clear relationship to a gradient of agricultural activity or 13cis-4-oxo-RA quantified in plasma. In contrast, the in vitro RA oxidation in females increased with the levels of contamination and coincided in vivo with higher plasma 13cis-4-oxo-RA concentration. The levels of circulating 4-oxo-derivatives could be influenced by hepatic RA oxidative metabolism as well as isomerization conditions or RA precursor levels.

Retinoic Acid Signaling Regulates Sonic Hedgehog and Bone Morphogenetic Protein Signalings During Genital Tubercle Development

Retinoic acid (RA) plays pivotal roles in organogenesis, and both excessive and reduced amounts of RA cause developmental abnormalities. Reproductive organs are susceptible to teratogen toxigenicity, and the genital tubercle (GT) is one such representative organ. The physiological function of endogenous RA signaling and the mechanisms of RA-induced teratogenicity are poorly understood during the GT development. The objective of this study is to understand the developmental and teratogenic roles of RA during GT development by analyzing genetically modified mouse models. We found dynamic patterns of gene expression for the RA-synthesizing enzyme, Raldh2, and for the RA-catabolizing enzyme, Cyp26b1, during GT development. Rarb, an indicator gene for RA signaling, starts its expression in the prospective corpus cavernosum penis and in the urethral plate epithelium (UE), which plays central roles during GT development. Excessive RA signaling in Cyp26b1(-/-) mutants leads to abnormal extents of cell proliferation and differentiation during GT development, and also upregulates expression of growth factor signalings. They include Sonic hedgehog (Shh) signaling and Bone morphogenetic protein (Bmp) signaling, which are expressed in the UE and its bilateral mesenchyme. RA signaling positively regulatesShh and Bmp4 expression during GT development as testified also by the experiment of RA administration and analyses of loss-of-function of RA signaling mutants. Thus, RA signaling is involved in the developmental cascade necessary for UE formation and GT development.

Development of a Neural Teratogenicity Test Based on Human Embryonic Stem Cells: Response to Retinoic Acid Exposure

The aim of this study was the development of an alternative testing method based on human embryonic stem cells for prenatal developmental toxicity with particular emphasis on early neural development. To this purpose, we designed an in vitro protocol based on the generation of neural rosettes, representing the in vitro counterpart of the developing neural plate and neural tube, and we challenged this complex cell model with retinoic acid (RA), a well-known teratogenic agent. The cells were exposed to different concentrations of RA during the process of rosettes formation. Morphological and molecular parameters were evaluated in treated as compared with untreated cells to detect both cytotoxicity and specific neural toxicity. Transcriptomic analysis was performed with microarray Affymetrix platform and validated by quantitative real-time PCR for genes relevant to early neural development such as HoxA1, HoxA3, HoxB1, HoxB4, FoxA2, FoxC1, Otx2, and Pax7. The results obtained demonstrated that neural rosette forming cells respond to RA with clear concentration-dependent morphological, and gene expression changes remarkably similar to those induced in vivo, in the developing neural tube, by RA exposure. This strict correspondence indicates that the neural rosette protocol described is capable of detecting specific teratogenic mechanisms causing perturbations of early neural development and therefore represents a promising alternative test for human prenatal developmental toxicity.

Teratogenic effects of triphenyltin on embryos of amphibian ( Xenopus tropicalis): A phenotypic comparison with the retinoid X and retinoic acid receptor ligands

Triphenyltin (TPT) has high binding affinity with the retinoid X receptor (RXR) in animals. The natural ligand of RXR, 9-cis-retinoic acid (RA), is known to induce featured malformations in vertebrate embryos by disrupting RA signal. Limited information is available on the TPT effects on amphibians. We exposed embryos of amphibian ( Xenopus tropicalis) to TPT, 9-cis-RA, all- trans-RA (ligand of retinoic acid receptor, RAR), and LGD1069 (a selective ligand of RXR). The 72 h LC50 of TPT was 5.25 μg Sn/L, and 72 h EC50 was 0.96 μg Sn/L. TPT induced multiple malformations including enlarged proctodaeum and narrow fins. TPT at 5 μg Sn/L inhibited the differentiation of skins and muscles. The reduced brain, loss of external eyes and bent axis were observed in RXR and RAR ligands treatments. TPT and tributyltin (TBT) inhibited the mRNA expression of RXRα and increased that of TRβ. The phenotypes of malformations induced by TPT were similar to those by TBT and were much different from those by the RXR and RAR ligands. These results indicated that TPT was acute toxic and had high teratogenicity to amphibian embryos, and that TPT induced phenotypes of malformations. TPT and TBT might have a similar teratogenic mechanism, which seems not to be mainly mediated through RA signal.

Exposure to Non-Steroidal Anti-Inflammatory Drugs during Pregnancy and the Risk of Selected Birth Defects: A Prospective Cohort Study

BackgroundSince use of non-steroidal anti-inflammatory drugs (NSAIDs) during pregnancy is common, small increases in the risk of birth defects may have significant implications for public health. Results of human studies on the teratogenic risks of NSAIDs are inconsistent. Therefore, we evaluated the risk of selected birth defects after prenatal exposure to prescribed and over-the-counter NSAIDs.Methods and FindingsWe used data on 69,929 women enrolled in the Norwegian Mother and Child Cohort Study between 1999 and 2006. Data on NSAID exposure were available from a self-administered questionnaire completed around gestational week 17. Information on pregnancy outcome was obtained from the Medical Birth Registry of Norway. Only birth defects suspected to be associated with NSAID exposure based upon proposed teratogenic mechanisms and previous studies were included in the multivariable logistic regression analyses. A total of 3,023 women used NSAIDs in gestational weeks 0–12 and 64,074 women did not report NSAID use in early pregnancy. No associations were observed between overall exposure to NSAIDs during pregnancy and the selected birth defects separately or as a group (adjusted odds ratio 0.7, 95% confidence interval 0.4–1.1). Associations between maternal use of specific types of NSAIDs and the selected birth defects were not found either, although an increased risk was seen for septal defects and exposure to multiple NSAIDs based on small numbers (2 exposed cases; crude odds ratio 3.9, 95% confidence interval 0.9–15.7).ConclusionsExposure to NSAIDs during the first 12 weeks of gestation does not seem to be associated with an increased risk of the selected birth defects. However, due to the small numbers of NSAID-exposed infants for the individual birth defect categories, increases in the risks of specific birth defects could not be excluded.

Understanding specific effects of prenatal alcohol exposure on brain structure in young adults

Prenatal alcohol exposure (PAE) is associated with various adverse effects on human brain and behavior. Recently, neuroimaging studies have begun to identify PAE effects on specific brain structures. Investigation of such specific PAE effects is important for understanding the teratogenic mechanism of PAE on human brain, which is critical for differentiating PAE from other disorders. In this structural MRI study with young adults, PAE effects on the volumes of automatically segmented cortical and subcortical regions of interest (ROIs) were evaluated both through a group difference approach and a parametric approach. In the group difference approach (comparing among two PAE and a control groups), a disproportionate PAE effect was found in several occipital and temporal regions. This result is inconsistent with previous studies with child samples. Moreover, a gender difference in PAE effect was shown in some cortical ROIs. These findings suggest that sampling and gender may be important factors for interpreting specific PAE effects on human brain. With the parametric approach, it was demonstrated that the higher the PAE level, the smaller the entire brain, the lower the IQ. Several cortical and subcortical ROIs also exhibited a negative correlation between the PAE level and ROI volume. Furthermore, our data showed that the PAE effect on the brain could not be interpreted by the PAE effect on general physical growth until the young adult age. This study provides valuable insight into specific effects of PAE on human brain and suggests important implications for future studies in this field.

Pharmacogenetics of Drug-induced Birth Defects: What is known so Far?

A literature review was performed to collect information on the role of pharmacogenetics in six proposed teratogenic mechanisms associated with drug use during pregnancy: folate antagonism, oxidative stress, angiotensin-converting enzyme inhibition and angiotensin II receptor antagonism, cyclooxygenase-1 and -2 inhibition, 5-hydroxytryptamine-reuptake inhibition and drug transporters in the placenta. Data on the direct relationship between pharmacogenetics and drug-induced birth defects were found for folate metabolism, oxidative stress caused by phenytoin exposure and drug transporters in the placenta. Although no specific data to support pharmacogenetic-related birth defects were found for the NSAIDs, paroxetine and fluoxetine, it might be expected that polymorphisms modify their teratogenic effects. The usually low prevalence of drug-induced malformations impedes the demonstration of the contribution of pharmacogenetics. Large-scale studies, preferably case-control studies, are needed.

サリドマイドの催奇性メカニズム

およそ半世紀前に鎮静剤として開発されたサリドマイドは，1960年代始めに催奇性が発覚し，一度，市場からの撤退を余儀なくされた．しかし，ハンセン病や血液癌の一種である多発性骨髄腫といった難病に対して著しい効果を有することから再び脚光を浴び，現在は厳しい統制を受けながらも，その処方が認可されている．このようにサリドマイドは，半世紀以上の歴史を有するきわめてよく知られた薬剤であるが，その催奇性メカニズムは長い間不明であった．最近になり，磁性ナノ微粒子(半田ビーズ)を用いたアフィニティ精製により，サリドマイド催奇性における主要な標的因子であるセレブロン(cereblon，CRBN)が単離・同定され，その分子機構が解明された．

Toxicological Pathology in the Rat Placenta

The placenta grows rapidly for a short period with high blood flow during pregnancy and has multifaceted functions, such as its barrier function, nutritional transport, drug metabolizing activity and endocrine action. Consequently, the placenta is a highly susceptible target organ for drug- or chemical-induced adverse effects, and many placenta-toxic agents have been reported. However, histopathological examination of the placenta is not generally performed, and the placental toxicity index is only the placental weight change in rat reproductive toxicity studies. The placental cells originate from the trophectoderm of the embryo and the endometrium of the dam, proliferate and differentiate into a variety of tissues with interaction each other according to the development sequence, resulting in formation of a placenta. Therefore, drug- or chemical-induced placental lesions show various histopathological features depending on the toxicants and the exposure period, and the pathogenesis of placental toxicity is complicated. Placental weight assessment appears not to be enough to evaluate placental toxicity, and reproductive toxicity studies should pay more attention to histopathological evaluation of placental tissue. The detailed histopathological approaches to investigation of the pathogenesis of placental toxicity are considered to provide an important tool for understanding the mechanism of teratogenicity and developmental toxicity with embryo lethality, and could benefit reproductive toxicity studies.

Retinoid signaling in inner ear development: A “Goldilocks” phenomenon

Retinoic acid (RA) is a biologically active derivative of vitamin A that is indispensable for inner ear development. The normal function of RA is achieved only at optimal homeostatic concentrations, with an excess or deficiency in RA leading to inner ear dysmorphogenesis. We present an overview of the role of RA in the developing mammalian inner ear, discussing both how and when RA may act to critically control a program of inner ear development. Molecular mechanisms of otic teratogenicity involving two members of the fibroblast growth factor family, FGF3 and FGF10, and their downstream targets, Dlx5 and Dlx6, are examined under conditions of both RA excess and deficiency. We term the effect of too little or too much RA on FGF/Dlx signaling a Goldilocks phenomenon. We demonstrate that in each case (RA excess, RA deficiency), RA can directly affect FGF3/FGF10 signaling within the otic epithelium, leading to downregulated expression of these essential signaling molecules, which in turn, leads to diminution in Dlx5/Dlx6 expression. Non-cell autonomous affects of the otic epithelium subsequently occur, altering transforming growth factor-beta (TGFβ) expression in the neighboring periotic mesenchyme and serving as a putative explanation for RA-mediated otic capsule defects. We conclude that RA coordinates inner ear morphogenesis by controlling an FGF/Dlx signaling cascade, whose perturbation by deviations in local retinoid concentrations can lead to inner ear dysmorphogenesis.

Malformations in infants of diabetic mothers

Maternal insulin-dependent diabetes has long been associated with congenital malformations. As other causes of mortality and morbidity have been eliminated or reduced, malformations have become increasingly prominent. Although there is not universal agreement, the great majority of investigators find a two- to threefold increase in malformations in infants of insulin-dependent diabetic mothers. This increase is not seen in infants of gestational diabetics. It probably is not present in women whose diabetes can be controlled by diet or oral hypoglycemic agents. The risk does not appear to be primarily genetic since diabetic fathers do not have an increased number of malformed offspring. Most studies show a generalized increase in malformations involving multiple organ systems. Multiple malformations seem to be more common in diabetic than non-diabetic infants. Caudal regression has the strongest association with diabetes, occurring roughly 200 times more frequently in infants of diabetic mothers than in other infants. The teratogenic mechanism in diabetes is not known. Hyperglycemia may be important but human studies focusing on the period of organogenesis are lacking. Hypoglycemia has also been suggested based mainly on animal experiments. Insulin appears unlikely. Numerous other factors including vascular disease, hypoxia, ketone and amino acid abnormalities, glycosylation of proteins, or hormone imbalances could be teratogenic. None has been studied in sufficient detail to make a judgment. A large-scale prospective study is required to determine early fetal loss rates, correlate metabolic status during organogenesis with outcome, and assess the effect of diabetic control on malformation rates.