Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque (Macaca fascicularis): III. Developmental and hematologic studies

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Evaluation of the thermal effects of prenatal ultrasound on hematological analysis of young Oryctolagus Cuniculus

Elevated temperatures can induce changes in red blood cell (RBC), white blood cell (WBC) and platelet (PLT) counts. Ultrasound heating during obstetric scans has the potential to increase body temperature owing to the phenomenon of absorption. We conducted a study to determine the thermal effects of prenatal ultrasound on RBCs, hemoglobin concentration (Hb), WBCs and PLTs in young rabbits. We selected 69 rabbits that were 1 month of age and 73 that were 5 months of age, and allocated them to four groups. The control group consisted of four pregnant does that were allowed to have a full term delivery without any ultrasound exposure. The experimental groups were subjected to one-time ultrasound exposure for 30, 60 and 90 min in the middle of each gestational stage accordingly. RBCs and Hb showed significant reductions in the experimental groups of 1- and 5-month-old rabbits (P<0.05). In addition, WBCs and PLTs yielded significant differences in the 1-month group that were not observed in the 5-month group (P>0.05). The highest values recorded were those of the WBCs of 1-month-old subjects that received 90 min of exposure at the second stage of gestation. The PLTs were the lowest values recorded in 1-month-old subjects following 90 min of ultrasound exposure at the third stage of gestation. These findings suggest that hematological fluctuations during the early stages of postnatal life persisted until 1 month of age and recovered thereafter, as the subjects progressed into adulthood. Therefore, ultrasound heating can cause significant, yet reversible effects on the hematological parameters of rabbits.

Organ targeted prenatal gene therapy--how far are we?

Prenatal gene therapy aims to deliver genes to cells and tissues early in prenatal life, allowing correction of a genetic defect, before long-term tissue damage has occurred. In contrast to postnatal gene therapy, prenatal application can target genes to a large population of dividing stem cells, and the smaller fetal size allows a higher vector-to-target cell ratio to be achieved. Early-gestation delivery may allow the development of immune tolerance to the transgenic protein which would facilitate postnatal repeat vector administration if needed. Targeting particular organs will depend on manipulating the vector to achieve selective tropism and on choosing the most appropriate gestational age and injection method for fetal delivery. Intra-amniotic injection reaches the skin, and other organs that are bathed in the fluid however since gene transfer to the lung and gut is usually poor more direct injection methods will be needed. Delivery to the liver and blood can be achieved by systemic delivery via the umbilical vein or peritoneal cavity. Gene transfer to the central nervous system in the fetus is difficult but newer vectors are available that transduce neuronal tissue even after systemic delivery.

Ultrasonic imaging: safety considerations

Modern ultrasound imaging for diagnostic purposes has a wide range of applications. It is used in obstetrics to monitor the progress of pregnancy, in oncology to visualize tumours and their response to treatment, and, in cardiology, contrast-enhanced studies are used to investigate heart function and physiology. An increasing use of diagnostic ultrasound is to provide the first photograph for baby's album-in the form of a souvenir or keepsake scan that might be taken as part of a routine investigation, or during a visit to an independent high-street 'boutique'. It is therefore important to ensure that any benefit accrued from these applications outweighs any accompanying risk, and to evaluate the existing ultrasound bio-effect and epidemiology literature with this in mind. This review considers the existing laboratory and epidemiological evidence about the safety of diagnostic ultrasound and puts it in the context of current clinical usage.

Craniorachischisis and omphalocele in a stillborn cynomolgus monkey (Macaca fascicularis)

Nonhuman primates have been a common animal model to evaluate experimentally induced malformations. Reports on spontaneous malformations are important in determining the background incidence of congenital anomalies in specific species and in evaluating experimental results. Here we report on a stillborn cynomolgus monkey (Macaca fascicularis) with multiple congenital anomalies from the colony maintained at the Southwest National Primate Research Center at the Texas Biomedical Research Institute, San Antonio, Texas. Physical findings included low birth weight, craniorachischisis, facial abnormalities, omphalocele, malrotation of the gut with areas of atresia and intussusception, a Meckel diverticulum, arthrogryposis, patent ductus arteriosus, and patent foramen ovale. The macaque had normal male external genitalia, but undescended testes. Gestational age was unknown but was estimated from measurements of the limbs and other developmental criteria. Although cytogenetic analysis was not possible due to the tissues being in an advanced state of decomposition, array Comparative Genomic Hybridization analysis using human bacterial artificial chromosome clones was successful in effectively eliminating aneuploidy or any copy number changes greater than approximately 3-5 Mb as a cause of the malformations. Further evaluation of the animal included extensive imaging of the skeletal and neural tissue defects. The animal's congenital anomalies are discussed in relation to the current hypotheses attempting to explain the frequent association of neural tube defects with other abnormalities.

The cynomolgus monkey as a model for developmental toxicity studies: variability of pregnancy losses, statistical power estimates, and group size considerations

BACKGROUND

This work evaluates pregnancy and infant loss in 1,069 vehicle-treated cynomolgus monkeys from 78 embryo-fetal development (EFD) studies and 14 pre-postnatal development (PPND) studies accrued during 1981-2007.

METHODS

Losses were analysed by survival function and hazard ratio using logistic regression for influence of year, study type (e.g., dose duration), and test item route of administration (ig, im, iv, sc).

RESULTS

Neither study type nor route of dosing affected pregnancy outcome. Losses were higher pre-1990 (104 losses/347 pregnancies) compared to 1990 onwards (94 losses/722 pregnancies). Losses were greatest before gestation day 50 and at parturition. Using post-1989 data, Monte-Carlo simulations of pregnancy outcomes were created. The power associated with the comparison of vehicle survival curves and simulated adverse survival curves was examined. This showed that EFD studies with initial vehicle group sizes of 16 and 20 have an 80% probability of having 13 and 16 ongoing pregnancies at gestational day 100, respectively. For PPND studies with initial vehicle group sizes of 16, 20, or 28, there is an 80% likelihood of having 9, 11, or 16 infants at day 7 post-partum, respectively. A PPND study initiated with group size 20 could detect a threefold increase of test item-related pregnancy or infant loss.

CONCLUSIONS

For designing and managing primate developmental toxicity studies, this type of analysis provides an objective tool to facilitate decisions either by supplementing groups with additional pregnant animals or stopping a group because an adverse effect on offspring survival has already been adequately revealed.

Fetal thermal effects of diagnostic ultrasound

Processes that can produce a biological effect with some degree of heating (ie, about 1 degrees C above the physiologic temperature) act via a thermal mechanism. Investigations with laboratory animals have documented that pulsed ultrasound can produce elevations of temperature and damage in biological tissues in vivo, particularly in the presence of bone (intracranial temperature elevation). Acoustic outputs used to induce these adverse bioeffects are within the diagnostic range, although exposure times are usually considerably longer than in clinical practice. Conditions present in early pregnancy, such as lack of perfusion, may favor bioeffects. Thermally induced teratogenesis has been shown in many animal studies, as well as several controlled human studies; however, human studies have not shown a causal relationship between diagnostic ultrasound exposure during pregnancy and adverse biological effects to the fetus. All human epidemiologic studies, however, were conducted with commercially available devices predating 1992, that is, with acoustic outputs not exceeding a spatial-peak temporal-average intensity of 94 mW/cm2. Current limits in the United States allow a spatial-peak temporal-average intensity of 720 mW/cm2 for fetal applications. The synergistic effect of a raised body temperature (febrile status) and ultrasound insonation has not been examined in depth. Available evidence, experimental or epidemiologic, is insufficient to conclude that there is a causal relationship between obstetric diagnostic ultrasound exposure and obvious adverse thermal effects to the fetus. However, very subtle effects cannot be ruled out and indicate a need for further research, although research in humans may be extremely difficult to realize.

Dopplerfluxometria no estudo da circulação fetal: revisão do aspecto segurança

Os autores apresentam os métodos Doppler e sua evolução no estudo da circulação fetal, dando ênfase à segurança e aos bioefeitos. Os aparelhos de ultra-sonografia utilizados correntemente funcionam com índice térmico máximo e índice mecânico automaticamente mantidos em níveis inferiores a 1,0. Até os dias atuais, não foi descrita lesão biológica em fetos humanos submetidos ao Doppler diagnóstico. Portanto, o Doppler pulsado, o colorido e o "power" Doppler são seguros na exposição ultra-sonográfica do pré-natal.

The sensitivity of biological tissue to ultrasound

Mammalian tissues have differing sensitivities to damage by physical agents such as ultrasound. This article evaluates the scientific data in terms of known physical mechanisms of interaction and the impact on pre- and postnatal tissues. Actively dividing cells of the embryonic and fetal central nervous system are most readily disturbed. As a diagnostic ultrasound beam envelopes a small volume of tissue, it is possible that the effects of mild disturbance may not be detected unless major neural pathways are involved. There is evidence that ultrasound can be detected by the central nervous system; however, this does not necessarily imply that the bioeffect is hazardous to the fetus. Biologically significant temperature increases can occur at or near to bone in the fetus from the second trimester, if the beam is held stationary for more than 30 s in some pulsed Doppler applications. In this way, sensory organs that are encased in bone may be susceptible to heating by conduction. Reports in animals and humans of retarded growth and development following frequent exposures to diagnostic ultrasound, in the absence of significant heating, are difficult to explain from the current knowledge of ultrasound mechanisms. There is no evidence of cavitation effects occurring in the soft tissues of the fetus when exposed to diagnostic ultrasound; however, the possibility exists that such effects may be enhanced by the introduction of echo-contrast agents.

Characterisation of the possible effect on birthweight following frequent prenatal ultrasound examinations

The objective of this study was to evaluate and characterise by study of newborn biometry a possible effect on birthweight which we observed previously in a randomised controlled trial of multiple prenatal ultrasound examinations. A total of 2743 women with single pregnancies had been allocated at random to either a protocol of ultrasound imaging and continuous wave Doppler studies at 18, 24, 28, 34 and 38 weeks gestation (intensive group), or to a protocol of a single imaging examination at 18 weeks and further imaging scans only as clinically indicated (regular group). When compared with those in the regular group, and adjusted for other confounding variables, normally formed babies of term gestational age in the intensive group tended to be shorter when measured at birth (P = 0.123) and on day 2-3 of age (P = 0.068). There were statistically insignificant reductions in the circumferences of the chest, abdomen and mid-arm; and in the skinfold thicknesses of the triceps, parascapular and subscapular regions. Principal component analysis showed a trend for a reduction for the skeletal component (P = 0.085) but not for the soft tissue component (P = 0.332). Comparison of the neonatal biometry in the two groups is not conclusive, but the differential effects on the various growth parameters suggest that if multiple scans do indeed restrict fetal growth, the mechanism is more likely to be an effect on bone growth rather than a reduction in nutrient supply from the placenta.

Diagnostic ultrasound in veterinary practice: How safe is it?

This paper provides information on the safety of ultrasonic diagnostic procedures as currently used in veterinary practice. The known mechanisms of action are described and selected literature on biological effects of ultrasound is reviewed. Current international consensus is presented on the safety of medical ultrasound with respect to thermal effects. To date, there is no independently verified clinical evidence that the level of exposure delivered to the tissues during scanned grey-scale ('B-mode') imaging has any adverse effects. Lung haemorrhage has been observed in animal experiments using diagnostic exposures, but the effects have not been reported in the foetus. Equipment that uses pulsed Doppler transmits higher acoustic outputs in a stationary beam, and can produce temperature increases that may have significant biological consequences. When considering sonographic and pulsed Doppler examinations of the prenatal animal, the safety margins are small and the operator should be aware of the acoustic output of the equipment, the exposure time, and the sensitivity of target tissues.

Teratogenic effects of repeated exposures to X-rays and/or ultrasound in mice

Pregnant Swiss mice were exposed to 9 mGy of 70 kVp X-rays or 10 min of ultrasound (3.5 MHz, approximately 65 mW, ISPTP = 1 W/cm2, ISATA = 240 mW/cm2) on Days 6.5 and 11.5 of gestation in four combinations: X-rays on both days (X + X), ultrasound on both days (U + U), X-rays on Day 6.5 postcoitus (PC) and ultrasound on day 11.5 PC(X + U) and ultrasound at 6.5 days PC and X-rays on day 11.5 PC(U + X). Sham-treated controls were maintained for comparison. Effects on prenatal development, postnatal growth and adult behavior were studied. U + U group showed an increase in percent growth retarded fetuses and a nonsignificant increase was seen in the U + X group. Transient growth retardation was observed in all the exposure groups. This is less likely to be of any biological significance as the animals recovered during postweaning period. The postnatal mortality was significantly higher only in the U + U group. In the X + U group, the exploratory activity was affected at 6 months of age. There was a significant change in the locomotor activity with a reduction in the total activity as 3 and 6 months of age in the U + U group. Latency in learning capacity was also noticed in this group. The results indicate that repeated exposures to ultrasound or its combination with X-rays could be detrimental to the embryonic development and can impair adult brain function when administered at certain stages of organogenesis.

Hematologic and growth-related effects of frequent prenatal ultrasound exposure in the long-tailed macaque (Macaca fascicularis)

Prior investigations have shown that reduced birth weights and transient neutropenias result from frequent exposure of monkey fetuses to ultrasound. To further explore these findings, 26 animals were studied (16 exposed, 10 controls; "triple mode"; ATL Ultramark 9 with HDI; ISPTAd approximately 645 to 714 mW/cm2). Exposures were performed daily for 5 days each week from gestational days (GD) 21 to 35 (5 min), three times weekly from GD 36 to 60 (5 min), then weekly from GD 61 to 153 +/- 1 (10 min). Fetal blood samples (FBS) were collected for complete blood counts (CBCs), hematopoietic progenitor assay, circulating insulin-like growth factors (IGF-I, IGF-II) and binding proteins (IGFBP-3) (GD 120, 140, 153 +/- 1). Animals were delivered by Cesarean section at term (GD 153 +/- 1), and body weights, morphometrics, CBCs, and bone marrow aspirates assessed at delivery and postnatally for 3 months. Fetal neutropenias were noted in exposed animals in addition to reduced circulating progenitors (colony forming unit-granulocyte-macrophage [CFU-GM]). Growth of CFU-GM from bone marrow was exuberant at term, whereas circulating levels were diminished comparable to prenatal samples. Exposed animals were smaller at birth; marked reductions in IGFBP-3 were noted prenatally. These data suggest that frequent prenatal ultrasound exposure can transiently alter the neutrophil lineage, although these findings may be the result of enhanced margination and organ sequestration. Data also suggest that transient, altered growth patterns may be due to perturbations of the IGF axis.

Glycoprotein and ganglioside changes in human trophoblasts after exposure to pulsed Doppler ultrasound

Changes in glycoprotein and ganglioside composition in human trophoblasts (eighth week of gestation) after in vitro exposure to pulsed Doppler ultrasound (pulse duration 1.22 microseconds; repetition frequency 11.1 kHz; center frequency 4 MHz; ISPPA = 175.5 W/cm2; ISPTA = 0.59 W/cm2) were investigated. Evacuated trophoblasts were divided in two halves and insonated for 10 min on top of a 6-cm layer of 5% gelatin in 50-mL tubes (Falcon) at 37 degrees C. One half of each trophoblast was sham insonated and served as an internal control. After insonation trophoblasts were maintained at 37 degrees C for 24 h. Glycoproteins were detected using alpha-D-mannose specific lectins from Galanthus nivalis and Narcissus pseudonarcissus. A decrease in the expression of mannose containing glycoprotein mgp47 and an increase in expression of mgp54 were observed. Ganglioside composition was also significantly altered. Concentrations of two gangliosides migrating similarly to GM2, and one similarly to GQ1, decreased by more than 75%. At the same time, concentrations of one ganglioside migrating similarly to GM3, and two other unidentified gangliosides increased two- to fourfold.

Ultrasound-induced lung hemorrhage in the monkey

Studies with the mouse have shown that lung hemorrhage can result from exposure to ultrasound at a peak pressure of approximately 1 MPa at 4 MHz (Mechanical Index [MI] approximately 0.5). In order to determine whether a comparable outcome could occur in a larger animal with characteristics similar to humans, studies were performed with monkeys using a clinical scanner under maximum output conditions (imaging + pulsed and color Doppler; derated pr of 3.7 MPa [4.5 MPa, measured in water], 4 MHz; MI approximately 1.8) (N = 57). Monkeys ranged in age from 1 day of life to 16 years with exposures limited to the right lung lobes (5 min cranial, 5 min caudal; N = 41 exposed, N = 12 sham-exposed controls, N = 4 colony controls). Results showed that animals ranging in age from 3 months to 5 years (mean age of 2.5 years) had a greater propensity for the occurrence of multiple well-demarcated circular hemorrhagic foci (0.1-1.0 cm), which were not observed in either control group. These lesions were characterized by marked congestion of alveolar capillaries with accumulation of red blood cells within the alveolar spaces, and were unassociated with major vessels or respiratory bronchioles. Further studies will be required in order to determine the relevance of these findings to the human, although it was concluded that ultrasound-induced lung hemorrhage in the monkey is of a significantly lesser degree when compared to the mouse.

Effect of in utero exposure to diagnostic ultrasound on the postnatal survival and growth of mouse

Pregnant Swiss albino mice were exposed to 3.5 MHz diagnostic ultrasound for 10 min (upper limit for ISPTP = 1 W/cm2 and for ISATA = 240 mW/cm2, acoustic power = approximately 65 mW) on day 3.5 (preimplantation period), 6.5 (early organogenesis period), 11.5 (late organogenesis period), or 14.5 (early fetal period) of gestation. The offspring were observed for changes in litter size at birth, and sex ratio at 4 weeks of age, and postnatal mortality and growth retardation up to 6 weeks of age. No significant difference from control in litter size or sex ratio was observed in the offspring exposed to ultrasound on any of the gestation days studied. Exposure at the early organogenesis period produced a marginally significant increase in the postnatal mortality. A significant number of ultrasound exposed animals showed lesser body weights than the control group. However this growth retardation was transient and the normal growth pattern was restored by 6 weeks of age. It is concluded that the early stages in mouse gestation may be sensitive to the lethal effects of ultrasound than the later stages of pregnancy. Even though a small increase in the postnatal mortality was observed in the ultrasound exposed animals, the normal growth was not affected in the surviving animals except for a transient growth retardation. Low birth weight may be a characteristic effect of exposure only at the preimplantation period.

Effect of prenatal ultrasound exposure on adult behavior in mice

Pregnant Swiss mice were exposed to diagnostic levels of ultrasound (3.5 MHz, Maximum acoustic output: ISPTP = 1 W/cm2 and ISATA = 240 mW/cm2, acoustic power = 65 mW) for 10 min on days 11.5 or 14.5 postcoitus (PC). At 3 and 6 months postpartum, offspring were subjected to the following behavioral tests: bright and dark arena test for locomotor/exploratory activity and passive avoidance test for learning and memory. Anxiolytic activity and latency in learning were noticed in the ultrasound-treated animals. The effect was more pronounced in the 14.5 days PC group than in the 11.5 days PC group. But memory was not affected in the ultrasound-exposed animals. There was a nonsignificant decrease in the total locomotor activity at 6 months of age in all the exposed animals. Thus, the present data demonstrate that exposure to diagnostic ultrasound during late organogenesis period or early fetal period in mice may cause changes in postnatal behavior as evidence by selected adult offspring behavioral tests. However, any conclusive statement in this regard should await results from more detailed investigations.

Effects of frequent ultrasound during pregnancy: a randomised controlled trial

Despite widespread application of ultrasound imaging and Doppler blood flow studies, the effects of their frequent and repeated use in pregnancy have not been evaluated in controlled trials. From 2834 women with single pregnancies at 16-20 weeks gestation, 1415 were selected at random to receive ultrasound imaging and continuous-wave Doppler flow studies at 18, 24, 28, 34, and 38 weeks gestation (the intensive group) and 1419 to receive single ultrasound imaging at 18 weeks (the regular group). Outcome data was obtained from 99% of women who entered the study. The only difference between the two groups was significantly higher intrauterine growth restriction in the intensive group, when expressed both as birthweight < 10th centile (relative risk 1.35; 95% confidence interval 1.09 to 1.67; p = 0.006) and birthweight < 3rd centile (relative risk 1.65; 95% confidence intervals 1.09 to 2.49; p = 0.020). While it is possible that this finding was a chance effect, it is also plausible that frequent exposure to ultrasound may have influenced fetal growth. Repeated prenatal ultrasound imaging and Doppler flow examinations should be restricted to those women to whom the information is likely to be of clinical benefit.