Effect of antenatal betamethasone treatment on microtubule-associated proteins MAP1B and MAP2 in fetal sheep

Addressing the long-term risks of administering antenatal steroids

INTRODUCTION

A single course of antenatal steroid (ANS) therapy is standard of care for women at risk of preterm birth, reducing the risk of neonatal respiratory distress syndrome, neonatal morbidity, and mortality. An unresolved challenge relates to the potential risk of adverse long-term effects, and how these risks might be balanced with therapeutic benefit.

AREAS COVERED

We outline key concepts in glucocorticoid signaling, pharmacokinetics/pharmacodynamics, and clinical use before presenting data on the potential long-term harms of ANS therapy.

EXPERT OPINION

Our assessment is that: i) Currently used, high dose ANS regimens can induce multi-system changes in the fetus that alter growth and development, potentially increasing long-term disease risk; and ii) relative risks likely increase proportionally to the magnitude and duration of steroid exposure, in late preterm and term ANS use, and in off-target treatments. A single course of ANS therapy to at risk women between 24- and 34-weeks' gestation is well justified. Efforts should be made to improve dosing and patient selection. At periviable gestations, the high immediate risk of serious disease or death justifies modest long-term risks. At late preterm and term gestations, where steroids do not provide notable survival or health benefits, supporting routine ANS use is more difficult.

The impact of maternal prenatal psychological distress on the development of epilepsy in offspring: The Japan Environment and Children's Study

The relationship between maternal prenatal psychological distress and epilepsy development in offspring has not yet been clarified. Herein, we used a dataset obtained from the Japan Environment and Children's Study, a nationwide birth cohort study, to evaluate the association between six-item Kessler Psychological Distress Scale (K6) scores and epilepsy among 1-3 years old. The data of 97,484 children were retrospectively analyzed. The K6 was administered to women twice: during the first half (M-T1) and second half (M-T2) of pregnancy. M-T1 ranged from 12.3-18.9 (median 15.1) weeks, and M-T2 ranged from 25.3-30.1 (median 27.4) weeks. Participants were divided into six groups based on K6 scores of two ranges (≤4 and ≥5) at M-T1 and M-T2. The numbers of children diagnosed with epilepsy at the ages of 1, 2, and 3 years were 89 (0.1%), 129 (0.2%), and 149 (0.2%), respectively. A maternal K6 score of ≥5 at both M-T1 and M-T2 was associated with epilepsy diagnosis ratios among 1-, 2-, and 3-year-old children in the univariate analysis. Moreover, multivariate analysis revealed that a maternal K6 score of ≥5 at both M-T1 and M-T2 was associated with epilepsy diagnosis ratios among 1-, 2-, and 3-year-olds. Continuous moderate-level maternal psychological distress from the first to the second half of pregnancy is associated with epilepsy among 1-, 2-, and 3-year-old children. Hence, environmental adjustments to promote relaxation such as mindfulness in pregnant women might be necessary.

In vivo biomarkers of structural and functional brain development and aging in humans

Brain aging is a major determinant of aging. Along with the aging population, prevalence of neurodegenerative diseases is increasing, therewith placing economic and social burden on individuals and society. Individual rates of brain aging are shaped by genetics, epigenetics, and prenatal environmental. Biomarkers of biological brain aging are needed to predict individual trajectories of aging and the risk for age-associated neurological impairments for developing early preventive and interventional measures. We review current advances of in vivo biomarkers predicting individual brain age. Telomere length and epigenetic clock, two important biomarkers that are closely related to the mechanistic aging process, have only poor deterministic and predictive accuracy regarding individual brain aging due to their high intra- and interindividual variability. Phenotype-related biomarkers of global cognitive function and brain structure provide a much closer correlation to age at the individual level. During fetal and perinatal life, autonomic activity is a unique functional marker of brain development. The cognitive and structural biomarkers also boast high diagnostic specificity for determining individual risks for neurodegenerative diseases.

Cardiovascular effects of prenatal stress-Are there implications for cerebrovascular, cognitive and mental health outcome?

Prenatal stress programs offspring cognitive and mental health outcome. We reviewed whether prenatal stress also programs cardiovascular dysfunction which potentially modulates cerebrovascular, cognitive and mental health disorders. We focused on maternal stress and prenatal glucocorticoid (GC) exposure which have different programming effects. While maternal stress induced cortisol is mostly inactivated by the placenta, synthetic GCs freely cross the placenta and have different receptor-binding characteristics. Maternal stress, particularly anxiety, but not GC exposure, has adverse effects on maternal-fetal circulation throughout pregnancy, probably by co-activation of the maternal sympathetic nervous system, and by raising fetal catecholamines. Both effects may impair neurodevelopment. Experimental data also suggest that severe maternal stress and GC exposure during early and mid-gestation may increase the risk for cardiovascular disorders. Human data are scarce and especially lacking for older age. Programming mechanisms include aberrations in cardiac and kidney development, and functional changes in the renin-angiotensin-aldosterone-system, stress axis and peripheral and coronary vasculature. Adequate experimental or human studies examining the consequences for cerebrovascular, cognitive and mental disorders are unavailable.

Development of somatosensory-evoked potentials in foetal sheep: effects of betamethasone

AIM

Antenatal glucocorticoids are used to accelerate foetal lung maturation in babies threatened with premature labour. We examined the influence of glucocorticoids on functional and structural maturation of the central somatosensory pathway in foetal sheep. Somatosensory-evoked potentials (SEP) reflect processing of somatosensory stimuli. SEP latencies are determined by afferent stimuli transmission while SEP amplitudes reveal cerebral processing.

METHODS

After chronic instrumentation of foetal sheep, mothers received saline (n = 9) or three courses of betamethasone (human equivalent dose of 2 × 110 μg kg^-1 betamethasone i.m. 24 h apart, n = 12) at 0.7, 0.75 and 0.8 of gestational age. Trigeminal SEP were evoked prior to, 4 and 24 h after each injection and at 0.8 of gestational age before brains were histologically processed.

RESULTS

Somatosensory-evoked potentials were already detectable at 0.7 of gestation age. The early and late responses N20 and N200 were the only reproducible peaks over the entire study period. With advancing gestational age, SEP latencies decreased but amplitudes remained unchanged. Acutely, betamethasone did not affect SEP latencies and amplitudes 4 and 24 h following administration. Chronically, betamethasone delayed developmental decrease in the N200 but not N20 latency by 2 weeks without affecting amplitudes. In parallel, betamethasone decreased subcortical white matter myelination but did not affect network formation and synaptic density in the somatosensory cortex.

CONCLUSION

Somatosensory stimuli are already processed by the foetal cerebral cortex at the beginning of the third trimester. Subsequent developmental decrease in SEP latencies suggests ongoing maturation of afferent sensory transmission. Antenatal glucocorticoids affect structural and functional development of the somatosensory system with specific effects at subcortical level.

In-line non-invasive turbidimetry as a tool to ensure content uniformity in the betamethasone filling process

The filling process of liquid suspensions is a difficult operation,mainly due to drug settling. Small variations during the process may lead to serious deviations in the API content uniformity of the finished product, particularly if the drug settles fast. Real-time non-invasive monitoring of liquid suspensions is a useful approach to ensure an acceptable API content in the finished product. The aim of this study was to develop a method based on non-invasive turbidity measurements for in-line determinations of betamethasone content uniformity during the filling process of injections. Owing to the constructive features of the developed system, the determinations were performed in a non-destructive and non-invasive way, thus allowing the analysis of the whole batch and minimizing the risk of contaminating the product. The results obtained by the method proposed in this study demonstrated that non-invasive turbidimetry is a powerful tool for continuous monitoring of the filling process of betamethasone injections, within the Quality by Design framework (FDA, 2009).

Fetal Neurology: The Role of Fetal Stress

Fetal development and growth, as well as the timing of birth is influenced by the intrauterine environment. Many environmental factors causing the fetal stress can interfere with fetal development and leave long-term and profound consequences on health. Fetal glucocorticoid overexposure has primarily significant consequences for the development of the central nervous system. In response to an adverse intrauterine conditions, the fetus is able to adapt its physiology to promote survival. However, these adaptations can result in permanent changes in tissue and organ structure and function that directly ‘program’ predisposition to disease. Cardiometabolic disorders, behavioral alterations and neuropsychiatric impairments in adulthood and/ or childhood may have their roots in the fetal period of life. Fetal response to stress and its prenatal and lifelong consequences are discussed in this review.

How to cite this article

Kadić AS. Fetal Neurology: The Role of Fetal Stress. Donald School J Ultrasound Obstet Gynecol 2015;9(1):30-39.

Delay of cortical thinning in very preterm born children

BACKGROUND

Cortical gray matter thinning occurs during childhood due to pruning of inefficient synaptic connections and an increase in myelination. Preterms show alterations in brain structure, with prolonged maturation of the frontal lobes, smaller cortical volumes and reduced white matter volume. These findings give rise to the question if there is a differential influence of age on cortical thinning in preterms compared to controls.

AIMS

To investigate the relationship between age and cortical thinning in school-aged preterms compared to controls.

STUDY DESIGN AND OUTCOME MEASURES

The automated surface reconstruction software FreeSurfer was applied to obtain measurements of cortical thickness based on T1-weighted MRI images.

SUBJECTS

Forty-one preterms (<32weeks gestational age and/or <1500g birth weight) and 30 controls were included in the study (7-12years).

RESULTS

In preterms, age correlated negatively with cortical thickness in right frontal, parietal and inferior temporal regions. Furthermore, young preterms showed a thicker cortex compared to old preterms in bilateral frontal, parietal and temporal regions. In controls, age was not associated with cortical thickness.

CONCLUSION

In preterms, cortical thinning still seems to occur between the age of 7 and 12years, mainly in frontal and parietal areas whereas in controls, a substantial part of cortical thinning appears to be completed before they reach the age of 7years. These data indicate slower cortical thinning in preterms than in controls.

Microtubule-associated protein 2 and synaptophysin in the preterm and near-term ovine fetal brain and the effect of intermittent umbilical cord occlusion

We have determined the change in immunoreactivity (IR) for microtubule-associated protein 2 (MAP-2) and synaptophysin (SYN) as markers for dendritic and presynaptic nerve development, respectively, in the ovine fetal brain with advancing gestation and in response to intermittent umbilical cord occlusion (UCO), which might then contribute to adverse neurodevelopment. Fetal sheep (control and experimental groups preterm at 111-115 and near term at 132-138 days of gestation; term = 145 days) were studied over 4 days with UCOs performed by inflation of an occluder cuff for 90 seconds every 30 minutes for 3 to 5 hours each day. Animals were then euthanized and fetal brains assessed for IR of MAP-2 and SYN. In control animals, the IR of SYN increased in the gray matter with advancing gestation consistent with a developmental increase in presynaptic vesicles and/or nerve terminals as expected; however, the IR of MAP-2 decreased in all brain regions studied, suggesting concurrent refinement in dendritic branching and spine development. Intermittent UCO as studied with marked but limited hypoxemia resulted in a decrease in IR of SYN for the brain regions of the preterm animals when protein turnover is higher and indicates decreased presynaptic vesicle formation; whereas, MAP-2 IR was selectively increased in the hippocampus CA1 and thalamus of the near-term animals, consistent with reactive dendritic change and heightened vulnerability for neuronal injury. As such, intermittent cord compressions in the ovine fetus can impact protein markers for dendritic and presynaptic nerve development depending on their timing, which might then lead to alterations in synapse formation and neuronal circuitry.

Glucocorticoids and preterm hypoxic-ischemic brain injury: the good and the bad

Fetuses at risk of premature delivery are now routinely exposed to maternal treatment with synthetic glucocorticoids. In randomized clinical trials, these substantially reduce acute neonatal systemic morbidity, and mortality, after premature birth and reduce intraventricular hemorrhage. However, the overall neurodevelopmental impact is surprisingly unclear; worryingly, postnatal glucocorticoids are consistently associated with impaired brain development. We review the clinical and experimental evidence on how glucocorticoids may affect the developing brain and highlight the need for systematic research.

Exogenous glucocorticoids and adverse cerebral effects in children

Glucocorticoids are commonly used in treatment of paediatric diseases, but evidence of associated adverse cerebral effects is accumulating. The various pharmacokinetic profiles of the exogenous glucocorticoids and the changes in pharmacodynamics during childhood, result in different exposure of nervous tissue to exogenous glucocorticoids. Glucocorticoids activate two types of intracellular receptors, the mineralocorticoid receptor and the glucocorticoid receptor. The two receptors differ in cerebral distribution, affinity and effects. Exogenous glucocorticoids favor activation of the glucocorticoid receptor, which is associated with unfavorable cellular outcomes. Prenatal treatment with glucocorticoids can compromise brain growth and is associated with periventricular leukomalacia, attentions deficits and poorer cognitive performance. In the neonatal period exposure to glucocorticoids reduces neurogenesis and cerebral volume, impairs memory and increases the incidence of cerebral palsy. Cerebral effects of glucocorticoids in later childhood have been less thoroughly studied, but apparent brain atrophy, reduced size of limbic structures and neuropsychiatric symptoms have been reported. Glucocortioids affect several cellular structures and functions, which may explain the observed adverse effects. Glucocorticoids can impair neuronal glucose uptake, decrease excitability, cause atrophy of dendrites, compromise development of myelin-producing oligodendrocytes and disturb important cellular structures involved in axonal transport, long-term potentiation and neuronal plasticity. Significant maturation of the brain continues throughout childhood and we hypothesize that exposure to exogenous glucocorticoids during preschool and school age causes adverse cerebral effects. It is our opinion that studies of associations between exposure to glucocorticoids during childhood and impaired neurodevelopment are highly relevant.

Repeated courses of antenatal corticosteroids: are there effects on the infant's auditory brainstem responses?

Our objective was to assess the effects of repeated antenatal corticosteroid treatments on the neonatal auditory brainstem response (ABR), a sensitive measure of neonatal brain maturity and auditory function. To achieve this, we performed and blindly evaluated neonatal ABRs on a subset of infants delivering within a multicenter randomized placebo-controlled clinical trial comparing single versus repeated courses of antenatal corticosteroid treatments for women at 23-31 weeks gestation who remained at increased risk for preterm birth. The women were randomly assigned to either the single or the repeated antenatal corticosteroid treatment group. Women in the repeated antenatal corticosteroid group received weekly antenatal corticosteroid treatments until 34 weeks gestation or until they reached a study-determined limited number of courses, whereas women in the single antenatal corticosteroid group received an initial course of corticosteroid followed by weekly placebo injections. We performed ABR testing on their infants prior to discharge. The latencies of waves I, III and V and the peak-to-trough amplitudes of waves I and V were compared between those in the single (n=27) and repeated antenatal corticosteroid treatment (n=24) groups. The majority of repeated antenatal corticosteroid infants (20 of 24) were exposed to ≥ 4 antenatal corticosteroid treatments. Even though gestational age was similar between our subset of single and repeated antenatal corticosteroid treatment groups, infant birth weight and length and head circumference were significantly smaller in the repeated antenatal corticosteroid group (p <0.05). Despite these differences in birth sizes, there were no significant group differences in the ABR wave latencies or amplitudes. We concluded that our repeated antenatal corticosteroid treatments, in comparison to a single treatment, did not significantly benefit or harm the neonatal ABR despite significant effects on birth size.

Adverse effects of antenatal glucocorticoids on cerebral myelination in sheep

OBJECTIVE

To determine in fetal sheep the effect of betamethasone on myelination in relation to stage of myelination, number of treatment courses, dose, and route of administration.

METHODS

Fetal expression of myelin basic protein (MBP), a marker of mature oligodendrocytes and myelin, was determined between 0.27 and 0.93 gestation. Short-term betamethasone effects were examined 24 hours after one maternal intramuscular treatment course (weight adjusted to equal the clinical dose of 2 x 8 mg betamethasone to a 70-kg woman) at 0.63, 0.75, and 0.87 gestation or after continuous 48-hour fetal intravenous infusion at 0.75 and 0.87 gestation. Lasting effects were examined 20 days after one and two treatment courses weight-adapted to the clinical dose of 2 x 8 mg or 2 x 12 mg betamethasone at 0.75 gestation.

RESULTS

Myelin basic protein immunoreactivity was first detected in the internal capsule at 0.53 gestation, followed by the centrum semiovale, the superficial white matter, and corpus callosum at 0.63 gestation. Within 24 hours after treatment, betamethasone reduced the number of mature oligodendrocytes and MBP immunoreactivity. The effect decreased with gestational age. Maternal and fetal betamethasone administration had similar effects. Loss of MBP immunoreactivity was not reversed 20 days after two treatment courses, independent of dose.

CONCLUSION

Betamethasone-induced delayed cerebral myelination is dependent on the stage of brain development in sheep. Betamethasone-related disturbances in myelination and any potential contribution to childhood behavior deficits need to be confirmed in clinical studies.

Effects of maternal antenatal glucocorticoid treatment on apoptosis in the ovine fetal cerebral cortex

We examined the effects of single and multiple maternal glucocorticoid courses on apoptosis in the cerebral cortices of ovine fetuses (CC). Ewes received single dexamethasone or placebo courses at 104-106 or 133-135 days or multiple courses between 76-78 and 104-106 days gestation. In the single-course groups, ewes received four 6 mg dexamethasone or placebo injections every 12 hr for 48 hr. Multiple-course groups received the same treatment once per week for 5 weeks. Neuronal and nonneuronal apoptotic cell numbers per square millimeter were determined with TUNEL and NeuN staining and with caspase-3 enzyme activity on CC tissues harvested at 106-108 (70%) or 135-137 (90%) days of gestation. Apoptotic cell numbers and caspase-3 activity were 50% lower (P < 0.02) after single placebo courses at 90% than 70% gestation; 90% of apoptotic cells were (P < 0.01) nonneuronal at both ages. Nonneuronal apoptotic cells and caspase-3 activity were 40% and 20% lower (P < 0.02) after single dexamethasone than placebo courses at 70%, but not 90%, gestation. Caspase-3 activity was 20% lower (P < 0.01) after multiple dexamethasone than placebo courses, but apoptotic cell number did not differ. We conclude that nonneuronal apoptosis represents the major form of apoptosis in the CC at both 70% and 90% of gestation. Apoptosis in nonneuronal cells decreases with maturity and after a single course of dexamethasone at 70%, but not at 90%, gestation and not after multiple courses at 70% gestation. We speculate that a single course of glucocorticoids exerts maturational changes on the rate of apoptosis in the cerebral cortex of preterm ovine fetuses.

Na+, K+-ATPase activity and subunit isoform protein abundance: effects of antenatal glucocorticoids in the frontal cerebral cortex and renal cortex of ovine fetuses

We examined the effects of single and multiple maternal glucocorticoid courses on cerebral cortical (CC) and renal cortical (RC) Na(+),K(+)-ATPase activity and protein isoform abundance in fetal sheep. Ewes received four dexamethasone or placebo injections in the single course (SC) groups, and the same treatment once a week for five-weeks in the multiple course (MC) groups. CC Na(+),K(+)-ATPase a(2)-abundance was higher (P<0.05) and beta(2)-abundance lower in the SC dexamethasone than placebo group, but Na(+),K(+)-ATPase activity did not change. CC Na(+),K(+)-ATPase activity, a(1)-, beta(1) -, and beta(2)-abundance were lower in the MC dexamethasone than placebo group, but a(2)- and a(3)-abundance did not change. Both dexamethasone courses did not affect CC cell number. RC Na(+),K(+)-ATPase activity, a(1)- and beta(1) -abundance were higher in the MC dexamethasone than placebo group, but did not change in the SC dexamethasone group. We conclude MC, but not a SC of dexamethasone, affect fetal cerebral and renal Na(+),K(+)-ATPase, and MC result in differential effects on Na(+),K(+)-ATPase in these organs.

The microtubule-associated protein doublecortin-like regulates the transport of the glucocorticoid receptor in neuronal progenitor cells

In neuronal cells, activated glucocorticoid receptor (GR) translocates to the nucleus guided by the cytoskeleton. However, the detailed mechanisms underlying GR translocation remain unclear. Using gain and loss of function studies, we report here for the first time that the microtubule-associated protein doublecortin-like (DCL) controls GR translocation to the nucleus. DCL overexpression in COS-1 cells, neuroblastoma cells, and rat hippocampus organotypic slice cultures impaired GR translocation and decreased GR-dependent transcriptional activity, measured by a specific reporter gene assay, in COS-1 cells. Moreover, DCL and GR directly interact on microtubule bundles formed by DCL overexpression. A C-terminal truncated DCL with conserved microtubule-bundling activity did not influence GR translocation. In N1E-115 mouse neuroblastoma cells and neuronal progenitor cells in rat hippocampus organotypic slice cultures, laser-scanning confocal microscopy showed colabeling of endogenously expressed DCL and GR. In these systems, RNA-interference-mediated DCL knockdown hampered GR translocation. Thus, we conclude that DCL expression is tightly regulated to adequately control GR transport. Because DCL is primarily expressed in neuronal progenitor cells, our results introduce this microtubule-associated protein as a new modulator of GR signaling in this cell type and suggest the existence of cell-specific mechanisms regulating GR translocation to the nucleus.

Effects of antenatal glucocorticoids on cerebral substrate metabolism in the preterm ovine fetus

OBJECTIVE

Although the benefits of antenatal glucocorticoids are well known for infants who are born preterm, there is increasing evidence of adverse effects on brain development, which may relate to altered metabolic activity. We have determined the effect of maternal glucocorticoid administration at doses that are used clinically on cerebral substrate metabolism in the preterm ovine fetus.

STUDY DESIGN

Chronically instrumented pregnant sheep at 0.85 gestation received 2 intramuscular injections of betamethasone at 170 microg/kg maternal weight (n = 13) or saline (n = 10) 24 hours apart together with a continuous infusion of L-[1-(13)C] leucine to the fetus. Fetal cerebral substrate arteriovenous differences (O2, glucose, leucine, leucine enrichment) and blood flow (fluorescent microspheres) were measured at baseline, 24 hours after the first betamethasone/saline injection (late beta/saline 1), and 4 hours after the second betamethasone/saline injection (early beta/saline 2) to obtain substrate deliveries and fractional extractions.

RESULTS

Fetal pH, blood gases, and metabolites were little changed in either group over the course of the study, except for glucose values in the betamethasone animals, which increased 1.4- and 1.9-fold, measured late beta 1 and early beta 2, respectively (both P < .01). Cerebral blood flow, although little changed in the control group or at late beta 1, was decreased at early beta 2 by approximately 30% (P < .05). As such, early beta 2 animals showed a decrease in cerebral O2 delivery of approximately 20% (P = .06) and conversely an increase in cerebral glucose delivery of 1.4- and 1.3-fold at late beta 1 (P < .05) and early beta 2 (P = .08), respectively. Fractional extraction values for these substrates were not changed significantly, which resulted in corresponding decreases in estimated O2 uptake and increases in estimated glucose uptake, such that the glucose/oxygen quotient (as an index of glucose oxidative metabolism) measured 1.6 at early beta 2, which was considerably greater than baseline values at 1.1 (P < .05). Fractional extraction values for leucine and leucine enrichment averaged 2%-3%; although somewhat higher in the betamethasone animals, none of the between or within group differences were significant.

CONCLUSION

Fetal cerebral metabolism in the preterm ovine fetus is altered by antenatal glucocorticoid administration, which is comparable with that used in human pregnancy, and includes an acute decrease in cerebral blood flow and a probable increase in anaerobic glucose metabolism. Although likely of short duration in conjunction with peak glucocorticoid levels, these metabolic effects may place the developing brain at added risk for superimposed hypoxic injury.

Effects of antenatal glucocorticoids on cerebral protein synthesis in the preterm ovine fetus

OBJECTIVE

Although antenatal glucocorticoids have well-known benefits for infants who are born preterm by the enhancement of pulmonary maturation, adverse effects on brain growth and development have been reported in several animal-based studies. We have used the chronically catheterized ovine fetus to determine the effects of synthetic glucocorticoids that are administered at doses used clinically on cerebral protein synthesis during early brain development using [13C]-leucine tracer method.

STUDY DESIGN

Chronically instrumented pregnant sheep at 0.85 gestation received 2 intramuscular injections of betamethasone at 170 microg/kg maternal weight or saline 24 hours apart together with a continuous infusion of L-[1-(13)C]-leucine to the fetus on the second day of experimentation. Measurements were obtained for fetal plasma leucine enrichment at steady-state and brain tissue intracellular free and protein-bound leucine enrichment at necropsy, followed by the determination of cerebral protein fractional synthetic rates (FSRs). A coefficient of variation was determined for plasma and tissue enrichment measurements to assess the inherent methodologic variance with the use of [13C]-leucine tracer technology.

RESULTS

The cerebral protein FSR averaged approximately 112% per day and approximately 35% per day when the intracellular free and plasma enrichment values were used for the precursor pool measurements, respectively, providing for maximal and minimal FSR values. There were no differences between cortical and cerebellar tissues nor between the saline control and the betamethasone animal groups. The coefficient of variation for the plasma-enrichment values averaged approximately 2%; the coefficient of variation for the tissue enrichment values averaged approximately 10%, with an inverse relationship between the [13C]-leucine enrichment values and the coefficient of variation values.

CONCLUSION

Although cerebral FSR values for the preterm ovine fetus are high and indicate high rates of protein synthesis and degradation, we found no evidence that these are altered by betamethasone as used clinically and thereby do not account for the reported structural alterations in the brain after a single-course of antenatal glucocorticoids.

Corticosteroids in perinatal medicine: how to improve outcomes without affecting the developing brain?

Antenatal glucocorticoid therapy remains one of the most striking successes in the perinatal management of complicated pregnancies that result in premature birth. The anti-inflammatory and maturative properties of fluorocorticoids are such that all women at risk of preterm delivery before 34weeks gestation should be treated. Betamethasone is preferred to dexamethasone and no more than two courses, 2weeks apart, should be given until the evidence from further controlled trials on repeated doses becomes available. In particular, the early use of postnatal dexamethasone should be avoided in preterm infants because of the deleterious effects on neurological development, including not only cerebral palsy but also cognitive function and psychiatric-related behavior. Treatment with other steroids should be restricted to the context of randomized controlled trials.

Betamethasone-related acute alterations of microtubule-associated proteins in the fetal sheep brain are reversible and independent of age during the last one-third of gestation

OBJECTIVE

The purpose of this study was to examine whether glucocorticoid effects on neuronal cytoskeleton, which we have shown previously at 0.87 gestation when the hypothalamo-pituitary-adrenal axis matures, are age-dependent and reversible.

STUDY DESIGN

Fetal sheep received 3.3 microg kg(-1) h(-1) betamethasone (n = 10) or saline solution (n = 9) intravenously over 48 hours at 0.75 gestation (ie, before the hypothalamo-pituitary-adrenal axis matures and when betamethasone is administered clinically).

RESULTS

Betamethasone diminished microtubule-associated protein (MAP) 1B and 2 immunoreactivity in the frontal neocortex and caudate putamen (P < .05) and MAP2 in the hippocampus (P < .05), which is similar to the effects that are seen at 0.87 gestation. In agreement, the number of glucocorticoid receptors did not differ at both ages. Loss of MAP1B and MAP2 immunoreactivity was not accompanied by neuronal death and was reversible within 24 hours.

CONCLUSION

Alteration of neuronal cytoskeletal proteins caused by antenatal betamethasone exposure is transient and independent of age during late gestation.

Auditory neural maturation after exposure to multiple courses of antenatal betamethasone in premature infants as evaluated by auditory brainstem response

OBJECTIVE

Our goal was to determine if multiple courses of antenatal betamethasone affect auditory neural maturation in 28 to 32 weeks' gestational age infants.

PATIENTS AND METHODS

A retrospective cohort study was performed to compare auditory neural maturation between premature infants exposed to 1 course of betamethasone and infants exposed to > or = 2 courses of betamethasone. Inclusion criteria included all 28 to 32 weeks' gestational age infants delivered between July 1996 and December 1998 who had auditory brainstem response testing performed (80-dB click stimuli at a repetition rate of 39.9/second) within 24 hours of postnatal life as part of bilirubin-auditory studies. Infants with toxoplasmosis, rubella, cytomegalovirus, herpes infections, chromosomal disorders, unstable conditions, exposure to antenatal dexamethasone, and exposure to < 1 complete course of betamethasone were excluded. Auditory waveforms were categorized into response types on response replicability and peak identification as types 1 through 4 (type 1 indicating most mature). Absolute and interpeak wave latencies were measured when applicable. Categorical and continuous variables were analyzed by using the chi2 test and Student's t test, respectively.

RESULTS

Of 174 infants studied, 123 received antenatal steroids. Of these, 50 received 1 course and 29 received > or = 2 courses of betamethasone. There were no significant differences in perinatal demographics between the 2 groups. After controlling for confounding variables, there was no significant difference in mean absolute wave latencies, mean interpeak latencies, or distribution of response type between the 2 groups. There also was no significant difference in any auditory brainstem response parameters between infants exposed to 1 course of betamethasone (n = 50) and infants exposed to > 2 courses of betamethasone (n = 17).

CONCLUSION

Compared with a single recommended course of antenatal steroids, multiple courses of antenatal betamethasone are not associated with a deleterious effect on auditory neural maturation in 28 to 32 weeks' gestational age infants.

Lack of effect of antenatal glucocorticoid therapy in the fetal baboon on cerebral cortical glucose transporter proteins

BACKGROUND

Maternal antenatal glucocorticoid therapy is used to accelerate lung maturation of immature babies at risk of preterm delivery. It acutely affects brain activity of the human fetus and reduces the immunoreactivity of neurocytoskeletal and synaptic proteins in the fetal baboon brain. These effects might be based on cerebral energy failure due to a decreased neuronal glucose uptake that has been shown in vitro.

METHODS

Glucose uptake into the brain is selectively facilitated by GLUT1 expressed in the blood-brain barrier and GLUT3 expressed in the neuronal membrane. Immunohistochemical distribution of GLUT1 and GLUT3 were examined in the frontal neocortex of the fetal baboon brain at 0.73 gestation (i.e. similar to 28 weeks of human gestation) after maternal betamethasone administration, mimicking the clinical dose regimen.

RESULTS

Betamethasone did not alter GLUT1 and GLUT3 immunoreactivity.

CONCLUSIONS

The results suggest that inhibition of glucose uptake is not the mechanism for the cerebral effects of antenatal glucocorticoids.

Microtubule-associated protein 1B, a growth-associated and phosphorylated scaffold protein

Microtubule-associated protein 1B, MAP1B, is one of the major growth associated and cytoskeletal proteins in neuronal and glial cells. It is present as a full length protein or may be fragmented into a heavy chain and a light chain. It is essential to stabilize microtubules during the elongation of dendrites and neurites and is involved in the dynamics of morphological structures such as microtubules, microfilaments and growth cones. MAP1B function is modulated by phosphorylation and influences microtubule stability, microfilaments and growth cone motility. Considering its large size, several interactions with a variety of other proteins have been reported and there is increasing evidence that MAP1B plays a crucial role in the stability of the cytoskeleton and may have other cellular functions. Here we review molecular and functional aspects of this protein, evoke its role as a scaffold protein and have a look at several pathologies where the protein may be involved.

Kinetics of betamethasone and fetal cardiovascular adverse effects in pregnant sheep after different doses

OBJECTIVE

To study the pharmacokinetics of different betamethasone doses and preparations used to enhance fetal lung maturation in the maternal and fetal circulation of sheep and the adverse effects on fetal blood pressure.

METHODS

Doses of 170 (n = 6) and 110 microg/kg (n = 6) betamethasone phosphate equivalent to 12 or 8 mg, respectively, administered to a 70 kg pregnant woman or 170 microg/kg (n = 6) of a depot formulation (50% betamethasone phosphate and 50% betamethasone acetate) were injected intramuscularly to chronically instrumented pregnant sheep.

RESULTS

Both betamethasone preparations produced highest maternal concentrations after 15 min followed by an exponential decline with a t(1/2) of about 3 hours. The drug fell below the limit of detection at 8 to 12 hours. Betamethasone was first detectable in the fetal circulation at 1 hour, peaked at 3 hours, and decreased below the limit of detection at 8 hours independently of the dose or preparation. Maternal and fetal betamethasone concentrations achieved with the phosphate and acetate formulation were one half of those obtained with betamethasone phosphate, suggesting that very little betamethasone is released from the acetate within the first 8 hours when the effect on lung maturation is needed. Betamethasone led to a maximal increase of mean fetal blood pressure from 42+/-1 to 51+/-1 mm Hg (P < .05) and did not differ between the doses and preparations, although plasma concentrations showed a clear dose-concentration relationship.

CONCLUSION

The doses of betamethasone used in obstetrics are supramaximal in terms of cardiovascular effects in sheep. Risk-benefit studies are needed to find the effective steroid dose with the least adverse effects.

Glucose transporter proteins GLUT1 and GLUT3 like immunoreactivities in the fetal sheep brain are not reduced by maternal betamethasone treatment

Synthetic glucocorticoids administered to accelerate fetal lung maturation in threatened preterm delivery change electrocortical brain activity in the human and sheep fetus and alter structural neuronal proteins in fetal baboon and sheep. We hypothesized that these changes are due to a decreased amount of glucose transporter proteins (GLUT). Glucose uptake into cerebral neurons is selectively facilitated by glucose transporter protein GLUT1 in the blood brain barrier and GLUT3 in neuronal membranes. GLUT1 and GLUT3 immunoreactivity was examined in fetal sheep brain sections of the frontal neocortex, caudate putamen and hippocampus at 0.73 gestation after fetal exposure to betamethasone by direct fetal intravenous infusion or maternal intramuscular injections at the clinically relevant dosage. Betamethasone did not alter GLUT1 and GLUT3 immunoreactivity in any of the brain regions investigated, independently of the dose and route of administration. These data indicate that alteration of GLUT expression is unlikely to explain the cerebral functional effects of antenatal glucocorticoids.

Cognition- and anxiety-related behavior, synaptophysin and MAP2 immunoreactivity in the adult rat treated with a single course of antenatal betamethasone

We investigated the effects of a single course of antenatal betamethasone on cognition- and anxiety-related behavior and synaptophysin and microtubule-associated protein 2 (MAP2) immunoreactivity in the adult rat hippocampus. On d 20 of gestation, pregnant rats were injected with either 1) 170 microg/kg body weight of betamethasone ("clinically equivalent dose," equivalent to 12 mg twice, 24 h apart); 2) half this dose; or 3) vehicle. Cognition- and anxiety-related behavior of the offspring was analyzed at an age of 5 mo using the Morris water maze, object recognition task, and open field test. Subsequently, synaptophysin and MAP2 immunoreactivity were measured in the hippocampus. We report no detrimental effects of antenatal betamethasone on cognition- and anxiety-related behavior and synaptophysin immunoreactivity in the adult rat. On the other hand, MAP2 immunoreactivity was decreased by betamethasone in males, suggesting a permanent impairment in the hippocampus. Interestingly, the lower dose appears to have less influence in terms of growth restriction, known to be associated with an increased risk of disease in adulthood. Further research might elucidate whether the betamethasone effect on hippocampal neurons persists later in life and could affect the aging process increasing the risk for neuropathology of the adult.

Effects of multiple courses of antenatal corticosteroids on blood-brain barrier permeability in the ovine fetus

OBJECTIVE

To test the hypothesis that multiple courses of antenatal corticosteroids accentuate the decreases in blood-brain barrier permeability observed after a single course of corticosteroids in preterm ovine fetuses.

METHODS

Chronically instrumented 106-day gestation ovine fetuses were studied after single and multiple courses of dexamethasone or placebo were given to ewes beginning at 104 to 106 or 76 to 78 days of gestation, respectively. In the single-course groups, the ewes received dexamethasone (6 mg, n = 6) or placebo (n = 6) as four intramuscular injections every 12 hours over 48 hours. In the multiple course groups, the ewes received the same treatment (dexamethasone, n = 9, or placebo, n = 8), once per week for 5 weeks starting at 76 to 78 days of gestation. Blood-brain barrier permeability was quantified with the blood-to-brain transfer constant (K(i)) for alpha-aminoisobutyric acid (AIB) in the brain regions of the fetuses 12 hours after the last injection of dexamethasone was given to the ewes at 106 to 107 days of gestation.

RESULTS

Both single (analysis of variance [ANOVA]; main effects for dexamethasone treatment, F = 5.92, P <.04) and multiple (ANOVA; main effects for dexamethasone treatment, F = 4.74, P <.04) courses of antenatal corticosteroids were associated with decreases in blood-brain barrier permeability in the brain regions of the ovine fetus. However, the multiple courses did not accentuate (ANOVA; main effects for single versus multiple courses, F = 1.06, P = .32) the decreases in permeability observed after a single course.

CONCLUSION

Contrary to our hypothesis, antenatal treatment with a 5-week course of corticosteroids did not accentuate the reductions in blood-brain barrier permeability that we observed after a single course of corticosteroids in the fetus.

Cerebral cortical tissue damage after hemorrhagic hypotension in near-term born lambs

Hypotension reduces cerebral O(2) supply, which may result in brain cell damage and loss of brain cell function in the near-term neonate. The aim is to elucidate 1) to what extent the functional disturbance of the cerebral cortex, as measured with electrocortical brain activity (ECBA), is related to cerebral cortical tissue damage, as estimated by MAP2; and 2) whether there is a relationship between the glutamate, nitric oxide (NO), cGMP pathway and the development of cerebral cortical tissue damage after hemorrhagic hypotension. Seven lambs were delivered at 131 d of gestation. Hypotension was induced by withdrawal of blood until mean arterial blood pressure was reduced to 30% of normotension. Cerebral O(2) supply, consumption, and ECBA were calculated in normotensive conditions and after 2.5 h of hypotension. Concentrations of glutamate and aspartate in cerebrospinal fluid (CSF), NO(2) and NO(3) (NOx) in plasma, and cGMP in cortical brain tissue were determined in both conditions. CSF and brain tissue from siblings were used to determine normotensive values. Cortical neuronal damage was detected after 2.5 h of hypotension. ECBA was negatively related to the severity of the cortical damage. ECBA was related to respectively glutamate, NOx, and cGMP concentrations. In conclusion, cortical neuronal damage is detected after 2.5 h of hemorrhagic hypotension in the near-term born lamb. The damage is reflected by a reduction of ECBA. The glutamate, NOx, cGMP pathway is likely to be involved in the pathogenesis of cerebral cortical damage.

Microtubule-associated protein MAP1A, MAP1B, and MAP2 proteolysis during soluble amyloid beta-peptide-induced neuronal apoptosis. Synergistic involvement of calpain and caspase-3

A growing body of evidence supports the notion that soluble oligomeric forms of the amyloid beta-peptide (Abeta) may be the proximate effectors of neuronal injuries and death in the early stages of Alzheimer disease. However, the molecular mechanisms associated with neuronal apoptosis induced by soluble Abeta remain to be elucidated. We recently demonstrated the involvement of an early reactive oxygen species-dependent perturbation of the microtubule network (Sponne, I., Fifre, A., Drouet, B., Klein, C., Koziel, V., Pincon-Raymond, M., Olivier, J.-L., Chambaz, J., and Pillot, T. (2003) J. Biol. Chem. 278, 3437-3445). Because microtubule-associated proteins (MAPs) are responsible for the polymerization, stabilization, and dynamics of the microtubule network, we investigated whether MAPs might represent the intracellular targets that would enable us to explain the microtubule perturbation involved in soluble Abeta-mediated neuronal apoptosis. The data presented here show that soluble Abeta oligomers induce a time-dependent degradation of MAP1A, MAP1B, and MAP2 involving a perturbation of Ca2+ homeostasis with subsequent calpain activation that, on its own, is sufficient to induce the proteolysis of isoforms MAP2a, MAP2b, and MAP2c. In contrast, MAP1A and MAP1B sequential proteolysis results from the Abeta-mediated activation of caspase-3 and calpain. The prevention of MAP1A, MAP1B, and MAP2 proteolysis by antioxidants highlights the early reactive oxygen species generation in the perturbation of the microtubule network induced by soluble Abeta. These data clearly demonstrate the impact of cytoskeletal perturbations on soluble Abeta-mediated cell death and support the notion of microtubule-stabilizing agents as effective Alzheimer disease drugs.

Prenatal corticosteroid impact on hippocampus: implications for postnatal outcomes

Prenatal administration of corticosteroids is common in obstetrics to improve the outcome of premature deliveries. Many pregnant women receive multiple corticosteroid courses. Long-term follow-up studies in humans are limited, but those available suggest detrimental effects on the behavior of those children. Animal data also show adverse effects of prenatal corticosteroids mainly in the hippocampus, a structure sensitive to corticosteroid action. Several molecules involved in neuronal survival, seizure susceptibility, and behavior have been identified as possible targets of prenatal corticosteroid effects. These molecules include hippocampal glucocorticoid receptors, brain-derived neurotrophic factor, corticotropin-releasing hormone, and neuropeptide Y. Prenatal corticosteroid treatment permanently reprograms expression of these molecules. The future goals of research in this area include development of specific antagonists of corticosteroid activation pathways that would help differentiate between positive main effects and undesired adverse effects of prenatally administered corticosteroids.

Betamethasone effects on fetal sheep cerebral blood flow are not dependent on maturation of cerebrovascular system and pituitary-adrenal axis

Synthetic glucocorticoids are administered to pregnant women in premature labour to accelerate fetal lung maturation at a time when fetal cerebrovascular and endocrine systems are maturing. Exposure to glucocorticoids at 0.8-0.9 of gestation increases peripheral and cerebrovascular resistance (CVR) in fetal sheep. We examined whether the increase of CVR and its adverse effect on cerebral blood flow (CBF) depend on the current level of maturation of the pituitary-adrenal axis and the cerebrovascular system. Using fluorescent microspheres, regional CBF was measured in 11 brain regions before and 24 h and 48 h after the start of 3.3 microg kg(-1) h(-1) betamethasone (n = 8) or vehicle (n = 7) infusions to fetal sheep at 0.73 of gestation. Hypercapnic challenges were performed before and 24 h after the onset of betamethasone exposure to examine betamethasone effects on cerebrovascular reactivity. Betamethasone exposure decreased CBF by approximately 40% in all brain regions after 24 h of infusion (P < 0.05). The decline in CBF was mediated by a CVR increase of 111 +/- 16% in the cerebral cortex and 129 +/- 29% in subcortical regions (P < 0.05). Hypercapnic cerebral vasodilatation and associated increase in CBF were blunted (P < 0.05). Fetal CBF recovered after 48 h of betamethasone administration. There were no differences in glucocorticoid induced CBF and CVR changes compared with our previous findings at 0.87 of gestation. We conclude that the cerebrovascular effects of antenatal glucocorticoids are independent of cerebrovascular maturation and preparturient increase in activity of the fetal pituitary-adrenal axis.

Corticothérapie post-natale chez le prématuré : bénéfices et risques

This review examines the risk/benefit ratio of postnatal steroid treatment in preterm infants and correlates epidemiological data with special emphasis on experimental evidence concening the impact of steroid on brain development. With all regimens, steroid treatment consistently reduced the need for assisted ventilation at 28 days of postnatal age or at term. However, neither oxygen at term nor neonatal mortality has been decreased by this treatment. Conversely, respiratory benefits should be weighed against several adverse effects: hyperglycemia, hypertension, gastrointestinal bleeding or perforation, increased risk of cerebral palsy. The impact of dexamethasone on brain development and risk factors of white matter damage could be involved in the association between postnatal steroid treatment and neurological impairment in treated infants. Injectable preparations of dexamethasone contain sulphiting preservatives which could account for the alterations in neuronal maturation observed in animal models. Early use of dexamethasone should especially be avoided for postnatal steroid treatment in premature infants. Other glucocorticoids as alternatives to dexamethasone need to be evaluated in appropriate and large controlled trials with long term follow up.

The response of synaptophysin and microtubule-associated protein 1 to restraint stress in rat hippocampus and its modulation by venlafaxine

As part of our continuing study of neural plasticity in rat hippocampus, we examined two structural proteins involved in neuronal plasticity, synaptophysin (SYP) and microtubule-associated protein 1 (MAP1) for their response to repeated restraint stress and modulation of such response by the antidepressant drug venlafaxine. This drug has the pharmacological action of inhibiting the reuptake of serotonin and norepinephrine in nerve terminals. We subjected the rats to restraint stress for 4 h per day for three days, and then injected the animals intraperitoneally (i.p.) with vehicle or 5 mg/kg/day of venlafaxine for various time periods. In all, eight groups of 10 rats each were used. The expression of these two proteins in hippocampal tissue of the rats was examined by means of western blot and immunohistochemical staining techniques. We found that restraint stress decreased the expression of SYP in the rat hippocampus by 50% (p < 0.01), and increased the expression of MAP1 by 60% (p < 0.01). SYP returned to the pre-stress levels in three weeks and MAP1 in two weeks. In animals treated with venlafaxine post-stress, SYP returned to pre-stress levels after 2 weeks and MAP1 after 1 week. These findings enhance our understanding of the compromise of the hippocampus by stressful assaults, and may be relevant to the action of venlafaxine in the treatment of patients with major depression, a mental disease thought to be related to the mal-adaptation of subjects to environmental stressors.

MAP-2 expression in the human adenohypophysis and in pituitary adenomas. An immunohistochemical study

MAP-2, a well characterized member of the microtubule associated protein (MAP) family, binds to and stabilizes microtubules and is involved in cell proliferation as well as neuronal differentiation. The aim of the present work was to study MAP-2 expression in human adenohypophyses and pituitary adenomas. To our knowledge, data regarding MAP-2 expression in human pituitaries has not been reported to date. For immunohistochemistry, the streptavidin-biotin-peroxidase complex method was used. Nine non-tumorous adenohypophyses and 77 adenomas (GH-, PRL-, ACTH-, TSH-, FSH/LH- and/or alpha subunit- producing or immunonegative tumors) were investigated. The results show that MAP-2 is expressed in the cytoplasm of non-tumorous adenohypophysial cells as well as of various pituitary adenoma types. No significant correlation was found between MAP-2 expression and gender, patient age, mitotic activity, MIB-1 labelling indices, hormone immunoprofile, and endocrine status, ie. hormonal activity or lack thereof. Thus MAP-2 expression cannot be used to estimate cell proliferation rate, growth potential, endocrine activity or biologic behaviour of an adenoma. Immunopositivity appeared to be stronger in the cytoplasm of adenoma cells than in that of non-tumorous adenohypophysial cells, implying that the adenoma cells contain larger quantities of MAP-2. It can be concluded that the functional activity of MAP-2 is not associated with the manufacture of any specific adenohypophysial hormone(s) and is not limited to one specific cell type.

Recovery of glucocorticoid-related loss of synaptic density in the fetal sheep brain at 0.75 of gestation

Antenatal glucocorticoids routinely used to accelerate fetal lung maturation in human pregnancy at risk of preterm delivery decrease synaptic density and complex electrocortical activity in the fetal sheep brain at 0.87 gestation. We examined whether the effects of betamethasone on synaptic density depend on maturation of hypothalamo-pituitary-adrenal (HPA) axis and whether these effects are reversible. Betamethasone infusion to fetal sheep comparable to the dose used clinically (3.3 microg kg(-1) h(-1) over 48 h) at 0.75 gestation and, thus, before the prepartum increase of cortisol, reduced synaptophysin immunoreactivity (SY-IR) in the frontal neocortex, caudate putamen and hippocampus (P < 0.05). Loss of SY-IR exceeded that shown previously at 0.87 gestation (P < 0.05). It was not accompanied by neuronal damage and was reversible within 24h. In conclusion, fetal betamethasone exposure induces a gestational age-dependent decrease of synaptic density that is transient and more severe in younger fetuses.

Postnatal steroid treatment and brain development

This review examines the risk/benefit ratio of postnatal steroid treatment in preterm infants and correlates epidemiological data with experimental evidence on the effect of glucocorticosteroids on brain development.

Effects of three courses of maternally administered dexamethasone at 0.7, 0.75, and 0.8 of gestation on prenatal and postnatal growth in sheep

OBJECTIVES

To evaluate the effects of repeated low doses of maternally administered dexamethasone (DM) on growth in sheep during fetal life and the first 2 years of postnatal life.

METHODS

Ewes received 3 courses of DM (1 course: four 2-mg intramuscular injections at 12-hour intervals) or saline beginning at 103, 110, and 117 days of gestation (dGA). At 119 dGA, fetal BW and organ weight were recorded. Total placentome number, weight, and morphologic distributions were recorded. Placentome glucocorticoid receptor expression was determined by immunocytochemistry. Newborn BW and organ weight were recorded within 12 hours of birth. Duration of gestation was recorded. Measurements were collected on body weight (BW), biparietal diameter (BPD), crown-to-rump length, thoracic girth circumference, abdominal girth circumference, and radial bone length for 2 months. Maternal estradiol and progesterone levels were measured daily from 135 dGA.

RESULTS

At 119 dGA, DM significantly decreased BW. Placentome glucocorticoid receptor expression increased after DM exposure. DM did not significantly decrease BW at birth but did prolong gestation length. DM decreased maternal estradiol before lambing. DM decreased newborn brain weight and BPD. After 2 weeks of age, no effect of DM on postnatal growth could be found.

CONCLUSIONS

This study shows that repeated maternal DM treatment at doses threefold lower than what women in preterm labor receive results in decreased fetal BW, prolonged gestation length, decreased newborn brain weight, and BPD.

Antenatal corticosteroid therapy: benefits and risks

Antenatal glucocorticoid therapy remains one the most striking successes in perinatal management of complicated pregnancies leading to premature birth. All women at risk of preterm delivery before 34 weeks gestation should be treated, given the anti-inflammatory and maturative properties of fluorocorticoids. Betamethasone is preferred to dexamethasone and no more than two courses, two weeks apart, should be given, until the evidence from further controlled trials on repeated doses becomes available.

Brainstem maturation after antenatal steroids exposure in premature infants as evaluated by auditory brainstem-evoked response

OBJECTIVE

Antenatal steroids result in fetal lung maturation, but may retard brain development. Auditory brainstem-evoked response (ABR) is a noninvasive assessment of brainstem maturation. The objective of this study was to determine if antenatal steroids affect brainstem maturation in infants </=32 weeks gestational age (GA).

DESIGN/METHODS

Bilateral monaural ABR were performed within the first 24 hours using 80 db nHL unfiltered click stimuli at a repetition rate of 39.9/seconds. ABR waveforms were categorized into Response Types based on response replicability and peak identification. Absolute wave latencies and interpeak latencies were measured when applicable. Data were collected for antenatal steroid exposure, mode of delivery, chorioamnionitis in utero, exposure to illicit drugs, exposure to magnesium sulfate, mechanical ventilation and 5 minute Apgar score <5 minute. Infants with TORCH infections, unstable conditions, and chromosomal disorders were excluded.

RESULTS

Of 186 infants studied, 130 received antenatal steroids. Data were analyzed in 2 week GA intervals. There was a significant difference (P<0.05) in race (29 vs 39% African-American), birth weight (1231 vs 1416 gm) and use of magnesium sulfate (60 vs 32%) among infants who did and did not receive antenatal steroids, respectively. There was no significant difference in the other parameters measured. Even after controlling for confounding variables, there was no difference between absolute wave latencies or interpeak latencies between groups at either 28 to 29 weeks' or 30 to 31 weeks' postmenstrual age. There was no significant difference in frequency distribution of ABR waveform Response Types between groups.

CONCLUSIONS

Antenatal steroids have neither a deleterious nor beneficial effect on brainstem maturation as measured by ABR in infants at </=32 weeks GA.

Glucocorticoid exposure at the dose used clinically alters cytoskeletal proteins and presynaptic terminals in the fetal baboon brain

Glucocorticoids have been used for 30 years to accelerate fetal lung maturation in human pregnancy at risk of preterm delivery. Exposure to inappropriate levels of steroid, however, leads to altered maturation of the cardiovascular, metabolic and central nervous systems. The effects of betamethasone on neuronal development and function were determined in the fetal baboon brain by examination of cytoskeletal microtubule associated proteins (MAPs) and the presynaptic marker protein synaptophysin. At 0.73 gestation, commencing 28 weeks of gestation, pregnant baboons received four doses of saline (n = 8) or 87.5 microg (kg body weight)(-1) betamethasone I.M. (n = 7) 12 h apart. This dose is equivalent to 12 mg betamethasone administered daily over two consecutive days to a 70 kg woman. Baboons underwent Caesarean section 12 h after the last injection. Paraffin sections of the fetal neocortex and the underlying white matter were labelled immunohistochemically against MAP1B, MAP2abc, MAP2ab and synaptophysin and stained histochemically with hematoxylin-eosin and silver. Tissue staining was quantified morphometrically. Betamethasone exposure resulted in decreased immunoreactivity (IR) of MAP1B by 34.3 % and MAP2abc by 34.1 % (P < 0.05). Loss of MAP2 IR was due to loss of IR of the juvenile isoform MAP2c (P < 0.05). MAP1B and MAP2c are involved in neuritogenesis and neuronal plasticity. Synaptophysin IR was reduced by 51.8 % (P < 0.01). These changes might reflect functional neuronal disturbances because they were not accompanied by an alteration of the density of neurofibrils or neuronal necrosis. These results are in agreement with earlier findings of alterations of cytoskeletal proteins and presynaptic terminals in the fetal sheep brain after betamethasone infusion directly to the fetus and support a common effect of inappropriate fetal exposure to glucocorticoids on neuronal cytoskeleton and synapses in mammalian species.