Reversible umbilical cord occlusion: effects on thermogenesis in utero

Preparing for Life After Birth: Introducing the Concepts of Intrauterine and Extrauterine Sensory Entrainment in Mammalian Young

Presented is an updated understanding of the development of sensory systems in the offspring of a wide range of terrestrial mammals, the prenatal exposure of those systems to salient stimuli, and the mechanisms by which that exposure can embed particular sensory capabilities that prepare newborns to respond appropriately to similar stimuli they may encounter after birth. Taken together, these are the constituents of the phenomenon of "trans-natal sensory continuity" where the embedded sensory capabilities are considered to have been "learnt" and, when accessed subsequently, they are said to have been "remembered". An alternative explanation of trans-natal sensory continuity is provided here in order to focus on the mechanisms of "embedding" and "accessing" instead of the potentially more subjectively conceived outcomes of "learning" and "memory". Thus, the mechanistic concept of "intrauterine sensory entrainment" has been introduced, its foundation being the well-established neuroplastic capability of nervous systems to respond to sensory inputs by reorganising their neural structures, functions, and connections. Five conditions need to be met before "trans-natal sensory continuity" can occur. They are (1) sufficient neurological maturity to support minimal functional activity in specific sensory receptor systems in utero; (2) the presence of sensory stimuli that activate their aligned receptors before birth; (3) the neurological capability for entrained functions within specific sensory modalities to be retained beyond birth; (4) specific sensory stimuli that are effective both before and after birth; and (5) a capability to detect those stimuli when or if they are presented after birth in ways that differ (e.g., in air) from their presentation via fluid media before birth. Numerous beneficial outcomes of this process have been reported for mammalian newborns, but the range of benefits depends on how many of the full set of sensory modalities are functional at the time of birth. Thus, the breadth of sensory capabilities may be extensive, somewhat restricted, or minimal in offspring that are, respectively, neurologically mature, moderately immature, or exceptionally immature at birth. It is noted that birth marks a transition from intrauterine sensory entrainment to extrauterine sensory entrainment in all mammalian young. Depending on their neurological maturity, extrauterine entrainment contributes to the continuing maturation of the different sensory systems that are operational at birth, the later development and maturation of the systems that are absent at birth, and the combined impact of those factors on the behaviour of newborn and young mammals. Intrauterine sensory entrainment helps to prepare mammalian young for life immediately after birth, and extrauterine sensory entrainment continues this process until all sensory modalities develop full functionality. It is apparent that, overall, extrauterine sensory entrainment and its aligned neuroplastic responses underlie numerous postnatal learning and memory events which contribute to the maturation of all sensory capabilities that eventually enable mammalian young to live autonomously.

Hyperthermia, inflammation, and perinatal brain injury

Hyperthermia at the time of or following a hypoxic-ischemic insult has been associated with adverse neurodevelopmental outcome. Moreover, an elevation in temperature during labor has been associated with a variety of other adverse neurologic sequelae such as neonatal seizures, encephalopathy, stroke, and cerebral palsy. These outcomes may be secondary to a number of deleterious effects of hyperthermia including an increase in cellular metabolic rate and cerebral blood flow alteration, release of excitotoxic products such as free radicals and glutamate, and hemostatic changes. There is also an association between chorioamnionitis at the time of delivery and cerebral palsy, which is thought to be secondary to cytokine-mediated injury. We review experimental and human studies demonstrating a link between hyperthermia and perinatal brain injury.

Can extrauterine growth approximate intrauterine growth? Should it?

Most studies evaluating the growth of preterm infants use the so-called intrauterine growth curve and reference fetus as standards. These curves might not be the optimal standards, however, for several reasons. The curves were constructed from small numbers of infants with uncertainty about gestational age, reasons for preterm birth, and, for body-composition data, the reasons for the death of the infant. Second, preterm infants after birth are not comparable with fetuses, being in a completely different environment and receiving a completely different nutrition. For instance, a higher percentage of body fat in preterm infants might well be an adequate adaptation to their environment. To get preterm infants to adhere to their supposed growth curve percentile, catch-up growth is needed. Recent studies indicate that catch-up growth might be advantageous for brain development. It might at the same time increase the incidence of cardiovascular disease in later life. The use of intrauterine growth curves to evaluate postnatal growth needs a critical reevaluation.

The importance of ‘awareness’ for understanding fetal pain

Our understanding of when the fetus can experience pain has been largely shaped by neuroanatomy. However, completion of the cortical nociceptive connections just after mid-gestation is only one part of the story. In addition to critically reviewing evidence for whether the fetus is ever awake or aware, and thus able to truly experience pain, we examine the role of endogenous neuro-inhibitors, such as adenosine and pregnanolone, produced within the feto-placental unit that contribute to fetal sleep states, and thus mediate suppression of fetal awareness. The uncritical view that the nature of presumed fetal pain perception can be assessed by reference to the prematurely born infant is challenged. Rigorously controlled studies of invasive procedures and analgesia in the fetus are required to clarify the impact of fetal nociception on postnatal pain sensitivity and neural development, and the potential benefits or harm of using analgesia in this unique setting.

Responsiveness, behavioural arousal and awareness in fetal and newborn lambs: experimental, practical and therapeutic implications

This review distinguishes between physical responsiveness, behavioural arousal and awareness in fetal and newborn lambs, and summarises the physical and physiological factors which activate and suppress behavioural arousal. Important activators include: rising blood oestrogen concentrations just before birth; physical stimuli during delivery; exposure to cold on delivery, and; elevation in blood oxygen levels following the onset of pulmonary respiration. Suppressors of behavioural arousal and awareness are: low oxygen levels and high concentrations of progesterone and its metabolites in the fetal circulation, and; exposure to a warm intrauterine environment and to a circulating placental factor that inhibits activity including breathing.</br> In view of the relatively high levels of oxygen required to sustain awareness in adult animals, the low levels in fetal circulation, and the actions of other suppressors, it is unlikely that awareness occurs in the fetus. Nevertheless, fetuses perform a range of physical acts that would be supported or initiated by brainstem activity. In addition they show physical responses to potentially painful stimuli during late gestation, but it has yet to be demonstrated that these are linked to perception of pain. It is postulated that perception of pain could only occur once there is a level of oxygenation that supports overall awareness, and under normal circumstances this would only occur once the newborn starts breathing air. The implications for the welfare of fetal lambs and calves during experimental surgery, slaughter of the pregnant dam, collection of blood (serum) from fetuses at slaughter, and during fetotomy are favourable, indicating that current practices, when carefully undertaken, are humane.</br>

Metabolic and endocrine responses to cold exposure in chronically incubated extrauterine goat fetuses

To investigate developmental aspects of metabolic and endocrine responses to cold exposure in fetuses, we conducted experiments on six goat fetuses, three aged 95-116 d of gestation (dGA; group I), and three aged 122-134 dGA (group II), using an extrauterine fetal incubation system that provided arterio-venous extracorporeal membrane oxygenation (A-V ECMO). The fetuses were cannulated via the umbilical vessels, and their blood gas exchange was totally supported by A-V ECMO, while they were maintained in an isothermal incubator containing artificial amniotic fluid. After confirming that fetuses were in metabolically stable condition in the extrauterine incubation system, fetal core temperature was lowered by 2 degrees C over 2 h by decreasing the temperature of incubating fluid from 39.5 degrees C. During and after cold exposure, fetal heart rate and arterial blood pressure remained unchanged. We observed significant increases in oxygen consumption and plasma concentrations of norepinephrine, epinephrine, adrenocorticotropic hormone, and cortisol in group II but not in group I fetuses. In addition, based on regression analysis, maximal changes of these parameters during cold exposure were linearly correlated with gestational age significantly, and the regression lines were found to intersect the x (gestational age) axis at around 98-106 dGA. These results suggest that metabolic and endocrine responses to cold exposure develop with gestational age in the goat fetus, the responses being manifested around 100 dGA.

Perinatal thermogenesis

The rapid initiation of thermogenesis is crucial for the survival of newborn infants. At birth the fetus must adapt to cooling, increased oxygenation and separation from the placenta. An experimental approach in the chronically instrumental fetal sheep of 'simulated birth in utero' allowed the evaluation of each of these stimuli sequentially. Cooling stimulated shivering, cardiovascular and endocrine responses but not nonshivering thermogenesis (NST). Ventilation of the cooled fetus with oxygen caused only modest NST which was not altered by an infusion of triiodothyronine. Occluding the umbilical cord was followed by a rapid substantial rise in NST which was maintained until the placental circulation was re-established. Thus the placenta is secreting factors into the fetal circulation which inhibit the ability of the brown adipose tissue to respond to either hormonal or neural stimuli. Placental prostaglandin E2 and probably adenosine are tonic inhibitors of thermogenesis in utero. Effective thermogenesis after birth requires the combination of separation from the placental inhibitors of lipolysis, increased oxygenation from breathing and the stimulation of cutaneous cold receptors.

Role of prostaglandin E2 and prostacyclin in nonshivering thermogenesis during simulated birth in utero

Prostaglandin E2 (PGE2) inhibits and prostacyclin (PGI2), stimulates lipolysis in vitro. Their role in initiating nonshivering thermogenesis at birth was investigated in 16 fetal sheep at 129-143 days gestation. In 10 fetuses indomethacin, a prostaglandin synthesis inhibitor, was infused; in 6 fetuses saline was administered as a control. 16 h later birth was simulated in utero. The plasma levels of PGE2 and PGI2 were unaffected by cooling. In the control fetuses, ventilation with oxygen caused PGE2 to fall, PGI2 to rise, and initiated moderate thermogenesis, signaled by a twofold increase in plasma free fatty acids (FFA). After umbilical cord occlusion, PGE2 decreased further (PGI2 was unchanged) and thermogenesis accelerated. In indomethacin-treated fetuses, in which the prostanoids had decreased and remained at approximately 20% normal, cooling initiated moderate nonshivering thermogenesis, and ventilation and cord occlusion caused no further changes. Changes in plasma adenosine were similar in control and indomethacin-treated groups. We conclude that declining PGE2 and rising PGI2 contribute to the initiation of thermogenesis at birth, but that other agents possibly of placental origin may play a contributory role.