Effect of alteration of maternal plasma progesterone concentrations on fetal behavioural state during late gestation

Evaluating changes in GABAergic and glutamatergic pathways in early life following prenatal stress and postnatal neurosteroid supplementation

BACKGROUND

A correct balance of activity of the GABA and glutamate systems is vital for optimal neurodevelopment and general CNS function, and the dysregulation of this balance has been implicated in a number of neurological conditions. Maternal exposure to stressors is known to have long lasting, deleterious impacts on neurobehaviour, and similarly, results in dysregulation of inhibitory and excitatory pathways in the offspring. The current study aimed to examine effects on these pathways in a guinea pig model of prenatal stress and to elucidate whether increased neuroprotective support by postnatal neurosteroid supplementation would ameliorate adverse outcomes.

METHODS

Prenatal stress was achieved by exposing pregnant guinea pigs dams to a strobe light for 2hrs/day on gestational age (GA) 50, 55, 60 and 65. Dams were allowed to spontaneously deliver (~GA70) and pups were orally administered either allopregnanolone analogue, ganaxolone (5 mg/kg/day in 45% cyclodextrin), the translocator protein (TSPO) agonist, emapunil (XBD173; 0.3 mg/kg/day in 1% tragacanth gum) or vehicle on postnatal days (PND) 1-7. Hippocampal samples were collected at PND30 to measure relative mRNA expression of components involved in the inhibitory GABAergic pathway and exctitatory glutamatergic pathway by real-time PCR. GABAergic interneurons were quantified by assessing immunohistochemical protein expression of markers parvalbumin, calbindin and calretinin.

RESULTS

mRNA expression of GABAergic pathway components at one week of age indicated immature expression profiles of the GABA_A receptors as well as decreased GABA synthesis and transport suggesting reduced extrasynaptically-mediated tonic inhibition. Expression profiles of the pathways examined evolved between one week and one month of age but an imbalance in inhibitory/excitatory components persisted. The allopregnanolone analogue ganaxolone offered some protection against excitotoxicity in female hippocampus, however neurosteroid supplementation with ganaxolone or emapunil were unable to fully correct the GABAergic/glutamatergic imbalance observed following prenatal stress.

CONCLUSION

Prenatal stress leads to programmed lasting effects on the major inhibitory and excitatory pathways in the guinea pig brain that continue evolving between the equivalent of early and late childhood. Neurosteroid therapies particularly improved outcomes in females. Further studies are required to identify additional therapeutic targets that are able to fully restore imbalances in the excitatory and inhibitory systems, which may act to prevent development of childhood behavioural disorders.

Impaired Oligodendrocyte Development Following Preterm Birth: Promoting GABAergic Action to Improve Outcomes

Preterm birth is associated with poor long-term neurodevelopmental and behavioral outcomes, even in the absence of obvious brain injury at the time of birth. In particular, behavioral disorders characterized by inattention, social difficulties and anxiety are common among children and adolescents who were born moderately to late preterm (32-37 weeks' gestation). Diffuse deficits in white matter microstructure are thought to play a role in these poor outcomes with evidence suggesting that a failure of oligodendrocytes to mature and myelinate axons is responsible. However, there remains a major knowledge gap over the mechanisms by which preterm birth interrupts normal oligodendrocyte development. In utero neurodevelopment occurs in an inhibitory-dominant environment due to the action of placentally derived neurosteroids on the GABA_A receptor, thus promoting GABAergic inhibitory activity and maintaining the fetal behavioral state. Following preterm birth, and the subsequent premature exposure to the ex utero environment, this action of neurosteroids on GABA_A receptors is greatly reduced. Coinciding with a reduction in GABAergic inhibition, the preterm neonatal brain is also exposed to ex utero environmental insults such as periods of hypoxia and excessive glucocorticoid concentrations. Together, these insults may increase levels of the excitatory neurotransmitter glutamate in the developing brain and result in a shift in the balance of inhibitory: excitatory activity toward excitatory. This review will outline the normal development of oligodendrocytes, how it is disrupted under excitation-dominated conditions and highlight how shifting the balance back toward an inhibitory-dominated environment may improve outcomes.

Early pregnancy maternal progesterone administration alters pituitary and testis function and steroid profile in male fetuses

Maternal exposure to increased steroid hormones, including estrogens, androgens or glucocorticoids during pregnancy results in chronic conditions in offspring that manifest in adulthood. Little is known about effects of progesterone administration in early pregnancy on fetal development. We hypothesised that maternal early pregnancy progesterone supplementation would increase fetal progesterone, affect progesterone target tissues in the developing fetal reproductive system and be metabolised to other bioactive steroids in the fetus. We investigated the effects of progesterone treatment during early pregnancy on maternal and fetal plasma progesterone concentrations, transcript abundance in the fetal pituitary and testes and circulating steroids, at day 75 gestation, using a clinically realistic ovine model. Endogenous progesterone concentrations were lower in male than female fetuses. Maternal progesterone administration increased male, but not female, fetal progesterone concentrations, also increasing circulating 11-dehydrocorticosterone in male fetuses. Maternal progesterone administration altered fetal pituitary and testicular function in ovine male fetuses. This suggests that there may be fetal sex specific effects of the use of progesterone in early pregnancy, and highlights that progesterone supplementation should be used only when there is clear evidence of efficacy and for as limited time as necessary.

Reduced Neurosteroid Exposure Following Preterm Birth and Its' Contribution to Neurological Impairment: A Novel Avenue for Preventative Therapies

Children born preterm are at an increased risk of developing cognitive problems and neuro-behavioral disorders such as attention deficit hyperactivity disorder (ADHD) and anxiety. Whilst neonates born at all gestational ages, even at term, can experience poor cognitive outcomes due to birth-complications such as birth asphyxia, it is becoming widely known that children born preterm in particular are at significant risk for learning difficulties with an increased utilization of special education resources, when compared to their healthy term-born peers. Additionally, those born preterm have evidence of altered cerebral myelination with reductions in white matter volumes of the frontal cortex, hippocampus and cerebellum evident on magnetic resonance imaging (MRI). This disruption to myelination may underlie some of the pathophysiology of preterm-associated brain injury. Compared to a fetus of the same post-conceptional age, the preterm newborn loses access to in utero factors that support and promote healthy brain development. Furthermore, the preterm ex utero environment is hostile to the developing brain with a myriad of environmental, biochemical and excitotoxic stressors. Allopregnanolone is a key neuroprotective fetal neurosteroid which has promyelinating effects in the developing brain. Preterm birth leads to an abrupt loss of the protective effects of allopregnanolone, with a dramatic drop in allopregnanolone concentrations in the preterm neonatal brain compared to the fetal brain. This occurs in conjunction with reduced myelination of the hippocampus, subcortical white matter and cerebellum; thus, damage to neurons, astrocytes and especially oligodendrocytes of the developing nervous system can occur in the vulnerable developmental window prior to term as a consequence reduced allopregnanolone. In an effort to prevent preterm-associated brain injury a number of therapies have been considered, but to date, other than antenatal magnesium sulfate and corticosteroid therapy, none have become part of standard clinical care for vulnerable infants. Therefore, there remains an urgent need for improved therapeutic options to prevent brain injury in preterm neonates. The actions of the placentally derived neurosteroid allopregnanolone on GABAA receptor signaling has a major role in late gestation neurodevelopment. The early loss of this intrauterine neurotrophic support following preterm birth may be pivotal to development of neurodevelopmental morbidity. Thus, restoring the in utero neurosteroid environment for preterm neonates may represent a new and clinically feasible treatment option for promoting better trajectories of myelination and brain development, and therefore reducing neurodevelopmental disorders in children born preterm.

Waking up too early - the consequences of preterm birth on sleep development

Good quality sleep of sufficient duration is vital for optimal physiological function and our health. Sleep deprivation is associated with impaired neurocognitive function and emotional control, and increases the risk for cardiometabolic diseases, obesity and cancer. Sleep develops during fetal life with the emergence of a recognisable pattern of sleep states in the preterm fetus associated with the development, maturation and connectivity within neural networks in the brain. Despite the physiological importance of sleep, surprisingly little is known about how sleep develops in individuals born preterm. Globally, an estimated 15 million babies are born preterm (<37 weeks gestation) each year, and these babies are at significant risk of neural injury and impaired brain development. This review discusses how sleep develops during fetal and neonatal life, how preterm birth impacts on sleep development to adulthood, and the factors which may contribute to impaired brain and sleep development, leading to altered neurocognitive, behavioural and motor capabilities in the infant and child. Going forward, the challenge is to identify specific risk factors for impaired sleep development in preterm babies to allow for the design of interventions that will improve the quality and quantity of sleep throughout life.

Maternal stress in pregnancy affects myelination and neurosteroid regulatory pathways in the guinea pig cerebellum

Prenatal stress predisposes offspring to behavioral pathologies. These may be attributed to effects on cerebellar neurosteroids and GABAergic inhibitory signaling, which can be linked to hyperactivity disorders. The aims were to determine the effect of prenatal stress on markers of cerebellar development, a key enzyme in neurosteroid synthesis and the expression of GABA_A receptor (GABA_AR) subunits involved in neurosteroid signaling. We used a model of prenatal stress (strobe light exposure, 2 h on gestational day 50, 55, 60 and 65) in guinea pigs, in which we have characterized anxiety and neophobic behavioral outcomes. The cerebellum and plasma were collected from control and prenatally stressed offspring at term (control fetus: n = 9 male, n = 7 female; stressed fetus: n = 7 male, n = 8 female) and postnatal day (PND) 21 (control: n = 8 male, n = 8 female; stressed: n = 9 male, n = 6 female). We found that term female offspring exposed to prenatal stress showed decreased expression of mature oligodendrocytes (∼40% reduction) and these deficits improved to control levels by PND21. Reactive astrocyte expression was lower (∼40% reduction) following prenatal stress. GABA_AR subunit (δ and α6) expression and circulating allopregnanolone concentrations were not affected by prenatal stress. Prenatal stress increased expression (∼150-250% increase) of 5α-reductase type-1 mRNA in the cerebellum, which may be a neuroprotective response to promote GABAergic inhibition and aid in repair. These observations indicate that prenatal stress exposure has marked effects on the development of the cerebellum. These findings suggest cerebellar changes after prenatal stress may contribute to adverse behavioral outcomes after exposure to these stresses.

Cerebral haemodynamic response to somatosensory stimulation in neonatal lambs

KEY POINTS

Cerebral haemodynamic response to neural stimulation has been extensively studied in adults, but little is known about cerebral haemodynamic response in the fetal and neonatal brain. The present study describes the cerebral haemodynamic response measured by near infrared spectroscopy to somatosensory stimulation in newborn lambs, in comparison to recent findings in fetal sheep. The cerebral haemodynamic responses in the newborn lamb brain can involve an increase in oxyhaemoglobin (oxyHb), or a decrease of oxyHb suggestive of reduced perfusion and oxygenation. Positive correlations between changes in oxyHb and mean arterial blood pressure were found in newborn but not fetal sheep, which suggests the result is unlikely to be due to immature autoregulation alone. In contrast to adult studies, hypercapnia increased the changes in cerebral blood flow and oxyHb in most of the lambs in response to somatosensory stimulation.

ABSTRACT

The neurovascular coupling response has been defined for the adult brain, but in the neonate non-invasive measurement of local cerebral perfusion using near infrared spectroscopy or blood oxygen level-dependent functional magnetic resonance imaging have yielded variable and inconsistent results, including negative responses suggesting decreased perfusion and localized tissue tissue hypoxia. Also, the impact of permissive hypercapnia (P aC O2 > 50 mmHg) in the management of neonates on cerebrovascular responses to somatosensory input is unknown. Using near infrared spectroscopy to measure changes in cerebral oxy- and deoxyhaemoglobin (ΔoxyHb, ΔdeoxyHb) in eight anaesthetized newborn lambs, we studied the cerebral haemodynamic functional response to left median nerve stimulation using stimulus trains of 1.8, 4.8 and 7.8 s. Stimulation always produced a somatosensory evoked response, and superficial cortical perfusion measured by laser Doppler flowmetry predominantly increased following median nerve stimulation. However, with 1.8 s stimulation, oxyHb responses in the contralateral hemisphere were either positive (i.e. increased oxyHb), negative, or absent; and with 4.8 and 7.8 s stimulations, both positive and negative responses were observed. Hypercapnia increased baseline oxyHb and total Hb consistent with cerebral vasodilatation, and six of seven lambs tested showed increased Δtotal Hb responses after the 7.8 s stimulation, among which four lambs also showed increased ΔoxyHb responses. In two of three lambs, the negative ΔoxyHb response became a positive pattern during hypercapnia. These results show that instead of functional hyperaemia, somatosensory stimulation can evoke negative (decreased oxyHb, total Hb) functional responses in the neonatal brain suggestive of decreased local perfusion and vasoconstriction, and that hypercapnia produces both baseline hyperperfusion and increased functional hyperaemia.

Ontogenetic Change in the Regional Distribution of Dehydroepiandrosterone-Synthesizing Enzyme and the Glucocorticoid Receptor in the Brain of the Spiny Mouse (Acomys cahirinus)

The androgen dehydroepiandrosterone (DHEA) has trophic and anti-glucocorticoid actions on brain growth. The adrenal gland of the spiny mouse (Acomys cahirinus) synthesizes DHEA. The aim of this study was to determine whether the brain of this precocial species is also able to produce DHEA de novo during fetal, neonatal and adult life. The expression of P450c17 and cytochrome b5 (Cytb5), the enzyme and accessory protein responsible for the synthesis of DHEA, was determined in fetal, neonatal and adult brains by immunocytochemistry, and P450c17 bioactivity was determined by the conversion of pregnenolone to DHEA. Homogenates of fetal brain produced significantly more DHEA after 48 h in culture (22.46 ± 2.0 ng/mg tissue) than adult brain homogenates (5.04 ± 2.0 ng/mg tissue; p < 0.0001). P450c17 and Cytb5 were co-expressed in fetal neurons but predominantly in oligodendrocytes and white matter tracts in the adult brain. Because DHEA modulates glucocorticoids actions, the expression of the glucocorticoid receptor (GR) was also determined. In the brainstem, medulla, midbrain, and cerebellum, the predominant GR localization changed from neurons in the fetal brain to oligodendrocytes and white matter tracts in the adult brain. The change of expression of P450c17, Cytb5 and GR proteins with cell type, brain region and developmental age indicates that DHEA is an endogenous neurosteroid in this species that may have important trophic and stress-modifying actions during both prenatal and postnatal life.

Allopregnanolone in the brain: protecting pregnancy and birth outcomes

A successful pregnancy requires multiple adaptations in the mother's brain that serve to optimise foetal growth and development, protect the foetus from adverse prenatal programming and prevent premature delivery of the young. Pregnancy hormones induce, organise and maintain many of these adaptations. Steroid hormones play a critical role and of particular importance is the progesterone metabolite and neurosteroid, allopregnanolone. Allopregnanolone is produced in increasing amounts during pregnancy both in the periphery and in the maternal and foetal brain. This review critically examines a role for allopregnanolone in both the maternal and foetal brain during pregnancy and development in protecting pregnancy and birth outcomes, with particular emphasis on its role in relation to stress exposure at this time. Late pregnancy is associated with suppressed stress responses. Thus, we begin by considering what is known about the central mechanisms in the maternal brain, induced by allopregnanolone, that protect the foetus(es) from exposure to harmful levels of maternal glucocorticoids as a result of stress during pregnancy. Next we discuss the central mechanisms that prevent premature secretion of oxytocin and consider a role for allopregnanolone in minimising the risk of preterm birth. Allopregnanolone also plays a key role in the foetal brain, where it promotes development and is neuroprotective. Hence we review the evidence about disruption to neurosteroid production in pregnancy, through prenatal stress or other insults, and the immediate and long-term adverse consequences for the offspring. Finally we address whether progesterone or allopregnanolone treatment can rescue some of these deficits in the offspring.

Abnormal plasma neuroactive progestagen derivatives in ill, neonatal foals presented to the neonatal intensive care unit

REASONS FOR PERFORMING THE STUDY

Increased levels of pregnanes have been reported in foals with neonatal maladjustment syndrome (NMS). These steroids may cross the blood-brain barrier and have depressive effects in the central nervous system leading to behavioural abnormalities and altered states of consciousness in affected foals.

OBJECTIVES

The aim of this study was to determine the pregnane profile of foals with NMS and compare it with that of healthy controls and sick, non-NMS foals.

STUDY DESIGN

Prospective-clinical study.

METHODS

Thirty-two foals with a clinical diagnosis of NMS, 12 foals with other neonatal disorders and 10 healthy control foals were selected for the study. Heparinised blood samples were collected from each group of foals and pregnane and androgen concentrations determined using liquid chromatography mass spectrometry at 0, 24 and 48 h of age.

RESULTS

Healthy foals showed a significant decrease in pregnane concentrations over the first 48 h of life (P<0.01). Foals with NMS and sick, non-NMS foals had significantly increased progesterone, pregnenolone, androstenedione, dehydroepiandrosterone and epitestosterone concentrations compared with healthy foals (P<0.05). Progesterone and pregnenolone concentrations of sick, non-NMS foals decreased significantly over 48 h (P<0.05), whereas concentrations in NMS foals remained increased.

CONCLUSIONS AND POTENTIAL RELEVANCE

Pregnane concentrations of ill, neonatal foals remain increased following birth, reflecting a delayed, or interrupted, transition from intra- to extra-uterine life. Serial progesterone and pregnenolone measurement may be useful in aiding diagnosis of NMS.

Neurosteroids for a successful pregnancy

Steroid hormones play a critical role in the initiation and maintenance of pregnancy. In particular, the important role that the progesterone metabolite, and neurosteroid, allopregnanolone, may play in fetal and adolescent development is becoming increasingly evident. Unlike steroid hormones, neurosteroids act at nontraditional targets in the central and peripheral nervous systems, including GABA(A) receptor complexes. This commentary discusses the three works in this issue that elucidate the important role of allopregnanolone in the mechanisms that regulate stress hypo-sensitivity of rodents in late pregnancy, neuroprotective effects in fetal sheep exposed to a hypoxic insult, and the continuing role that prefrontal cortex formation of allopregnanolone may play on the cognitive development of gestationally stressed rat offspring, grown to adolescence. The narrative that these works comprise was facilitated by the 5(th) International Meeting on Steroids and the Nervous System (Torino, Italy), which is organized to update our knowledge on the relationships between steroid hormones synthesized in different organs and the nervous system. Topics covered in this most recent meeting included sex differences in, and hormonal influences on, cannabinoid-regulated biology; steroids and pain; the importance of co-regulatory factors for steroid receptor action in the brain; mechanism and role of estrogen-induced nonclassical signaling in the brain; vitamin D as the forgotten neurosteroid; neurosteroids and GABA(A) receptors; and pathogenic mechanisms mediated by glucocorticoid receptors in psychiatric disorders. The 6(th) International Meeting on Steroids and the Nervous System will be held in Torino, Italy in February 2011.

The role of progesterone in prevention of preterm birth

Preterm birth continues to provide an enormous challenge in the delivery of perinatal health care, and is associated with considerable short and long-term health consequences for surviving infants. Progesterone has a role in maintaining pregnancy, by suppression of the calcium-calmodulin-myosin light chain kinase system. Additionally, progesterone has recognized anti-inflammatory properties, raising a possible link between inflammatory processes, alterations in progesterone receptor expression and the onset of preterm labor. Systematic reviews of randomized controlled trials evaluating the use of intramuscular and vaginal progesterone in women considered to be at increased risk of preterm birth have been published, with primary outcomes of perinatal death, preterm birth <34 weeks, and neurodevelopmental handicap in childhood. Eleven randomized controlled trials were included in the systematic review, involving 2714 women and 3452 infants, with results presented according to the reason women were considered to be at increased risk of preterm birth. While there is a potential beneficial effect in the use of progesterone for some women considered to be at increased risk of preterm birth, primarily in the reduction in the risk of preterm birth before 34 weeks gestation, it remains unclear if the observed prolongation of pregnancy translates into improved health outcomes for the infant.

Progesterone regulation of primordial follicle assembly in bovine fetal ovaries

Fertility in mammals is dependant on females having an adequate primordial follicle pool to supply oocytes for fertilization. The formation of primordial follicles is called ovarian follicular assembly. In rats and mice progesterone and estradiol have been shown to inhibit follicle assembly with assembly occurring after birth when the pups are removed from the high-steroid maternal environment. In contrast, primordial follicle assembly in other species, such as cattle and humans, occurs during fetal development before birth. The objective of the current study is to determine if progesterone levels regulate primordial follicle assembly in fetal bovine ovaries. Ovaries and blood were collected from bovine fetuses. Interestingly, ovarian progesterone and estradiol concentrations were found to decrease with increasing fetal age and correlated to increased primordial follicle assembly. Microarray analysis of fetal ovary RNA suggests that progesterone membrane receptor and estrogen nuclear receptor are expressed. Treatment of fetal bovine ovary cultures with a higher progesterone concentration significantly decreased primordial follicle assembly. Observations indicate that progesterone affects ovarian primordial follicle assembly in cattle, as it does in rats and mice.

Progesterone after previous preterm birth for prevention of neonatal respiratory distress syndrome (PROGRESS): a randomised controlled trial

BACKGROUND

Neonatal respiratory distress syndrome, as a consequence of preterm birth, is a major cause of early mortality and morbidity during infancy and childhood. Survivors of preterm birth continue to remain at considerable risk of both chronic lung disease and long-term neurological handicap. Progesterone is involved in the maintenance of uterine quiescence through modulation of the calcium-calmodulin-myosin-light-chain-kinase system in smooth muscle cells. The withdrawal of progesterone, either actual or functional is thought to be an antecedent to the onset of labour. While there have been recent reports of progesterone supplementation for women at risk of preterm birth which show promise in this intervention, there is currently insufficient data on clinically important outcomes for both women and infants to enable informed clinical decision-making. The aims of this randomised, double blind, placebo controlled trial are to assess whether the use of vaginal progesterone pessaries in women with a history of previous spontaneous preterm birth will reduce the risk and severity of respiratory distress syndrome, so improving their infant's health, without increasing maternal risks.

METHODS

DESIGN

Multicentered randomised, double blind, placebo-controlled trial.

INCLUSION CRITERIA

pregnant women with a live fetus, and a history of prior preterm birth at less than 37 weeks gestation and greater than 20 weeks gestation in the immediately preceding pregnancy, where onset of labour occurred spontaneously, or in association with cervical incompetence, or following preterm prelabour ruptured membranes. Trial Entry & Randomisation: After obtaining written informed consent, eligible women will be randomised between 18 and 23+6 weeks gestation using a central telephone randomisation service. The randomisation schedule prepared by non clinical research staff will use balanced variable blocks, with stratification according to plurality of the pregnancy and centre where planned to give birth. Eligible women will be randomised to either vaginal progesterone or vaginal placebo. Study Medication & Treatment Schedules: Treatment packs will appear identical. Woman, caregivers and research staff will be blinded to treatment allocation. Primary Study Outcome: Neonatal Respiratory Distress Syndrome (defined by incidence and severity).

SAMPLE SIZE

of 984 women to show a 40% reduction in respiratory distress syndrome from 15% to 9% (p = 0.05, 80% power).

DISCUSSION

This is a protocol for a randomised trial.

Neurosteroids in the fetus and neonate: Potential protective role in compromised pregnancies

Complications during pregnancy and birth asphyxia lead to brain injury, with devastating consequences for the neonate. In this paper we present evidence that the steroid environment during pregnancy and at birth aids in protecting the fetus and neonate from asphyxia-induced injury. Earlier studies show that the placental progesterone production has a role in the synthesis and release of neuroactive steroids or their precursors into the fetal circulation. Placental precursor support leads to remarkably high concentrations of allopregnanolone in the fetal brain and to a dramatic decline with the loss of the placenta at birth. These elevated concentrations influence the distinct behavioral states displayed by the late gestation fetus and exert a suppressive effect that maintains sleep-like behavioral states that are present for much of fetal life. This suppression reduces CNS excitability and suppresses excitotoxicity. With the availability of adequate precursors, mechanisms within the fetal brain ultimately control neurosteroid levels. These mechanisms respond to episodes of acute hypoxia by increasing expression of 5alpha-reductase and P450scc enzymes and allopregnanolone synthesis in the brain. This allopregnanolone response, and potentially that of other neurosteroids including 5alpha-tetrahydrodeoxycorticosterone (TH-DOC), reduces hippocampal cell death following acute asphyxia and suggests that stimulation of neurosteroid production may protect the fetal brain. Importantly, inhibition of neurosteroid synthesis in the fetal brain increases the basal cell death suggesting a role in controlling developmental processes late in gestation. Synthesis of neurosteroid precursors in the fetal adrenal such as deoxycorticosterone (DOC), and their conversion to active neurosteroids in the fetal brain may also have a role in neuroprotection. This suggests that the adrenal glands provide precursor DOC for neurosteroid synthesis after birth and this may lead to a switch from allopregnanolone alone to neuroprotection mediated by allopregnanolone and TH-DOC.

Inhibition of neurosteroid synthesis increases asphyxia-induced brain injury in the late gestation fetal sheep

Allopregnanolone (AP) is a potent GABAergic agonist that suppresses CNS activity, seizure threshold, and excitotoxicity in the adult brain. AP is present in the fetal sheep brain and increases rapidly after asphyxial insult due to increased 5alpha-reductase type-2 (5alphaR-2) expression. The aim of this study was to use finasteride to suppress fetal neurosteroid synthesis, and then determine the effect on brain injury, particularly in the hippocampus, of asphyxia induced in utero by brief occlusion of the umbilical cord. Catheters and an inflatable umbilical cord cuff were implanted in fetal sheep at approximately 125 days gestation. Five days later the fetuses received either finasteride (20 mg/kg/h) or vehicle (40% hydroxypropyl-beta-cyclodextrin) for 2 h. The umbilical cord was occluded (UCO) for 5 min at 30 min after starting the infusion. The fetal brain was obtained 24 h later for examination of activated caspase-3 expression as an index of apoptosis, and to measure AP content. Finasteride treatment alone significantly reduced AP content and increased the number of caspase-3 positive cells in the hippocampus, cerebellum, and the subcallosal bundle, indicating that AP modulates the normal rate of apoptosis in the developing brain. UCO in vehicle and finasteride-treated fetuses produced a similar, marked decrease in O2 saturation (5.8+/-0.6%), but after finasteride treatment UCO caused a significantly greater increase in the number of caspase-3 positive cells in the hippocampal cornu ammonis 3 (CA3) (57.3+/-1.6%) compared with the vehicle-treated fetuses. Thus, 5alpha-reduced steroids such as AP may be protective in reducing cell death following acute fetal asphyxia. Perturbation of normal fetal neurosteroid levels in late gestation (e.g. due to preterm birth, or maternal synthetic steroid treatment to induce fetal lung maturation) could adversely affect brain development and increase its vulnerability to injury.

Stress in pregnancy activates neurosteroid production in the fetal brain

Neurosteroids such as allopregnanolone are potent agonists at the GABA(A) receptor and suppress the fetal CNS activity. These steroids are synthesized in the fetal brain either from cholesterol or from circulating precursors derived from the placenta. The concentrations of allopregnanolone are remarkably high in the fetal brain and rise further in response to acute hypoxic stress, induced by constriction of the umbilical cord. This response may result from the increased 5alpha-reductase and cytochrome P-450(SCC) expression in the brain. These observations suggest that the rise in neurosteroid concentrations in response to acute hypoxia may represent an endogenous protective mechanism that reduces excitotoxicity following hypoxic stress in the developing brain. In contrast to acute stress, chronic hypoxemia induces neurosteroidogenic enzyme expression without an increase in neurosteroid concentrations and, therefore, may pose a greater risk to the fetus. At birth, the allopregnanolone concentrations in the brain fall markedly, probably due to the loss of placental precursors; however, stressors, including hypoxia and endotoxin-induced inflammation, raise allopregnanolone concentrations in the newborn brain. This may protect the newborn brain from hypoxia-induced damage. However, the rise in allopregnanolone concentrations was also associated with increased sleep. This rise in sedative steroid levels may depress arousal and contribute to the risk of sudden infant death syndrome. Our recent findings indicate that acute hypoxic stress in pregnancy initiates a neurosteroid response that may protect the fetal brain from hypoxia-induced cell death, whereas the decline in allopregnanolone levels after birth may result in greater vulnerability to brain injury in neonates.

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.

Progesterone supplementation for preventing preterm birth: a systematic review and meta-analysis

AIM

The aim of this study is to assess the role of progesterone in preterm birth prevention.

METHODS

A MEDLINE search (from 1966 to the present; date of last search January 2005) was performed - using the key words progesterone, pregnancy, preterm birth, preterm labor, and randomized, controlled trial - in order to identify randomized, controlled trials in which progesterone (either intramuscular or vaginal administration) was compared with placebo or no treatment. Data were extracted and a meta-analysis was performed.

RESULTS

Seven randomized, controlled trials were identified. Women who received progesterone were statistically significantly less likely to give birth before 37 weeks (seven studies, 1020 women, RR = 0.58, 95% CI = 0.48-0.70), to have an infant with birth weight of < or =2.5 kg (six studies, 872 infants, RR = 0.62, 95% CI = 0.49-0.78), or to have an infant diagnosed with intraventricular hemorrhage (one study, 458 infants, RR = 0.25, 95% CI = 0.08-0.82).

CONCLUSIONS

For progesterone supplementation to be advocated for women at the risk of preterm birth, the prolongation of gestation demonstrated in this meta-analysis must translate into improved infant outcomes, including a reduction in mortality. There is currently insufficient information to allow recommendations regarding the optimal dose, route, and timing of administration of progesterone supplementation.

Progestagen profiles during the last trimester of gestation in Thoroughbred mares with normal or compromised pregnancies

Progesterone (P4), pregnenolone (P5) and their metabolites are present in maternal plasma in pregnant mares. It is believed that one of these progestagens may maintain myometrial quiescence. The aims of this study were to identify specific progestagens in pregnant mares' plasma and determine whether these differed between mares with healthy or compromised pregnancies. Jugular blood samples were collected between 243 and 351 days gestation from 19 healthy Thoroughbred mares and 14 mares with placental pathology, including placentitis, and other clinical problems (uterine torsion/rupture, colic, laminitis). Ten progestagens were identified using gas chromatography-mass spectrometry, of which seven increased significantly with gestational age in healthy mares while P4 was undetectable. Mares with placentitis had increased concentrations of either P5 and/or P4 and several metabolites (5alpha-DHP, P5betabeta, betabeta-diol, betaalpha-diol, 20alpha-5P) suggesting increased fetal production of P5 and/or P4 and increased metabolism in the utero-placental tissues in response to chronic stress. Mares with other placental pathology had raised P4 concentrations while 5alpha-DHP and 3beta-5P were low possibly due to reduced placental function. In mares with problems unrelated to the placenta, most progestagens were substantially lower than control values. Although progestagen profiles differed between normal and abnormal pregnancies, no clear link was demonstrated between maternal plasma concentrations of P4, 5alpha-DHP or any other progestagen and the maintenance of pregnancy.

Changes in 5alpha-pregnane steroids and neurosteroidogenic enzyme expression in fetal sheep with umbilicoplacental embolization

Pregnane steroids have sedative and neuroprotective effects on the brain, due to interactions with the steroid-binding site of the GABAA receptor. In the adult brain, synthesis of the pregnane steroids is increased in response to stress. Therefore, we have used umbilicoplacental embolization to mimic chronic placental insufficiency during late gestation in sheep, to investigate the expression of the steroidogenic enzymes p450scc, 5alpha-reductase type I (5alphaRI), 5alpha-reductase type II (5alphaRII), and allopregnanolone (AP) content in the fetal brain. Umbilicoplacental embolization was induced from 114 d gestation (term approximately 147 d) by daily injection of inert microspheres into the umbilical artery and continued for 17-23 d. Fetal arterial oxygen saturation was reduced to approximately 60% of the preembolization value in each fetus, with a significant reduction in blood arterial Po2, pH, and plasma glucose concentrations (p < 0.05) and a significant increase in blood arterial Pco2 and plasma lactate concentrations (p < 0.05). At postmortem at 131-137 d gestation, embolized fetuses were growth-restricted (2.10 +/- 0.14 kg, n = 5) compared with age-matched controls (4.43 +/- 0.56 kg, n = 7, p < 0.05). Umbilicoplacental embolized fetuses showed increased P450scc expression in the primary motor cortex; 5alphaRI expression was not changed in any of the regions examined, whereas 5alphaRII expression was markedly increased in all brain regions. Brain AP content did not significantly change, whereas plasma concentrations were increased. These findings suggest that the increased expression of p450scc and 5alphaRII may be a response that maintains AP concentration in the fetal brain after compromised placental function and/or intrauterine stress.

Changes in 5alpha-pregnane steroids and neurosteroidogenic enzyme expression in the perinatal sheep

Pregnane steroids have sedative and neuroprotective effects on the brain as a result of interactions with the steroid-binding site of the GABAA receptor. To determine whether the fetal brain is able to synthesize pregnane steroids de novo from cholesterol, we measured the expression of cytochrome P450 side-chain cleavage (P450scc) and 5alpha-reductase type II (5alphaRII) enzymes in fetal sheep from 72 to 144 d gestation (term approximately 147 d) and in newborn lambs at 3 and 19-26 d of age. Both P450scc and 5alphaRII expression was detectable by 90 d gestation in the major regions of the brain and also in the adrenal glands. Expression increased with advancing gestation and was either maintained at fetal levels or increased further after birth. In contrast, the relatively high content (200-400 pmol/g) of allopregnanolone (5alpha-pregnan-3alpha-ol-20-one), a major sedative 5alpha-pregnane steroid, present throughout the brain from 90 d gestation to term, was reduced significantly (<50 pmol/g) immediately after birth. These results suggest that although the perinatal brain has the enzymes potentially to synthesize pregnane steroids de novo from cholesterol, either the placenta is a major source of these steroids to the brain or other factors associated with intrauterine life may be responsible for high levels of allopregnanolone production in the fetal brain until birth.

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>

Endotoxin increases sleep and brain allopregnanolone concentrations in newborn lambs

Infection has been identified as a risk factor for sudden infant death syndrome (SIDS). Synthesis of allopregnanolone, a neuroactive steroid with potent sedative properties, is increased in response to stress. In this study, we investigated the effect of endotoxin (lipopolysaccharide, LPS) on brain and plasma allopregnanolone concentrations and behavior in newborn lambs. LPS was given intravenously (0.7 micro g/kg) at 12 and 15 d of age (n = 7), and resulted in a biphasic febrile response (p < 0.001), hypoglycemia, lactic acidemia (p < 0.05), a reduction in the incidence of wakefulness, and increased nonrapid eye movement sleep and drowsiness (p < 0.05) compared with saline-treated lambs (n = 5). Plasma allopregnanolone and cortisol were significantly (p < 0.05) increased after LPS treatment. These responses to LPS lasted 6-8 h, and were similar at 12 and 15 d of age. Each lamb was then given LPS at 20 d of age and killed 3 h posttreatment to obtain samples of the brain. Allopregnanolone concentrations were increased (p < 0.05) in all brain areas except the cerebellum and diencephalon. We suggest that LPS-induced increase of allopregnanolone in the brain may contribute to somnolence in the newborn, and may be responsible for the reduced arousal thought to contribute to the risk of SIDS in human infants.

Effect of finasteride on behavioural arousal and somatosensory evoked potentials in fetal sheep

This study examines the effect of inhibiting the synthesis of gamma-aminobutyric acid(A) (GABA(A)) agonist steroids on behavioural activity and somatosensory evoked potentials (SEP) in late gestation fetuses. Pregnane steroid production was suppressed by infusion of the 5alpha-reductase inhibitor, finasteride in chronically catheterised fetal sheep, 130-135 days gestation. Finasteride treatment (160 mg in 10 ml of vehicle over 2 h) significantly increased the incidence of fetal arousal during the period 4-10 h after commencing the infusion (P<0.05, n=6), whereas other behavioural parameters were not effected. In three of four animals, finasteride produced an increase in the amplitude of the N22 peak of the SEP during high voltage electrocortical activity. We conclude that suppression of pregnane steroid synthesis, by inhibition of the 5alpha-reductase enzyme, increases arousal activity in the fetus which is consistent with a reduction in GABA(A) receptor mediated inhibition.

Characterisation of GABA(A) receptors in fetal, neonatal and adult ovine brain: region and age related changes and the effects of allopregnanolone

Progesterone metabolites acting via GABA(A) receptors suppress central nervous system (CNS) activity. The aim of the present study was to examine binding characteristics of GABA(A) receptors in fetal, newborn and adult sheep brains using [(35)S]TBPS, and to determine the effects of allopregnanolone on this binding. Receptor affinity (K(D)) and density (B(MAX)) in the brainstem were not different in fetal, newborn (1-2 days old) and adult brains. In the hypothalamus K(D) and B(MAX) increased significantly in the fetus between 85 and 128 days gestation, and were then similar to postnatal and adult values. In the frontal cortex K(D) and B(MAX) increased progressively between 85 days and term ( approximately 147 days gestation), and were then not different from postnatal and adult values. The K(i) values for the GABA(A) receptor antagonist picrotoxin was similar at all ages. Allopregnanolone inhibited [(35)S]TBPS binding in the presence of 5 microM GABA, but enhanced binding in the absence of GABA. These results show that (i), functional GABA(A) receptors are present in the fetal brain from at least 85 days gestation; (ii), 3alpha-pregnane steroids modify receptor affinity in the late gestation fetal brain; and (iii) there are region-specific changes in GABA(A) receptor binding parameters. Steroid modulation of the GABA(A) receptor in the fetal brain is likely to influence fetal CNS activity in late gestation.

Effect of a neuroactive steroid infused into the cerebral ventricles of fetal sheep in utero using small infusion volumes

Placental progesterone metabolites may influence fetal behaviour during late gestation. We have investigated the effect of the neuroactive metabolite, pregnanolone, on the sleep/awake behaviour of fetal sheep. These studies can only be effectively performed in unanesthetized animals with chronically implanted leads and catheters. The relatively large internal volumes of these catheters raises problems for cerebroventriclear infusions. Therefore, we developed a device with negligible deadspace ( approximately 10 microl) consisting of a ventricular cannula attached to a small cap which allowed the instillation of microl volumes of neuroactive steroids into a cerebral ventricle of fetal sheep in utero. Two catheters attached to the cap allow it to be filled in a push-pull configuration. The smaller internal diameter of the ventricular cannular prevents the solution entering the ventricle until the outflow catheter is occluded and solution is forced through the probe. Using this device, the infusion of 5beta-pregnane-3alpha-ol-20-one (pregnanolone, 1 mg), in 35% hydroxypropyl-beta-cyclodextrin, resulted in a marked suppression of fetal behaviour parameters indicative of arousal, while vehicle alone did not affect these parameters. We conclude that neuroactive steroids can be infused into the cerebroventricular system of chronically catheterised fetal sheep in small volumes and that pregnanolone may act directly to influence fetal behaviour.

Physiological correlates of maternal-offspring behaviour in sheep: a factor analysis

The onset of maternal behaviour in sheep is controlled by levels of oestrogen and progesterone in gestation and the release of oxytocin during delivery. Factor analysis was used to investigate the relationships between maternal behaviour, offspring behaviour, and maternal ovarian hormone levels during gestation in sheep. Ewes gave birth to lambs following embryo transfer between two breeds (Suffolk and Scottish Blackface), which differ in their expression of maternal behaviour. Plasma oestradiol-17beta concentration was significantly higher in Blackface ewes in the last 6 weeks of pregnancy, whereas plasma progesterone was higher in Suffolk ewes in early and mid gestation. Factor analysis revealed three factors that accounted for 50% of the total variation between variables. Factor 1 described lamb activity and had positive loadings for lamb behavioural latencies immediately postpartum, and negative loadings for sucking frequency. Factor 2 described some aspects of ewe maternal behaviour, and had positive loadings for ewe-lamb separation and lamb vocalisation, and negative loadings for ewe grooming behaviour and plasma oestradiol concentration. Factor 3 described ewe and lamb-sucking interactions, and had positive loadings for ewe moving as the lamb made sucking attempts, and negative loadings for ewe and lamb vocalisation. Factor 1 scores were significantly affected by lamb breed: Suffolk lambs received positive scores, indicating a longer latency to right and stand, whereas Blackface lambs had negative scores. Maternal progesterone concentration was significantly correlated with Factor 1 scores. Factor 2 and 3 scores were significantly affected by ewe breed. This study has shown that there are two behavioural axes to maternal behaviour in sheep, and that maternal oestradiol concentration is related to affiliative behaviours (e.g., grooming) but only weakly to ewe responsiveness to lamb-sucking attempts.

Effects of pregnanolone on behavioural parameters and the responses to GABA(A) receptor antagonists in the late gestation fetal sheep

Placental progesterone metabolites may suppress fetal behaviour by interacting with GABA(A) receptors. In an initial study, the effect of 5beta-pregnan-3alpha-ol-20-one (pregnanolone) given as a bolus (2.5 and 5.0 mg) or infused at a rate of 25 mg/h was investigated in unanaesthetized, catheterized fetal sheep, 127-135 days gestation. The incidence of fetal breathing movements (FBM) and behavioural arousal activity, defined as nuchal muscle electromyographic (EMG) activity during low voltage electrocortical (LV ECoG) activity were suppressed by pregnanolone administered as a bolus, while the pregnanolone infusion produced a significant decrease in arousal and EOG activity, and an increase in the presence of HV ECoG. The effect of pregnanolone on fetal behaviour and arousal induced by the GABA(A) antagonist picrotoxin was also investigated. Picrotoxin was given as a bolus (approximately 300 microg/kg) and pregnanolone was subsequently administered as a bolus (5.0 mg), and behavioural parameters were recorded and analysed. The incidence of arousal and FBM were 1.1 +/- 1.6 min/10 min and 2.5 +/- 2.3 min/10 min, respectively, before picrotoxin treatment and increased during the 10-20 and 20-30 min epochs after picrotoxin treatment (arousal: 5.0 +/- 2.2 and 6.5 +/- 3.6 min/10 min, respectively, n = 6, P < 0.05; FBM: 7.3 +/- 3.2 and 9.3 +/- 1.2 min/10 min, respectively, n = 6, P < 0.05). The picrotoxin-induced increases in arousal and FBM were significantly suppressed (n = 6, P < 0.05) by pregnanolone treatment to 1.6 +/- 1.5 min/10 min and 4.6 +/- 2.3 min/10 min, respectively. We conclude that; (i) the GABA(A) active steroid pregnanolone suppresses basal and picrotoxin-induced fetal arousal and FBM; and (ii) steroid sensitive GABA(A) receptors may regulate fetal behaviour and breathing.

Effect of pregnane steroids on electrocortical activity and somatosensory evoked potentials in fetal sheep

The effect of infusing the neuroactive steroids pregnanolone and iso-pregnanolone on somatosensory evoked potentials (SEP) and electrocortical (ECoG) activity was studied in unanaesthetised fetal sheep, 130-135 days gestation. Intravenous infusion of pregnanolone (6 mg/kg per h) significantly increased the proportion of high voltage ECoG (56.1+/-4.8% vs. control 43.5+/-3.2%, P < 0.05), and decreased low voltage ECoG (43.9+/-4.8% vs. control 56.6+/-3.2%, P < 0.05). Pregnanolone treatment decreased the amplitude of the N25 peak of the SEP (89.9+/-2.8% of control, P < 0.05) evoked following stimulation of the skin of the upper lip. In contrast, iso-pregnanolone treatment had no effect on ECoG activities, or on the amplitude and latency of peaks in the SEP. We conclude that 3alpha-hydroxy pregnane steroids are active at GABA(A) receptors in fetal sheep and can modulate sleep/wake activity before birth.