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This study investigated the effects of a range of pharmaceutical drugs with ion channel-blocking activity on the heart of gestation day 13 rat embryos in vitro. The general hypothesis was that the blockade of the I(Kr)/hERG channel, that is highly important for the normal functioning of the embryonic rat heart, would cause bradycardia and arrhythmia. Concomitant blockade of other channels was expected to modify the effects of hERG blockade. Fourteen drugs with varying degrees of specificity and affinity toward potassium, sodium, and calcium channels were tested over a range of concentrations. The rat embryos were maintained for 2 hr in culture, 1 hr to acclimatize, and 1 hr to test the effect of the drug. All the drugs caused a concentration-dependent bradycardia except nifedipine, which primarily caused a negative inotropic effect eventually stopping the heart. A number of drugs induced arrhythmias and these appeared to be related to either sodium channel blockade, which resulted in a double atrial beat for each ventricular beat, or I(Kr)/hERG blockade, which caused irregular atrial and ventricular beats. However, it is difficult to make a precise prediction of the effect of a drug on the embryonic heart just by looking at the polypharmacological action on ion channels. The results indicate that the use of the tested drugs during pregnancy could potentially damage the embryo by causing periods of hypoxia. In general, the effects on the embryonic heart were only seen at concentrations greater than those likely to occur with normal therapeutic dosing., (© 2010 Wiley-Liss, Inc.)

Drugs blocking the potassium current IKr of the heart (via hERG channel-inhibition) have the potential to cause hypoxia-related teratogenic effects. However, this activity may be missed in conventional teratology studies because repeat dosing may cause resorptions. The aim of the present study was to investigate an alternative protocol to reveal the teratogenic potential of IKr-blocking drugs. The IKr blocker astemizole, given as a single dose (80 mg/kg) on gestation day (GD) 13 to pregnant rats caused digital defects. In whole rat embryo culture (2h) on GD 13, astemizole caused a decrease in embryonic heart rate at 20 nM, and arrhythmias at 200-400 nM. Cetirizine, without IKr-blocking properties, did not affect the rat embryonic heart in vitro. The present study shows that single dose testing on sensitive days of development, together with whole embryo culture, can be a useful methodology to better characterize the teratogenic potential of IKr-blocking drugs., (Copyright 2010 Elsevier Inc. All rights reserved.)

Drugs blocking the potassium current IKr, either as an intended pharmacologic effect (eg antiarrhythmics dofetilide and almokalant) or as an unwanted side-effect (eg antihistamine astemizole, propulsive drug cisapride, antidepressive drugs and macrolide antibiotics) are potential human teratogens. It is the contention of this paper that the existing repeat dose regimen used in teratology studies to fulfil regulatory requirements, does not properly identify the teratogenic risk of these drugs. Results from conventional studies for dofetilide and almokalant showed high rates of postimplantation embryonic death with few malformed fetuses. For astemizole and cisapride only embryonic death was seen. These latter results were not considered important because they occurred either in the presence of maternal toxicity and/or at high doses. Subsequent studies have shown that IKr-blockers are highly teratogenic when administered on single gestational days (GD) during a sensitive period of rat pregnancy (GD 10-14) when they induce a high incidence of stage-specific malformations. This teratogenic activity of astemizole and cisapride was missed in the original teratology studies. Mechanistically IKr-blockers cause bradycardia and arrhythmia of the embryonic heart and while an embryo may be able to survive a single day exposure to a teratogenic dose, repeat dosing often leads to death of the embryo. With this review we suggest that new drugs identified at the preclinical stage of development as having IKr-blocking properties, should undergo more comprehensive teratology testing including single GD dosing and studies using embryo culture. This would further help identify and characterise their teratogenic potential.

There is considerable evidence that phenytoin-induced birth defects in the rat are a consequence of a period of bradycardia and hypoxia in the embryos. Experiments were designed to test the hypothesis that phenytoin-induced birth defects result from free-radical damage to the embryos during the reoxygenation period posthypoxia. Female rats (>9 per group) were fed either a control diet or a diet high in antioxidants (vitamins C and E and coenzyme Q(10)) both before and during pregnancy and were then given a teratogenic dose of phenytoin (180 mg/kg) on GD 11. The rats were killed on GD 20 and the fetuses were examined for malformations. The initial results showed that the antioxidant diet had a significant protective effect, with far fewer antioxidant-group fetuses showing cleft lip or maxillary hypoplasia compared with the control group. However, this result was confounded by reduced food intake by the rats fed the antioxidant diet and a significantly lower maternal body weight at the time of phenytoin administration. Since the phenytoin was administered by intraperitoneal injection (i.p.) the control rats received higher absolute doses of phenytoin and it is speculated that this results in higher fetal exposure. A second experiment, in which the rats were pair-fed, failed to demonstrate any protective effect of the high antioxidant diet. These results do not support the reoxygenation hypothesis for phenytoin teratogenesis. An alternative explanation would be hypoxia-induced transcription-related changes resulting in cell cycle arrest and apoptosis.

Prescribing drugs in pregnancy is an unusual risk-benefit situation. Drugs that may be of benefit or even life-saving to the mother can deform or kill the fetus. However, the risk to the fetus should not be exaggerated. There are only approximately 20 drugs or groups of drugs which are known to cause birth defects in humans. For one of these drugs to cause birth defects, a number of criteria must be fulfilled. The drug exposure must take place at a critical stage of pregnancy and the dose must be high enough to cause a threshold of exposure for an appropriate duration of time. For most of the known human teratogens, > 90% of pregnancies exposed during the first trimester result in normal offspring. Although only a few drugs are known to cause birth defects in humans, uncertainty about the safety of the majority may lead to underprescribing for pregnant women and women of childbearing age. Epidemiological studies of pregnancy outcome after specific drug exposures are often superficially reassuring, but most are severely limited in their power to detect adverse outcomes. Safety in animal studies may also be reassuring but species differences demand caution in this interpretation. Concerns about prescription drugs in the first trimester, when they can cause birth defects, are mostly quite different to concerns about use in the second and third trimesters. As the fetal organ systems mature, the fetus can be affected by the pharmacological activity of the drug in the same way as the mother. Many drugs have pharmacological effects on the fetus in the second and third trimesters but in most cases, they are well recognised and can be managed or avoided. The material presented in this paper is mostly concerned with the 'risks' associated with drugs in pregnancy. No attempt has been made to quantitate the possible benefits to the mother or fetus. Communicating the risk-benefit situation to the patient is always a challenge for physicians with limited time and sometimes limited knowledge. Fear of litigation is an unfortunate and an unwanted parameter in the assessment. Better knowledge of the parameters that determine teratogenicity may allow physicians to feel more confident in assessing the risks and benefits associated with prescribing in pregnancy.

Whole embryo culture appears to be an excellent method to screen chemicals for teratogenic hazard. Compared to in vivo testing it is cheap and rapid and does not involve experimentation on live adult animals. Also in the important area of risk estimation whole embryo culture offers distinct advantages over in vivo teratogenicity testing. Adverse embryonic outcomes (malformations or embryotoxicity) are directly related to the serum concentration of the compound being tested and can be compared to the serum concentration in the human. A similar comparison is not possible after in vivo testing because for most compounds there are major pharmacokinetic differences between humans and experimental animals. In vivo testing is also limited by the possibility that metabolites that occur in the human do not occur in the test animal. This problem can be overcome in the in vitro system by adding the metabolite directly at the desired concentration either with or without the parent compound. There is only one major disadvantage to in vitro testing and that is the limited period of embryogenesis that is undertaken in the commonly used culture system. This restricts the range of malformations that can be induced and may render the testing system unsuitable for compounds that are likely to exert their major toxicological effect late in gestation. Any evaluation of whole embryo culture for hazard and risk assessment in teratology must take into account the limited value of currently used in vivo methods. Over 2000 chemicals have been reported to be teratogenic in experimental animals exposed in vivo (Shepard, Catalog of Teratogenic Agents, 1989). In comparison only about 20 chemicals are known to cause birth defects in the human. This large number of in vivo false-positive cannot easily be distinguished from true-positives. In this respect in vivo testing is severely deficient. The embryo culture testing system would also be expected to produce many false-positives; but by comparing effective drug concentrations with human therapeutic concentrations they can be differentiated from true-positives. The most serious deficiency for an in vivo or in vitro teratogenicity testing system would be false-negatives. This has not been a problem in the validation of in vitro testing so far (except perhaps procarbazine), but difficult drugs such as thalidomide were not included. Thalidomide remains an important index chemical because it is not teratogenic in rats or mice but is teratogenic in the rabbit and human. It is likely that these species differences are due to metabolic differences between species and it is possible that if the proximate teratogen/s of thalidomide were identified they would be teratogenic in rat embryo culture. Whole embryo culture remains a very powerful technique that should continue to contribute to the determination of the safety of drugs and other chemicals during pregnancy.

Drugs with class III antiarrhythmic activity are potential human teratogens because of their ability to cause bradycardia in the embryo during the organogenic period. Three drugs with class III antiarrhythmic activity, almokalant, dofetilide and d-sotalol, were compared in vitro using rat embryo culture. Each of these drugs caused a concentration-dependent bradycardia in 11- or 13-day rat embryos. For each drug the effective concentration was considerably greater than the human therapeutic plasma concentration. The reproductive outcome was also compared in vivo in Sprague-Dawley rats by oral administration of almokalant or dofetilide on single days during the organogenic period. Both drugs caused increased resorptions and the same stage-dependent malformations. Dosing on gestational day (GD) 11 was associated with right-sided oblique cleft lip and short tail, while dosing on day 13 caused digital hypoplasia and/or amputation. Susceptibility to these drugs started on GD 9 when the embryonic heart starts beating and ended on GD 15. The malformations were preceded by hemorrhage; which is consistent with the proposed pathogenesis that the drug-induced bradycardia caused embryonic hypoxia/ischemia. This study indicates that the induction of malformations/embryonic death by class III antiarrhythmic drugs which inhibit Ikr is a class effect secondary to a common pharmacological action on the embryonic heart.

Ten patients with maxillonasal hypoplasia (Binder "syndrome"), who were prenatally exposed to phenytoin (usually in combination with other anticonvulsants), were identified retrospectively. In addition to their facial anomalies, 6 of the patients were radiographed neonatally and showed punctate calcification, characteristic of chondrodysplasia punctata. Evidence is presented that the facial abnormalities seen in these children are due to anticonvulsant-induced vitamin K deficiency, causing abnormal development of the cartilaginous nasal septum. We propose that early vitamin K supplementation of at-risk pregnancies may prevent the development of maxillonasal hypoplasia, which in some patients is severely disfiguring and causes great emotional distress. Correction of this facial defect requires surgical and dental treatment over a long period of time.

Exposure to aromatic hydrocarbon solvents during pregnancy has been reported to adversely affect human embryonic development. This exposure may be due to deliberate abuse or may occur in the workplace. Xylene and toluene are the most common solvents encountered in the workplace and toluene is a constituent of commonly abused substances. This study was performed in an endeavour to fulfil two requirements for proof of teratogenicity of a substance, namely development of an animal model and demonstration of a dose-response relationship of teratogenicity. To fulfil these aims, the possible teratogenic and embryotoxic effects of xylene and toluene on rat embryos during the organogenic period was investigated in vitro. Rat embryos were explanted on day 9.5 of gestation and cultured in heat-inactivated rat serum to which xylene or toluene (0.1, 0.5 or 1.0 microL/mL) had been added, dispersed in 0.1% DMSO. The amount of solvent in the culture medium was quantitated using gas chromatography. Neither xylene nor toluene had any observable teratogenic effect on the embryos in terms of increased malformations. However, both solvents were embryotoxic and caused a dose-dependent retardation of growth and development. A no-effect level was not established for either xylene or toluene, however, the lowest levels used for each of these compounds caused only a slight retardation of growth. Although there was no indication that exposure to these solvents caused a teratogenic effect, there was clear evidence of embryotoxicity. The embryotoxic levels of these solvents needed in culture were higher than blood levels likely to occur in the human following industrial exposure or recreational abuse.

At the in vitro threshold serum concentration of 500 ng/ml, isotretinoin induces defects of visceral arch development in 9.5-day rat embryos grown in culture for 48 h. Experiments were performed to determine the minimum period of exposure necessary to induce these arch defects and whether an increase in concentration of isotretinoin could compensate for reduced exposure time. The results showed that a minimum 6-h exposure to 500 ng/ml immediately prior to cranial neural crest migration was necessary to induce severe defects of the second visceral arch in a majority of embryos. Maximal increase in isotretinoin concentration to 16,000 ng/ml did not compensate for shorter exposure periods. These results suggest that to cause malformations of the visceral arches, the embryo must be exposed to isotretinoin for a minimum period of time regardless of the concentration of isotretinoin above the threshold.

Cocaine hydrochloride was administered to pregnant Sprague-Dawley rats as a single intraperitoneal dose or as two doses 1-4 hours apart. A single dose administered on day 16 of gestation was teratogenic in a dose-dependent manner, with 40 mg/kg being a no-effect dose and 50 mg/kg the lowest teratogenic dose; 80 mg/kg was lethal to the dam. Forty-eight hours after exposure to a teratogenic dose on day 16 of pregnancy, the fetuses showed severe hemorrhage and edema in the their extremities, particularly the footplates, tail, genital tubercle, and upper lip/nose. When the fetuses were examined on day 21 of gestation, the main externally visible malformations were reduction deformities of the limbs and tail. When two doses of cocaine were administered 1-4 hours apart, the incidence of affected fetuses increased as the time interval between the two doses decreased. Two doses of cocaine administered 2 hours apart were not teratogenic on day 9, 10, 11, 12, 13, or 14 of gestation but did induce reduction deformities on days 15, 16, 17, 18, or 19. The same dose administered 1 hour apart was teratogenic on days 14-19. In general, cocaine administration on gestational days 14, 15, or 16 induced more severe and more widespread hemorrhage and edema than administration on days 17, 18, or 19. In the latter cases, damage was restricted to the distal parts of the hindlimb digits and the tail. The results show that in the rat cocaine is only teratogenic during the late organogenic or postorganogenic period.(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnant mice were exposed to a single dose of alcohol (0.03 ml of 25% alcohol X g-1 mouse) or two doses (2 X 0.015 ml of 25% alcohol X g-1 mouse) 4 h apart, by intraperitoneal injection or by gavage, on days 7, 8, 9 or 10 of gestation. The mice were killed on the day before term and the fetuses examined for heart defects. Alcohol exposure on day 8, 9 or 10 of gestation caused a high incidence of ventricular septal defects (60%, 75% and 15% respectively). Defects of both the membranous and muscular parts of the septum were seen as well as more complex ventricular septal defects involving the great vessels. Day 7 was resistant to the induction of heart defects. This study has demonstrated that a relatively short exposure to high doses of alcohol during pregnancy in mice can cause congenital heart defects. This has important implications both as a possible cause of congenital heart anomalies in humans and for the counselling of mothers of affected children.

Severe congenital malformations have been associated with the inadvertant use in early pregnancy of a new dermatological drug, isotretinoin. We present proposals for the pathogenesis of this embryopathy based on the study of animal models. The characteristic malformations of the face, thymus, and great vessels were induced in mice by prenatal exposure to the drug during the early somite stages of development. From histological examination of mouse embryos it was shown that the drug directly interferes with the development of cranial neural crest cells. Subsequent deficiency of crest cell-derived mesenchyme adequately explains most of the observed malformations. Rat embryo culture studies showed that, when used at concentrations of 500 ng/ml, both isotretinoin and its main metabolite in the human, 4-oxo-isotretinoin, induce malformations similar to those seen in vivo. Since during normal repetitive dosing in the human the mean trough blood concentration of isotretinoin ranges from 132 to 196 ng/ml, while 4-oxo-isotretinoin ranges from 610 to 791 ng/ml, it is likely that the metabolite plays a major role in the induction of the isotretinoin embryopathy.