Misoprostol exposure during the first trimester of pregnancy: Is the malformation risk varying depending on the indication?

OBJECTIVE: To report the prospective follow-up of pregnancies exposed to misoprostol during the first trimester and analyse the teratogenic risk depending on the indication for use. STUDY DESIGN: Prospective observational study of 265 women exposed to misoprostol during the first 12 weeks of pregnancy and followed until the delivery. Women were included if they or their physician had contacted a French pharmacovigilance centre before 22 weeks of gestation (WG) to obtain information on the risk of misoprostol exposure, and if there had been misoprostol exposure before 13 WG. Data were collected at the time of the first contact, and the pregnancy outcome was recorded at follow-up. Women were prospectively enrolled from January 1988 to December 2013. RESULTS: The main indication for misoprostol was voluntary abortion (60.9%). Ten major malformations (5.5%) (95% CI 2.65-9.82%) were reported and five of them were consistent with the pattern of malformations attributed to misoprostol: Möbius sequence, hydrocephalus, terminal transverse limb reduction associated with a clubfoot, syndactyly, and complete posterior encephalocele. The rate of malformations was higher, but not significantly, in women exposed to misoprostol for voluntary abortion (7.9%) compared with women exposed to misoprostol for other or unknown indications (3.2%). CONCLUSIONS: Our results confirmed a specific pattern of malformations due to misoprostol use in early pregnancy, even with low dose of misoprostol. Despite the small number of cases, we observed a higher proportion of major malformations in fetuses born to women who continued their pregnancy after a failed voluntary abortion with misoprostol. Further studies should be conducted to evaluate other potential factors, such as combination treatment with mifepristone and the socio-environmental characteristics in this group of women.

Cytotoxicity mechanism of α-MMC in normal liver cells through LRP1 mediated endocytosis and JNK activation.

Alpha-momorcharin (α-MMC), a type I ribosome-inactivating protein isolated from Momordica charantia, is a potential drug candidate with strong anti-tumor activity. However, α-MMC has a severe hepatotoxicity when applied in vivo, which may greatly hinders its use in clinic in the future. The biological mechanism of hepatotoxicity induced by α-MMC is largely unknown, especially the mechanism by which α-MMC enters the hepatocytes. In this study, we investigated α-MMC-induced cytotoxicity in normal liver L02 cell line as well as the mechanism underlying it. As expected, α-MMC is more toxic in L02 cells than in various normal cells from other organs. The cytotoxic effect of α-MMC on L02 cells is found to be mediated through cell apoptosis as detected by flow cytometry and fluorescence microscopy. Importantly, α-MMC was shown to bind to a specific receptor on cell membrane, as the density of the cell membrane receptor is closely related to both the amount of α-MMC endocytosed and the cytotoxicity in different cell lines. By using LRP1 competitive inhibitor α2-M or siRNA targeting LRP1, we further identified that LRP1 protein served as the membrane receptor for α-MMC. Both α2-M and siRNA targeting LRP1 can significantly inhibit α-MMC's endocytosis as well as its cytotoxicity in L02 cells. In addition, it was found that α-MMC can activate the JNK signalling pathways via LRP1 in L02 cells. As JNK activation often leads to cell apoptosis, the activation of JNK may play an important role in α-MMC-induced cytotoxicity. To our knowledge, this is the first report showing that LRP1 mediates the cytotoxicity of α-MMC through (1) endocytosis and induced apoptosis and (2) the activation of the JNK pathway. Our findings shed light on the fundamental mechanism of hepatotoxicity of α-MMC and offer reference to understand its mechanism of lymphocytotoxicity and neurotoxicity.

Methotrexate induces germ cell apoptosis and impairs spermatogenesis in a rat.

PURPOSE: The primary toxic effects of methotrexate (MTX) are myelosuppression and/or intestinal mucositis. The objective of the present study is to investigate the effect of MTX on germ cell apoptosis and spermatogenesis in a rat. METHODS: Male Sprague-Dawley rats were divided into three experimental groups: control rats treated with vehicle; MTX-2 rats treated with one dose (20 µg/kg) of MTX given IP and killed on the second day; and MTX rats treated with IP MTX (20 µg/kg) and killed on day 4. Johnsen's criteria and the number of germinal cell layers in the testes were used to categorize the spermatogenesis. TUNEL assay was used to determine germ cell apoptosis. Western blotting was used to determine Bax and Bcl-2 protein levels. Statistical analysis was performed using the non-parametric Kruskal-Wallis ANOVA test, with p less than 0.05 considered statistically significant. RESULTS: On day 2, MTX-treated animals demonstrated minimal changes in the histological parameters of spermatogenesis, but germ cell apoptosis increased significantly (threefold increase, p = 0.002) compared to control rats. On day 4, MTX-treated rats demonstrated a trend toward a decrease in germ cell apoptosis, compared to day 2, and showed histological signs of impaired spermatogenesis (decreased number of germ cell layers and Johnsen's criteria). A significant increase in cell apoptosis in MTX-treated rats was correlated with higher Bax/Bcl-2 protein levels. CONCLUSIONS: MTX induced germ cell apoptosis and impaired spermatogenesis in rat testes.

Birth defects after exposure to misoprostol in the first trimester of pregnancy: prospective follow-up study.

Misoprostol during the first trimester of pregnancy is associated with a specific malformative pattern (Moebius sequence and limb defects) whose incidence remains unknown. Data originate mostly from illegal use for abortion and are mainly retrospective. The present prospective controlled study analyses outcomes of first trimester misoprostol exposures after medical prescriptions. Malformation rate was higher among 236 pregnancies exposed before 12 gestational weeks (4%) than in 255 controls (1.8%), although not statistically significant (OR=2.2 [95% CI=0.6-7.7]). Three malformations (2%) in the exposed group were consistent with the misoprostol malformative pattern. This is the largest prospective study on first trimester misoprostol exposure and the first one relying on prescriptions. A trend toward a doubling of the overall rate of malformations was observed and for the first time an estimation of the incidence of misoprostol specific spectrum is proposed (2%). Brainstem injuries including severe trismus might be added to this specific pattern.

[Evaluation of embryotoxicity of misoprostol using the whole embryo culture assay]. / Evaluación de la embriotoxicidad de misoprostol utilizando el ensayo cultivo de embriones postimplantación.

BACKGROUND: Approximately 15% of misoprostol-induced-abortions may not be successful, leading to in utero exposure to the drug and to the induction of a series of defects including central nervous system, limb and visceral defects. A common proposal is that the drug causes disruption of the fetal vasculature leading to embryonic or fetal hypoxia. AIM: To evaluate the teratogenicity of misoprostol using the rat post-implantation embryo culture. MATERIAL AND METHODS: Rat embryos were collected at the beginning of organogenesis and cultured in rat serum containing misoprostol at concentrations of 200, 2,000 or 20,000 pg/ml. Functionality, morphology and morphometry parameters were evaluated. RESULTS: Misoprostol induced a dose-dependent embryotoxic effect causing a decrease in embryo viability and function (poor vascular development and survival) and morphometry (alterations in branchial arches, heart and cephalic portions of the neural tube, among others). CONCLUSIONS: All the manifestations observed are indicative of the ability of misoprostol to directly induce developmental retardation and alterations.

Evaluación de la embriotoxicidad de misoprostol utilizando el ensayo cultivo de embriones postimplantación / Evaluation of embryotoxicity of misoprostol using the whole embryo culture assay

Background: Approximately 15 percent of misoprostol-induced-abortions may not be successful, leading to in utero exposure to the drug and to the induction of a series of defects including central nervous system, limb and visceral defects. A commonproposal is that the drug causes disruption of the fetal vasculature leading to embryonic or fetal hypoxia. Aim: To evaluate the teratogenicity of misoprostol using the rat post-implantation embryo culture. Material and Methods: Rat embryos were collected at the beginning of organogenesis and cultured in rat serum containing misoprostol at concentrations of 200, 2,000 or 20,000 pg/ml. Functionality, morphology and morphometry parameters were evaluated. Results: Misoprostol induced a dose-dependent embryotoxic effect causing a decrease in embryo viability and function (poor vascular development and survival) and morphometry (alterations in branchial arches, heart and cephalic portions of the neural tube, among others). Conclusions: All the manifestations observed are indicative of the ability of misoprostol to directly induce developmental retardation and alterations.

Retrograde transport of a traditional Chinese medicine, alpha-trichosanthin, and its selective neural toxicity.

OBJECTIVE: To investigate the peripheral neuronal toxicity of a traditional Chinese medicine, alpha-trichosanthin (TCS). METHODS: TCS and rhodamine-conjugated TCS were separately injected into the rat sciatic nerve. Saline and rhodamine were used alone and separately as control solutions. The motor neurons in the spinal cord and sensory neurons in the dorsal root ganglia were separately counted. The entry of TCS molecules into neurons was observed under the fluorescence microscope. The glial reactions were studied by lectin staining and immunohistochemical method. The muscles innervated by the sciatic nerve and distal to the injection sites, and the nerves proximal to the injection sites were also collected and examined. RESULTS: TCS was taken up and transported by peripheral axons, and at a dose of 1 nmol, killed more than 90% of the motor neurons in 5 days, but only one-third of the sensory neurons of the injected nerve. The loss of neurons was permanent, while the increase of glial activities was mild and transient. CONCLUSION: TCS is retrogradely transported by axons of the injected nerve. TCS shows a selective neurotoxicity on different types of neurons. Hence TCS is useful in producing neural lesion in research, and this use may also be of applicational value in treating chronic spasticity, hyperalgesia, and pain.

Synergistic effects of DL111-IT in combination with mifepristone and misoprostol on termination of early pregnancy in preclinical studies.

This study evaluated the effectiveness and acute toxicity of DL111-IT combined with mifepristone (RU486) and misoprostol (MISO) on early pregnancy termination. In the pregnant rats experiments, the ED(50) values of RU486 in two-drug combinations were 0.16 (combined with DL111-IT) and 0.40 (combined with MISO) mg x kg(-1) x d(-1), while in three-drug combination treatment group (DL111-IT 9.0 mg x kg(-1) (

[Contragestational effects of dihydroartemisinin and artesunate].

In experiments carried out in mice, hamsters, guinea pigs and rabbits both dihydroartemisinin and artesunate showed contragestational effect. In mice and rabbits they caused embryo absorption whereas in hamsters and guinea pigs they induced abortion. The contragestational ED50 of dihydroartemisinin given sc on d 7 of pregnancy in mice and d 5 of pregnancy in hamsters were 32.8(27.7-38.9) mg.kg-1 and 6.1(5.6-6.7) mg.kg-1 respectively. The ED50 of this drug given im on d 18 of pregnancy in guinea pigs was 18.3(13.9-24.2) mg.kg-1. Dihydroartemisinin also showed mid-pregnancy terminating effect in hamsters. The contragestational ED50 of artesunate given sc on d 5 of pregnancy in hamsters and the ED50 of sodium artesunate given sc on d 5-8 of pregnancy in hamsters were 12.2(10.3-14.4) mg.kg-1 and 1.0(0.9-1.2) mg.kg-1 daily respectively. Results of light microscopic examination revealed that dihydroartemisinin was selectively toxic to embryo sac. At dose levels sufficient to induce embryo sac necrosis, dihydroartemisinin did not injure the uterus and ovary of the maternal animals. On the ground of the foregoing observations we consider that dihydroartemisinin, artesunate and their analogous drugs should not be used to treat malaria in pregnant women and there is the possibility to exploit intentional abortion agents from artemisinin derivatives.

[An experimental study of sulprostone as an agent in preparation for abortion]. / Eksperimental'noe issledovanie sul'prostona kak sredstva podgotovki k abortu.

The prostaglandin E sulprostone was studied in experiments on pregnant rats. It was shown to stimulate the bioelectrical activity of the uterus, by increasing the amplitude and frequency of biological potentials. Sulprostone was found to have abortive and embryotoxic effects which were especially pronounced during placentation. The drug induced a slight teratogenic effect.

Embryotoxicity and teratogenicity of DL111-IT, an early pregnancy-terminating agent, in the subsequent gestation following administration in rats.

DL 111-IT is a new non-hormonal early pregnancy-terminating agent. The subsequent embryotoxic and teratogenic effects of DL111-IT were studied in the rats whose first pregnancy had been terminated by the agent. The secondary pregnancy of the treated rats were allowed to initiate at 30-, 45-, and 90-day intervals, respectively, after the termination of the first pregnancy. The toxicities primed with DL111-IT, such as resorbed embryos and nephrohydrosis fetuses, were found to be 8.0% and 8.5%, respectively, in the rats with pregnancy at 30-day interval. This is significantly different from 4.0% resorbed embryos and 2.4% nephrohydrosis fetuses in vehicle control (P less than 0.05). However, the rate of resorbed embryos decreased to 7.0% or 6.0% in the rats with pregnancy at 45- or 90-day intervals, respectively. No other significant embryotoxicity and teratogenicity were observed in those rats initiating their pregnancy 45 days later after first-pregnancy termination by DL111-IT. Thus, DL111-IT appears to have very low subsequent toxicity in the course of rat pregnancy cycles.

Toxicities of trichosanthin and alpha-momorcharin, abortifacient proteins from Chinese medicinal plants, on cultured tumor cell lines.

Trichosanthin and alpha-momorcharin are abortifacient proteins extracted from Chinese medicinal herbs. Study of their in vitro cytotoxicities showed that the two proteins selectively injured choriocarcinoma and melanoma cells. Hepatoma cells represented the most resistant cell line among the various cell lines investigated. Cytotoxicity profiles of trichosanthin and alpha-momorcharin differed from those of anti-cancer drugs which interfere with DNA metabolism such as cisplatin, methotrexate and 5-fluorouracil. Radioactive precursor incorporation studies suggested that the two abortifacient proteins inhibited cellular protein synthesis. The marked decrease in secretion of human chorionic gonadotrophin and progesterone by choriocarcinoma cells after treatment with the proteins could be attributed mainly to loss of cells.

Adverse effects of the antifertility agent DL 717-IT (Canocenta, Byk Gulden, FRG). Pathological findings in the rabbit.

The post-coital antifertility agent DL 717-IT (Canocenta, Byk Gulden, FRG) was administered to sixteen female (5 pregnant and 11 nonpregnant) New Zealand White (NZW) rabbits by single i.m. injections at a dose of 2.5 mg/kg body weight. The corresponding number of controls received the vehicle of the drug only. Pregnancy was interrupted in all the DL 717-IT-treated rabbits. Obvious loss of bodyweight (-15% at mean) was observed in all the test animals during the first two test weeks after treatment. Same sized groups of test and control animals were euthanasized 3, 4, 5, and 6 weeks after the initiation of the treatment and complete necropsies and histological examinations were performed. One of the test animals died on day 21. Pathological findings involved epidermal hyperplasia, hyper- and dyskeratosis seen in 16/16, zonal and massive liver necrosis in 8/16, generalized degeneration of the skeletal muscles in 6/16, and focal myocardial necrosis in 5/16 test animals. Vitamin A concentrations in liver tissue were found to be significantly reduced in the experimental animals compared to the controls. Consequently the skin lesions may possibly be explained as the result of reduced vitamin A synthesis due to DL 717-IT-induced hepatocellular damage. The results of this study indicate severe toxic effects of DL 717-IT in the given formulation in the rabbit at dosages reported to be well tolerated in several species and recommended for veterinary use to terminate unwanted pregnancies in the bitch.

Anti-implantation activity of the fruit of Lagenaria breviflora Robert.

The fruit of Lagenaria breviflora Robert (Adenopus breviflorus Benth) family Cucurbitaceae used by natives as an abortifacient in Nigeria, was investigated for anti-implantation activity. The ethyl acetate extract of the whole fruit and methanol extract of the seed were very toxic to rats. Using ten female virgin albino rats for each extract, the World Health Organization special protocol and doses on a moisture-free basis: 20 g/kg whole fruit methanol extract gave 60% anti-implantation activity, 2.5 g/kg fruit pulp gave 80% and 5 g/kg fruit pulp gave 100% activity while 2 g/kg seed also gave 100% activity but four of the rats died. Statistical evaluation of the data showed that the results were significant.

Teratology study with the synthetic prostaglandin ONO-802 given intravaginally to rabbits.

ONO-802, a synthetic E1 prostaglandin, was administered intravaginally via pessaries to Dutch belted rabbits at doses of 250, 62.5, and 12.5 micrograms/kg on days 6 through 18 of gestation. Rabbits in a vehicle control group were treated with pessaries that did not contain ONO-802 during the same period. Another group of animals remained untreated throughout gestation. Necropsies were performed on rabbits found dead and on those killed on gestation day 30. Body weight, food and water consumption, and clinical signs were monitored during the experiment. Major organs were weighed when the dams were necropsied on gestation day 30, and litter and fetal data were collected. Abortion and maternal deaths occurred in drug-treated groups. Body weight gains and food and water consumption were adversely affected by treatment particularly at the 250 and 12.5 micrograms/kg dose levels. Wastage (postimplantation loss) was significantly increased among treated groups (all dose levels), while other litter and fetal parameters were unaffected. ONO-802 was not teratogenic at maternal and embryotoxic dose levels.

Two-phase teratology study with the synthetic prostaglandin ONO-802 given intravaginally to rats.

The synthetic prostaglandin ONO-802 was administered intravaginally to Sprague Dawley rats at doses of 1.0, 0.5, and 0.125 mg/kg on days 6 through 15 of gestation. A vehicle control group was treated with pessaries that did not contain the drug while another group remained untreated. Body weight, food, water consumption, and clinical signs were monitored during the experiment. In Phase One, 20 pregnant animals from each group were sacrificed at term, major organs were weighted, and litter and fetal data were collected. In Phase Two ten dams per group were allowed to deliver their litters, and the offspring were evaluated for survival, growth, developmental signs, and physiological function. Selected F1 offspring were retained to assess learning and emotional behavior or reproductive capacity. Administration of either 0.5 or 1.0 mg/kg of ONO-802 resulted in a slight reduction in food consumption and body weight gain. Water consumption was increased both during and after the dosing period for the mid and high dose dams. Significantly increased weights for the heart, lungs, liver, adrenals, and ovaries and decreased weights for the thymus gland were noted at term sacrifice of the 1.0 mg/kg dams, whereas the 0.5 mg/kg group had increased weights of the adrenals and ovaries only. Litter parameters were unaffected by treatment. Weights of the female fetuses of the 1.0 and 0.5 mg/kg groups were significantly reduced when compared to controls. There were no significant drug-related abnormalities among the F1 offspring and no evidence that treatment of the F0 dams affected the development, behavior, or reproductive performance of the F1 offspring. Thus, ONO-802 was not teratogenic when given to rats by the intravaginal route.

Comparative effects of hyperosmolar urea administered by intra-amniotic, intravenous, and intraperitoneal routes in rhesus monkeys.

Hypertonic urea solutions (58 per cent weight/volume) were injected rapidly into ten anesthetized rhesus monkeys at a dose of approximately 2 Gm. per kilogram by the intravenous, intraperitoneal, or intra-amniotic routes. An additional monkey received an intra-amniotic dose of 12.5 Gm. per kilogram. A tracer dose 14C-urea was included for measuring absorption and elimination. The following parameters were monitored before and for four hours after urea injection: arterial and cerebrospinal fluid pressures, heart and respiration rates, urine flow, and urea clearance. Serum electolytes, hematocrit and white count, and cumulative urea excretion were measured for one week. Monkeys were observed for three to six months after injection. At doses up to approximately twice the human dose (on a body weight basis) there were no urea-related deaths and no serious side effects noted in any of the experiments. These results support the suggestion that urea is a relatively safe hyperosmolar agent for inducing midtrimester abortions, especially with regard to inadvertent systemic injection.