the influence of betamethasone on the feto-placental unit

120 Negulescu et al. Influence of betamethasone

J. Perinat. Med.5(1977) 120

The influence of betamethasone on the feto-placental unitA preliminary report*

Radul. Negulescu**, Jürgen R. Strecker, Christian Lauritzen, Shrikantabushan Pal

Department of Obstetrics and Gynecology, University of Ulm, West-Germany

Curriculum vitae

RADU IOAN NEGULESCUwas born in 1941. 1959-1965 studies in medicineat the University Medi-cal School Cluj-Napoca,Romania. 1964-1967internship at the UniversityClinic Cluj-Napoca andsince 1969 resident inobstetrics and gynecology.1974 Dr. med. sei. afterstudies on EPH-gestosis.1975-1976 Humboldt-research fellow at the De-partment of Obstetrics and Gynecology, University ofUlm.Current studies on the influence of corticosteroids on thefeto-placental unit.

The prophylacticaltreatmentofrespiratoiy distresssyndrome with betamethasone is used successfullyinmanyclinics[2,6,19,20J21,27].Adisadvantageof betamethasone administration is the regulär fallof estrogen levels in maternal urine or plasma,which may lead to difficulties in the evaluation ofthe fetal condition in pregnancies at risk.SIMMER et al. [24] and OHRLANDER and GENNSER[18] have studied steroidgenesis in the fetoplacen-tal unit following corticosteroid injection. They

* This work was supported by Humboldt-Foundation andDeutsche Forschungsgemeinschaft SFB 87, Project C4, C5and C7.** At present Humboldt Fellow. Permanent adress: De-partment of Obstetrics and Gynecology, University ofCluj-Napoca, Romania.

could show a decrease of total estrogens in 24-hour-urine. OHRLANDER [18] and GENNSER [8]where able to demonstrate a decrease of Cortisol inmaternal and fetal plasma and amniotic fluidfollowing betamethasone injection. ARAI [1]reported a drop of estrogens in maternal and fetalplasma after intramuscular injection of dexa-methasone into the fetus in utero. TOWNSLEY [29]showed a 19% reduction of estrogen excretion in24-hour-urine following betamethasone injectionto the pregnant baboon. TOMBY RAJA [28] injectedbetamethasone in order to reduce estrogen levelsäs a treatment to prevent premature labour.In our investigations we wanted to examine theinfluence of betamethasone on estrogen-bio-synthesis in the piacenta and fetus. To our know-ledge there is no study examining the changes ofsteroid hormone levels in maternal plasma in shortintervals after betamethasone injection to themother. Furthermore we wanted to know wetherthe changes of estrogen concentration in plasmafollowing betamethasone administration to themother could be of use äs a new dynamic functionaltest of the piacenta and the fetus. It was alsoplanne d to test the steroidbiogenetic-function ofthe piacenta after betamethasone suppression-ofthe fetal pituitary-adrenal axis by DHA-S loading.

s

l Material and methods

We used Celestan Solubile made by BYK ESSEX,l ml containing 5.3 mg. betamethasone-sodium-

J. Perinat, Med. 5 (1977)

Negulescu et al. Influence of betamethasone 121

phosphate, representing 4 mg. betamethasone.Maternal plasma concentrations of estroneestradiol-17-beta (E2), estriol (E3), cortisol andtotal estrogens in 24-hour-urine where determinedin normal and pathological third trimester preg-nancies.A total of 32 volunteers was examined and sub-divided into VII groups.

Group I: Threepatientswith normaluncomplicatedpregnancies received 12 mg betamethasone intra-muscularly on two successive days.Group II: TwopatientssufferingfromEPH-gestosisand one from placental insufficiency received12 mg betamethasone intramuscularly on twosuccessive days.Group III: Four patients with normal pregnanciesreceived 8 mg betamethasone intravenously.Group IV: Three patients with normal pregnanciesreceived 8 mg. betamethasone and an additional25 mg DHA-S intravenously three hours later.Group V: Two patients with pathological preg-nancies (placental insufficiency) received 8 mgbetamethasone. Three hours later they received25 mg DHA-S intravenously.Group VI: Four patients with normal pregnanciesreceived 8 mg betamethasone. 50 mgDHA-Sweregiven intravenously 30 minutes later.Group VII: Six patients with normal and six withpathological pregnancies (placental insufficiency)received 8 mg betamethasone and an additional50 mg DHA-S intravenously three hours later.

Collection of 24-hour-urine for determination oftotal estrogens was performe d the day beforeinjection and during the six following days.Maternal venous blood for determination of E1?

E2, E3, äs well äs cortisol was drawn before injectionof betamethasone and at short intervals during thefirst day of treatment (see figures for exact timing)and one hour after the second injection on day 2in groups I and II. One blood sample was drawn oneach of the six subsequent days at 9 a.m. Theplasma was separated by centrifugation at 3000 rpmand stored frozen until used for the assay.Radioimmunoassays of EJ, E2 and E3 were per-formed with specific antibodies which were a giftfrom Dr. GOEBEL, München and Dr. KÜNZIG,Köln. The assay procedure was described previously

[25]. Different volumes of undiluted plasma wereextracted with 10 volumes of ether for determina-tion of the unconjugated estrogen fractions. Aphotometric method was employed to determinethe total urinary estrogens. Unconjugated cortisolwas determined by the method of MURPHY [16].

2 Results and discussion

The basal values of E l 9 E2, E3 in maternal plasmawere considerably higher in normal pregnanciescompared to pathological pregnancies (Fig. l, 2).Following injection of betamethasone, plasma andurinary concentrations of estrogensdecreasebecauseof diminished adrenocortical precursor availabilityin the fetal and maternal compartment [23, 24].

The decrease of plasma-estrogens, cortisol and ofthe urinary-estrogens is dose-dependent and reachesa maximum after the second betamethasone in-jection. A greater percentage of the total diminu-ition in plasma estrogens is observed three hoursafter the first betamethasone injection (Fig. l ,2,4).The investigation of plasma estrogen changesfollowing betamethasone shows a great differencebetween normal and pathological pregnancies. Thedecrease of E2 three hours after intramuscularinjection of betamethasone was 69% of controlvalues in normal compared to 33% in pathologicalcases. The drop of E3 was also more prominent innormal pregnancies(63%) compared to complicatedcases (42%), (Fig. 1,2).In normal pregnancies it took 3 days for estrogenvalues to return to basal levels. In pathologicalpregnancies 5 days were required before basalvalues were attained. Thus pathological cases seemto reach preinjection control estrogen values laterthan normal pregnancies. Plasma E3 concentrationsneed the longest time to return to basal values.This could be caused by a longer suppression ofthe fetal than of the maternal pituitary-adrenalaxis [24], Betamethasone may produce suppressionof 16X-hydroxlase in the fetal liver without in-fluencing the placental aromatisation.In one case of EPH-gestosis and intrauterine fetaldeath, concentrations of E l 5 E2, and E3 showedlittle change following betamethasone in contrastto normal control cases. A more pronounced

J. Perinat. Med. 5 (1977)


Plasma E2ng/mlng/mlA ι Betamethasone ι 12mg im.

„ 112mg im. t

normal pregnancies (n=3)pathological pregnancies (n»3)

VI VII days

' Fig. 1. Plasma estradiol-17-0 after betamethasone administration in normal and pathological pregnancies. Mean values.Normal: base values = 20-40-12 ng/ml, SD = 14.42; 3 hrs. after = 6.8-11-4, SD = 3.52. Pathological: base values= 8-7-2.3, SD = 3.04; 3 hrs after = 5.2-5.4-0.75, SD = 2.62.

Plasma E3ng/ml

12-

10-

8-

6-

4-

2-

l Betamethasone12mg im. { 12mg i

·—· normal pregnancies (n=3)pathological pregnancies (n=3)

hrs.0 1 2 3 4 5 6ι 1

daylII Hl IV VI VII days

Fig. 2. Plasma estriol after betamethasone administration in normal and pathological pregnancies. Mean values. Normal:base values = 12-16-6.8, SD = 4.61; 3 hrs. after = 2.5-7-2.2, SD = 2.68. Pathological: base values = 3-5.2-2.3SD = 1.51; 3 hrs. after = 2.2-3.2-0.70, SD = 1.25.

decrease of plasma estrogens in cases of in- In contrast to the studies of' HRLANDER [18],trauterine fetal death should be,expected if the who described a return to basal cortisol valuesmatemal adrenal cortex is suppressed to a major after three weeks, we found that a nonnaUsationextent- of cortisol values has already occurred three days



Estrogens

mg/24 hrs.Betamethasone

,12mg,t im. f

*—a normal pregnancies (n=3)pathological pregnancies (n»3)

VI days

Fig. 3. Total estrogens in 24-h-urine after betamethasone administration. Mean values. Normal: base values = 18-27.9-19.7, SD = 5.29; 3 days after = 7.6-3, SD = 3.25. Pathological: base values = 5.2-10.6 SD = 3.8; 3 days after = 2-6 mg/24H,'SD = 2.82.

ng/ml

40-36-32-28-24-20-16-12-8-4-

1 BetamethasoneT 8mg iv.

0 15 30 60 120 180 300 min.

Fig. 4. Estrone, estradiol-17-0 and estriol in plasma after iv. injection of 8 mg betamethasone. Mean values of 4 normalpregnancies. For El base vaiues = 24-16-30-17, SD = 6.55; 3 hrs. after = 21-16.5-16-10.4, SD = 4.34. For E2base values = 31-37.5-30-54, SD = 11.09; 3 hrs. after = 20-25-8.5-6.2, SD = 9.03. For E3 base values = 33-17.5-18-34, SD = 9.10; 3 hrs. after = 4.3-1.6-6-7.2, SD = 2.42.

after the second betamethasone application. It isto be stressed however that the cortisol levels inour patients were mostly within normal limits.The concentrations of DHA in maternal plasmaand urine show only a small change following

betamethasone application in normal and patho-logical pregnancies [17].Since the suppression of the maternal adrenalcortex following betamethasone is about the samein normal and pathological pregnancies, one could



draw the conclusion that differences in estrogendecreases are mostly due to the difference insuppression of estrogen precursor-biosynthesisbetween the normal fetus and the fetus at risk.

Changes of plasma estrogens following beta-methasone application correspond well withchanges of urinary estrogens (Fig. 3). The maximalmean decrease of urinary estrogens was 76% innormal pregnancies. It was reached the first dayafter the second betamethasone application. Atthe same time the maximal drop for the lowercontrol values of pathological pregnancies wasonly 50% of basal values. The return to basalvalues was not reached within four days after thesecond betamethasone injection in both groups.It has been reported, that the return to basal valuesis reached in 2—3 weeks [5, 20] or after 5—6 days

421,22].Maternal plasma concentrations of estrone (E^did not show specific changes during the first daysfollowing betamethasone injection.According to the results from the patients of groupIV, V and VI plasma E2 and E3 show morepronounced decreases in normal pregnancies thanin pathological pregnancies. The E2 and E3 increaseoccurring 30 minutes after DHA-S injection is alsohigher in normal pregnancies (Fig. 5,6).Intravenous injection of 50 mg DHA-S immediatelyafter intravenous betamethasone injection causes a

smaller increase of plasma E3 (since the suppressionof the fetal pituitary-adrenal axis is still minimal atthis time) than a smaller ;dose of DHA-S (25 mg)administered three hours later (Fig. 7).

A hypothetical explanation is that endogenousestrogen precursors and exogenous DHA-S competefor aromatisation in the placent [10,13, 30].The increase of plasma E3 (89%) following DHA-Sinjection in patients of group IV is quite similar tothat in the cases examined by STRECKER andLAURITZEN [25]. BUSTER [3] did not find anincrease of plasma E3 following DHA-S injection.The increase of E3 after betamethasone Inhibitioncould be explained by an activation of the „phenolicpathway" (16-alfa-hydroxylation in the maternalliver)[7,22j.

The different patterns of plasma concentrationsfor £2, E3 and urinary estrogens following beta-methasone and DHA-S injection in normal andpathological pregnancies encouraged us to applythis idea to a new modified dynamic test of feto-placental function: „A betamethasone suppression-PHA-S Stimulation Test". We think that this testwill give us more and new Information about fetaland placental compartments in normal and patho-logical pregnancies.

The influence of betamethasone on the feto-placental unit is demonstrated in Fig. 8.

Plasma E:ng/ml

32-2824-20-16-.12-·8-4-

• Betamethasone , DHA-S112 mg iv . t 25 mg iv.

, BetamethasoneM2mg IV

day l

Fig. 5. Plasma estradiol-17-0 after betamethasone administration and additional injection of 25 mg DHA^S iv. MeaniTs^Tln ™ <nUeo *0

12ρΛ^~9·6' SD = h28; 3 hrS' **" betametha*one = 6.5-2-12.4, SD = 5.2; 30' after- ntS ",2Vn ~ fi ' ?ΛΤ 2:**·Ρ*'*°*>&** (dotted line): base values = 16 8.5, SD = 5.30; 3 hrs. after betamethasone- 9.5-5.5, SD = 2.82; 30' after DHA-S = 16-14.5, SD = 1.06.



Plasma E3ng/ml

12-

10-

8-

6-

4-

2-

I Betamethasone , DMA -S112mg i v . t 25mg iv. » Betamethasone

12mg i v .

0 3060 120 180 min. 300ι ι0 1

l2

— r3

^1 |

4day 1

— ι —5

— ι —6 hrs. 8

jII II! days

Fig. 6. Plasma estriol after betamethasone administration and additional injection of 25 mg DHA-S i.v. Mean values.Normal: base values = 12-11.6-9.6, SD = 1.28; 3 hrs. after betamethasone = 5.8 3.4-4.6, SD = 1.2; 30' after DHA-S= 10-9-6.4, SD = l.SS.Pathological (dotted line): base values = 5-3.6, SD = 0.98; 3 hrs. after betamethasone = 4.1-4,SD = 0.70; 30' after DHA-S = 3.8-3.6, SD = 0.84.

Plasmang/ml

Betamethasone12mg iv.

DHA-S25mg iv.

*

normal pregnancies50mg DHA-S i.v. (n=4)normal pregnancies25mg DHA-S i.v. (n=3)

ι BetamethasoneM2mgiv.

. l ι0 1

l

l2 3 4 5 6

day l

hrs./yι// ι8 II III days

Fig. 7. Plasma estriol after betamethasone administration and subsequent injection of 25 or 50 mg DHA-S in normalpregnancies. Mean values. For 25 mg DHA-S the individuel values and SD are identical with values of Fig. 6. For 50 mgDHA-S: base values = 8.4-6-6.4-7.3, SD = 1.06; 30' after betamethasone = 7.6-4.2-4.2-7.6, SD = 1.96; 30' afterDHA-S = 7.5-2.6-5.6-3.2, SD = 2.3.



Mother

Betamethasone >

5

ι— l

ι

Pituitary

- ACTH!

' T iCorticosteroid-(hormones -χ

(<

t

- Steroids(DHAt)Adrenalcortex

K)

(0) r > Corticoides \

Betamethasone ^PFetusPituitary

ACTH!

/*

5 r

Steroids(DHAt)

Adrenalcortex

Stimulation: /Inhibition: ,decrease: t .

Fig. 8. Schematic outline of the inhibiting effect of betamethasone on steroid production in maternal and fetal adrenalss consequence of ACTH-suppression in the pituitary.

3 Basal theoretical knowledge concerning the test

Investigations of ophorectomized patients haveshow that there is a minimal basal DHA secretion ofthe adrenal cortex even after complete suppressionof ACTH. Also, it is well known that there is nogonadal DHA production in the fetus. OHRLANDER[18] could show there is minimal estriol excretionin maternal urine (aproximately 2 mg) even aftercomplete suppression of ACTH. These results showthe existence of a basal adrenal cortex secretion ofestrogen precursors which is independent of hypo-thalamic-pituitary Stimulation. One could say thatafter suppression of the pituitary-adrenal cortexaxis by betamethasone, the determination of plasmaestrogens gives Information about the basal adrenalsecretion of estrogen precursors and the extent ofadrenal cortical suppression.CHALLIS [4] has examined plasma concentrationsof androstenedione, testosterone, estrogens andcortisol after betamethasone application to rhesusmonkeys. He found a more pronounced suppressionof estrogens than androgens. The androgensremained at a constant level after an initial drop.The decrease of estrogens was continual, indicatingthat it was caused by a suppression of the fetaladrenal cortex.

SIMMER demonstrated [23, 24] that the decreaseof €χ9 estrogen precursors following corticosteroidapplication was more intense in the umbilical veinthan in maternal plasma.We believe that the dynamic determination ofmaternal plasma estrogens after betamethasoneapplication represents a test for the suppressionof the pituitary-adrenal cortex axis.The following reasons are listed in support of thiscontention:

1. The extent of the plasma estrogen decreasefollowing betamethasone application showspredominantiy the fetal portion of the pool ofestrogen-precursors. Maternal precursors showlittle change.

2. The basal estrogen level that remains constantover a period of time after betamethasonesuppression shows preponderately the maternalportion of the pool of estrogen precursors.

3. The extent of the estrogen-fall represents ameasure of the fetal pituitary-adrenal suppressionand of the ability of the adrenal cortex torespond to factors acting on the feed backmechanisms. This may be important for theadaptation to situations of stress in utero.



4. After maximal suppression of the fetal estrogenprecursors, conditions of an "in vivo" isolationof the placenta are created.

In this way it should be possible to evaluate separa-tely e.g. the aromatisation rate of the placentaafter DHA-S loading without interference from thefetal or maternal side.

The response of the adrenal cortex to pituitaryACTH depends on the intensity and duration ofthis Stimulation. The adrenal cortex of a normalfetus reacts with an imme diäte and adequatesecretion of corticosteroids. ISHERWOOD andOAKEY [9] could demonstrate an increased pro-duction of androgens "in vitro" following ACTH-stimulation. Direct injection of ACTH and HCGinto the fetus showed significant rises of maternalestrogens via an increase of fetal estrogen precursors[1,12,26].Animal investigations have shown an increasedsecretion of ACTH in fetus suffering from chronicor acute hypoxia. There was no rise of plasma-cortisol levels found in fetuses with chronichypoxia [31].The estrogen response pattern following beta-methasone application changes with the conditionof the fetus. A healthy, normal fetus reacts with amore intense decrease of estrogens than a fetus atrisk, and the retum to values before injection ismore rapid.In normal pregnancies the decline of E3 threehours after intravenous injection of 8 mg beta-methasone exceeds 50% of preinjection values.This decrease showed good correlations to clinicalUndings, erg. the cardiotocogram and humanplacental lactogen (HPL).HPL levels are not influenced by corticosteroidapplication to themother[19,20,32].OHRLANDE R[18] could show a direct correlation between basalestriol-excretion in the 24-h-urine and its decreaseafter betamethasone injection.In pathological pregnancies the decline of theprimarily low estrogen levels is less distinct and thereturn to basal values is slower.The most important criteria for the Interpretationof the estrogen curves following betamethasonesuppression seem tobe the extension of the plateau

together with the amplitude of the curve and thetime required for preinjection control values to bereached.With an additional application of 50 mg DHA-Sthree hours after betamethasone injection to themother and determination of maternal plasmaestrogens in short intervals there might be thepossibility of a new more sophisticated functionalmethod of determining placental function: "AnInhibition test of the fetal pituitary-adrenal cortexaxis combined with a loading-test of the placenta."

This test could evaluate the condition of the fetusby determination of E3 after betamethasoneapplication to the mother and could also clarifythe reserve capacity of the placenta followingDHA-S loading, in a state of maximal suppressionof the endogenous estrogen-precursors by deter-mination of E2 (Fig. 9).There are numerous reports about the theory andthe clinical value of the DHA-S loading-test inplasma [10,11,13,14,15, 25, 30].The criteria of normality for this part of the com-bined test mentioned above agree with those.reported by STRECKER and LAURITZEN [25].In this way an improvement of the DHA-S loadingtest may be possible since the fetal and to asmaller extent the maternal estrogen precursors areexcluded.

The following conclusions can be drawn from ourinvestigations

l.The changes of plasma and urinary estrogenlevels depend on the dose of betamethasone andon the way of application.

2. The maximal decrease of maternal E2 and E3 isreached three hours after injection. The returnto preinjection values takes more than 4-5days.

3. The decline of estrogens following beta-methasone injection to the mother is caused bysuppression of adrenocortical estrogen-precursorsmainly derived from the fetus.

4. The changes of maternal plasma estrogens afterbetamethasone and subsequent DHA-S loadingoffer new possibilities for testingthe fetoplacentalunit.



Plasma £3ng/ml

Plasma £2ng/ml

Betamethasonesuppression -r DHA-S-loading-test

Fig. 9. "A betamethasone suppression DHA-S-loading test". Suppression of plasma estriol after betamethasoneadministration äs index of fetal condition and subsequent evaluation of placental function by DHA-S loading. A hypo-thesis for a new combined test of fetus and placen ta demonstrated in 6 normal and 6 pathological (placental insufficiency)cases. Mean and SD values. For E3 base and 3 hrs. after betamethasone values p < 0,0025 (Student test).

Summary

The effect of betamethasone on the estrogen-biosynthesisin placenta and fetus was tested. It was ashed whether thechanges of estrogen concentration in plasma followingbetamethasone administration to the mother could be ofuse äs a new dynamic functional test of the placenta andthe fetus. It was also planned to test the placental steroido-genetic function after betamethason suppression of thefetal pituitary-adrenal axis, by DHA-S loading.Maternal plasma concentrations of estrone (Ej), estradiol17-0 (E2), estriol (E3), cortisol and total estrogens in24-h-urine where determined in normal and pathologicalthird trimester pregnancies.A total of 32 patients was examined und subdivided intoVII groups.Group 1,11 andlllreceived 12 mg betamethasoneim. or 8 mg iv. Group IV, V,VI, VII received betamethasoneand also 25 or 50 mg DHA-S iv.Maternal venous blood for determination of Ej, E2 andE3 äs well äs cortisol was drawn before injection ofbetamethasone and at short intervals during the first dayof treatment (see figures for exact timing) and one hourafter the second injection on day II in the cases of group Iand II. One blood sample was drawn on each of the sixsubsequent day s at 9 a.m.E!, E2 and E3 were determined by radioimmunoassay.A photometric method was employed to determine thetotal urinary estrogens.Unconjugated cortisol was determined by the method ofMURPHY.The basal values of E1? E2, E3 in mafernal plasma whereconsiderably higher in normal pregnancies than in patho-logical pregnancies (Fig. l, 2, 3, 4).

The decrease of plasma-estrogens, cortisol and of theurinary-estrogens is dose dependent and reaches a mäxi-mum on the second betamethasone injection (Fig. l, 2, 3).Plasma estrogen changes following betamethasone show agreat difference between normal and pathological preg-nancies. The decrease of E2 three hours after intramuscularinjection of betamethasone was 69% in normal compaiedto 33% in pathological cases.The drop of E3 was also more prominent in normal preg-nancies (63%) than in complicated cases (42%) (Fig. land 2).Estrogen values of normal pregnancies returned to basalvalues three days after injection. In pathological preg-nancies 5 days elapsed before values were normal again.In patients of group IV, V and VI the increases of plasmaE2 and E3 occurring 30 minutes after DHA^S injectionare also higher in normal that in pathological pregnancies(Fig. 5, 6).The different patterns of plasma concentrations of E2, E3and urinary estrogens following betamethasone and DHA-Sinjection in normal and pathological pregnancies encour-aged us to apply this idea to a.new modified dynamic testof feto-placental function: "AJbetamethasone suppressionDHA-S-loading Test".The estrogen response pattern following betamethasoneapplication changes with the condition of the fetus. Ahealthy, normal fetus reacts with a more intense decreaseof estrogens than a fetus at risk and the return to valuesbefore injection is more rapid.



In cases of a "normal response" the decline of E3 threehours after intravenous injection of 8 mg betamethasoneexceeds 50% of preinjection values.In pathological pregnancies the decline of the primarilylow estiogen levels is less distinct and the return to basalvalues is slower.With an additional application of 50 mg DHA-S threehours after betamethasone injection to the mother anddetermination of maternal plasma estrogens in short inter-vals there might be the possibility of a new functionalmethod determining placental function: "An Inhibitiontest of the fetal pituitary-adrenal axis combined with aloading-test of the placenta.".This test could evaluate the condition of the fetus bydetermination of £3 after betamethasone application tothe mother and could also clarify the reserve capacity ofthe placenta following DHA-S loading in a state of maxi-

mal suppression of the endogenous estrogen-precursorsby determination of E2 (Fig. 9).The following conclusions can be drawn from our in-vestigations:

1. The changes of plasma and urinary estrogens depend onthe dose of betamethasone and on the way of application.

2. The maximal decrease of maternal E2 and £3 is reachedthree hours after injection. The return to preinjectionvalues takes more than 4-5 days.

3. The decline of estrogens following betamethasone in-jection to the mother is causes by suppression ofadrenocortical estrogen-precursors mainly derived fromthe fetus.

4. The changes of maternal plasma estrogens after beta-methasone and subsequent DHA-S loading offer newpossibilities for testing the fetoplacental unit.

Keywords: DHA-S-loading test, dynamic functional test, feto-placental unit, placental insufficiency

Zusammenfassung

Der Einfluß von Betamethason auf die fetoplazentareEinheit.In unserer Studie soll der Einfluß von Betamethason aufdie Oestrogen-Biosynthese in Fet und Plazenta untersuchtwerden. Weiterhin wollen wir herausfinden, ob Verände-rungen der mütterlichen Östrogenkonzentration im Plasmanach Verabreichung von Betamethason an die Mutter alsein neuer, dynamischer funktioneller Test für Fet undPlazenta herangezogen werden können. Ebenso war vor-gesehen, die Plazenta durch DHA-S- Belastung zu testen,nachdem, die fetale Hypophysen-Nebennierenrindenachsedurch Betamethason supprimiert wurde.Die mütterlichen Plasma-Spiegel von Östron (Ej), Östra-diol 17-0 (E2), Östriol (E3), Cortisol und die Gesamt-Östrogene im 24-h-Urin wurden bei normalen und patho-logischen Schwangerschaften im 3. Trimenon bestimmt.

Die Gesamtzahl von 32 Patientinnen wurde in 7 Gruppenunterteilt.Die Gruppen I, II und III erhielten 12 mg Betamethasoni.m. oder 8 mg i.v. Die Gruppen IV, V, VI, VII erhieltenBetamethason und zusätzlich 25 oder 50 mg DHA-S i.v.Mütterliches Venenblut für die Bestimmungen von EI, E2,E3 und Cortisol wurden vor der Injektion von Betametha-son und in kurzen Zeitabständen während des 1. Behand-lungstages (genaue Zeitabstände bitte den Abbildungenentnehmen) sowie l Stunde nach der 2. Injektion am TagII in der Gruppe I und II abgenommen. Eine Probe wurdejeweils an den 6 folgenden Tagen um 9.00 h entnommen.E!, E2 und E3 wurden radioimmunologisch bestimmt, dieGesamtöstrogene im Urin wurden photometrisch gemessen.Freies Cortisol wurde nach der Methode von Murphy be-stimmt.Die Basalwerte von EI, E2 und E3 im mütterlichen Plasmawaren bei normalen Schwangerschaften signifikant höher,als bei pathologischen Fällen (Abb. l, 2, 3,4).Der Abfall der Plasma-Östrogene, Cortisol und der Ge-samtöstrogene im Urin ist dosisabhängig und erreichtein Maximum nach der 2. Be tarne thason-Injektion(Abb. 1,2,3).

Die Untersuchungen der Verlaufskurven für die Plasma-Östrogene nach Betamethason zeigen einen großen Unter-schied zwischen normalen und pathologischen Schwan-gerschaften. Der Abfall von Östradiol drei Stunden nachintramuskulärer Injektion von Betamethason betrug 69%bei normalen, im Vergleich zu 33% bei pathologischenFällen. Der Abfall von £3 war bei normalen Schwanger-schaften ebenfalls ausgeprägter als bei kompliziertenFällen (63 gegen 42%) (Abb. l und 2).Die Östrogenwerte erreichten bei normalen Schwanger-schaften den Basalwert nicht vor 3 Tagen nach der In-jektion im Gegensatz zu 5 Tagen bei pathologischenFällen.Gemäß den Ergebnissen, die wir bei den Patienten-Gruppen IV, V und VI erhalten haben, sind die Anstiegevon E2 und E3 30 Minuten nach DHA-S-Injektion beinormalen Schwangerschaften höher als bei pathologischenFällen (Abb. 5 und 6).Die unterschiedlichen Kurvenverläufe von E2, £3 und derUrin-Östrogene nach Betamethason-Injektionen bei nor-malen und pathologischen Schwangerschaften veranlaßtenuns, einen neuartigen, modifizierten, dynamischen Testfür die Beurteilung der fetoplazentaren Funktion vorzu-schlagen: „den Betamethason-Suppressions-DHA-S-Belastungstest!"Das Antwortmuster der Östrogene nach Betamethason-Verabreichung verändert sich mit dem Zustand des Feten.Ein gesunder, normaler Fet reagiert mit einem stärkerenAbfall der Östrogene, als ein vorgeschädigter Fet und dasWiederaufsteigen zu den Basalwerten geschieht schneller.Bei Fällen mit einer normalen Antwort übersteigt der Ab-fall von £3 -3 Stunden nach intravenöser Injektion von8 mg Betamethason - 50% des Basalwertes.Bei pathologischen Schwangerschaften ist der Abfall derschon primär niedrigen Östrogenwerte weniger ausgeprägtund die Rückkehr zu den Basalwerten langsamer. Mit zu-sätzlicher Verabreichung von 50 mg DHA-S, 3 Std. nachBe tarne thasongabe an die Mutter und Bestimmung dermütterlichen Plasma-Östrogene in kurzen Zeitabständen,könnte sich ein Weg zu einem neuen, funktioneilen Test



für die Beurteilung der Plazenta-Funktion ergeben: EinHemmungstest der fetalen Hypophysen-Nebennieren-rindenachse kombiniert mit einem Belastungstest für diePlazenta. Dieser Test könnte durch die E3-Bestimmungnach Betamethason-Verabreichung an die Mutter Aus-kunft über den Zustand des Feten geben und zudem dieReserve-Kapazität der Plazenta nach DHA-S-Belastungdurch die Bestimmung von E2 beurteilen. In diesem Zu-stand ist nämlich die Produktion der endogenen Östrogen-Präkursoren maximal supprimiert (Abb. 9).Folgende Schlußfolgerungen können aus unseren Unter-suchungen gezogen werden:l.Die Veränderungen der Plasma- und Urin-Östrogene

sind abhängig von der Betarnethason-Dosis und derVerabreichungsform.

Schlüsselwörter: DHA-S-Belastungstest, dynamischer Plazentafunktionstest, fetoplazentare Einheit, Plazentarinsuffizienz.

2. Der maximale Abfall von mütterlichem E2 und E3wird drei Stunden.nach der Injektion erreicht. DieRückkehr zu Basalwerten, erfolgt erst nach vier bisfünf Tagen.

3. Der Abfall der Östrogene nach Betamethason-Injektionan die Mutter entsteht hauptsächlich durch die Suppres-sion der adreno-corticalen Östrogenpräkursoren, dievom Feten stammen.

4. Die Veränderungen der mütterlichen Plasma-Östrogenenach Betamethason und nachfolgender DHA-S-Belastungzeigen neue Wege auf, den Zustand der feto-plazentarenEinheit beurteilen zu können.

Resume

v Influence de la betamethasone sur Tunke foeto'placentaireDans le present article nous avons examine Finfluence debetamethasone sur la biosynthese des oestrogenes dans leplacenta et le foetus. De plus, nous avons cherche a savoirsi des modifications des concentrations dOestrogenesdans le plasma apres administration de betamethasone ala mere pourraient etre utilisees comme un nouveau testfonctionnel et dynamique du placenta et du foetus. Nousavons essaye aussi de tester par Charge DHA-S la fonctionsteroidobiogenetique du placenta apres la suppression deTaxe hypophiso-adrenocortical par betamethasone.A cet effet, nous avons determine les concentrations plas-ma tiques maternelles de l'oestrone (OEj), de l'oestradiol(OE2>, de l'oestriol (OE3), du Cortisol et ceUes desoestrogenes de l'urine de 24 heures au troisieme trimestredegrossesses normales et pathologiques. Les 32 parturientesexaminees ont ete reparties en VII groupes. Les groupesI, II et III ont re$u 12 mg ou 8 mg de betamethasone i.mLes groupes IV, V, VI et VII ont regu la betamethasene etaussi 25 mg ou 50 mg de DHA-S i.v.L'OEj, 2 et 3 ainsi que le cortisol ont ete determi-nes dans le sang veineux avant l'injection de betamethasoneet a courts intervalles pendant la premiere journee dutraitement (cf. les graphiques pour les temps precis) etune heure apres la seconde injection au deuxieme jourdans les cas des groupes I et II.Un prelevement a ete effectue a 9 h. du matin chacun dessix jours suivants. LOEi, 1OE2 et 1OE3 plasmiques ontete definis par la methode radioimmunologique et lesoestrogenes totaux urinaires par methode photometrique.Le cortisol non-conjugue a ete determine par la methodede MURPHY.Les concentrations d'OElf dOE2 et d'OE3 en plasmamaternel avant l'injection de betamethasone ont eteconsiderablement plus elevees dans les grossesses normalesque dans ceUes pathologiques (fig. l, 2, 3,4).La baisse des oestrogenes plasmatiques, du cortisol et desoestrogenes urinaires depend de la (lose et atteint unmaximum apres la.seconde injection de betamethasone(fig. l, 2, 3). Les investigations des changements des

oestrogenes plasmatiques apres betamethasone montrentune grande difference entre les grossesses normales etpathologiques. La baisse d'OE^ trois heures apres l'injec-tion intramusculaire de betamethasone a atteint 69%dans les grossesses normales et seulement 33% dans lesgrossesses pathologiques' La baisse dOE3 a ete egalementplus importante dans les cas normaux (63%) que dans lescas compliques (42%) (fig. l et 2).Les valeurs des oestrogenes en grossesse normale ontretrouve leur niveau de depart trois jours seulement apresl'injection et meme 5 jours pour les grpsses pathologiques.Selon les resultats des patientes des groupes IV, V et VI,les hausses dOE2 et dOE3 plasmiques 30 minutes apresl'injection de DHA-S sont plus grandes en grossessenormale qu'en grossesse pathologique. (fig. 5 et 6).La difference des courbes des concentrations plasmiquesd'OE2, d'OE3 et des oestrogenes urinaires apres l'injectionde betamethasone et de DHA-S entre les grossesses normaleset pathologiques nous a incites a„appliquer cette ideecomme un nouveau test dynamique de la fonction foeto-placentaiie: «Un test d'inhibition par betamethasone et deStimulation par DHA-S».La reaction des oestrogenes apres l'injection de betametha-sone varie selon la condition du foetus. Un foetus normalet sain reagit par une baisse plus forte des oestrogenesqu'un foetus «a risque» et le retour aux valeurs de base(c.a.d. precedant l'injection) est plus rapide.Dans les cas d'une «reaction normale», la baisse d'OE3trois heures apres l'injection intraveineuse de 8 mg debetamethasone depasse 50% des valeurs initiales. Dans lescas des grossesses pathologiques la baisse des valeursinitialement basses des oestrogenes est moins prononceeet le retour aux valeurs de base est plus lent.L'injection supplementaire de 50 mg de DHA-S troisheures apres l'injection de betamethasone a la mere et ladetermination des oestrogenes plasmatiques maternels acourts intervalles pourrait nous donner la possibilited'appliquer une nouvelle methode pour definir la fonctionplacentaire: «Un test d'inhibition de Taxe hypophiso-adrenocortical combine avec un loading-test» du placenta.

J. Perinat. Med. S (1977)


Ce test pourrait permettre d'evaluer la condition du foetusen determinant 1OE3 apres l'injection de betamethasoneä la mere ainsi que la capacite de reserve placentaiie apresPadministration de DHA-S au moment de la suppressionmaximale des precurseurs endogenes des oestrogenes pardetermination dOE2 (fig. 9). Les resultats obtenus nousont permis de tirer les conclusions suivantes:

1. Les vaiiations des oestrogenes plasmatiques et urinaiiesdependent de la dose et de la maniere d'application dela betamethasone.

2. La baisse maximale de 2 et de 1OE3 materneisplasmatiques est obtenue trois heures apres l'injection.Le retour aux valeurs initiales dure plus de 4-5 jours.

3. La baisse des oestrogenes suivant l'injection de beta-methasone resulte de la suppression des precurseursadrenocorticals des oestrogenes, principalementproduits par le foetus.

4. Les variations des oestrogenes plasmatiques materneisapres l'injection de betamethasone et de DHA-S nousoffre des nouvelles perspectives pour tester l'unitefoeto-placentaire.

Mots-cles: DHA-S-«loading-test», insufficance placentaire, test fonctionnel dynamique, unite foeto-placentaire.

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Received July 21 st, 1976. Accepted December 13,1976.

Dr. med. Radu Negulescu3400 Cluj^NapocaStr. Racovita Nr. 20Romania

J. Perinat, Med. 5 (1977)

the influence of betamethasone on the feto-placental unit

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