TERATOGENICITY OF THERAPEUTIC

m
AGENTS m i|

THOMAS H. SHEPARD, M.D.

0045-9380/79/12001-43505.00
9 1979 Year Book Medical Publishers Inc.
 TABLE OF CONTENTS

S E L F - A s s E S S M E N T QUESTIONS . . . , . . . . . . . . . . 3

TERATOGENIC SUSCEPTIBILITY AND THE STAGE OF

DEVELOPMENT . . . . . . . . . . . . . . . . . 6

SERIES V A R I A T I O N IN RESPONSE TO TERATOGENIC A G E N T S . . . . 9

D R U G QUANTITY AND TERATOGENICITY . . . . . . . . . . . 10

MUTAGENICITY AND CARCINOGENICITY . . . . . . . . . . . . 10

MULTIFACTORIAL CAUSES OF CONGENITAL DEFECTS . . . . . . 10

INTERPRETATION OF EPIDEMIOLOGIC FINDINGS . . . . . . . . 11

How TO ADVISE THE P A T I E N T AT RISK . . . . . . . . . . 13

INFORMATION ON TERATOGENICITY . . . . . . . . . . . . 14

CRITERIA FOR DECIDING AN A G E N T ' S TERATOGENICITY IN

HUMANS . . . . . . . . . . . . . . . . . . . 14

METHODS FOR DETECTION AND PREVENTION OF HUMAN

TERATOGENICITY . . . . . . . . . . . . . . . . 16

PROVED H U M A N TERATOGENS . . . . . . . . . . . . . . 19

POSSIBLE, SUSPECTED AND UNPROVED D R U G S AND

TREATMENTS . . . . . . . . . . . . . . . . . . 29

SELF-ASsESSMENT ANSWERS . . . . . . . . . . . . . . . 42
SELF-ASSESSMENT QUESTIONS
1. Rate as low, intermediate or high the relative teratogenic
sensitivity of the human fetus at the following periods:
a. Before organogenesis (days 1 through 18).
b. During organogenesis (days 19 through 60).
c. After organogenesis and during histogenesis (days 61 to
birth).
2. Time of teratogenic sensitivity. Connect the gestational time
period (days from fertilization) to the malformation produced.
a. Thalidomide-induced 1. After 65- 70 days.
dysmelia. 2. 21- 40 days.
b. Radioiodine-caused fe- 3. After 120 days.
tal thyroidectomy. 4. Before 90 days.
c. Androgenic fusion of
labial folds.
d. Tetracycline staining of
dental enamel.
3. Which of the following statements is false:
a. Species variability in teratogenic reaction makes it diffi-
cult to extrapolate data from experimental animals to
man.
b. Nearly all drugs given in high enough doses will cause
some fetotoxicity in experimentals.
c. Sodium chloride and sucrose are both animal teratogens.
d. The Delaney clause stipulates excluding animal terato-
gens from the human diet.
4. List the possible causes for false positive teratogenic associa-
tions between drug ingestion and congenital malformations.
5. Describe the approach to advising parents who are at risk
from exposure to teratogens.
6. Teratogenic potential of most drugs can be predicted by
chemical structure. True or false?
7. Which of the following agents is not teratogenic in the hu-
man?
a. X-irradiation.
b. Aspirin.
c. Aminopterin.
d. 17-Ethinyltestosterone (Pranone, Progestoral, Lutocylol).
8. Which of the following agents is probably not teratogenic in
the human?
a. Diphenylhydantoin (Dilantin).
b. Phenobarbital.
c. Oral anticoagulants (Coumadin derivatives).
d. Radioiodine in therapeutic doses.
3
 9. List the 4 m a i n teratogenic hazards of x-irradiation.
10. Diazepam (Valium) has been shown to be associated with a
small increase in the incidence of cleft lip and palate. True or
false?
11. Rate the h u m a n teratogenic potential of the following agents
(none, unknown, low or high):
a. Meclizine.
b. Bendectin.
c. Imipramine.
d. Lithium.
e: LSD.
f. Marijuana.
g. Rubella vaccine.

Answers are listed at the end of the article.

4
THOMAS H. SHEPARD

is Professor of Pediatrics and Head of the Central Labora-

tory for Human Embryology at the University of Wash-
ington, Seattle, Washington. He received his M.D. degree
and pediatric training from the University of Rochester
School of Medicine. He is a past president of the Teratolo-
gy Society and the Western Society for Pediatric Re-
search. Dr. Shepard has published numerous research ar-
ticles and a book entitled A Catalog of Teratogenic Agents
(2d edition, Hopkins Press, 1976). His main research in-
terests have been pediatric endocrinology and teratology.

BIRTH DEFECTS, irrespective of their cause, create such great

medical and societal problems t h a t the subject needs little ampli-
fication. Approximately 3% of all newborns have a congenital
anomaly requiring medical attention, and about one third of
these conditions can be regarded as life-threatening. As the child
ages, more t h a n twice as m a n y congenital defects are detected.
The problem is so great t h a t close to one half of the children in
hospital wards are there because of prenatally acquired defects.
Our knowledge concerning the cause and prevention of these
defects is extremely limited. About 10% are associated with gene
mutations and another 5% with chromosomal aberrations. From
3 to 5% of the remaining anomalies are known to be due to a
teratogenic agent. Although more t h a n 600 agents are known to
produce congenital anomalies in experimental animals, fewer
than 25 are known to cause defects in man (Table 1).
A teratogenic agent is a drug, chemical, virus, physical agent
or deficiency state that, by acting during the embryonic or fetal
period, alters morphology or subsequent function in the postnatal
period. Teratology is a science dealing with causes, mechanisms
and manifestations of developmental deviations of either a struc-
tural or a functional nature. The past achievements in and the
future hope of the field are based on the cooperative approaches of
a number of branches of science. These include pediatrics, epide-
miology, anatomy, pathology, pharmacology, zoology, genetics
and obstetrics.
This publication was supported in part by the National Institutes of Health
Grant No. HD-00836.
 TABLE 1.-KNOWN TERATOGENIC AGENTS IN MAN

Radiation
therapeutic
radioiodine
atomic weapon
Infections
rubella
cytomegalovirus
herpes simplex (oral and genital) (?)
toxoplasmosis
syphilis
varicella (?)
Venezuelan equine encephalitis
Maternal metabolic imbalance
endemiccretinism
diabetes (?)
phenylketonuria
virilizingtumors
alcoholism
Drugs and environmentalchemicals
androgenichormones
aminopterin and methylaminopterin
cyclophosphamide
busulfan
thalidomide
mercury
chlorobiphenyl
diethylstilbestrol
diphenylhydantoinand trimethadione
coumadin derivatives

TERATOGENIC SUSCEPTIBILITY AND THE STAGE

OF DEVELOPMENT
The period of development when the conceptus is exposed to an
agent controls, to a large extent, its sensitivity to teratogenesis
(Fig 1). Damage during the preimplantation and presomite peri-
ods ( 0 - 1 4 days) generally produces little altered morphogenesis
because the ovum either dies or regenerates completely, whereas
during organogenesis (0- 60 days) the embryo is highly sensitive
and exposure m a y produce major morphologic changes. During
the subsequent period, the fetus is less sensitive to morphologic
alterations, but changes in functional capacity such as intellect,
reproduction or the process of aging m a y develop in later life.
This time specificity has been found in all cases where the terato-
genesis of the h u m a n has been proved and studied in detail
(Table 2). Another point of interest, learned from experimental
animals, is t h a t during the latter part of the fetal period the con-
ceptus becomes sensitive to transplacental carcinogens and, in
some cases, the fetus is even more susceptible t h a n the mother.
The concept of susceptibility as related to a stage of embryonic
6
>-

I- F u n c t i o n a l Maturation--

u"
0 } ,o I\- -- Histogenesis - - I
,.,|.~ ~.~/ \

Embryonic period Fetal period

ENTIRE DEVELOPMENTAL SPAN
Fig 1.--Curve approximating the susceptibility to teratogenesis from fertiliza-
tion throughout intrauterine development. The highest sensitivity, at least to
structural deviation, occurs during the period of organogenesis, which in the
human is from day 18 through day 60. As organogenesis ends, susceptibility to
anatomical defects diminishes greatly, but minor structural deviation is possible
until histogenesis is completed late in the fetal period. Deviations during the fe-
tal period are more likely to involve growth or functional aspects because these
are the predominant developmental features at this time. In the early period from
fertilization until shortly after implantation there is a relative resistance to tera-
togenesis, which is probably accounted for by an increased lethality or an ability
anthe conceptus to completely regenerate after sublethal exposures. (From Wil-
soln, J. G.: Environment and Birth Defects [New York: Academic Press, 1973].
Used by permission.)

or fetal development is based largely on work in experimental

animals where it is possible to control and study the effect oftera-
togenic agents at different times. This point is well illustrated in
Figure 2 for the rat embyro/fetus. Specific time tables such as this
have been worked out for a number of chemical teratogens. Un-
fortunately, the type of defect produced cannot be precisely pre-
dicted on the basis of the time of insult. For example, there are
some teratogenic agents which, by vasoconstriction, cause dam-
age to the extremities, thus producing a reduction defect during
fetal development considerably later after the embryogenesis of
the limbs. However, this concept is generally useful in advising
parents of the dangers of known or potential teratogens and in
doing investigative work using maternal history. An example of
this is the work by Miller et al. 1, which associated maternal hy-
perthermia in 11% of a group of women giving birth to children
with anencephaly. The significance of this study is that the
hyperthermia occurred between days 14 and 28 of gestation,
which coincides roughly with closure of the anterior neural tube,
a process believed to be interrupted in anencephaly. This associa-
tion needs to be confirmed by other investigators before it can be
accepted as a significant teratogenic physical agent.
7
 TABLE 2 . - ~ M E S P E C I F I C ~ Y OF A C ~ O N
FOR HUMAN TERATOGENS

GESTATIONAL AGE
FROM FERTILIZATION
TERATOGEN (DAYS) MALFORMATION

Rubella 0 - 60 Cataracts or heart disease

0-120+ Deafness
Thalidomide 21 - 40 Reduction defects of
extremities
Male hormones (androgen, 0 - 90 Clitoral hypertrophy and
and hormone-producing labial fusion
tumors, progesterone) 90+ Only clitoral hypertrophy
Sodium warfarin 0 - 100 Hypoplasia of nose and
stippling of epiphyses
100+ Mental retardation (?)
Radioiodine 65+ Chemical thyroidectomy
Goitrogens and iodides 180+ Congenital goiter
Tetracycline 120 + Staining of crowns of
primary teeth
250+ Staining of crowns of
permanent teeth

Fig 2 . - G r o u p of curves representing the susceptibility of particular organs

and systems in a rat embryo to a hypothetical teratogenic agent given on dif-
ferent days of gestation. For instance, if the agent were applied on day 10, the
resulting syndrome would affect the organs whose curves on this graph are in-
tersected by the vertical line; the percentages of incidence correspond to those
points on the ordinate at which the curves are crossed. Shifting the time of
treatment from day 10 to another day would alter the composition of the syn-
drome both qualitatively and quantitatively. The anterior neural tube is closing
between days 10 and 11 and the fetus is born on day 21. (From Wilson, J. G.:
Environment and Birth Defects [New York: Academic Press, 1973]. Used by per-
mission.)
A Brief Pulse of Teratogenic Treatment on
the IOth Day of Gestation Would Result
in the Following Incidence of Malforma-
tions
50- 3 5 % Brain Defects
3 5 % Eye Defects
E e 2 4 % Heart Defects
40- / , " ~ . 1 8 % Skeletal Defects
~. / 8rain.,..~..~l. . . . 6 % U r o g e n i t a l Defects
~ 50- / -.if
.'i:. .... "~"" ......... O % P a l a t e Defects
@ I /./He.a.grj_a.r~dk_
\"" Pq.[g.t.e........ Uro enital
' /
.~- Axtal _~'/"%=, .". .- . .. . . . . .
" " ~
20- . S k e l e t o n A_---~-::~,,-'.--~_ / ....... \

/f ~" I .: \ ~ ~.~ "'-.. "

IO- :/ : ., .,, -,,, ....

I .... I I I I I I I I
8 9 I0 II 12 13 14 15 16
Days of Gestation in Rat
SPECIES VARIATION IN RESPONSE
TO TERATOGENIC AGENTS
S o m e species o f a n i m a l s a r e m u c h m o r e s u s c e p t i b l e t o a s p e c i f i c
teratogenic agent than are others. Aspirin, cortisone and several
vitamin deficiencies are highly teratogenic in the rodent, but
there is no solid evidence of their teratogenicity in humans. The
thalidomide epidemic would not have been prevented by testing
prenatal mice and rats, but the drug is highly teratogenic in rab-
bits, monkeys and humans. An understanding of the pharmaco-
logic, physiologic and genetic variations that lead to teratogenesis
is critically heeded in order to protect the human embryo/fetus
from environmental drug damage. Biologically speaking, it
seems very likely that there are certain common denominators
between experimental animals and man. Various pharmacologic
and physiologic mechanisms that operate in the mother control
the blood concentration of a given teratogen, as shown in Figure
3. In addition, interspecies differences exist in placental transport
and embryonic metabolism. One developing hypothesis is that
the species variability is due in large part to variations in bio-
transformation of the administered drug. There is an increasing

Fig 3 . - D i a g r a m of the factors that influence embryo dose of a foreign chem-

ical present in the maternal bloodstream. Major individual and species dif-
ferences in the absorption and homeostatic dispersal control the blood concen-
tration that is exposed to the placenta. Variations in placental transfer exist be-
tween species. Relatively little work has been done on the interspecies differ-
ences in drug metabolism by the embryo. The formulation ED/t = (BC - HD)/PT
is in no sense a precise mathematical one but does attempt to state the basic
fact that embryo dose (ED), over a given period of time (t), depends on the ma-
ternal blood concentration (BC), which tends constantly to be reduced by ho-
meostatic dispersal (HD) and by placental transfer (PT). (From Wilson, J. G.:
Environment and Birth Defects [New York: Academic Press, 1973]. Used by
permission.)

/i:-~ E,,.,o CL aLo|

ED/! =(BC-HD)/PT ~ ~

PLACENTAL HOMEOSTATIC
TRANSFER D~SPERSAL
interest in the role that the hepatic microsomal monoxygenase
(mixed function oxidative) system plays in the metabolism of
more than 70% of drugs. The rate of breakdown or the type of
byproduct produced by this system might help to explain species
specificity (Juchau2).

DRUG QUANTITY AND TERATOGENICITY

It is fairly well accepted by most teratologists that any drug
given in large enough amounts will adversely affect fetal develop-
ment. This action usually occurs through deleterious effects on
maternal health and is expressed as either embryo/fetus death,
fetal growth retardation or osseous development retardation.
Both sodium chloride and sucrose given in sufficient amounts to
experimental animals will produce these effects. Many of the
warnings in drug inserts about potential teratogenicity are relat-
ed to this phenomenon. When interpolating the findings from
animal experiments to humans, it is important to take into con-
sideration the ratio (on a per kilogram basis) between the ter-
atogenic dose in the animal and the therapeutic dose in the
human.

MUTAGENICITY AND CARCINOGENICITY

A common question is: If a compound is mutagenic or carcino-
genic, is it not also teratogenic? Information is appearing that
there is a strong concurrence between mutagenicity and terato-
genicity (around 70%). We have reviewed 78 agents that have
been studied for mutagenicity and teratogenicity and found that
3 7 - 4 7 % are positive in both of the testing systems. Nine percent
were only mutagenic and 43% were only teratogenic.
The Delaney clause excludes any agent that is carcinogenic in
animals from being incorporated into food. Several years ago the
question of a similar clause concerning teratogens was brought
up at the Teratology Society's annual meeting, and during the
next year a mail poll of the members was taken. The results
were c l e a r - c u t - i t was felt that the Delaney clause had no appli-
cation to teratology. This statement and the voting results were
published in several journals as letters from the society's secre-
tary. This action contributed to a more moderate view by the con-
gressional legislature concerning the extrapolation of animal
data to h u m a n s in teratology.

MULTIFACTORIAL CAUSES OF CONGENITAL DEFECTS

According to their etiology, congenital defects can be divided
into 3 general types: (1) those due to the single action of a mu-
10
tated gene (e.g., achondroplasia or phenylketonuria); (2) those
due to the single action of an environmental agent (e.g., congeni-
tal rubella infection or aminopterin); or (3) those produced by a
combination of several or more gene defects and environmental
agents. The last multifactorial cause probably accounts for the
major proportion of congenital defects. This theory is discussed
thoroughly by Carter? Congenital dislocation of the hip and most
forms of cleft lip and palate are commonly used examples of mul-
tifactorially caused congenital malformations. Fraser and his
students have illustrated this mechanism in certain inbred
strains of mice (A/J) and have begun to make practical h u m a n ap-
plications to the control of certain defects (Fraser4; Fraser and
PashayanS). The A/J mouse exhibits a higher natural incidence of
cleft lip and palate than do certain other strains; this is because of
differences in the topographic relation of the embryonic facial
processes (Trasler6). Other controlling genes for the development
of the palate are known to predispose to clefts. Examples such as
shortening of the head, changes in mandibular length or mecha-
nisms by which tongue obstruction might prevent normal palatal
shelf closure have been studied using m u t a n t genes or inbred ani-
mal models. Most of the environmental agents (e.g., aspirin or
cortisone) known to produce clefts are more effective in these
inbred strains. It seems imperative to accelerate the application
of these principles to man. This requires quantitative methods
for identifying the susceptible h u m a n genotypes (the A/J man?)
and the environmental agents that might contribute to the multi-
factorially caused defects. Since the modification of gene action
m a y be technically impossible for some time to come, the removal
of environmental agents might be the simplest solution to this
problem. In the offspring of mothers being treated for chronic
seizure disorders with diphenylhydantoin or trimethadione,
the frequency of malformations appears to be about doubled
and the frequency of cleft lip and palate to be increased around
20-fold. Since it has been shown that the offspring of fathers
who take diphenylhydantoin have a significantly increased con-
genital defect rate, it seems probable that there are other factors,
perhaps genetic, contributing to this association.

INTERPRETATION OF EPIDEMIOLOGIC FINDINGS

There are many published reports that associate drugs or other
agents with congenital malformations. The conclusions drawn
from these reports are either of borderline significance or are pro-
duced by artifacts of collection or questionable statistical analy-
sis or both. This incomplete information, released through news
reports or package inserts, leads to some panic in exposed preg-
nant women and their doctors. The danger of a given drug is es-
11
pecially likely to be played up in news reports, whereas the subse-
quent, more detailed, studies, which often do not support the
original release, are either omitted or given only brief mention.
Public h e a l t h officials and the pharmaceutical firms m u s t help to
disseminate the more detailed reports if they wish to assume the
safest stance possible with the data at hand.
Most of the bias in congenital defect epidemiologic studies
leads to a positive association between the teratogen and some
forms of malformation. The positive rather t h a n the negative
associations are n a t u r a l l y more likely to be written up by the
investigator and also are more likely to be accepted by journal
editors. Regardless of how hard one tries to be impartial, there is
a distinct tendency to be overenthusiastic about positive findings
and at the same time to be less vigorous and critical when search-
ing for malformations in the control groups. Collecting positive
and interesting associations can easily create a snowball effect in
t h a t the initial observation, after being broadcast, tends to at-
tract other case associations. Double-blind studies are nearly
impossible to carry out. Yerushalmy 7 and other experienced epi-
demiologists emphasize t h a t this area of study depends on careful
observation rather t h a n on controlled experimental studies.
Other positive biases t h a t occur in the collection of data include
improved recall of events by parents of malformed children; in-
creased defect rates found by multiple observers (i.e., the hier-
archy of examiners in the university hospitals where the at-risk
pregnancies are likely to be referred); and an increased rate found
when a full autopsy is performed. These last two factors are espe-
cially important when considering such rare conditions as diabe-
tes, which tends to be seen more often in large medical centers.
Rubin and Murphy 8 have shown how autopsy examinations can
inflate the data on malformation in the offspring of diabetic
mothers.
When a positive association is found between a teratogen and a
type of malformation and the level of probability for this is less
t h a n 5%, it is important to consider the total number of hy-
potheses tested. At this level of probability, if there are 20, 1 asso-
ciation would be expected by chance.
Another serious drawback in epidemiologic studies is the ex-
tremely large number of cases needed to exclude teratogenicity at
a certain probability level. This is especially true where only lim-
ited numbers of mothers are susceptible to the teratogenic action
of a drug. Given the extreme genetic heterogeneity of the h u m a n
population, there is always a possibility t h a t a single individual
or a small group will have a different susceptibility t h a t could
lead to excessive levels of a relatively safe drug or its metabolites
and, consequently, to embryo toxicity.
Several improvements in the collection and analysis of data
12
have been made recently. In large studies it is often possible to
match the affected mother to a cohort with similar parity, age
and social class distributions. In the analysis of data from the
Collaborative Perinatal Project,* a mathematical model was de-
veloped to adjust for confounding variables, t h a t is, variables that
are related both to rates of drug usage and to malformations
(Heinonen et al.9). Another technique t h a t controls memory bias
is using a control group of parents who have offspring with types
of congenital defects t h a t are known to be unrelated to the drug
under study. For example, a study may encompass parents of in-
fants with Down's syndrome. Another but more expensive way is
illustrated by the work of Milkovich and van den Berg, 1~ who
were able to link computer-stored prescription data on the moth-
ers to the findings in their newborns. Some interesting positive
associations for meprobamate and chlordiazepoxide were found,
but another large prospective study based on history taking did
not confirm this (Hartz et al.H). In the computerized study, it is of
interest t h a t all of the significant prescriptions were written by
physicians who were treating the women for something other t h a n
pregnancy, while none were given by the obstetrician. This last
occurrence emphasizes the fact t h a t so much of the teratogenic
period of pregnancy occurs before definite diagnosis of pregnancy
can be made.

HOW TO ADVISE THE PATIENT AT RISK

In advising the patient at risk, it is essential at the start to ob-
tain the clinical facts. These include the exposure time during
pregnancy, dosage, nature of the underlying disease and necessi-
ty of using the medication. Animal and h u m a n teratologic infor-
mation should be reviewed. (Literature sources are covered in the
following section.) All too often very few data are available. The
animal experiments are usually positive at doses which are sig-
nificantly higher t h a n would be achieved in a woman. In analyz-
ing the surveys of pregnant women, the problem of false interpre-
tation of the findings arises, as discussed before. In any case, one
should try to give the complete data to the parents in simple
terms, emphasizing the lack of precision in predicting the out-
come. Of course, the parents should never be completely reas-
sured since the n a t u r a l occurrence rate of malformation in
the newborn is about 2-3%. When talking about relative
risk it is useful to give actual risk figures for a certain group.
For instance, in dealing with a low diagnostic radiation dose
during pregnancy and the risk of childhood malignancy in

*A large prospective study carried out by the National Institute of Neuro-

logical Diseases and Stroke.
13
the offspring, we usually cite the data of Bithell and Stewart, '2
which show a relative risk of about 1.5 (or, in more easily grasped
figures, an increase from 10 cases per 10,000 in the nonirradiat-
ed to 15 cases per 10,000 in the irradiated children). However,
these authors state that with current reductions in the dose
and the number of x-ray procedures performed, the increase
may well become virtually undetectable in future investigations.

INFORMATION ON TERATOGENICITY
Information concerning teratogenicity is widely dispersed
throughout most of the biomedical literature. An excellent gen-
eral introductory discussion of teratology is available in Wilson's
Environment and Birth Defects. '3 The annotated Catalog of Ter-
atogenic Agents (Shepard'4), which includes more than 600
agents that have been studied for teratogenesis in animals and
man, m a y prove useful for reference and entry into the literature
regarding specific chemical compounds, viruses and physical
agents. Schardein's book on teratogenic drugs 15 is another useful
source. Heinonen et al. 9 have reported on their experience with
more than 50,000 pregnancies and have given tables listing the
risk rates in women taking various drugs. Congenital Malforma-
tions: Notes and Comments (Warkany16), Recognizable Pat-
terns of Human Malformation (Smith '7) and Syndromes of
the Head and Neck (Gorlin et al. TM) help to define and extend
the description of h u m a n defect syndromes. McKusick's Men-
delian Inheritance in Man TM includes more than 300 congenital
syndromes produced by gene mutations.

CRITERIA FOR DECIDING AN AGENT'S

TERATOGENICITY IN HUMANS
As indicated above, there is a growing accumulation of data on
the effect of drugs during pregnancy, but very often a public
health decision must be made in the absence of strong evidence of
teratogenicity. A suspicion of teratogenicity can be transformed
into a drug warning which then evokes anguish in both patients
and doctors and sometimes even leads to unnecessary abortions.
Unfortunately, the time interval from the observation of the de-
fect to the proof of its cause can be a very lengthy period. Consider
the oral anticoagulants, which elicit a very specific malformation.
It took approximately 6 years from the initial case observation in
1968 until sufficient cases were collected, by 1974, to arrive at a
convincing positive association.
Some standards for deciding whether an agent is teratogenic
should be developed. Perhaps, as in the following examples, it
14
may be possible to modify Koch's postulates and derive some use-
ful criteria for h u m a n teratogenicity:

Koch's Postulates Application to Teratology

A specific microorganism must
be present in every case of the
disease.
It must be capable of cultiva-
tion in pure culture, and the
organism must produce a simi-
lar disease in the experimen-
tal animal.
Organisms from the experi-
mental animal must be recov-
ered and again grown in pure
culture.
The agent must be present dur-
ing the critical period of devel-
opment of the malformed indi-
vidual.
The agent should produce con-
genital defects in an experi-
mental animal. The defect
rate should be statistically
higher in the treated group
than in the control animals
receiving the same agent or
undergoing the same proce-
dure.
Proof should be obtained that
the agent in an unaltered state
acts on the embryo/fetus direct-
ly or indirectly through the
placenta. In this area, biochem-
istry and organ culture are
more often used than bacteri-
ology.

The fulfillment of the first two conditions is sufficient to define

a teratogenic agent. The third may be considered desirable but
not essential. There are few animal teratogens that fit all three of
these criteria. Surprisingly, teratogenic agents in the h u m a n
generally do fulfill all three criteria, as in the cases of rubella,
irradiation and androgens that masculinize the female fetus.
Thalidomide, although accepted universally as a teratogen, does
not fit the third criterion because the compound in its unaltered
state has not been demonstrated to affect the conceptus directly.
Although the third criterion may seem unnecessary to many ter-
atologists, it is believed that a more complete knowledge of these
important molecular mechanisms can more rapidly generate the
means for preventing malformations.
Further comments on the associations of Koch's postulates with
h u m a n teratogenicity have been made by Brent. 2~ He recom-
mends that a dose-response relationship between the agent and
the incidence of embryonic mortality or malformation be verified.
He adds that a nongenetic type of malformation should show an
increase in exposed individuals. This is a good point. However,
many genetic syndromes are probably still unidentified. He also
~5
suggests t h a t the malformation be proved unique. This would be
a great help, but it m a y be t h a t our experience so far has been to
discover only the unique syndromes while missing m a n y of the
more common associations. This is particularly true of a terato-
gen t h a t might interfere with the maturation of the embryonic or
fetal nervous system.

METHODS FOR DETECTION AND PREVENTION OF

HUMAN TERATOGENICITY*
An estimated 2,000 new chemicals and drugs are introduced
into the environment each year. It is possible to envision these
existing defenses against teratogenicity as walls or hurdles (Fig
4). The standard teratogenicity testing in pregnant laboratory
animals would represent part of the first barrier. Created only
after the devastating effects of thalidomide in the early 1960s,
this defense is held by a few to be effective, but is recognized by
the majority of scientists to have severe limitations. The use of
chemical structure (also a part of this first defense) as a predictor
ofteratogenicity is theoretically of great promise, but to date has
seen little practical application except, perhaps, in revealing the
teratogenic effect of chemotherapeutic agents. A number of new
tests based on in vitro techniques are available but are used rela-

Fig 4.-Perspective of our major defenses against teratogenic agents. (From

Shepard, T. H.: Teratogenicity from drugs-an increasing problem, D.M. 6,
1974. Used by permission.)

*Many of the ideas expressed in this section are derived from published reports
of symposia (Shepard et al.21; Brent and Harris'2).
16
tively little at present. The second defense (or, more properly, a
watchtower) consists of monitoring and is necessary because of
the admitted inadequacy of the first defense. Monitoring may be
carried out on embryonic or fetal loss, on amniotic fluid or on the
newborn. A third defense, just recently being used, is late moni-
toring. An example of this is the demonstration that females who
were exposed to diethylstilbestrol during the first trimester of
their fetal life are at increased risk of vaginal cancer in adult-
hood.

ANIMAL TESTING AND PHARMACOLOGIC PREDICTION

Unfortunately, a narrow view of teratology is often taken that
includes only the administration of various drugs and chemicals
to small laboratory animals. Although this area of teratology is a
substantial and legitimate one, it is clear that the field as a whole
includes a wide spectrum of scientists and encompasses many
endeavors, from cell biology to h u m a n epidemiology.
What priorities should guide us in the choice of agents to be
tested on pregnant laboratory animals? Substances to which the
entire population will be exposed should receive priority. Exam-
ples of these are food additives (found on the Generally Released
Additive Substances [GRAS] list) currently under scrutiny by the
Food and Drug Administration and compounds such as ni-
trilotriacetic acid. Nitrilotriacetic acid, a biodegradable substitute
for phosphates in detergents, if widely marketed, might be in-
gested by humans at a level of around 100 t~g/day. The second
category of agents that should be tested includes those to which
pregnant women m a y be exposed. Some substances might inad-
vertently be ingested by pregnant women and others, such as an-
tibiotics and diuretics, m a y be necessary therapeutic agents. The
third category comprises the virologic agents. If it can be shown
that a virus resides in the embryo/fetus, careful, long-term
testing is indicated. Unintentional in utero exposure to live vac-
cines or virus diseases before therapeutic or spontaneous abor-
tion should merit virologic culture of the conception product on
an ongoing basis. Finally, any agent that becomes suspect from
clinical observations certainly deserves immediate attention.
The question arises as to which species should be used for these
tests. Some recommend the testing of mongrelized or genetically
heterogeneous groups of animals in order to identify any genetic
subgroup that might be highly susceptible to the teratogenic
agent. Although this is an important goal, the field of pharmaco-
genetics is probably not sufficiently developed technically to
make this achievement feasible in the near future. The use of
subhuman primates should probably be reserved for special situ-
ations where an agent must be used during h u m a n pregnancy or
where there is clinical reason to suspect h u m a n teratogenicity.
~7
 The dosage of the test substance should be maximal but should
not interfere appreciably with the health of the pregnant animal.
J. G. Wilson '3 and many others recommend that a fetotoxic re-
sponse should be obtained when testing substances. The general
acceptance by regulatory agencies that compounds do have a feto-
toxic dose should help us to avoid excluding the many therapeutic
agents which are unnecessarily discarded because of fetotoxic
effects at a high dosage. The use of high-dose pulses of the test
substance over short periods tends to decrease the maternal adap-
tations to prolonged exposure that might lead to reduced levels
reaching the fetus.
At some point in the future our knowledge of pharmacologic
action of chemicals should allow us to predict accurately the bio-
logic activity of new substances. This field of endeavor should be
encouraged in every way, but at the present time it offers little
aid in preventing h u m a n teratogenicity.

IN VITRO TESTING
Many teratologists accept the idea that in vitro testing should
play a more important role in our defenses against teratogenic
agents. However, at the same time, it is thought that routine
screening by these methods would be of little help and would cer-
tainly not displace the use of pregnant animal testing. The use of
ova and organ or whole embryo culture is especially important
when elucidating mechanisms of teratogenesis. It should be pos-
sible by the use of liver microsomal systems to activate terato-
gens in vitro and study their effect on explanted embryos or their
parts. Differences in species sensitivity to teratogenesis might
also be partly unraveled by using maternal microsomal prepara-
tions from different species. With better understanding of the
mechanisms, more intelligent measures can be directed toward
interruption of h u m a n embryopathy. A number of investigators
recommend that h u m a n material, particularly that gathered dur-
ing therapeutic abortion, be used for tissue in organ culture test-
ing of teratogenic agents.

HUMAN MONITORING
The 3% of neonates with congenital defects represents only the
tip of the iceberg when compared to the total number of embryon-
ic/fetal losses. We can learn a great deal by studying the larger
part of this iceberg. One might expect that prenatal losses would
be a more dramatic and sensitive index of the response to a terato-
genic agent. By studying embryos and fetuses from spontaneous
abortions in the 1st trimester, an earlier indication of trouble
might be noted, which could provide epidemiologic information
some 6 months before a teratogenic effect would be detected in
13
newborns. Another advantage of this early monitoring is a short-
ened period from the teratogenic exposure to the analysis and
examination of the mother. This could be less t h a n a week as
compared to the 7- to 8-month interval when the history is taken
from the mother of a neonate. Systematic monitoring of h u m a n
embryonic and fetal loss should be introduced.
Monitoring facilities for defects in neonates exist in m a n y
countries. These facilities probably fail to detect minor changes
in brain function or long-term carcinogenesis. Generally, only
easily recognized physical defects are recorded; the larger portion
of congenital disease (60%) is identified after the newborn period
and so is not included. Although the facilities' results are varied
because of artifacts associated with data collection, a continuous
recording of time and place and registry of congenital defects
should provide an important warning of teratogenic action by a
new chemical, physical or infectious agent. The neonatal data
may be used to test hypotheses, as in the initial report from Aus-
tralia t h a t a tricyclic antidepressant (imipramine) might be the
cause of limb reduction defects.14 Using their own case data, moni-
toring groups in Atlanta and Canada were able to make a rapid,
detailed survey of all women who gave birth to children with limb
defects. The negative results they got by studying the data on
hundreds of women offered strong evidence t h a t this drug was not
a highly potent h u m a n teratogen. ~
In the United States, a computerized monitoring system of
1,500 hospitals (with an average of 1 million births a year) is
maintained by the Center for Disease Control and Commission of
Professional Hospital Activities. Dr. Godfrey Oakley at the Cen-
ter for Disease Control in Atlanta is responsible for this program.
Unfortunately there is no regulatory agency with either the au-
thority or the facilities for launching an investigation of any sus-
pected teratogenic outbreak. The response to an outbreak of ty-
phoid fever is much more organized t h a n what can be done in the
face of an epidemic of malformations. One of the difficulties is
t h a t government agencies control various types of toxins and
other hazards (i.e., drugs, pesticides, work exposure, and so on)
and in m a n y cases it is hard to decide which agency has jurisdic-
tion; in other cases an epidemic is suspected but no agent has
been identified.

PROVED HUMAN TERATOGENS

CANCER CHEMOTHERAPEUTIC AGENTS

Since cancer chemotherapeutic agents are used to decrease the
rate of cell proliferation in the mother's malignant tissue, they
may pose a t h r e a t to the rapidly dividing cells of her embryo/
fetus. Chaube and Murphy 23 have reviewed the chemistry
19
 TABLE 3 . - T E R A T O G E N I C I T Y OF CANCER CHEMOTHERAPEUTIC
AND IMMUNOSUPPRESSIVE DRUGS*

TOTAL TOTAL
EXPOSED DEFORMED
DRUGS~ INFANTS INFANTS DEFECT

Aminopterin and
methotrexate 41 8 Cranial ossification defect (5);
small mandible (5); palate
defect (1); hydrocephalus (1)
Busulfan 30 10 Spontaneous abortion and
p r e m a t u r i t y (10); cleft
palate (1); eye defect (1)
Chlorambucil 5 1 Absence of u r e t e r and kidney (1)
Colchicine 16 0
Cyclophosphamide 4 2 Absence of digits (2)
Mercaptopurine 26 1 Cleft palate (1); eye defect (1)
Nitrogen mustards 8 0
Procarbazine 3 1 Small pelvic kidneys
Triethylenemelamine 3 0
Urethan 8 0
Vinblastine 4 0
Azathioprine 25 2 P r e m a t u r i t y (2)
*See Wilson, ~3 Shepard TM and Schardein2 '~
tAll potentially teratogenic. 1st trimester t r e a t m e n t more commonly asso-
ciated with defects. Damaging effects during 2d and 3d trimesters unknown.
Often given in combinations and to a n acutely ill mother. One infant aged 9 mo
developed leukemia.

and teratogenic action of these compounds, and Sokol and

Lessmann, 24 and Nicholson 2~ have summarized the results ob-
served after h u m a n pregnancy treatment. The effect of an indi-
vidual drug on the fetus has been difficult to assess because in
m a n y instances a number of drugs have been used. In general,
there appears to be much more danger to the fetus when treat-
ment is given in the first trimester.
The possibility t h a t the maternal oocyte might be damaged by
chemotherapy of neoplasms was tested by following 88 pregnan-
cies in which the mothers had received various cytotoxic agents
before conception (Van Thiel et al.2~). No increase in fetal wastage
or congenital abnormalities was found.
Table 3 summarizes some clinical experiences with cancer
chemotherapeutic and immunosuppressive drugs.
AMINOPTERIN AND METHOTREXATE (METHYLAMINOPTERIN). -- I n
an attempt to evaluate medical means for producing therapeutic
abortions, medical abortions were performed on 12 patients in
whom surgical interruption was not indicated. A total dosage of
6 - 1 2 mg was given daily over several days and, in three fetuses,
malformations such as hydrocephalus, cleft palate and meningo-
myelocele were detected. There are three other reported cases of
malformed children born to mothers who had t a k e n the drug.
20
Small stature, abnormal cranial ossification, arched palate and
reduction in derivatives of the first branchial arch were observed.
Two infants, with hypertelorism, oxycephaly due to fusion of
the coronal sutures and digital defects, were born following
methotrexate therapy during the 1st trimester of pregnancy. One
mother took 2.5 mg/day for 5 days between the 8th and 10th week
and the other took 5 mg daily during the first 2 months. The sec-
ond woman was under t r e a t m e n t for psoriasis. Nicholson 25 has
recorded 5 cases in which normal infants were delivered to worn-
en treated after the 1st trimester.
AZATHIOPRINE (IMURAN).--Golby27 studied 25 pregnancies of
mothers with renal transplants who were treated with azathio-
prine and other drugs. Eighteen of the offspring were normal, 5
were early abortions and 2 were premature.
6-AzAuRIDINE. This compound was administered to women as
- -

an abortifacient and caused micromolar degeneration of the cho-

rionic villi, but no congenital malformations were found follow-
ing 8 days of treatment.
BUSULFAN (~IYLERAN). -- A stunted infant, with cleft palate, eye
defects and generalized cytomegaly of cells, was born to a mother
who received mercaptopurine, x-ray treatments and busulfan
( 4 - 6 mg daily). The authors attributed the effects to busulfan
because in a previous pregnancy, in which only mercaptopurine
and x-rays were used, no fetal defects appeared. Some reports of
normal offspring have been reported, but approximately one h a l f
of these have had birth weights under 2,500 gm and spontaneous
abortion was a common occurrence. In summary, Nicholson 2~
found t h a t among 22 mothers treated in the first trimester, only 2
infants had malformations. All 10 of the fetuses exposed during
the second and third trimesters were normal.
CHLORAMBUCIL (LEUKERAN).- One h u m a n fetus with congeni-
tal absence of one ureter and kidney has been described after the
mother received 6 mg daily during pregnancy, but 4 other pa-
tients treated later in pregnancy gave birth to normal infants.
COLCHICINE OR DESACETYLMETHYLCOLCHICINE.-- In the 16
known pregnancies in which one of these drugs has been used, a
spontaneous abortion, a macerated stillborn and 14 live babies
resulted. Twelve of these women received t r e a t m e n t during the
first trimester. One of the infants developed cirrhosis at 2 years of
age, probably following infectious hepatitis.
CYCLOPHOSPHAMIDE (CYTOXAN). -- O n e normal infant was born
following t r e a t m e n t of the mother with this drug during the lat-
ter part of pregnancy. In another instance, when a mother re-
ceived 1,800 mg during intensive intravenous therapy from the
77th to the 82d day of gestation, a 1,900 gm infant was delivered
21
with 4 toes on each foot and flattening of the bridge of the nose.
Absence of the toes has been reported in anot her fetus exposed to
both cyclophosphamide and irradiation.
MERCAPTOPURINE. -- At least 12 mothers have been: treated
with this drug during the first trimester; of these, 3 aborted, 1
delivered a deformed child and the others had normal infants
(Nicholson2~). The deformed infant is the same one described
under busulfan, and it is the author's opinion t h a t the defects
were not due to mercaptopurine. Twenty-five surviving mothers
who were tr ea t e d after the first t r i m e s t e r gave birth to normal
children.
NITROGEN MUSTARDS (MECHLORETHAMINE HYDROCHLORIDE).--
Eleven women have been treated during pregnancy with this
drug and no abnormalities were detected among 8 fetuses surviv-
ing at the time of delivery.
PROCARBAZINE.- One w om an t r e a t e d with 100 mg daily from
the 28th to the 35th gestational day gave birth to a fetus with
small pelvic kidneys. Two other women t reat ed in early pregnan-
cy gave birth to normal children.
TRIETHYLENEMELAMINE. -- T h e r e are 3 case reports of women
treated during pregnancy with this drug. All 3 gave birth to nor-
mal infants but only 1 was treated during the first trimester.
URETHAN. This drug has been used in 8 pregnancies, in 3 dur-
- -

ing the first trimester. One mother died undelivered and 7 gave
birth to live normal babies.
VINBLASTINE.- This drug was given in 4 pregnancies, includ-
ing 2 during the first trimester. All 4 newborns were normal.
COMBINATION CHEMOTHERAPY OF ACUTE LEUKEMIA.- Informa-
tion on 2 leukemic mothers given allopurinol, hydroxyurea, dau-
norubicin, arabinosylcytosine and prednisone during the second
t r i m e s t e r is available. One was therapeutically aborted during
remission and the fetus was normal except for e n l a r g e m e n t of the
spleen. The other gave birth to a p r e m a t u r e infant who was nor-
mal except for the fact t h a t his weight remained below the third
percentile t h r o u g h o u t his first year. It seems especially impor-
t a n t to collect data on postnatal intellectual development in these
exposed children. At present there are few data available to use
in advising at-risk leukemic families.

THALIDOMIDE (~-PHTHALIMIDOGLUTARIMIDE;
DISTAVAL; COUNTERGAN)
Thalidomide has become the most notorious teratogen known
to man. It was originally advertised as being the safest drug a
22
p r e g n a n t woman could take, although this was done in the ab-
sence of any tests on p r e g n a n t animals. Although these events
have become par t of medical history, several teratologic princi-
ples were forcefully illustrated by observations on the outbreak.
The first point was t h a t t her e existed extreme variability in spe-
cies susceptibility to thalidomide. Mouse and rat embryos are
relatively insensitive to thalidomide whereas rabbit, monkey and
h u m a n embryos are sensitive. Cahen 28 has listed 14 separate
publications concerning the sensitivity of the mouse. N earl y all
reported negative findings or else a few defects t h a t did not re-
semble the thalidomide syndrome. A similar outcome was found
when several strains of rats were studied. The New Zealand rab-
bit has been shown to be the most sensitive small animal terato-
logically, and doses of 250 mg/kg given on days 8 - 10 were capa-
ble of producing limb defects. In the monkey, a single dose of 8 -
10 mg/kg from the 25th to the 30th day produced the thalidomide
syndrome. In women, a single dose of less t h a n 1 mg/kg has pro-
duced the syndrome.
The type of defect observed in children has been well correlated
with the time of t r e a t m ent . G er m an workers (Knapp et al. 29) were
able to trace the data of prescription in 86 cases, and in this group
the approximate date of conception was known in 32 mothers.
Based on these data the time from conception until drug adminis-
tration was calculated. None of these mothers giving birth to
defective children were known to have t a k e n the drug only
before the 27th day or only after the 40th day of gestation.
Accordingly, the critical period for limb dysmorphogenesis
appears to be no longer t h a n 14 days. F u r t h e r m o r e , adminis-
tration of the drug between the 27th and 30th day was asso-
ciated most often with defective arms, whereas t r e a t m e n t
from the 30th to the 33d day caused more leg deformities with
less involvement of the arms. These findings correlate with
the appearance of the lower limb buds in the h u m a n embryo
at about the 30th day. (The previously quoted time of 2 7 - 28 days
for appearance of the lower limb buds in the h u m a n has been in-
creased by more recent observations by 2 or 3 days.) Defects of the
external ears are the earliest of the thalidomide anomalies and
may occur between the 21st and the 28th day after fertilization.
Other anomalies which are associated with phocomelia are facial
hemangioma, atresia of the esophagus or duodenum, tetralogy of
Fallot and renal agenesis. Cleft palate was a rare complication
and the central nervous system is not affected adversely. It has
been estimated t h a t defective children were born to about 20% of
mothers who ingested the drug during the period of sensitivity.
Although much careful work has been done in an at t em pt to
u n d er s tan d the mechanisms of action, the reason for the chemical
and species specificity remains an intriguing pharmacologic rid-
dle. Smith et al. 3~ cite numerous studies made on compounds
23
amount of hormone given to the mother between the 8th and 13th
weeks of pregnancy. Complete fusion with penile urethra has
been observed. Treatment after the 13th menstrual week usually
does not produce labioscrotal fusion, but clitoromegaly may be
found. This coincides somewhat with the completion of labial fu-
sion in the normal male fetus by approximately 8 0 - 90 days after
fertilization.

DIETHYLSTILBESTROL (STILBESTROL)
In 1971 it was reported that clear cell adenocarcinoma of the
vagina in relatively young women was associated in 7 out of 8
instances with Stilbestrol treatment of the mother of the patients
during the first trimester of pregnancy. A high incidence of be-
nign adenosis of the vagina was found. The authors comment that
prenatal exposure to the synthetic estrogen may have increased
the amount of benign tissue subsequently at risk for malignant
change. This certainly is a remarkable delay in teratogenic re-
sponse and has obvious implications in terms of prenatal expo-
sure causing del.ayed malignancies.
Further studies of this problem (Herbst et a12 s) based on many
more cases indicate that precancerous vaginal adenosis occurs in
73% of women exposed before the 9th week of gestation but in
only 7% of those exposed after the 17th week. Ninety percent of
the clear cell carcinoma occurred after the age of 14. The total
dose of diethylstilbestrol received by cancer patients varied from
1.5 mg to 225 mg. Two other nonsteroidal estrogens (Dienestrol
and Hexestrol) may have the same effect. It is estimated that the
risk of development of adenocarcinoma after in utero exposure is
exceedingly small, at least in those under 25 years. It has been
suggested that the drug produces adenosis by either inhibiting
upward growth of the vaginal plate or stimulating Miillerian epi-
thelium resulting in its persistence in the developing vagina. A
comprehensive review of the experimental model and the h u m a n
clinical experience is given by McLachlan and Dixon2 ~ Sporadic
reports of epididymal cysts in the male have been the only effect
observed when the male fetus is exposed.

ORGANIC MERCURY
An epidemic of cerebral palsy with microcephaly occurred in
Minamata, Japan, the cause believed to be maternal ingestion of
fish contaminated with methyl mercury. Two autopsy reports
with mercury analyses and detailed brain examinations have
been given by Matsumoto et al. 4~ Murakami 4' reviewed 25 cases
of fetal Minamata disease and reported that cerebral palsy was
the primary feature, although in 7 cases an association with mi-
crocephaly occurred. Subtle dental changes were observed also,
25
but with the exception of i case of external ear deformity, other
congenital defects did not occur. Severe central nervous system
damage in an infant whose mother ate meat from pig contaminat-
ed by a mercury-containing grain diet has been reported. The
ingestion occurred during the 3rd gestational month. A major
outbreak of methyl mercury poisoning due to mercury-contami-
nated wheat occurred in Iraq in 1972. Wannag and Skjaerasen 42
studied mothers exposed to elemental mercury through their
dental work place and found significantly increased mercury con-
tent in their babies' placentas and membranes. A long-term fol-
low-up of the postnatal function of these children will be impor-
tant.
The various forms of organic mercury have a very strong affini-
ty for the developing central nervous system. This has been
shown in several animals. A teratogenic action of this type, it
appears, can occur either in the embryonic period or during fetal
development.

GOITROGENS AND ANTITHYROID DRUGS

Although life-threatening thyroid hypertrophy and hypothy-
roidism may occur in the offspring of mothers ingesting goitro-
gens and antithyroid drugs, there is no evidence that these drugs
interfere with embryonic or early fetal growth (Klevit43).

HYDANTOINS (DIPHENYLHYDANTOINAND TRIMETHADIONE)

The offspring of epileptic mothers treated with diphenylhydan-
toin have been reported to have about twice the expected rate of
congenital defects (Fedrick44; Monson et al.45). The types of de-
fects encountered have included cleft lip and palate, congenital
heart disease and microcephaly. Hypoplasia of the nails and dis-
tal phalanges may represent a specific malformation in as many
as 18% of the pregnancies associated with this drug. This type of
defect tends to become less noticeable with age and it could easily
be overlooked in the newborn (Hanson et al.4~). Hanson et al.,
drawing on a Seattle study and the records of the Collaborative
Perinatal Project of the National Institute of Neurological and
Communication Disorders and Stroke, emphasize that while only
11% of exposed offspring have the hydantoin syndrome, 33% have
impairment of performance, especially intellectual performance.
Some reports have indicated no increase in malformation after
diphenylhydantoin exposure, and these studies tended to be more
prospective than retrospective in nature. Goujard et al., 47 in a
study of their own and a review of 5 prospective studies, could
find no increase in malformations. Meyer 4s retrospectively
studied 199 children born of mothers treated with antiepileptics
and could not establish any proof of teratogenic activity. Since
26
m a n y malformations probably have a multifactorial etiology, the
roles of folic acid deficiency and genetic predisposition need to be
more thoroughly studied. Shapiro et al., 49 drawing on the Collab-
orative Perinatal Project in the United States and a large Finnish
registry, recorded an increase in malformations in the offspring
when either the mother or father was epileptic, and suggested
that the increased rate was not due to drug exposure. Based on
701 at-risk parents, the defect rate when the mother was epileptic
was 10.5%, when the father was epileptic, 8.3% and when neither
parent was affected, 6.4%.
Phenobarbital has not been associated with an increase in con-
genital defect rate (Fedrick44; Milkovich and van den Bergi0).
Mirkin ~~has shown t h a t diphenylhydantoin equilibrates across
the h u m a n placenta at term and when the fetus is 8 - 1 0 cm in
crown-rump length.
A specific phenotype in children born to mothers who took tri-
methadione has been described (German et al.51; Zackai et al.~2).
This syndrome includes developmental delay, v-shaped eye-
brows, low-set ears with anteriorly folded helix, high arched pal-
ate or cleft palate and irregular teeth. Feldman et al. ~3 have
summarized the clinical picture from 53 pregnancies.

ORAL ANTICOAGULANTS
It was first reported in 1968 t h a t coumarin derivatives admin-
istered during the first trimester of pregnancy were associated
with nasal hypoplasia. Later, calcific stippling of the secondary
epiphyses and small birth size (Conradi's syndrome) were found
with the nasal hypoplasia. The dose given to the mother had var-
led from 2.5-10 mg/day. One mother received only Coumadin
during the first 8 weeks and another took phenindione. Three of
the children were reported to be blind but their long-term devel-
opment is still unknown. The findings have been summarized by
Shaul and Hall ~4 and by Pauli et al. ~5W a r k a n y ~6has summarized
the clinical data and emphasized t h a t there may be possible cen-
tral nervous system problems, including hydrocephalus, in fetus-
es exposed during the second and third trimesters of pregnancy.
We still do not know the incidence of congenital malformations
in the offspring of mothers treated with coumarin derivatives.
Congenital defects following maternal use of heparin have not
been reported.

IRRADIATION
The hazards of irradiation to the h u m a n conceptus can be di-
vided into 4 areas: (1) damage to the developing embryo/fetus,
especially to the central nervous system by large doses; (2) in-
creased risk of chromosomal nondisjunction from doses delivered
27
to the female gonads; (3) increased risk of point mutation in the
offspring of exposed parents; (4) increased risk of malignancy in
the offspring of mothers receiving low dose or diagnostic x-rays.
Brent 57has reviewed this topic.
Extensive data on the effects of radiation on experimental ani-
mals have been published and defects t h a t involve nearly all or-
gans can be predicted by the gestational time at which the radia-
tion is given. The effects of accidental x-irradiation on the devel-
oping fetus are well documented. Driscoll et al. 58 report on the
histologic changes occurring in h u m a n fetuses following dosages
of about 500 R. Plummer 59observed, after the atomic bomb explo-
sion at Hiroshima, t h a t microcephaly was a common complica-
tion of intrauterine radiation and t h a t the degree was directly
related to the distance the mother was from the epicenter. Blot
and Miller 6~found mental retardation after dosages of only 50 rad
in Hiroshima, but after dosages of 200 R in Nagasaki. They sug-
gested t h a t the lower dose effect may have been due to a higher
neutron exposure in Hiroshima. Neel and Schul161 did not find
further health problems in survivors or significant increases in
defects in the offspring of parents exposed to the Japanese atomic
bomb explosions.
There is probably an increased risk of chromosomal nondis-
junction in the offspring of mothers who receive significant cumu-
lative doses to the ovaries. Uchida 62 has recently summarized 11
studies of mothers who gave birth to infants with Down's syn-
drome; although all the studies showed an increased exposure,
only 3 of them were significant statistically. An increase in spon-
taneous abortion has been associated with gonadal radiation
in studies by Alberman et al. 63 They reported t h a t matched
controls received 180 mr while all spontaneously aborting
women received 245 mr. Among the group having abortions
with abnormal karyotypes, the average exposure was 331
mr. The mothers of triploid embryos averaged 735 mr. Ham-
mer-Jacobsen 64 gives estimates for the mother's gonadal dose
during pelvimetry at 822 mr. There is a need to establish an
estimated gonadal accumulated dose at which amniocentesis and
karyotyping should be considered.
It has been argued t h a t a change in the sex ratio of the off-
spring of radiated parents would be an indication of point muta-
tions giving rise to early lethal situations. Although Neel and
Schul161 did not report significant sex ratio changes in the off-
spring of irradiated parents, Scholte and Sobels 65 offered some
evidence of a change in sex ratio after parents were given radia-
tion therapy. Macht and Lawrence 66 surveyed the offspring of
radiologists and could detect no increase in congenital defects.
The long-term effect of maternal radiation on the incidence of
malignancies in offspring has been reported by MacMahonY The
extensive data of the Oxford Survey of Childhood Cancers (Bithell
28
and Stewart 12) indicated a relative risk estimate of 1.47 for
mothers with prenatal radiation exposure. As indicated earlier,
this translates into an increase of from 10 to 15 cases per 10,000
children. The risk was dependent on the number of films taken,
and could be described as a linear relationship. Exposure in the
earlier months of pregnancy appeared to carry a much higher
risk. Other factors leading to maternal radiation are very hard to
separate from the radiation effect. Diamond et al. 68 studied
20,000 children exposed to radiation during gestation, and found
a tripling of the leukemia rate in the treated white group, but
none was observed in an equal size group of black children simi-
larly exposed.
RADIOIODINE THERAPY.- This isotope of iodine if given in milli-
curie doses can damage or obliterate the developing thyroid of the
h u m a n fetus. Hypothyroidism, either congenital or of later onset,
has been reported in at least 5 children whose mothers were
treated with 131I during pregnancy (Green et a129). The risk of
fetal radiochemical thyroidectomy commences with the onset of
the iodide concentrating ability of the fetal thyroid at around the
70th to 80th gestational day.

TETRACYCLINE
Baden TM has reviewed the literature on the staining of decid-
uous teeth by tetracycline. Brownish staining of the teeth may
occur following administration of tetracycline after the 4th
month of pregnancy. Generally only the deciduous teeth are in-
volved, although with administration close to term the crowns of
the permanent teeth may be stained.

POSSIBLE, SUSPECTED AND UNPROVED

DRUGS AND TREATMENTS
There is a large group of drugs and treatments about which our
knowledge of teratogenicity is incomplete. Some of them have
been publicly accused and yet, after r a t h e r extensive investiga-
tion, no teratogenicity has been found. Often the original sugges-
tive information has been displayed more prominently t h a n the
final negative information. This may lead to lingering questions
in the minds of physicians and lay people, which is the purpose of
including unproved drugs in this discussion. Actually, a drug
t h a t is given initial wide publicity as a teratogen but is exonerat-
ed later m a y have had the most rigorous testing possible for tera-
togenicity. This sort of public test is improper because it often is
based on emotionalism and so is unfair to the manufacturer. Fur-
thermore, it may be a t h r e a t to the credibility of the scientific
community. Many of these false accusations are based on too lim-
29
ited a sample and lack awareness of the proper control data. In
some cases, the announcements have come from incompletely
informed public officials under pressure. The identification of a
low dosage/low incidence teratogenic effect in the h u m a n is an
important challenge to investigators. The detection of small
but significant changes in postnatal function, especially in
the central nervous system, are deservedly receiving more
attention. In J a p a n and Great Britain the drug regulatory ad-
ministrations require postnatal studies on new pharmaceu-
tical products.
If the reader wishes additional references or drugs not cited
here the material of Shepard, 1~ Schardein '5 or Wilson 71 should be
consulted.
ABORTION, INDUCED.-The question of whether an induced
abortion affects subsequent pregnancies has been debated. Two
early reports found a slightly higher incidence of spontaneous
abortion during the second trimester of subsequent pregnancies
and raised the possibility t h a t cervical dilatation from the opera-
tion had produced a relative cervical incompetence. Clinical ap-
praisal of these and other reports suggested t h a t matched control
studies were needed in order to fully answer the question. One
such study by Daling and Emanuel 7~ was carefully matched for
social and other contributing factors but no effect on subsequent
pregnancies was found. The congenital defect rate was also unal-
tered.
ADHESIVE SPRAYS.-The initial reports associating the use of
these compounds with chromosome breakage and multiple con-
genital defects have been publicly retracted by the Consumer
Product Safety Commission. Separate studies of h u m a n s exposed
to spray adhesives and epidemiologic studies failed to find t h a t
spray adhesives were associated with chromosomal breakage or
birth defects.
ANESTHETICS. -- The preliminary observations of increased
spontaneous abortion rates in anesthesiologists in Denmark and
Russia have been confirmed by others. In the United States a con-
trolled study found a 38% abortion rate among anesthetists and a
30% rate among operating room nurses with only a 10% rate for
the control group of general nurses. Corbett et al.73 have reported
a higher t h a n expected rate of malformations among the offspring
of female anesthetists. Spence et al. TM have reviewed the com-
bined findings in Britain and the United States and believe t h a t
the increased risk of abortion in anesthetists and their wives is
significantly more t h a n the physician controls. The malformation
rate in anesthetists' offspring was 5.5% as compared to 4.4% in
the controls (P < 0.04). In the British study there was neither an
increase in the spontaneous abortion rate of wives of anesthetists
30
nor a significant increase in malformations. In the large studies,
no specific pattern of malformations was found b u t Tomlin 75
studied 75 families of anesthetists and found 3 with obstructive
lesions of the central nervous system.
There is no evidence that local anesthetics or general anesthe-
sia given to the mother produce congenital defects. Studies of
postnatal function of infants exposed to general anesthesia at
birth are being undertaken.
ANTIBIOTICS.-(See also streptomycin, isoniazid and tetracy-
cline.) There is no convincing evidence that other antimicrobial,
commonly used antibiotics are h u m a n teratogens.
ANTIEMETICS.--Meclizine and bendectin, two very commonly
used antiemetics during pregnancy, were once accused of being
h u m a n teratogens. However, following extensive data collection,
they have been shown to be unassociated with any increased de-
fect rate in children.
ASPIRIN. Since salicylates in large doses are known to be tera-
- -

togenic in animals there has been considerable interest in their

effect during h u m a n pregnancy. Turner and Collins TM studied 144
mothers taking salicylates regularly. The stillbirth rate was in-
creased and the birth weight was reduced as compared to
matched controls. No increase in congenital defects was noted.
They confirmed the findings of others that therapeutic doses of
salicylates are often associated with the postmaturity syndrome.
Nelson and Forfar 77 reported 8 anomalies in 458 pregnancies
where salicylates were taken in the first 28 days of gestation.
Although this was higher than the 3 malformations in 911 con-
trols, the exposed group included those with achondroplasia and
Down's syndrome, two defects of probable preconceptual origin.
Richards 78 studied the anomalies in 833 pregnancies and
matched them against pregnancies with normal offspring. For
the women ingesting salicylates during the first trimester, the
rate was 22 and the control 14, a difference which was significant
at the 0.1% level. The author did not find an increase in the num-
ber of salicylate-exposed malformation pregnancies during the
second and third pregnancies. A study of these papers illustrates
the problems in evaluating epidemiologic data as discussed in the
section above. At least it seems probable that if salicylates are
h u m a n teratogens, they are very weak ones. Acetaminophen is
not teratogenic when given in large doses to pregnant rats but
data on h u m a n exposure are unavailable, to the author's knowl-
edge.
It is possible that salicylates, by their blockade of platelet ag-
glutination in the fetus, might contribute to a higher hemorrhage
rate in the premature newborn.
BIRTH CONTROLPILLS.- (See oral contraceptives.)
31
 CHLORDIAZEPOXIDE. -- (See tranquilizers.)
CHLOROQUINE.- There is a report of a woman who during 4 of
her 8 pregnancies was given chloroquine; 2 of the children were
congenitally deaf, with instability of gait. One of these children
had chorioretinitis of the type associated with chloroquine toxic-
ity in the adult. A third exposed child had hemihypertrophy and
developed a Wilms' tumor (Hart and Naunton79). In the monkey
the drug has been shown to cross the placenta and concentrate in
the fetal retina and adrenal cortex.
CORTICOSTEROIDS. -- These compounds have been used exten-
sively by teratologists as a tool for the study of mechanisms
which produce cleft lip and palate in experimental animals.
Among 260 pregnant women treated with corticoids during preg-
nancy, Bongiovanni and McPadden 8~ found reports of only two
newborns with cleft palate, and Serment and Ruf 35 identified,
among 428 treated cases, 3 clefts of the palate or lip and a small
number of defects of other systems. Although this does not ex-
clude the possibility of h u m a n teratogenicity, it indicates t h a t
these compounds are not highly dangerous. Reports of newborn
infants with hypoadrenocorticism have appeared.
BROMIDE. Two children of short stature and with small crani-
- -

ums are reported to have been born to a mother ingesting large

amounts of bromide (Opitz et al.81). One of these children had
congenital heart disease.
DEXTROAMPHETAMINE.-This drug is teratogenic in mice, rats
and rabbits, and congenital defects of the h e a r t have been ob-
served among other species. Some significant increase in the inci-
dence of congenital heart disease following amphetamine inges-
tion was reported by Nora et al. s~ They found t h a t out of 184
mothers of children with congenital heart disease 20 had t a k e n
the drug during the vulnerable period of heart formation as op-
posed to 3 out of 108 control mothers who bore normal infants.
(P<.025). Milkovich and van den Berg 83 in a prospective study
found no increase in the malformation rate among 1,824 ex-
posed to 3 out of 108 control mothers who bore normal infants
Facial cleft occurred in 3 of 175 offspring exposed during the
first 56 days after the last menses. The authors state t h a t this
could have occurred by chance. They did not find an increase in
congenital heart defects.
DIAZEPAM. -- (See tranquilizers.)
GOLD THERAPY.-- There is evidence t h a t gold is transferred
across the placenta in the human. Miyamoto et al. s4 studied 26
patients who took gold during pregnancy and all of the offspring
were normal.
32
 HYPOGLYCEMIC AGENTS.-- Although the sulfonylurea drugs
carbutamide and tolbutamide are teratogenic in experimental
animals, only sporadic case reports have been made of deformed
children from exposed mothers. One fairly large negative study
has appeared (SterneSS).
IMIPRAMINE.-- Although a possible association between this
drug and h u m a n skeletal defects was reported from Australia,
surveillance groups in the United States and Canada reviewed
histories of hundreds of mothers who gave birth to children with
limb reduction defects and found no supporting evidence of an
association.
INSULIN.- No clear evidence of teratogenicity in m a n has been
established; however, the picture is confused by the possible in-
crease in the malformation rate of children of mothers with dia-
betes. Among 17 mothers treated for insulin shock, 4 deaths and
2 fetuses with multiple congenital defects were noted.
ISONIAZID.-- There are a number of reports on the effects of
treating pregnant women with antituberculous drugs including
isoniazid. Two studies including 93 exposed infants reported no
increase in the congenital defect rate. Another study found 12
anomalies in 123 children exposed in utero to various antituber-
culous drugs (VarpelaSG).
LITHIUM.-- The recommended h u m a n therapeutic dose is
990- 1,800 mg per day and this, on a per kilogram basis, is close
to the teratogenic dose found in animals. Weinstein and
Goldfield87 found 11 cardiovascular defects among 143 offspring
exposed in utero to lithium therapy. Four of these children had a
rare cardiac defect (Ebstein's anomaly). A registry of lithium-
treated pregnancies is maintained by Dr. Morton Weinstein of
the Langley Porter Neuropsychiatric Clinic in San Francisco.
LSD (LYSERGICACID D I E T H Y L A M I D E ) . - Although sporadic case
reports of defective infants born to mothers taking LSD have
appeared, no specific pattern or clear evidence for teratogenicity
has been produced. McGlothlin et al. ss carried out a prospective
study of 121 pregnancies and found no increase in defects. Long 89
has critically reviewed the literature.
M E P R O B A M A T E . -- (See tranquilizers.)
METHIMAZOLE.-Ulcer-like midline defects of the scalp were
reported in the offspring of 11 mothers, 2 of whom had t a k e n the
drug for hyperthyroidism (Milham and Elledgeg~
MARIHUANA.-Most studies with experimental animals have
reported no teratogenic activity. The originally reported chromo-
some breakage in m a r i h u a n a users was probably not due to the
33
marihuana. There have been sporadic reports of malformed chil-
dren of the users, but no specific pattern of malformation has
been observed.
NARCOTICS.- No well-documented case reports of embryotoxici-
ty or defect production have been found in exposed women. The
postnatal studies of infants of narcotics users are difficult to as-
sess since the infants m a y be subject to drug withdrawal, exces-
sive smoking, alcohol and the variables associated with early
maternal deprivation or adoption or both. SaxOn 91 found an in-
crease in oral clefts among the offspring of mothers who had tak-
en narcotics.
F E M A L E S E X H O R M O N E E X P O S U R E . - - The problems of interpreting
epidemiologic data of congenital defects, as discussed in the sec-
tions above, are well illustrated in the following compilation. The
associations of the various compounds with congenital defects
when found are, for the most part, of low significance and gener-
ally the positive findings are balanced by an equal number of
negative studies in the literature. Schardein 15 and Wilson 71 both
have reviewed the literature on this subject and, although they
recommend caution, have concluded t h a t insufficient evidence for
teratogenicity exists. No increased incidence of malformations
has been reported following the use of other contraceptive agents,
including foams, jellies, diaphragms and IUDs. An increased rate
o f p r e m a t u r i t y and uterine infection m a y occur when the IUD has
been retained during pregnancy.
Two large studies, including 6,580 women using oral contra-
ceptives, have found no increase in malformation rate. Janerich
et al. 92found a higher incidence of oral contraceptive users among
mothers of children with limb defects. Jaffe et al23 did not observe
an increase in advertent oral contraception continuance in 7
cases where limb reduction was found. Nora and Nora 94 have
suggested t h a t congenital heart disease was more common in
pregnancies during which birth control pills were continued.
Heinonen et al. 95 studied 1,042 women who received female hor-
mones during early pregnancy and found a heart defect rate of
18/1,000 which was compared to a control of 7.8/1,000. After con-
trolling the data for confounding factors, the difference was sig-
nificant at the probability level of 0.05. Reports which did not find
significant associated cardiac teratogenicity are available
(Mulvihill et al.9e; Yasuda and Miller97). Harlap et al. 9s prospec-
tively studied 11,468 pregnancies in Israel and found 5 with
heart disease when the expected rate was 2.6. Neither limb re-
duction nor esophageal atresia occurred in the studied group.
Goujard and Rumeau-Rouquette 99 reported a prospective study of
830 women receiving mostly hormone pregnancy tests. General
malformation rates and limb and heart defects were not in-
34
creased, but a microcephaly rate of 3.4/1,000 as compared to a
control of 0.6 was found.
Carr 1~176 reported 6 abnormal karyotypes in 8 specimens from
mothers previously taking oral contraceptives; the overall inci-
dence, and especially t h a t of triploidy, was significantly higher
t h a n t h a t found in the abortuses of mothers not taking contracep-
tives. Bou6 et al., 1~ reporting on studies from 333 unselected
spontaneous abortions, found a 61.6% incidence of abnormal
chromosomes with no increase in abortuses from mothers who
took oral contraceptives. They observed a much higher incidence
of abnormal karyotypes in the younger specimens, and pointed
out t h a t the apparent increase in Carr's series may have been
related to the presence of older specimens in the control group.
Two other groups have failed to observe an increase in abnormal
karyotypes from abortuses of mothers taking contraceptives.
Janerich et al. ~o2 found no increase in oral contraception use
among 103 mothers giving birth to children with Down's syn-
drome. Jagiello and Lin '~ studied the effect of a large number of
oral contraceptives on oocytes of several species. In over 175
h u m a n ova from oral contraceptive-taking women, about one-
third divided in v i t r o - a result similar to the control group. Po-
land and Ash '~ found a significantly higher incidence of ~disor-
ganized" abortuses from women who took oral contraceptives as
compared to women using other forms of contraception.
Gal '05 reported t h a t in a group of 100 mothers giving birth to
defective children, 19 had been given hormone pregnancy tests.
In a matched control, only 4 women had been tested. Smithells 1~
found only 3 cardiac congenital defects among 189 infants whose
mothers were pregnancy-tested with tablets. Oakley et al. '~ have
also reported no teratogenicity associated with this treatment.
P E N I C I L L A M I N E . - - T w o separate case reports detail an E h l e r s -
Danlos-like syndrome occurring in the offspring of women
treated with this medication. The possibility was raised t h a t the
medication caused skin and tendon laxity by interfering with the
cross-linking of collagen. Scheinberg and Sternlieb '~ have sum-
marized 29 pregnancies in women being treated for Wilson's dis-
ease and they reported no adverse fetal effects. The possibility
has been raised t h a t in Wilson's disease the effect of penicilla-
mine exposure is reduced because of its loss in the urine.
QUININE. - - Robinson et al. 1~ reported quinine ingestion during
early pregnancy in 2 out of 200 mothers giving birth to congeni-
tally deaf children. T a n i m u r a 11o has reviewed the h u m a n litera-
ture and reported t h a t from 21 attempted abortions, 10 central
nervous system defects (6 hydrocephalics), 8 limb, 6 face, 5 diges-
tive and 3 urogenital malformations resulted. The same author
summarizes results in experimental animals.
35
 RUBELLAVACCINES.- Ebbin et al. '1' studied the pregnancy out-
come of 60 women immunized in the first trimester and found no
adverse fetal effects.
SALICYLATES. -- (See aspirin.)
STREPTOMYCIN.--Two congenitally deaf children whose moth-
ers were treated with 1 gm of streptomycin per day during the
last 4 months of pregnancy have been reported (Robinson and
Cambon'12). Varpela et al. '13 found normal hearing in 50 children
who had been exposed in utero to dihydrostreptomycin or strepto-
mycin.
TRANQUILIZERS.-Milkovich and van den Berg, '~ in a study of
19,044 births, used a computer system of record linkage to study
the association between prescriptions filled for women and seri-
ous congenital defects in their offspring. A fourfold increase in
defect rate was found when mothers took meprobamate or chlor-
diazepoxide during the first 42 days of gestation. No pattern of
malformations was identified, but 5 infants of the 66 meprobam-
ate users had congenital heart disease. A group of women taking
phenobarbital did not have an increased malformation rate in
their offspring. Hartz et al.," in the follow-up of 50,282 pregnan-
cies, could not associate an increased defect rate with maternal
ingestion of meprobamate or chlordiazepoxide. The latter study
was carried out by interviewing the mothers.
Sax6n and SaxOn 114 reported a significant increase in the inci-
dence of cleft palate and cleft lip and palate among mothers in-
gesting antineurotics (mostly diazepam) during the first trimes-
ter. These observations were viewed as mostly prospective be-
cause prescriptions were required for the use of these drugs.
Safra and Oakley '15 also found a fourfold increase in the inges-
tion of this drug among mothers giving birth to children with fa-
cial clefts. The same authors H6 point out t h a t a fourfold increase
in oral clefts, if confirmed, would imply only a 0.4% risk for cleft
lip with or without cleft palate and a 0.2% risk for cleft palate.
Crombie et al. 117 gave preliminary results of French and British
studies of over 20,000 pregnancies. Of 288 women who took chlor-
diazepoxide, meprobamate or diazepam in the first 13 weeks of
pregnancy, no significant increase in the defect rate was found,
although in the French study of 67 meprobamate users, there
were 4 malformations.
Other antipsychotic agents in the phenothiazine and mono-
amine oxidase inhibitor groups have been found to have some de-
gree of teratogenicity in experimental animals. In humans, only
sporadic case reports have appeared and no strong evidence for
teratogenicity is available. Nobel ''8 reviewed 52 instances where
the mother was treated with chlorpromazine and found no in-
crease in defects or fetal wastage. He did observe respiratory dis-
36
tress in newborns of 3 women receiving very high doses up to
parturition.
Haloperidol, which has a remarkable delaying effect on the
time of implantation in the mouse and rat, has been associated in
2 cases with limb reduction defects in the offspring of treated
women (Kopelman et al.i~9). Van Waes and Van de Velde 12~eval-
uated a group of women treated for hyperemesis gravidarum with
haloperidol and found no adverse effects.
VITAMIN A , - Excess amounts of vitamin A and retinoic acid
are commonly used teratogens in experimental animals. Fantel
et al. ~2' found retinoic acid to be teratogenic in the monkey. They
found a syndrome with cleft palate and a clinical picture similar
to Goldenhar's syndrome. Two case reports of mothers poisoned
with vitamin A are reviewed; one mother gave birth to an infant
with Goldenhar's syndrome and the other to an infant with severe
u r i n a r y tract anomalies.
VITAMIN D. - Friedman 122 has reviewed the evidence t h a t vita-
min D m a y produce the syndrome of supravalvular aortic stenosis
with elfin faces and mental retardation. The virtual absence of
this cardiac lesion before the years of routine institution of vita-
min D prophylaxis, and the high incidence of the syndrome in
Gottingen, Germany, where rickets prophylaxis during, pregnan-
cy consisted of huge doses of vitamin D, m a y be circumstantial
evidence of the vitamin's role in supravalvular aortic stenosis.
Formerly the great difficulty in measuring vitamin D in serum
and the frequent absence of hypercalcemia in patients with su-
pravalvular aortic stenosis have made it impossible to definitely
implicate vitamin D in the etiology of supravalvular aortic
stenosis.

ACKNOWLEDGMENTS
Many of the concepts expressed in this paper were derived from
discussions with Drs. Alan Fantel, Ronald Lemire and Trent Ste-
phens and Ms. J. Greenaway. The ideas dealing with epidemiolo-
gy have evolved partially through discussions with Dr. Irvin
Emanuel.
The author expresses his t h a n k s to Ms. Barbara Brownfield for
her help in preparing the manuscript.

REFERENCES
1. Miller, P., Smith, D. W., and Shepard, T. H.: Maternal hyperthermia as a
possible cause of anencephaly,Lancet 1:519, 1978.
2. Juchau, M. R.: Drug BiotransformationReactions in the Placenta, in Mir-
kin, B. L. (ed.):Perinatal Pharmacology and Therapeutics (New York: Aca-
demicPress, 1976).
37
 3. Carter, C. O.: Multifactorial Genetic Disease, in Clairborne, R. (ed.): Medical
Genetics (New York: H. P. Publishing Co., Inc., 1973).
4. Fraser, F. C.: Gene-Environment Interactions in the Production of Cleft
Palate, in Nishimura, H., Miller, J. R., and Yasuda, M. (eds.): Methods for
Teratological Studies in Experimental Animals and Man (Tokyo: Igaku
Shoin Ltd., 1969), p. 34.
5. Fraser, F. C., and Pashayan, H.: Relation of face shape to susceptibility to
congenital cleft lip, J. Med: Genet. 7:112, 1970.
6. Trasler, D. G.: Pathogenesis of cleft lip and its relation to embryonic face
shape in A-J and C57BL mice, Teratology 1:33, 1968.
7. Yerushalmy, J.: Methodologic Problems Encountered in Investigating the
Possible Teratogenic Effects of Drugs, in Klingberg, M. A., Abramovici, A.,
and Chemke, J. (eds.): Drugs and Fetal Development (New York: Plenum
Publishing Corp., 1972).
8. Rubin, A., and Murphy, D. P.: Studies in human reproduction. III. The fre-
quency of congenital malformations in the offspring of nondiabetic and dia-
betic individuals, J. Pediatr. 53:579, 1958.
9. Heinonen, O. P., Slone, D., and Shapiro, S.: Birth Defects and Drugs in Preg-
nancy (Littleton, Mass.: Publishing Sciences Group, Inc., 1977).
10. Milkovich, L., and van den Berg, B. J.: Effects of prenatal meprobamate and
chlordiazepoxide hydrochloride on human embryonic and fetal development,
N. Engl. J. Med. 291:1268, 1974.
11. Hartz, S. C., Heinonen, O. P., Shapiro, S., Siskind, V., and Slone, D.: Antena-
tal exposure to meprobamate and chlordiazepoxide in relation to malforma-
tions, mental development, and childhood mortality, N. Engl. J. Med. 292:
726, 1975.
12. Bithell, J. F., and Stewart, A. M.: Pre-natal irradiation and childhood malig-
nancy: A review of the British data from the Oxford Survey, Br. J. Cancer
31:271, 1975.
13. Wilson, J. G.: Environmental and Birth Defects (New York: Academic Press,
1973).
14. Shepard, T. H.: A Catalog of Teratogenic Agents (2d ed.; Baltimore: Johns
Hopkins University Press, 1976).
15. Schardein, J, L.: Drugs as Teratogens (Cleveland: CRC Press, 1976).
16. Warkany, J.: Congenital Malformations: Notes and Comments (Chicago:
Year Book Medical Publishers, Inc., 1971).
17. Smith, D. W.: Recognizable Patterns of Human Malformation (2d ed.; Phila-
delphia: W. B. Saunders Co., 1976).
18. Gorlin, R. J., Pindborg, J. J., and Cohen, M. M.: Syndromes of the Head and
Neck (2d ed.; New York: McGraw-Hill Book Co., 1976).
19. McKusick, V.: Mendelian Inheritance in Man (4th ed.; Baltimore: Johns
Hopkins University Press, 1975).
20. Brent, R. L.: Weak Teratogens [letter], Teratology 17:183, 1978.
21. Shepard, T. H., Miller, J. R., and Marois, M.: Methods for Detection of Envi-
ronmental Agents That Produce Congenital Defects: Proceedings (Guade-
loupe Conference Sponsored by L'Institute de la Vie) New York: Elsevier-
North Holland Pub. Co., 1976).
22. Brent, R., and Harris, M.: Prevention of Embryonic, Fetal & Perinatal Dis-
ease Fogarty International Center Series on Preventive Medicine, Vol. 3
(DHEW Publication No. [NIH] 76-853, 1976).
23. Chaube, S., and Murphy, M. L.: The Teratogenic Effects of Recent Drugs Ac-
tive in Cancer Chemotherapy, in Woolman, D. H. M. (ed.): Advances in Tera-
tology, Vol. 3 (New York: Academic Press, 1968).
24. Sokol, J. E., and Lessmann, E. H.: Effects of cancer chemotherapeutic agents
on the human fetus, J.A.M.A. 172:1765, 1960.
25. Nicholson, H. O.: Cytotoxic drugs in pregnancy, J. Obstet. Gynaecol. Br.
Commonw. 75:307, 1968.
38
26. Van Thiel, D. H., Ross, G. T., and Lipsett, M. B.: Trophoblastic neoplasms,
Science 169:1326, 1970.
27. Golby, M.: Fertility after transplantation, Transplantation 10:201, 1970.
28. Cahen, R. L.: Experimental and clinical chemoteratogenesis, Adv. Pharma-
col. 4:263, 1966.
29. Knapp, K., Lenz, W., and Nowack, E.: Multiple congenital abnormalities,
Lancet 2:725, 1962.
30. Smith, R. L., Fabro, S., Schumacher, H. J., and Williams, R. T.: Studies on
the Relationships between Chemical Structure and Embryotoxic Activity of
Thalidomide and Related Compounds, in Robson, J. M., Sullivan, F. M., and
Smith, R. L. (eds.): Embryopathic Activity of Drugs (Boston: Little, Brovgn
and Co., 1965).
31. Taussig, H. B.: A study of the German outbreak of phocomelia: The thalid-
omide syndrome, J.A.M.A. 180:1006, 1962.
32. Lenz, W.: Malformations caused by drugs in pregnancy, Am. J. Dis. Child.
112:99, 1966.
33. Spiers, A. L.: Thalidomide and congenital abnormalities, Lancet 1:303, 1962.
34. Wilkins, L., et al.: Masculinization of the female fetus associated with ad-
ministration of oral and intramuscular progestins during gestation: Non-
adrenal female pseudohermaphrodism, J. Clin. Endocrinol. Metab. 18:559,
1958.
35. Serment, H., and Ruf, H.: Therapeutiques hormonales, Bull. Fed. Gynec.
Obstet. Franc. 20:69, 1968.
36. Bongiovanni, A. M., Digeorge, A. M., and Grumbach, M. M.: Masculinization
of the female infant associated with estrogenic therapy alone during gesta-
tion: Four cases, J. Clin. Endocrinol. Metab. 19:1004, 1959.
37. Grumbach, M. M., and Ducharme, J. R.: The effects of androgens on fetal
sexual development: Androgen-induced female pseudohermaphroditism,
Fertil. Steril. 11:157, 1960.
38. Herbst, A. L., et al.: Prenatal exposure to stilbestrol: A prospective compari-
son of exposed female offspring with unexposed controls, N. Engl. J. Med.
292:334, 1975.
39. McLachlan, J. A., and Dixon, R. L.: Toxicologic Comparisons of Experimen-
tal and Clinical Exposure to Diethylstilbestrol during Gestation, in Thomas,
J. A., and Singhal, R. L. (eds.): Regulatory Mechanisms Affecting Gonadal
Hormone Action, Advances in Sex Hormone Research, Vol. 3 (Baltimore:
University Park Press, 1977).
40. Matsumoto, H., Koya, G., and Takeughi, T.: Fetal Minamata disease: A neu-
ropathological study of two cases of intrauterine intoxication by a methyl-
mercury compound, J. Neuropathol. Exp. Neurol. 24:563, 1965.
41. Murakami, U.: Organic Mercury Problem Affecting Intrauterine Life, in
Klingberg, M. A. (ed.): Proceedings of the International Symposium on the
Effect of Prolonged Drug Usage on Fetal Development (New York: Plenum
Publishing Corp., 1972.
42. Wannag, A., and Skjaerasen, J.: Mercury accumulation in placenta and foe-
tal membranes: A study of dental workers and their babies, Environ. Physiol.
Biochem. 5:348, 1975.
43. Klevit, H. D.: Iatrogenic Thyroid Disease, in Gardner, L. I. (ed.): Endocrine
and Genetic Diseases of Childhood and Adolescence (2d ed.; Philadelphia:
W. B. Saunders Co., 1975).
44. Fedrick, J.: Epilepsy and pregnancy: A report from Oxford record linkage
study, Br. Med. J. 2:442, 1973.
45. Monson, R. R., et al.: Diphenylhydantoin and selected malformations, N.
Engl. J. Med. 289:1049, 1973.
46. Hanson, J., et al.: Risks to the offspring of women treated with hydantoin
anticonvulsants,wi~h emphasis on the fetal hydantoin syndrome, J. Pediatr.
89:662, 1976.
39
47. Goujard, J., Huel, G., and Rumeau-Rouquette, C.: Antiepileptiques et mal-
formations congenitales, J. Gynecol. Obstet. Biol. Reprod. 8:831, 1974.
48. Meyer, J. G.: The teratological effects of anticonvulsants and the effects on
pregnancy and birth, Eur. Neurol. 10:179, 1973.
49. Shapiro, S., et al.: Anticonvulsants and parental epilepsy in the development
of birth defects, Lancet 1:272, 1976.
50. Mirkin, B. L.: Diphenylhydantoin: Placental transport, fetal localization,
neonatal metabolism and possible teratogenic effects, J. Pediatr. 78:329,
1971.
51. German, J., Kowal, A., and Ehlers, K. H.: Trimethadione and human terato-
genesis, Teratology 3:349, 1970.
52. Zackai, E. H., et al.: The fetal trimethadione syndrome, J. Pediatr. 87:280,
1975.
53. Feldman, G. L , Weaver, D. D., and Lovrien, E. W.: The fetal trimethadione
syndrome, Am. J. Dis. Child. 131:1389, 1977.
54. Shaul, W. L., and Hall, J. G.: Multiple congenital anomalies associated with
oral anticoagulants, Am. J. Obstet. Gynecol. 127:191, 1977.
55. Pauli, R. M., et al.: Warfarin therapy initiated during pregnancy and pheno-
typic chondrodysplasia punctata, J. Pediatr. 88:506, 1976.
56. Warkany, J.: Warfarin embryopathy, Terato]ogy 14:205, I976.
57. Brent, R. L.: Radiations and Other Physical Agents, in Wilson, J. G., and
Fraser, F. C. (eds.): Handbook ofTeratology, Vol. 1 (New York: Plenum Pub-
lishing Corp., 1977).
58. Driscoll, S. G., et al.: Acute radiation injury to two human fetuses, Arch.
Pathol. 76:113, 1963.
59. Plummer, G.: Anomalies occurring in children exposed in utero to the atomic
bomb in Hiroshima, Pediatrics 10:687, 1952.
60. Blot, W. J., and Miller, R. W.: Mental retardation following in utero expo-
sure to the atomic bombs of Hiroshima and Nagasaki, Radiology 106:617,
1973.
61. Neel, J. V., and Schull, W. J.: The effect of exposure to the atomic bombs on
pregnancy termination in Hiroshima and Nagasaki, National Academy of
Science, Publication 461 (Washington, D. C.: National Research Council,
1956).
62. Uchida, I.: Maternal Radiation and Trisomy 21, in Hook, E. B., and Porter,
I. H. (eds.): Population Cytogenetics: Studies in Humans (New York: Aca-
demic Press, 1977).
63. Alberman, E., et al.: Parental x-irradiation and chromosome constitution in
their spontaneously aborted foetuses, Ann. Hum. Genet. 36:185, 1972.
64. Hammer-Jacobsen, E.: Gonad-doses in diagnostic radiology, J. Belge Radiol.
44:253, 1961.
65. Scholte, P. J. L., and Sobels, F. H.: Sex ratio shifts among progeny from pa-
tients having received therapeutic x-radiation, Humangenetik 16:26, 1964.
66. Macht, S. H., and Lawrence, P. S.: National survey of congenital malforma-
tions resulting from exposure to roentgen radiation, Am. J. Roentgenol. 73:
442, 1955.
67. MacMahon, B.: Prenatal x-ray exposure and childhood cancer, J. Natl. Can-
cer Inst. 28:1173, 1962.
68. Diamond, E. L., Schmerler, H., and Lilienfeld, A. M.: The relationship of in-
trauterine radiation to subsequent mortality and development of leukemia
in children: A prospective study, Am. J. Epidemiol. 97:283, 1973.
69. Green, H. G., et al.: Cretinism associated with maternal sodium iodide 1(131)
therapy during pregnancy, Am. J. Dis. Child. 122:247, 1971.
70. Baden, E.: Environmental Pathology of the Teeth, in Gorlin, R. J., and Gold-
man, H. M. (eds.): Thomas Oral Pathology (6th ed.; St. Louis: C. V. Mosby
Co., 1970).
71. Wilson, J. G.: Embryotoxicity of Drugs, in Wilson, J. G., and Fraser, F. C.
(eds.): Handbook ofTeratology, Vol. 1 (New York: Plenum Publishing Corp.,
1977).
40
72. Daling, J. R., and Emanuel, I.: Induced abortion and subsequent outcome of
pregnancy: A matched cohort study, Lancet 2:170, 1975.
73. Corbett, T. H., et al.: Birth defects among children of nurse anesthetists,
Anesthesiology 41:341, 1974.
74. Spence, A. A., et ah: Occupational hazards for operating room-based physi-
cians: Analysis to date from the United States and United Kingdom,
J.A.M.A. 238:955, 1977.
75. Tomlin, P. T.: Teratogenic effects of waste anesthetic gases, Br. Med. J. h
108, 1978.
76. Turner, G., and Collins, E.: Fetal effects of regular salicylate ingestion dur-
ing pregnancy, Lancet 1:606, 1965.
77. Nelson, M. M., and Forfar, J. O.: Associations between drugs administered
during pregnancy and congenital anomalies of the fetus, Br. Med. J. 1:523,
1971.
78. Richards, I. D. G.: Congenital malformations and environmental influences
in pregnancy, Br. J. Prev. Sec. Med. 23:218, 1969.
79. Hart, C. W., and Naunton, R. F.: The ototoxicity of chloroquine phosphate,
Arch. Otolaryngol. 80:407, 1964.
80. Bongiovanni, A. M., and McPadden, A. J.: Steroids during pregnancy and
possible fetal consequences, Fertil. Steril. 11:181, 1960.
81. Opitz, J. M., Grosse, F. R., and Haneberg, B.: Congenital effects ofbromism?,
Lancet 1:91, 1972.
82. Nora, J. J., et al.: Dexamphetamine: A possible environmental trigger in
cardiovascular malformations [letter], Lancet 1:1290, 1970.
83. Milkovich, L., and van den Berg, B. J.: Effects of antenatal exposure to
anorectic drugs, Am. J. Obstet. Gynecol. 125:244, 1976.
84. Miyamoto, T., Miyaji, S., and Horiuchi, Y.: Gold therapy in bronchial asthma
with special emphasis upon blood level of gold and its teratogenicity, J. Jpn.
Soc. Intern. Med. 63:54, 1974.
85. Sterne, J.: Antidiabetic drugs and teratogenicity, Lancet 1:165, 1963.
86. Varpela, E.: On the effect exerted by first-line tuberculosis medicines on the
fetus, Acta Tuberc. Scand. 45:53, 1964.
87. Weinstein, M., and Goldfield, M.: Cardiovascular malformations with lith-
ium used during pregnancy, Am. J. Psychiatry 132:529, 1975.
88. McGlothlin, W. H., Sparkes, R. S., and Arnold, D. O.: Effect of LSD on human
pregnancy, J.A.M.A. 212:1483, 1970.
89. Long, S. Y.: Does LSD induce chromosomal damage and malformation?: A
review of the literature, Teratology 6:75, 1972.
90. Milham, S., and Elledge, W.: Maternal methimazole and congenital defects
in children, Teratology 5:125, 1972.
91. SaxOn, I.: Assocations between oral clefts and drugs taken during pregnancy,
Int. J. Epidemiol. 4:37, 1975.
92. Janerich, D. T., Piper, J. M., and Glebatis, D. M.: Oral contraceptives and
congenital limb reduction defects, N. Engl. J. Med. 291:697, 1974.
93. Jaffe, P., et al.: Incidence of congenital limb-reduction deformities, Lancet h
526, 1975.
94. Nora, J. J., and Nora, A. H.: Birth defects and oral contraceptives, Lancet 1:
941, 1973.
95. Heinonen, O. P., et al.: Cardiovascular birth defects in antenatal exposure to
female sex hormones, N. Engl. J. Med. 296:67, 1976.
96. Mulvihill, J. J., Mulvihill, C. G., and Neill, C. A.: Congenital heart defects
and prenatal sex hormones, Lancet 1:1168, 1974.
97. Yasuda, M., and Miller, J. R.: Prenatal exposure to oral contraceptives and
transposition of the great vessels in man, Teratology 12:239, 1975.
98. Harlap, S., Prywes, R., and Davies, A. M.: Birth defects and oestrogens and
progesterones in pregnancy, Lancet 1:682, 1975.
99. Goujard, J., and Rumeau-Rouquette, C.: First trimester exposure to proges-
tagen/oestrogen and congenital abnormalities, Lancet 1:482, 1977.
100. Carr, D. H.: Chromosomes after oral contraceptives, Lancet 2:830, 1967.
41
101. Bout, J., Bout, A., and Lazar, P.: Retrospective and prospective epidemiolog-
ical studies of 1500 karyotyped spontaneous human abortions, Teratology
12:11, 1975.
102. Janerich, D. T., Flink, E. M., and Keogh, M. D.: Down's syndrome and oral
contraceptive usage, Br. J. Obstet. Gynaecol. 83:617, 1976.
103. Jagiello, G., and Lin, J. S.: Oral contraceptive compounds and mammalian
oocyte meiosis, Am. J. Obstet. Gynecol. 120:390, 1974.
104. Poland, B. J., and Ash, K. A.: The influence of recent use of an oral contra-
ceptive on early intrauterine development, Am. J. Obstet. Gynecol. 116:
1138, 1973.
105. Gal, I.: Hormonal Imbalance in Human Reproduction, in Woolman, D. H. M.
(ed.): Advances in Teratology, Vol. 5 (New York: Academic Press, 1972).
106. Smithells, R. W.: The problem of teratogenicity, Practitioner 194:104, 1965.
107. Oakley, G. P., Flynt, J. W., and Falek, A.: Hormone pregnancy tests and
congenital anomalies, Lancet 2:256, 1973.
108. Scheinberg, I. H., and Sternlieb, I.: Pregnancy in penicillamine-treated pa-
tients with Wilson's disease, N. Engl. J. Med. 293:1300, 1975.
109. Robinson, G. C., Brommitt, J. R., and Miller, J. R.: Hearing loss in infants
and preschool children. II. Etiological considerations, Pediatrics 32:115,
1963.
110. Tanimura, T.: Effects on Macaque Embryos of Drugs Reported or Suspected
to be Teratogenic to Humans, in Diczfalusy, E., and Standley, C. C. (eds.):
The Use o f Non-Human Primates in Research on H u m a n Reproduction
(Stockholm: WHO Research and Training Centre on Human Reproduction,
1972).
111. Ebbin, A. J., et al.: Inadvertent rubella vaccination in pregnancy, Am. J.
Obstet. Gynecol. 117:505, 1973.
112. Robinson, G. C., and Cambon, K. G.: Hearing loss in infants of tuberculous
mothers treated with streptomycin during pregnancy, N. Engl. J. Med. 271:
949, 1964.
113. Varpela, E., Hietalahti, J., and Aro, M. J. T.: Streptomycin and dihydro-
streptomycin medication during pregnancy and their effect on the child's in-
ner ear, Scand. J. Respir. Dis. 50:101, 1969.
114. SaxOn, I., and SaxOn, L.: Association between maternal intake of diazepam
and oral clefts, Lancet 2:498, 1975.
115. Safra, M. J., and Oakley, G. P.: An association of cleft lip with or without
cleft palate and prenatal exposure to Valium, Lancet 2:478, 1975.
116. Safra, M. J., and Oakley, G. P., Jr.: Valium: an oral cleft teratogen?, Cleft
Palate J. 13:198, 1976.
117. Crombie, D. L., et al.: Fetal effects of tranquilizers in pregnancy, N. Engl. J.
Med. 293:198, 1975.
118. Sobel, D. E.: Fetal damage due to ECT, insulin, coma, chlorpromazine or re-
serpine, A.M.A. Arch. Gen. Psychiatry 2:606, 1960.
119. Kopelman, A. E., McCullar, F. W., and Heggeness, L.: Limb malformations
following the maternal use ofhaloperidal, J.A.M.A. 231:62, 1975.
120. Van Waes, A., and Van de Velde, E.: Safety evaluation of haloperidol in the
treatment ofhyperemesis gravidarum, J. Clin. Pharmacol. 9:224, 1969.
121. Fantel, A. G., et al.: Teratogenic effects of retinoic acid in the macaque mon-
key (Macaca neminstrina). 1. The syndrome, Teratology 15:65, 1977.
122. Friedman, W. F.: Vitamin D and the Supravalvular Aortic Stenosis Syn-
drome, in Woolman, D. H. M: (ed.): Advances in Teratology, Vol. 3 (New
York: Academic Press, 1968).

42
SELF-ASSESSMENT ANSWERS
1. a, low; b, high; c, intermediate
2. a , 2 ; b , 1 ; c , 4 ; d , 3
3. d
4. a. Investigators publish positive but not negative findings.
b. Editors accept for publication positive but not negative find-
ings.
c. Increased recall for exposure by parents who have real-
formed children.
d. Increased numbers of examiners of the exposed infant.
e. Increased malformation rate because of autopsy examina-
tion of the infant.
f Chancepositivesbecauseofmultiplecorrelationtesting.
5. Obtain clinical facts-medication and time of exposure. Re-
view animal and human experience-give advice in simple
terms, keeping in mind that 2 - 3 % of all newborns have con-
genital defects. I f there is limited experience with the medica-
tion, be frank with parents about the uncertainty.
6. False
7. b
8. b
9. a. Tissue damage especially of CNS by large doses.
b. Chromosomal nondysjunction in the maternal oocyte.
c. Point genetic mutations in sperm and oocytes.
d. Possible increased cancer rate in the offspring of women
given diagnostic x-rays during pregnancy.
10. True
11. a. none
b. none
C. none
d. low
e. notre
f. none
g. none

43