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New Perspectives on the Late-Term Mare and Newborn Foal

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New Perspectives on the Late-Term Mare and Newborn Foal IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE New Perspectives on the Late-Term Mare and Newborn Foal Wendy Vaala, VMD, Diplomate ACVIM Author’s address: Equine Technical Services, Intervet Inc., 29160 Intervet Lane, Millsboro, DE 19966; e-mail: [email protected]. © 2007 AAEP. 1. Introduction dotal observations and conclusions can be inferred, A successful perinatal program requires the col- because there is not a large enough number of clin- laborative efforts of those trained in reproduction ical cases with similar problems from which to and neonatology. In ambulatory situations, one draw significant conclusions. Until larger, multi- person must often specialize in both areas; addition- centric collaborative trials validate the usefulness of ally, that person must have the equipment and monitoring specific hormones or the efficacy of var- expertise available to manage obstetrical complica- ious therapies designed to manage and maintain tions and to provide neonatal resuscitation and complicated pregnancies, it is the author’s recom- nursing care. Periparturient complications during mendation that no one therapy or monitoring aid late pregnancy may include severe maternal illness should be relied on exclusively. Any mare receiv- or colic, reproductive tract disease, or fetal anoma- ing therapy to prolong an abnormal pregnancy lies. The most serious threats to uteroplacental should receive frequent assessment. That way, the health and foal survival are perinatal sepsis, hypox- clinician can promptly determine if silent or unde- ia/ischemia, and maturation disorders. The chal- tected fetal demise occurs without ensuing abortion lenge is to improve our ability to recognize mares or if parturition occurs without the customary warn- with jeopardized pregnancies at an earlier stage in ing signs. gestation or in the disease process. This goal can This paper will focus on new or controversial man- be accomplished in two ways: (1) more proactive agement strategies and monitoring techniques for antepartum monitoring and reporting of clinical the late-term mare with periparturient complica- cases in the field and (2) the use of controlled exper- tions. The current understanding of pregnant- imental disease models designed to improve our un- mare physiology will be reviewed when applicable to derstanding of the evolution of uteroplacental help practitioners decide if and how they might in- dysfunction. corporate some of these interventional therapies Many clinical trials designed to examine hormone into their daily practice. Newborn foal evaluation changes in the at-risk mare or evaluate the efficacy will conclude this section with an emphasis on nor- of various treatment modalities on pregnancy out- mal behavior guidelines and a brief review of neo- come are underpowered statistically. Only anec- natal immunity. NOTES AAEP PROCEEDINGS ր Vol. 53 ր 2007 281 IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE 2. Controversies Regarding Hormone Therapy in the In healthy, late-term mares, progestagens are pro- Late-Term Mare duced by the uteroplacental tissues from the precur- sor, P5, supplied by the fetal adrenals.2,11 Fetal- Hormonal Profiles derived P5 is then converted to P4 by uteroplacental The search continues in equine perinatology for hor- metabolism and secreted into the umbilical circula- mones that reflect fetal and placental wellbeing. tion or metabolized further to 5␣-DHP in the endo- Progestagens and estrogens remain the most likely metrium or other progestagens within the fetus or candidates, but the specific endocrine mediators re- uteroplacental tissues. At least 10 progestagens sponsible for maintenance of pregnancy during late have been identified and measured in the late-term gestation and stimulation of the final stages of fetal mare.1 Seven of these metabolites increase with maturation and initiation of parturition remain the advancing gestational age, but levels of P4 remain focus of considerable research and controversy. virtually undetectable. Little is known about the In many compromised equine pregnancies, the pre- biological activity of most of these compounds, al- partum changes of these hormones and their metab- though 5␣-DHP is known to inhibit myometrial con- olites may be too acute to provide advanced warning tractility in women.12 It also binds more strongly of impending fetal demise. Non-lethal forms of fe- than P4 to the uterine progesterone receptor in tal compromise associated with infection, hypoxia, mares.13 or disrupted patterns of fetal development may be During the last week of gestation, an unknown even harder to detect using the hormonal assays stimulus results in an increase in fetal adrenocorti- currently available. cotropin hormone (ACTH) and the appearance of the enzyme 17 ␣-hydroxylase. This enzyme is respon- Progestagens sible for the conversion of progesterone to cortisol.14 The pre-partum hormonal changes in the mare are This pre-partum surge in fetal cortisol is associated different from those of other large-animal species. with the initiation of a critical cascade of endocrine In most other species, progesterone (P4) is the dom- events in the fetus that result in readiness for birth inant progestagen during pregnancy, and concentra- and an ability to adapt to extra-uterine life. Corti- tions of P4 decline before spontaneous labor, which sol stimulates an increase in the neutrophil:lympho- suggests that P4 withdrawal is conducive to active cyte (N:L) ratio and a rise in thyroid hormones that labor. In the mare, P4 is produced by the ovaries in turn have a positive impact on skeletal muscle until days 120–150 of gestation; at that time, the tone, body temperature regulation, and glucose ho- feto-placental tissues begin to synthesize P4 from meostasis. Maturation of the fetal hypothalamic- the pregnenolone (P5) supplied by the fetal adrenal pituitary-adrenal (PHA) axis is essential for glands. After days 180–240 of pregnancy, P4 con- triggering parturition and ensuring the final phase centrations are negligible in both maternal and fetal of fetal maturation. circulations. Instead, P4 is metabolized into a It is appealing to surmise that pregnancies jeop- number of other progestagens that include satu- ardized by placental anomalies or fetal compromise rated pregnanes and unsaturated pregnenes.1,2 will have altered concentrations of progestagens be- In the mare, progestagens other than P4 remain cause of disrupted or altered metabolic pathways relatively constant until 3 wk pre-partum. After within the feto-placental unit. A number of trials that time, progestagen levels rise gradually before have studied mares with either naturally occurring parturition.1,3,4 In particular, the concentration of high-risk pregnancies or with experimentally in- 5␣-pregnane,3,20-dione (5␣-DHP), a direct metabo- duced placental disease. Theses studies have doc- lite of P4, increases gradually during the last few umented wide variations in maternal concentrations weeks of gestation and then declines precipitously of plasma progestins including premature eleva- within days or hours of delivery.5,6 Interestingly, tions and precipitous declines.1,6,10,15,16 in human females, 5␣-DHP, rather than P4, under- Several patterns of progestagen activity during goes a pre-partum decline.7 late pregnancy begin to emerge. The worst sce- Commercial radioimmunoassays (RIAs) and en- nario is a pattern of rapidly declining progestagen zyme-linked immunosorbent assays (ELISAs) used concentrations with values approaching zero. In to measure “progesterone” concentrations in preg- pregnancies complicated by acute fetal distress, nant mares can be used to measure some of these there is a dramatic decline in progestagen produc- other progesterone metabolites that predominate tion, which reemphasized the importance of a during late pregnancy. This is possible, because healthy feto-placental unit for normal production the antibodies used in these assays cross-react with and metabolism of progestagens.1 Most of these many of the other progestagens, particularly the pregnancies were associated with fetal death and ␣-pregnanes. Values may vary between labs be- abortion. The second pattern is one of precociously cause of the different levels of cross-reactivity be- elevated levels of nearly all progestagen metabolites tween the different assay technologies.2,8,9 Using a that is often associated with bacterial placentitis, validated ELISA, progestagen values reported for enhanced fetal adrenocortical activity, and promis- mares between 180 and 310 days of gestation range ing neonatal survival.1,6,10 A few pregnancies com- from 2 to 6 ng/ml.10 promised by placental anomalies other than 282 2007 ր Vol. 53 ր AAEP PROCEEDINGS IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE bacterial placentitis, such as placental edema or vil- ture delivery, to have an infant of low birth weight, lous atrophy, exhibited a slightly different pattern. and to have an infant diagnosed with interventricular Levels of certain progestagens such as P4 were ele- hemorrhage.24–27 However, the use of progesterone vated, but other metabolites, including P5, were de- in pregnant women remains controversial, and its pre- creased, which possibly reflects a lack of functional cise mechanism of action, optimal formulation, route placenta.1 A third pattern of progestagen activity of administration, dose, and optimal gestational age at occurs when maternal progestins fail to show the initiation have yet to be determined.25
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