Embryo and Fetus Radiation has long been known to have profoundly damaging effects on the developing embryo.

For obvious reasons, systematic studies of the effects of radiation on the developing embryo have been conducted in laboratory animals, particularly mice and rats. These studies have resulted in a wealth of information on this subject, including the definition of specific effects induced by radiation. There are three general effects of radiation on the embryo and fetus: 1. Lethality 2. Congenital abnormalities present at birth 3. Long-term effects (late effects) that are not visible at birth but develop later in life These effects can be produced in the embryo and fetus by mutation in the ovum or sperm resulting in inherited (genetic) effects, or they can be directly induced by exposure of the fetus to radiation (congenital). This section will discuss those effects induced by irradiation in utero (congenital effects) and not those transmitted through a mutated ovum or sperm (genetic effects). In addition, the discussion will be limited to the lethal effects and congenital abnoramlities induced by radiation that are present at birth or shortly thereafter. Late effects will be discussed in a subsequent chapter. Because laboratory animals have been the primary source of information concerning this topic, the effects discussed will be those observed in these animals, unless otherwise stated. The extrapolation and implication of these findings for humans and observations in humans are presented at the end of this chapter. FETAL DEVELOPMENT Lethality and specific gross abnormalities induced in the embryo and fetus by radiation are dependent on the time of gestation (in fact, the part of day of gestation) at witch exposure occurs. For this reason, a basic knowledge of fetal development will give the reader a better understanding of radiation effects. Russel and Russel have divided fetal development into three general stage: preimplantation, major organogenesis and fetal (growth) stage. In humans the implantation stage occurs from conception to 10 days postconception and precedes implantation of the embryo in the uterine wall. During this time the fertilized ovum repeatedly divides forming a ball of cells which are highly undifferentiated. Implantation of this ball of cells (the embryo) in the uterine wall signals the onset of the second stage-major organogenesis-which extends through the sixth week postconception in humans. During this time the cells of the embryo begin differentiating into the various stem cell

that eventually will form all the organs of the body. The initial differentiation of cells to form a certain organ occurs on a specific gestational day. In humans, for example, neuroblasts (stem cells of the CNS) appear on the eighteenth gestational day, the forebrain and eyes begin to form on the twentieth day and on the twenty first day the primitive germ cells appear. At the end of the sixth week postconcepion, the embryo is termed a fetus and enters the fetal stage, primarily a period of growth. The fetus at this time contains most organs systems and many types of cells ranging from undifferentiated stem cells to more differentiated cells. One specific system that should be given further attention is the development of the central nervous system (CNS). In adults, the CNS consists primarily of nondividing highly differentiated cells; the fetal CNS is in direct contrast to this. The neuroblasts appear at a very early point in fetal development (in humans on the eighteenth day) and are the most abundant and scattered cells present in all stages of embryonic development. As development progresses and the fetus grows in size, the neuroblasts become more diffusely dispersed throughout the body, in addition to andergoing some differentiation and becoming less mitotically active. However, the majority of these cells continue to exist throughout fetal development and until at least 2 weeks after birth. In fact, complete development of the CNS in humans may not occur until 10-12 years af age. Based on the characteristics of fetal development and the fact that radiosensitivity is related to mitotic activity and differentiation, the fetus can be expected to be highly vulnerable not omly to te lethal effects of radiation but also to the induction of gross abnormalities recognizable at birth. After conception, one cell-the fertilized ovum-repeatedly divides and differentiates producing the millions of various cells in newborn animal. It is not surprising, then, that the developing embryo and fetus is exquisitely sensitive to radiation. Pre-implantation- the effects of radiation on the embryo and fetus are a function of the stage of development during which exposure occurs. Figure 6-7 illustrates the effect of 200 R on mouse embryos exposed on different gestation day. The early embryo during pre-implantation and major organogenesis is exquisitely sensitive to ionizing radiation. Exposure during the preimplantation stage result in a high incidence of prenatal death (death of the embryo before birth). This is not surprising because the embryo consists of relatively few cells at this time, therefore damage to one cell, the progenitor of many decendant cells, has a high probability of being fatal. Doses as low as 10 R have been reported as being fatal to the mouse embryo during this time. Those embrys which do survive exhibit few congenital abnoramlities at birth; one specific abnormality that has been reported as a result of irradiation during pre-implantation is exencephaly (brain hernia, or protrusion of te brain through the top of the skull). Major organogenesis. The incidence of congenital abnormalities in mouse embryos increase dramatically when exposure occurs during major organogenesis. Gross abnormalities have been observed in the mouse embryo exposed to 25 R during this stage. This is also the stage

during which rubella (German measles) and the drug Thalidomide are believed to wreak havoc on the fetus. Although all major organs are beginning to form during this time, differentiation of cells to form various organs begins on specific days. As a result, irradiation on certain gestational days will result in specific abnormalities. For example, exposure of the mouse embryo on the ninth day results in a high incidence of ear and nose abnormalities, whereas exposure on the tenth day results in bone abnormalities. The greatest variety of congenital abnormalities are produced when radiation is given during the eight to the twelfth day in the mouse, corresponding to the twenty- third to the thirty-seventh day in humans. The time in which these abnormalities are produced is short, appearing to be when the cells initially and assume characteristics of the developing organ. The majority of the effects of radiation on the fetus during this period of development are manifested in the CNS and related sense organs such as the eye. The sensitivity of the CNS is related to the abundance and immature characteristic of neuroblasts. Unlike the adult, where the majority of cells in the CNS are nondividing, highly differentiated and radioresistant, the neuroblasts in the fetus are highly undifferentiated, actively mitotic radiosensitive cells. These cells are scattered throughout of the fetus resulting in a high incidence of abnormalities involving the neurologic system. Some of the most common abnormalities of the CNS observed in mice after in utero irradiation include brain abnormalities such as microcephaly (small brain), hydrocephaly (water on the brain) and eye deformities such as microphtalmia (small eyes). Behavioral abnormalities such as mental retardation have been reported in humans. The developing musculoskeletal system also appears to be radiosensitive but not to the same degree as the CNS. Skeletal abnormalities such as stunted growth, abnormal limbs and others have been observed in the mouse fetus irradiated during the time of major organogenesis. The incidence the prenatal death decreases when exposure occurs during major organogenesis; however, there is an increase an neonatal death (death at birth). This may be partially due to the presence of abnormalities in the fetus that are fatal at term. Table 6-4 lists some of the most common abnormalities observed in rodents and humans following in utero exposure during major organogenesis. Figures 6-8, 6-9 and 6-10 show animals with gross abnormalities resulting from in utero irradiation. Fetal (growth) stage. Irradiation during the fetal period results in fewer obvious abnormalities and a decreased incidence of both prenatal and neonatal deaths. Higher doses are necessary during this time to produce lethality and gross abnormalities. This is not surprising because the cells in the fetus are more differentiated than at earlier stages of development. However, irradiation during this period of gestation may result in effects that occur later in life (e.g., cancer) or in functional disorders after birth.

Radiation Effects on Human embryos The devastating effects of radiation on the developing human embryo and fetus have been a subject of major concern for many years and are of particular interest today with the increased use of ionizing radiation for medical purposes. This is also a very controversial subject in terms of abnormalities produced by clinical doses, especially in the diagnostic range. Many reports have appeared in the literature implicating radiation as the cause of a specific anomaly. Although it is well known that radiation does have a very dramatic effect on the fetus in terms of both lethality and the induction of congenital abnormalities, it is difficult to establish a causal relationship between radiation and a specific abnormality. Two reasons for this are as follows: 1. The incidence of spontaneous congenital abnormalities in the population is approximately 6% 2. Radiation induces no unique congenital abnormalities (i.e., radiation-induced congenital abnormalities are the same as those that appear spontaneously or those caused by other factors). These two factors make it difficult to implicate radiation as the sole cause of a specific congenital abnormality. For obvious reasons, systematic studies of the effects of radiation on fetal development have been derived from laboratory animals, particularly mice. Although it is generally accepted that abnormalities produced in the mouse fetus by radiation also can be produced in humans, there are two factors that must be considered when extrapolating these findings to humans. One factor is time; the gestation period in mice is 20 days- in humans it is 270 days. Because the induction of specific anomalies is dependent on the period of development (i.e., gestation day) during which irradiation occurs, there will be a difference in the the time these effects are induced in humans as compared to rodents. The second important factor to consider is dose. The question arises as to whether the human embryo is more or less sensitive than the rodent embryo. Comparative studies between mice and fruit flies (Drosophila) have shown that the more highly developed species (fruit fly). In fact, it appears that the mouse embryo is fifteen times more sensitive than the fruit fly embryo! Because data of humans are rare and dose can, at best, be estimed in these cases, it can be assumed that the human embryo is at least as radiosensitive as the mouse, if not more so. Observations in humans. Radiations effects on developing human embryos have been observed in the following situations : atomic bomb survivors, accidental exposures, occupational exposures and the diagnostic and therapeutic axposure of pregnant patients. Congenital defects attributed to radiation in utero were described as early as 1930 by Murphy and Goldstein in a report of microcephaly related to in utero exposure. A subsequent study of the

children of 106 woman who received irradiation for therapeutic purposes reported that 28 of 75 children exhibited both central nervous system and skeletal defects including microcephalic idiocy, hydrocephaly, mental retardation without gross abnormalities, mongolism, spina bifida, double clubfoot, limb deformities and blindness and other eye deformities. In all these cases radiation occurred during the first trimester. Studies of children irradiated in utero at Hiroshima show that of 11 women who received a high dose of radiation, 7 of their children were microcephalics and mentally retarded while children whose mothers were at a greater distance from the hypocenter and therefore were exposed to a lower dose did not exhibit an increased incidence of microcephaly. Of 30 children irradiated in utero at Nagasaki, there were 7 fetal deaths, 6 neonatal deaths and 4 mentally retarded children among the survivors. In a study of the children of women irradiated with therapeutic doses during different stages of pregnancy, Dekaban draws the following conclusions: 1. Over 250 R delivered to human embryos before 2-3 weeks of gestation may result in a large number of prenatal deaths but produce very few severe abnormalities in those children brought to term 2. Irradiation of the human fetus between 4 and 11 weeks of gestation may lead to severe abnormalities of many organs, particularly the CNS and skeletal system 3. Irradiation during the eleventh and sixteenth weeks frequently produces mental retardation and microcephaly 4. Although the fetus is more radioresistant in terms of lethality an abnormalities after the twentieth gestational week, irradiation during this time may result in functional defects

CONCLUSIONS In general it can be stated that the embryo and fetus are more sensitive to the effects of ionizing radiation than is the organism at any other period of life. In addition, there are variations in the radiation sensitivity during embryonic life. The first trimester, particularly the first b6 weeks of development, appears to be the most radiosensitive in terms of both lethality and induction of congenital abnormalities. The fetus becomes more resistant as development progresses through the second and third trimesters with higher doses necessary to produce damage. Doses of 5 to 15 that have been observed to the both fatal and to produce CNS abnormalities in mouse embryos during pre-implantation also may be damaging to human embryos during the first 2 weeks of development. However, because pregnancy in the human is generally not known or even suspected at this early stage and because the embryo may be resorbed by the body or

aborted resulting in minimal, if any, indications of pregnancy, the implications to humans of these findings in mice are difficult to accurately assess. The most radiosensitive time in the development of the human fetus for the induction of abnormalities is from the second through the sixth week, particularly the twenty-third through the thirty-seventh day of gestation. If irradiation occurs in this time interval, the greatest variety of abnormalities will be observed. As in the mouse, most radiation-induced congenital abnormalities in the human are related to the CNS. The most common abnormalities that have been observed in humans are microcephaly, mental retardation, sense organ damage and stunted growth. The third through the twentieth week of human gestation appears to be the most sensitive period for skeletal changes. The sensitivity of the fetus during the first trimester is attributable to the large number of stem cells present during the early stages of development. The majority of abnormalities appear in the CNS and related sense organs due to the abundance and diffuseness of formative cells throughout the fetus and the exquisite radiosensitivity of these stem cells. The second and third trimester are more radioresistant than the first. Irradiation during the last two trimester result in a lower incidence of abnormalities than irradiation during the first trimester. However, these latter stages of development may result in more subtle abnormalities and functional disorder (e.g., sterility) and late changes such as malignancies, particularly leukemia. In addition, children irradiated in utero with therapeutic doses during the last trimester may exhibit signs and symptoms of the bone marrow syndrome at birth. The implications of fetal exposure in the medical uses of ionizing radiation will be discussed in following chapters.