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Am J Obstet Gynecol. 2019 Dec;221(6):549-562. doi: 10.1016/j.ajog.2019.06.013. Epub 2019 Jun 15.

The fetal origins of mental illness.

Author information

1
Department of Pediatrics, University of Washington, Seattle, WA.
2
Department of Obstetrics & Gynecology, University of Washington, Seattle, WA.
3
Department of Global Health, University of Washington Seattle, WA; Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA.
4
Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD.
5
Lieber Institute for Brain Development, Departments of Psychiatry, Neurology, Neuroscience, and McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine Baltimore, MD.
6
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA.
7
Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
8
Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA.
9
Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway.
10
Department of Obstetrics and Gynecology, Center for Reproductive Health Sciences, Washington University School of Medicine, St. Louis, MO.
11
Departments of Obstetrics and Gynecology and Pathology and Immunology, Center for Reproductive Health Sciences, Washington University School of Medicine, St. Louis, MO.
12
Center for Innate Immunity and Immune Disease, Department of Pediatrics, University of Washington, Seattle, WA; Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA.
13
Department of Obstetrics & Gynecology and Global Health, Center for Innate Immunity and Immune Disease, Center for Emerging and Reemerging Infectious Diseases, University of Washington, Seattle, WA; Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: adamsk@uw.edu.

Abstract

The impact of infections and inflammation during pregnancy on the developing fetal brain remains incompletely defined, with important clinical and research gaps. Although the classic infectious TORCH pathogens (ie, Toxoplasma gondii, rubella virus, cytomegalovirus [CMV], herpes simplex virus) are known to be directly teratogenic, emerging evidence suggests that these infections represent the most extreme end of a much larger spectrum of injury. We present the accumulating evidence that prenatal exposure to a wide variety of viral and bacterial infections-or simply inflammation-may subtly alter fetal brain development, leading to neuropsychiatric consequences for the child later in life. The link between influenza infections in pregnant women and an increased risk for development of schizophrenia in their children was first described more than 30 years ago. Since then, evidence suggests that a range of infections during pregnancy may also increase risk for autism spectrum disorder and depression in the child. Subsequent studies in animal models demonstrated that both pregnancy infections and inflammation can result in direct injury to neurons and neural progenitor cells or indirect injury through activation of microglia and astrocytes, which can trigger cytokine production and oxidative stress. Infectious exposures can also alter placental serotonin production, which can perturb neurotransmitter signaling in the developing brain. Clinically, detection of these subtle injuries to the fetal brain is difficult. As the neuropsychiatric impact of perinatal infections or inflammation may not be known for decades after birth, our construct for defining teratogenic infections in pregnancy (eg, TORCH) based on congenital anomalies is insufficient to capture the full adverse impact on the child. We discuss the clinical implications of this body of evidence and how we might place greater emphasis on prevention of prenatal infections. For example, increasing uptake of the seasonal influenza vaccine is a key strategy to reduce perinatal infections and the risk for fetal brain injury. An important research gap exists in understanding how antibiotic therapy during pregnancy affects the fetal inflammatory load and how to avoid inflammation-mediated injury to the fetal brain. In summary, we discuss the current evidence and mechanisms linking infections and inflammation with the increased lifelong risk of neuropsychiatric disorders in the child, and how we might improve prenatal care to protect the fetal brain.

KEYWORDS:

TORCH; autism; brain; depression; fetus; infection; inflammation; influenza virus; microglia; neuronal injury; pregnancy; schizophrenia; seasonality of birth hypothesis; urinary tract infection

PMID:
31207234
PMCID:
PMC6889013
[Available on 2020-12-01]
DOI:
10.1016/j.ajog.2019.06.013

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