Surveillance and management of TTTS and TRAP in MCDA twins

Multiple pregnancies pose unique challenges for many obstetricians. The average number of children in families has drastically reduced and women tend to decide to have children later in life than even a few decades ago. These facts mean, that the time window to have children is getting ever shorter and also that the number of twin and higher-grade multiple pregnancies continues to rise. As soon as the diagnosis of chorionicity of a multiple pregnancy is made clear guidelines should be followed for counseling, surveillance and for possible management of eventual complications. These guidelines have evolved over the last 10–15 years to a level, where early diagnosis, individual counseling are possible. In these cases timely referral to a management center can signifi cantly improve the survival rates of these pregnancies. It cannot be emphasized often enough, that it is the chorionicity and not the amnionicity of a twin pregnancy, which determines the risks and therefore the management of these pregnancies. The root of all possible complications in monochorionic pregnancies are the random connection of fetal blood vessels on the placental surface, and also a similarly random and unequal sharing of the placenta. Depending on the combination of these factors different pathologic conditions can occur. In case of subacute and acute AV anastomosis the classic twin-to-twin transfusion occurs. This is a massive volume shift between the twins. This happens in about 10% of al MCDA pregnancies. The trusted staging system recommended by Quintero helps us to assess the stage of the disease. The only causal therapy for TTTS is the functional di-chorionising of the placenta. This is done by coagulating the abnormal placental vessels using LASER light. The majority of these procedures result in the survival of both, but at least one of the twins. When the blood exchange between the fetuses slowly and chronically occurs, we usually do not see signifi cant volume shift as in TTTS, but there is a considerable difference in the hemoglobin counts of the fetuses. This condition is called TAPS (twin-anemia- polycytemia-sequence). This condition can also be managed by fetoscopic laser photocoagulation, but as a reasonable alternative an intrauterine blood transfusion will be offered. The talk presents guidelines and recommendations for the evidence based surveillance and management of TTTS and TAPS in monochorionic pregnancies

Surveillance and management of TTTS and TRAP in MCDA twins

Multiple pregnancies pose unique challenges for many obstetricians. The average number of children in families has drastically reduced and women tend to decide to have children later in life than even a few decades ago. These facts mean, that the time window to have children is getting ever shorter and also that the number of twin and higher-grade multiple pregnancies continues to rise. As soon as the diagnosis of chorionicity of a multiple pregnancy is made clear guidelines should be followed for counseling, surveillance and for possible management of eventual complications. These guidelines have evolved over the last 10–15 years to a level, where early diagnosis, individual counseling are possible. In these cases timely referral to a management center can signifi cantly improve the survival rates of these pregnancies. It cannot be emphasized often enough, that it is the chorionicity and not the amnionicity of a twin pregnancy, which determines the risks and therefore the management of these pregnancies. The root of all possible complications in monochorionic pregnancies are the random connection of fetal blood vessels on the placental surface, and also a similarly random and unequal sharing of the placenta. Depending on the combination of these factors different pathologic conditions can occur. In case of subacute and acute AV anastomosis the classic twin-to-twin transfusion occurs. This is a massive volume shift between the twins. This happens in about 10% of al MCDA pregnancies. The trusted staging system recommended by Quintero helps us to assess the stage of the disease. The only causal therapy for TTTS is the functional di-chorionising of the placenta. This is done by coagulating the abnormal placental vessels using LASER light. The majority of these procedures result in the survival of both, but at least one of the twins. When the blood exchange between the fetuses slowly and chronically occurs, we usually do not see signifi cant volume shift as in TTTS, but there is a considerable difference in the hemoglobin counts of the fetuses. This condition is called TAPS (twin-anemia- polycytemia-sequence). This condition can also be managed by fetoscopic laser photocoagulation, but as a reasonable alternative an intrauterine blood transfusion will be offered. The talk presents guidelines and recommendations for the evidence based surveillance and management of TTTS and TAPS in monochorionic pregnancies

Evidence of Human Milk Oligosaccharides in Cord Blood and Maternal-to-Fetal Transport across the Placenta

Human milk oligosaccharides (HMOs) are present in maternal serum in early gestation, raising the question of whether HMOs can cross the placental barrier and reach fetal circulation. Here, we aimed to detect HMOs in cord blood, and assess HMO composition and concentration in relation to maternal HMOs. In an ex-vivo placental perfusion model, we asked whether HMOs can pass over the placenta. Using HPLC, we measured HMOs in maternal serum and matching venous cord blood samples collected at delivery from normal pregnancies (n = 22). To investigate maternal-to-fetal transport, we perfused isolated placental cotyledons from term pregnancies (n = 3) with 2’-fucosyllactose (2′FL) in a double closed setting. We found up to 18 oligosaccharides typically present in maternal serum in all cord serum samples investigated. Median total cord blood HMO concentration did not differ from the concentration in maternal serum. HMO composition resembled the composition in maternal serum, with the strongest correlations for 2′FL and LDFT. After 180 min perfusion, we found 22% of maternally offered 2′FL in the fetal circuit without reaching equilibrium. Our results provide direct evidence of HMOs in cord blood, and suggest that the placenta transfers HMOs from the maternal to fetal circuit. Future studies will investigate potential differences in the transfer of specific HMOs, or in pregnancy disorders

Outcome of Bronchopulmonary Sequestration with Massive Pleural Effusion after Intrafetal Vascular Laser Ablation

Objective: To assess the outcome of 12 fetuses with bronchopulmonary sequestration (BPS) and massive pleural effusion after intrafetal vascular laser ablation (VLA). Methods: All fetuses with BPS and massive pleural effusion that were treated with intrafetal VLA during a 5-year period (2012-2016) were reviewed for safety, intrauterine course, and postnatal outcome. Results: In the study period, 12 fetuses with BPS were treated with VLA. In 7 (58.3%) fetuses, complete cessation of blood flow was achieved after the first VLA, while in 5 (41.7%) fetuses, residual perfusion of the feeding vessel was demonstrated at follow-up. A second intervention was successful in 4 of 5 (80%) fetuses. Overall, in 11 of 12 (91.7%) fetuses, complete coagulation of the feeding vessel could be achieved, followed by a reduction in size or complete resolution of the BPS. All 11 fetuses with successful prenatal intervention were live-born at a median gestational age of 39(+1) (range, 37(+5)-41(+2)) weeks. Postnatally, 2 (18.2%) of the 11 newborns underwent sequestrectomy, as well as the preterm newborn on which a second fetal intervention was not feasible. Conclusion: VLA is an effective and safe treatment of BPS that appears to be of benefit in improving prognosis and decreasing the need for postnatal sequestrectomy. (C) 2017 S. Karger AG, Base

Human Milk Oligosaccharides in Maternal Serum Respond to Oral Glucose Load and Are Associated with Insulin Sensitivity

(1) Background: Pregnancy presents a challenge to maternal glucose homeostasis; suboptimal adaptations can lead to gestational diabetes mellitus (GDM). Human milk oligosaccharides (HMOs) circulate in maternal blood in pregnancy and are altered with GDM, suggesting influence of glucose homeostasis on HMOs. We thus assessed the HMO response to glucose load during an oral glucose tolerance test (OGTT) and investigated HMO associations with glucose tolerance/insulin sensitivity in healthy pregnant women. (2) Methods: Serum of 99 women, collected at 0 h, 1 h and 2 h during a 75 g OGTT at 24–28 gestational weeks was analyzed for HMOs (2′FL, 3′SLN, LDFT, 3′SL) by HPLC; plasma glucose, insulin and C-peptide were analyzed by standard biochemistry methods. (3) Results: Serum 3′SL concentrations significantly increased from fasting to 1 h after glucose load, while concentrations of the other HMOs were unaltered. Higher 3′SL at all OGTT time points was associated with a generally more diabetogenic profile, with higher hepatic insulin resistance (HOMA-IR), lower insulin sensitivity (Matsuda index) and higher insulin secretion (C-peptide index 1). (4) Conclusions: Rapid increase in serum 3′SL post-oral glucose load (fasted-fed transition) indicates utilization of plasma glucose, potentially for sialylation of lactose. Associations of sialylated HMOs with a more diabetogenic profile suggest sustained adaptations to impaired glucose homeostasis in pregnancy. Underlying mechanisms or potential consequences of observed HMO changes remain to be elucidated