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. 2024 Mar;63(3):371-377.
doi: 10.1002/uog.27446. Epub 2024 Feb 3.

Consensus protocol for management of early and late twin-twin transfusion syndrome: Delphi study

E Krispin  1 , A Javinani  1 , A Odibo  2 , E Carreras  3 , S P Emery  4 , G Sepulveda Gonzalez  5 , M Habli  6 , K Hecher  7 , K Ishii  8 , J Miller  9 , R Papanna  10 , A Johnson  10 , A Khalil  11   12   13 , M D Kilby  14   15   16 , L Lewi  17   18 , M Bennasar Sans  19 , L Otaño  20 , M V Zaretsky  21 , N Sananes  22   23 , O M Turan  24 , F Slaghekke  25 , J Stirnemann  26 , T Van Mieghem  27 , A W Welsh  28 , Y Yoav  29 , R Chmait  30 , A A Shamshirsaz  1
Affiliations

Consensus protocol for management of early and late twin-twin transfusion syndrome: Delphi study

E Krispin et al. Ultrasound Obstet Gynecol. 2024 Mar.

Abstract

Objective: Fetoscopic laser photocoagulation (FLP) is a well-established treatment for twin-twin transfusion syndrome (TTTS) between 16 and 26 weeks' gestation. High-quality evidence and guidelines regarding the optimal clinical management of very early (prior to 16 weeks), early (between 16 and 18 weeks) and late (after 26 weeks) TTTS are lacking. The aim of this study was to construct a structured expert-based clinical consensus for the management of early and late TTTS.

Methods: A Delphi procedure was conducted among an international panel of experts. Participants were chosen based on their clinical expertise, affiliation and relevant publications. A four-round Delphi survey was conducted using an online platform and responses were collected anonymously. In the first round, a core group of experts was asked to answer open-ended questions regarding the indications, timing and modes of treatment for early and late TTTS. In the second and third rounds, participants were asked to grade each statement on a Likert scale (1, completely disagree; 5, completely agree) and to add any suggestions or modifications. At the end of each round, the median score for each statement was calculated. Statements with a median grade of 5 without suggestions for change were accepted as the consensus. Statements with a median grade of 3 or less were excluded from the Delphi process. Statements with a median grade of 4 were modified according to suggestions and reconsidered in the next round. In the last round, participants were asked to agree or disagree with the statements, and those with more than 70% agreement without suggestions for change were considered the consensus.

Results: A total of 122 experts met the inclusion criteria and were invited to participate, of whom 53 (43.4%) agreed to take part in the study. Of those, 75.5% completed all four rounds. A consensus on the optimal management of early and late TTTS was obtained. FLP can be offered as early as 15 weeks' gestation for selected cases, and can be considered up to 28 weeks. Between 16 and 18 weeks, management should be tailored according to Doppler findings.

Conclusions: A consensus-based treatment protocol for early and late TTTS was agreed upon by a panel of experts. This protocol should be modified at the discretion of the operator, according to their experience and the specific demands of each case. This should advance the quality of future studies, guide clinical practice and improve patient care. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: Delphi technique; TTTS; amnioreduction; expectant management; fetofetal transfusion; fetoscopic laser photocoagulation; multifetal; pregnancy reduction; qualitative research; twin-twin transfusion syndrome.

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References

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