(997) Consensus protocols for the management of early and late twin-twin-transfusion-syndrome (TTTS), a Delphi study

Thursday, February 9, 2023

10:30 AM – 12:00 PM

Objective: Fetoscopic laser photocoagulation (FLPC) is a well-established treatment for TTTS between 16 to 26 weeks’ gestation. Current data lacks uniform guidelines regarding the best treatment approach for early ( < 16 w) and late ( >26 w) TTTS. Moreover, the time period of 16-18 weeks has also demonstrated poorer outcomes and management protocols are not universally consistent. The aim of this study was to construct structured, scientific and expert-based clinical management guidelines for early and late TTTS.

Study Design: A Delphi procedure was conducted to reach a consensus on the clinical management by an international panel of experts. Key stakeholders were chosen by their clinical expertise and relevant publications, and invited to participate. A four-round Delphi survey was initiated. In the first 3 rounds, participants were asked to grade each statement in a Likert scale(1-5) and add any suggestions of modifications. Statements with a median grade of 5 and no suggestion for their change were accepted as the consensus. Statement with a median grade of less than 4 were regarded as the non-consensus and excluded from the Delphi. Statements with a grade of 4 were modified according to the suggestions and put to consideration in the next round. In the last round participants were asked to agree or disagree on the discusses statements, a statement with more than 70% agreement and no suggestion for change was considered the consensus.

Results:

A total of 122 scholar clinicians met the inclusion criteria and were invited to participate. Fifty-four agreed to participate in the study, of them 85% completed all 4 rounds. Following 4 rounds, a consensus regarding optimal management of early (prior to 16 weeks and 16-18 weeks) as well as late (after 26 weeks) TTTS have been obtained. The consensus statements are elaborated in the tables.

Conclusion: Utilizing a Delphi method allowed the construction of an optimal treatment protocol for early and late TTTS. Providing a standardized unified agreed upon treatment protocol should advance the quality of future studies, guide clinical practice, and improve patient care.

Primary & Presenting Author(s)

Eyal Krispin, MD (he/him/his)
Boston Children's Hospital
Newton, Massachusetts, United States

Coauthor(s)

Ali Javinani, MD (he/him/his)
Post-doctoral Research Fellow
Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School
Boston, Massachusetts, United States
Anthony O. Odibo, MD
Professor
Washington University School of Medicine
St. Louis, Missouri, United States
Jena L. Miller, MD (she/her/hers)
Assistant Professor
Johns Hopkins Center for Fetal Therapy
Baltimore, Maryland, United States
JS
Julien Stirnemann, MD
Department of Obstetrics and Maternal-Fetal Medicine,Hôpital Necker - Enfants Malades
Paris, France, France
Asma Khalil, MD, MSc (she/her/hers)
Professor of Maternal Fetal Medicine
St George's Hospital, University of London
London, England, United Kingdom
KH
Kurt Hecher, MD, PhD
University Medical Center Hamburg-Eppendorf, Department of Obstetrics and Fetal Medicine
Hamburg, Germany, Germany
Ramen H. Chmait, MD (he/him/his)
Director, Los Angeles Fetal Surgery; Professor, Department of Obstetrics and Gynecology
University of Southern California
Los Angeles, California, United States
EC
Elena Carreras, MD, PhD
Department of Obstetrics and Reproductive Medicine, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona
Barcelona, Catalonia, Spain, Spain
Mounria Habli, MD,MSCR
Director of TriHealth Fetal Care Center
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States
SE
Stephen Emery, MD
Magee-Womens Hospital
Pittsburgh, Pennsylvania, United States
GS
Gerardo Sepúlveda, MD
Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Morones Prieto 3000, 64710 Monterrey, NL, Mexico
Monterrey, Nuevo Leon, Mexico
MK
Mark Kilby, DSc
University of Birmingham
Birmingham, United Kingdom, United Kingdom
Liesbeth Lewi, MD PhD (she/her/hers)
Consultant Obstetrics Gynecology
Department of Obstetrics and Gynaecology, University Hospitals Leuven
Leuven, Vlaams-Brabant, Belgium
LO
Lucas Otano, MD
Servicio de Obstetricia, Hospital Italiano de Buenos Aires
Buenos Aires, Buenos Aires, Argentina
Michael V. Zaretsky, MD (he/him/his)
Associate Professor, Department of OB/GYN
Colorado Fetal Care Center
Aurora, Colorado, United States
NS
Nicolas Sananès, MD, MPH, PhD
Maternal Fetal Medicine, Strasbourg University Hospital
Strasbourg, France, France
YY
Yoav Yinon, MD
Head of Fetal Medicine Unit Chair of the Israeli Maternal Fetal Medicine Society
Sheba Medical Center
Ramat Gan, Israel
WA
Welsh Alec William, MD
Department of Obstetrics and Gynaecology, Women's and Children's Healthcare Network, Western Hospital
Melbourne, Australia, Australia
Ozhan M. Turan, MD, PhD
University of Maryland Medical Center
Baltimore, Maryland, United States
MB
Mar Bennasar, MD, PhD
Hospital Clinic Barcelona-BCNatal
Barcelona, Spain, Spain
Ramesha Papanna, MD, MPH
Professor
Department of Obstetrics, Gynecology and Reproductive Sciences McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States
FS
Femke Slaghekke, MD, PhD
Leiden University Medical Center
Leiden, Netherlands, Netherlands
TV
Tim Van Mieghem, MD, PhD
Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto
Toronto, Ontario, Canada
AS
Alireza Shamshirsaz, MD
Department of Obstetrics & Gynecology, Division of Fetal Intervention, Baylor College of Medicine and Texas Children’s Hospital
Houston, Texas, United States