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

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. 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. 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. 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.View Large Image Figure ViewerDownload Hi-res image Download (PPT)