Consensus update on twin-twin transfusion syndrome staging: An international Delphi study

Area of Science:

• Perinatal Medicine
• Maternal-Fetal Medicine
• Reproductive Medicine

Background:

• Twin-twin transfusion syndrome (TTTS) affects 15% of monochorionic pregnancies, leading to poor outcomes without intervention.
• The current Quintero staging system, while simple, is questioned for its depiction of TTTS progression.
• An updated staging system is needed to align with current understanding and improve clinical guidance.

Purpose of the Study:

• To update the twin-twin transfusion syndrome (TTTS) staging system.
• To reflect current knowledge of TTTS pathophysiology.
• To optimize clinical decision-making and future research in TTTS.

Main Methods:

• A four-round Delphi procedure involving an international panel of TTTS experts.
• Expert consensus was sought on proposed changes to the staging system.
• Consensus was defined as agreement of ≥70% among participating experts.

Main Results:

• Four key areas for revision were identified: pre-TTTS risk identification, donor/recipient differentiation in advanced stages, modified cardiovascular criteria for Stage III, and recognition of atypical TTTS presentations.
• A total of 112 experts participated across four rounds.
• Proposed changes aim to enhance the accuracy and clinical utility of TTTS staging.

Conclusions:

• An updated, consensus-based staging system for TTTS has been developed.
• The revised system aims to improve early disease identification, standardize follow-up, and support robust TTTS research.
• Prospective validation is recommended to confirm the clinical utility of the new staging system.