178: Maternal decision-making about fetal therapy for complicated monochorionic twin gestations: A qualitative exploration

Abstract

Women with complicated monochorionic twin gestations are faced with difficult choices when offered laser photocoagulation. We explored women’s decision-making process and their understanding of clinical options with the goal of improving physician counseling about fetal therapy. We performed a single-center prospective cohort study of women offered laser photocoagulation for twin-twin transfusion syndrome (TTTS) or twin anemia polycythemia sequence (TAPS). Participants were interviewed after they decided for or against surgery and again in the postpartum period. Interview topics included women’s understanding of TTTS or TAPS, the risks, benefits and alternatives of laser photocoagulation, expected outcomes, the rationale behind her decision, changes in perspective after delivery, and thoughts on the counseling provided by the care team. Qualitative thematic analysis of interview transcripts was performed using QRS NVivo 10. 32 women were offered laser photocoagulation, 31 agreed to participate in the study, of whom 27 completed the prenatal interview and 24 completed the postpartum interview. Women demonstrated adequate understanding of the risks, benefits and alternatives to fetal therapy (Table 1). The primary factor women considered was the chance of survival for one or both babies. Most women (63%) felt that laser photocoagulation represented their only viable clinical option. Only 19% of women considered termination or selective reduction. Additional factors influencing women’s decision included trust in the healthcare team and avoiding prematurity. 89% of women used internet resources, primarily hospital websites, TTTS Foundation and Facebook groups. In the postpartum interview women were highly satisfied with the counseling they received and did not later regret their decisions, but felt unprepared for the challenges of prematurity. Women with complicated monochorionic gestations understood the clinical options they were provided, including laser photocoagulation. Infant survival was the leading factor in their decision to pursue fetal surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)