Morgan J C, Rios J, Kahl T, Prasad M, Rausch A, Longman R, Mehra S, Shaaban A, Premkumar A
Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA.
Center for Fetal Care, Advocate Children's Hospital, Park Ridge, IL, USA.
Ultrasound Obstet Gynecol. 2025 Jan;65(1):39-46. doi: 10.1002/uog.29135. Epub 2024 Nov 27.
Monochorionic twin gestations affected by Type-II selective fetal growth restriction (sFGR) are at increased risk of intrauterine fetal demise, extreme preterm birth, severe neurodevelopmental impairment (NDI) and neonatal death of one or both twins. In the absence of a consensus on the optimal management strategy, we chose to evaluate which strategy was cost-effective in the setting of Type-II sFGR.
A decision-analytic model was used to compare expectant management (EM), bipolar cord occlusion (BCO), radiofrequency ablation (RFA) and fetoscopic laser photocoagulation (FLP) for a hypothetical cohort of 10 000 people with a monochorionic diamniotic twin pregnancy affected by Type-II sFGR. Probabilities and utilities were derived from the literature. Costs were derived from the Healthcare Cost and Utilization Project and adjusted to 2023 USD. The analytic horizon, taken from the perspective of the pregnant patient, extended throughout the life of the child or children. An incremental cost-effectiveness ratio of 50 000 USD per quality-adjusted life year defined the willingness-to-pay threshold. One-way and probabilistic sensitivity analysis was also performed.
For base-case estimates, RFA was the most cost-effective strategy compared with all of the other interventions included, with an incremental cost-effectiveness ratio of 14 243 USD per quality-adjusted life year. One-way sensitivity analysis demonstrated that the utilities assigned to fetal demise and severe NDI, as well as the costs of preterm birth before 32 weeks, most strongly impacted the model outcomes. On probabilistic sensitivity analysis, RFA was the most cost-effective strategy in 78% of runs, followed by BCO at 20%, EM at 2% and FLP in 0% of runs. When compared with EM, RFA led to 58 fewer births before 28 weeks' gestation, 273 fewer cases of severe NDI and 22 more deliveries after 32 weeks. When compared with FLP, RFA resulted in 259 fewer cases of severe NDI and 3177 more births after 32 weeks. When compared with BCO, RFA resulted in 1786 more neurologically intact neonates and 34 fewer cases of severe NDI.
On base-case analysis, RFA was found to be the most cost-effective strategy in the management of monochorionic diamniotic twin pregnancies affected by Type-II sFGR. However, these findings were not robust on sensitivity analysis, indicating the potential benefit of BCO and EM. In the absence of large clinical trials, these data should not be taken to guide management. Future studies should evaluate management strategies for Type-II sFGR related to long-term neonatal outcomes, inclusive of quality-of-life indicators, in a prospective multicenter cohort. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
受II型选择性胎儿生长受限（sFGR）影响的单绒毛膜双胎妊娠，其宫内胎儿死亡、极早产、严重神经发育障碍（NDI）以及单胎或双胎新生儿死亡的风险增加。在缺乏关于最佳管理策略的共识的情况下，我们选择评估哪种策略在II型sFGR情况下具有成本效益。
使用决策分析模型，对假设的10000名单绒毛膜双羊膜囊双胎妊娠且受II型sFGR影响的人群队列，比较期待治疗（EM）、双极脐带闭塞术（BCO）、射频消融术（RFA）和胎儿镜激光凝固术（FLP）。概率和效用值来自文献。成本来自医疗保健成本和利用项目，并调整为2023年美元。从孕妇的角度出发，分析期限涵盖一个或多个孩子的一生。每质量调整生命年50000美元的增量成本效益比定义了支付意愿阈值。还进行了单因素和概率敏感性分析。
对于基础病例估计，与所有其他纳入的干预措施相比，RFA是最具成本效益的策略，每质量调整生命年的增量成本效益比为14243美元。单因素敏感性分析表明，分配给胎儿死亡和严重NDI的效用值，以及32周前早产的成本，对模型结果影响最大。在概率敏感性分析中，RFA在78%的模拟中是最具成本效益的策略，其次是BCO（20%）、EM（2%）和FLP（0%）。与EM相比，RFA导致妊娠28周前出生的婴儿减少58例，严重NDI病例减少273例，32周后分娩增加22例。与FLP相比，RFA导致严重NDI病例减少259例，32周后出生增加3177例。与BCO相比，RFA导致神经功能正常的新生儿增加1786例，严重NDI病例减少34例。
在基础病例分析中，发现RFA是管理受II型sFGR影响的单绒毛膜双羊膜囊双胎妊娠中最具成本效益的策略。然而，这些发现在敏感性分析中并不稳健，表明BCO和EM可能有益。在缺乏大型临床试验的情况下，这些数据不应被用于指导管理。未来的研究应在前瞻性多中心队列中评估与长期新生儿结局（包括生活质量指标）相关的II型sFGR的管理策略。© 2024作者。《妇产科超声》由John Wiley & Sons Ltd代表国际妇产科超声学会出版。
