Fetoscopic Laser Ablation of Type II Vasa Previa: A Cost Benefit Analysis

Martha A Monson; Ramen H Chmait; Brett Einerson

doi:10.1055/s-0043-1771262

Fetoscopic Laser Ablation of Type II Vasa Previa: A Cost Benefit Analysis

Am J Perinatol. 2023 Jul 21. doi: 10.1055/s-0043-1771262. Online ahead of print.

Authors

Martha A Monson^{1

2}, Ramen H Chmait³, Brett Einerson^{1

2}

Affiliations

¹ Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City, Utah.
² Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.
³ Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California.

PMID: 37494587
DOI: 10.1055/s-0043-1771262

Abstract

Objective: We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard management (SM).

Study design: A decision analytic model and cost-benefit analysis from a health care perspective were performed. The population included patients with type II vasa previa at approximately 32 weeks. SM entailed 32-week antepartum admission and cesarean at approximately 35 weeks. FLS referral included consultation and possible laser surgery at 32 weeks for willing/eligible candidates. Successful laser surgery allowed the possibility of term vaginal delivery. Outcomes included antepartum admission, preterm birth, cesarean, neonatal transfusion, and death. Sensitivity analyses were performed.

Results: In base case analysis, FLS referral was cost saving compared with SM (total cost per patient $65,717.10 vs. 71,628.16). FLS referrals yielded fewer antepartum admissions, cesareans, premature births, neonatal transfusions, and deaths. Eligible referred patients choosing FLS incurred a total cost of $41,702.46, a >40% decrease compared with SM. FLS referral was cost saving in all one-way sensitivity analyses except when antepartum admission costs were low. In threshold analyses, FLS referral was cost saving unless laser surgery cost was >$39,892 (2.75x expected cost), antepartum admission cost for monitoring of vasa previa or ruptured membranes was <$7,455, <11% patients were eligible for laser surgery, and when <12% of eligible patients chose laser surgery. In two-way sensitivity analysis, FLS referral was cost saving except at very high laser surgery costs and extremely low antepartum admission costs.

Conclusion: Referral for FLS for type II vasa previa was cost saving and improved outcomes compared with SM, despite upfront costs, fetoscopy-related risks, and many patients being ineligible or not opting for surgery after referral.

Key points: · Vasa previa rupture may lead to fetal exsanguination and death.. · Late preterm cesarean is common practice for prenatally diagnosed vasa previa.. · Successful fetoscopic laser ablation for type II vasa previa has been described.. · Laser ablation of vasa previa allows for a safe-term vaginal delivery.. · Referral for laser surgery is cost saving and is associated with improved outcomes..