(430) Management of placenta accreta spectrum with cesarean hysterectomy versus conservative management: a cost-effectiveness analysis

Thursday, January 30, 2025

4:00 PM – 6:00 PM

Submitting Author and Presenting Author(s)

Ava D. Mandelbaum, BA (she/her/hers)

Oregon Health & Science University
Portland, OR, United States

Coauthor(s)

Binh Luu, BS (he/him/his)

Oregon Health and Science University
Vancouver, Washington, United States
AC

Andrew H. Chon, MD

Oregon Health & Science University
Portland, Oregon, United States
TE

Tania F. Esakoff, MD

Division of Maternal Fetal-Medicine, Department of Obstetrics and Gynecology
Cedars Sinai Medical Center
Los Angeles, California, United States
DL

Deirdre J. Lyell, MD

Professor
Stanford University
Palo Alto, California, United States
Aaron B. Caughey, MD, PhD

Professor and Chair
Oregon Health & Science University
Portland, Oregon, United States

Objective: Cesarean hysterectomy is the standard treatment for placenta accreta spectrum (PAS), but alternative conservative management strategies (e.g., leaving the placenta in situ), have been proposed to preserve fertility. This study aimed to evaluate the cost-effectiveness of conservative management for PAS.

Study Design: A decision-analytic model was built using TreeAge software to compare the outcomes and cost-effectiveness of cesarean hysterectomy versus conservative management. The theoretical cohort included 5,000 individuals in the U.S. with PAS. Maternal outcomes included severe postpartum hemorrhage ( >3000 mL estimated blood loss), adjacent organ injury, severe maternal morbidity (including intensive care unit admission, sepsis, and disseminated intravascular coagulation), endometritis, maternal death, and readmission. The number of hysterectomies performed within and after 24 hours of delivery (primary and delayed, respectively) was calculated for the conservative management group. Model inputs were derived from the literature. The threshold for cost-effectiveness was set at $100,000 per quality-adjusted life year (QALY). Sensitivity analyses were performed to assess the robustness of the results.

Results: Cesarean hysterectomy resulted in 2,137 more severe postpartum hemorrhages, 413 more adjacent organ injuries, and 516 more cases of non-hemorrhage SMM, and 8 more maternal deaths compared to conservative management. Conversely, conservative management led to 542 more cases of endometritis and 1,268 more readmissions. Additionally, 347 primary and 202 delayed hysterectomies were performed in the conservative management group. Conservative management resulted in a $64 million cost reduction and an increase of 7,609 QALYs relative to cesarean hysterectomy.

Conclusion: Compared to cesarean hysterectomy, conservative management was cost-effective, with distinct trade-offs in maternal outcomes, such as reduced severe hemorrhage and increased endometritis and readmission. Additional studies are needed to refine the selection of patients undergoing conservative management for fertility preservation.