(832) Cost-Effectiveness of Intramuscular Methylergonovine Prophylaxis at Cesarean Delivery for Twin Gestations: A Decision-Analytic Model

Twin pregnancies are at increased risk for postpartum hemorrhage (PPH), transfusion, and maternal death. A recent randomized controlled trial (RCT) demonstrated that prophylactic administration of intramuscular (IM) methylergonovine after cord clamping significantly reduced blood loss during planned cesarean delivery (CD) in twin gestations. This study aimed to evaluate the cost-effectiveness of IM methylergonovine for PPH prophylaxis at the time of CD in twin pregnancies.


Study Design:

A decision-analytic model was built using TreeAge software to compare the outcomes and cost-effectiveness of prophylactic IM methylergonovine versus a placebo saline injection at the time of CD in twin gestations. The theoretical cohort included 85,000 individuals, the estimated annual number of CD for twin gestations in the U.S. Maternal outcomes included postpartum hemorrhage, transfusion, ICU admission, hysterectomy, and maternal death. Probabilities, utilities, and costs were derived from the literature. A 50-year time horizon and 3% annual discount rate were applied. The threshold for cost-effectiveness was set at $100,000 per QALY.


Results:

In this cohort, prophylactic IM methylergonovine resulted in 31,450 fewer PPH events, 5,100 fewer transfusions, 326 fewer ICU admissions, three fewer hysterectomies, and the prevention of one maternal death, compared to placebo. IM methylergonovine was on average $100.48 less expensive per delivery and was the dominant strategy as it saved $8.5 million and led to an increase of 2,550 QALYs (Table 1). Univariate sensitivity analysis demonstrated that IM methylergonovine is the dominant strategy until its cost exceeds $500, and remains cost-effective until its cost exceeds $3,107, which is far above the current price (Figure 1).


Conclusion:

Routine administration of IM methylergonovine after cord clamping at the time of cesarean delivery for twin gestations is a cost-effective strategy that reduces maternal morbidity and improves quality-adjusted survival. These findings support the implementation of adjunctive uterotonic prophylaxis for high-risk cesarean deliveries.