Management of suspected fetal macrosomia: A cost-effectiveness analysis

Abstract

Management of fetal macrosomia presents challenges to practitioners as a potential outcome of shoulder dystocia with permanent brachial plexus injury is costly to both families and society. Practitioner options include labor induction, elective cesarean delivery, or expectant management. We performed a cost effective analysis to evaluate which of these management strategies was preferred to prevent the most permanent brachial plexus injuries with the least amount of dollars spent. Using decision analysis techniques, we compared 3 strategies for an infant with estimated fetal weight of 4500 grams: 1. Labor induction, 2. Elective cesarean delivery (CD), and 3. Expectant management. Baseline assumptions: Probability (prob) of shoulder dystocia in vaginal delivery (VD): .145; CD: .001; prob of plexus injury: .18; prob of permanent injury: .067; prob of CD with induction; .35; cost of VD: $3376; elective CD: $5200; CD with labor: $6500; lifetime cost of brachial plexus injury: $1,000,000. Sensitivity analyses were performed. Under baseline assumptions for an infant weighing 4500 g expectant management is the preferred strategy at a cost of $4014.33 per injury free child, compared to elective CD cost of $5212.06 and induction cost of $5165.08. Sensitivity analyses revealed that if the incidence of shoulder dystocia and permanent injury remained under 10% expectant management is the preferred method. Fetal macrosomia with possible permanent plexus injuries is a concern. Our analysis would suggest expectant management is the most cost effective approach to this problem.