Purpose: To determine the optimal strategy for patients with triplet gestations considering fetal reduction to either twins or singletons compared to continuing the pregnancy without reduction.
Method: A decision-analytic model was designed comparing maternal quality-adjusted life years (QALY) for women with triplet gestations electing to continue the pregnancy to those electing to reduce to twins or singletons. The probability of delivering at 24-28 weeks, 29-32 weeks, 33-36 weeks, and >37 weeks was incorporated into each decision arm as well as outcomes related to neonatal morbidity and mortality.
Result: Fetal reduction of triplets to twins optimizes neonatal outcomes and maternal QALY (25.71) compared to reduction to singletons (25.70) and not reducing (25.51). Per 10,000 live births, reducing to twin gestations reduces neonatal death by 127 and cases of severe neurological disability by 71. In sensitivity analysis, a loss rate of >15% when reducing to twins and >16% when reducing to singletons is the threshold after which continuing a triplet gestation optimizes outcomes. Varying maternal preferences for severe disability favors reducing to twins at a utility >0.58 and reducing to singletons below 0.58. Varying maternal preferences for early pregnancy loss (<24 weeks) favors reducing to singletons at a utility of >0.92 and reducing to twins below 0.92. There is no threshold for maternal preferences toward pregnancy loss or severe disability that make maintaining triplets optimal.
Conclusion: With a loss rate of <15%, reduction of triplet gestations to twins optimizes maternal outcomes.
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