The State of Ohio The State of Ohio Universal Prenatal Universal Prenatal

BookingBooking

David S. McKenna, MD, RDMSDavid S. McKenna, MD, RDMSMaternal-Fetal MedicineMaternal-Fetal Medicine

Miami Valley Hospital, Dayton OHMiami Valley Hospital, Dayton OH

OutlineOutline

Historical perspective of Prenatal careHistorical perspective of Prenatal care

Current Prenatal Care ScheduleCurrent Prenatal Care Schedule

First Trimester ScreeningFirst Trimester Screening

Two examplesTwo examples

Inverted PyramidInverted Pyramid

Proposal for Universal 1Proposal for Universal 1stst Prenatal Visit Prenatal Visit

HistoricallyHistorically

Up to 19Up to 19thth Century – time of delivery Century – time of delivery 2020thth Century Century

High infant and maternal mortalityHigh infant and maternal mortality PNC institutions establishedPNC institutions established

1929 – UK Ministry of Health1929 – UK Ministry of Health 16 Wks – 116 Wks – 1stst visit, then 24 & 28 Wks visit, then 24 & 28 Wks ““Fortnightly” 28 to 36 weeksFortnightly” 28 to 36 weeks Weekly after 36 weeksWeekly after 36 weeks

Schedule was not based on scienceSchedule was not based on science

Current Schedule of PNCCurrent Schedule of PNC

ACOG – Guidelines ACOG – Guidelines for Prenatal Care (6for Prenatal Care (6thth ed, 2007)ed, 2007)

80 years old80 years old Series of Routine Series of Routine

VisitsVisits

Implies that most complications occur in third Implies that most complications occur in third trimester; and most adverse outcomes are trimester; and most adverse outcomes are unpredictable in the 1st or 2nd trimesterunpredictable in the 1st or 2nd trimester

First Trimester ScreeningFirst Trimester Screening

Pathophysiology present in 1Pathophysiology present in 1stst trimester: trimester: Preeclampsia, fetal demise, gestational Preeclampsia, fetal demise, gestational

diabetes mellitus, preterm birth, fetal diabetes mellitus, preterm birth, fetal growth restriction and macrosomiagrowth restriction and macrosomia

At risk women can be identified:At risk women can be identified: Ultrasound Ultrasound Maternal biophysical parametersMaternal biophysical parameters Maternal historyMaternal history Biochemical markersBiochemical markers

Screening for AneuploidyScreening for Aneuploidy Originally 2Originally 2ndnd Trimester Trimester

Poor sensitivity and specificityPoor sensitivity and specificity 2010 - First Trimester Screen2010 - First Trimester Screen

Combines Ultrasound, age, blood testCombines Ultrasound, age, blood test Identifies 90% of all major aneuploidiesIdentifies 90% of all major aneuploidies

5% screen positive rate5% screen positive rate Over 20 years experience Over 20 years experience Offered to all women regardless of riskOffered to all women regardless of risk

Preterm Birth PredictionPreterm Birth Prediction

1st TM Screen Model (PTB < 28 Wks)1st TM Screen Model (PTB < 28 Wks) 15% Maternal History Alone15% Maternal History Alone

22% Mat. History + Characteristics 22% Mat. History + Characteristics 82% Add Cervical Length82% Add Cervical Length

Treat with Progesterone Treat with Progesterone Inexpensive, easy, no adverse effectsInexpensive, easy, no adverse effects Reduces risk of Recurrent PTBReduces risk of Recurrent PTB

The Inverted Pyramid of PNCThe Inverted Pyramid of PNC

Early risk estimationEarly risk estimation High risk: shift PNC High risk: shift PNC

from routine to disease-from routine to disease-specific approachspecific approach

Low risk: reduce number Low risk: reduce number of visitsof visits

Based on proposal for the UK by Kypros Nicolaides,Based on proposal for the UK by Kypros Nicolaides,http://www.fetalmedicine.com/fmf/online-education/08-pyramid-of-care/http://www.fetalmedicine.com/fmf/online-education/08-pyramid-of-care/

Universal Prenatal VisitUniversal Prenatal Visit

Ground RulesGround Rules Based on Inverted PyramidBased on Inverted Pyramid No cost to womenNo cost to women AccessibleAccessible Desirable (also cool)Desirable (also cool) Shared & Secure dataShared & Secure data

Universal Prenatal VisitUniversal Prenatal Visit ComponentsComponents

CounselingCounselingDiet, Safety, Pregnancy CareDiet, Safety, Pregnancy CareHealthcare FinancesHealthcare Finances

Screen for RisksScreen for RisksHistory, Maternal Characteristics, WeightHistory, Maternal Characteristics, WeightBlood Pressure, Ultrasound, BloodBlood Pressure, Ultrasound, Blood

Low RiskLow Risk Schedule for 20 week visitSchedule for 20 week visit

Universal Prenatal VisitUniversal Prenatal Visit

High RiskHigh Risk Fast trackFast track

Ohio MedicaidOhio MedicaidProtocols for Focused Prenatal CareProtocols for Focused Prenatal CareReferral for other resourcesReferral for other resources

Existing clinics at frequent intervalsExisting clinics at frequent intervalsTimely InterventionsTimely Interventions

Universal Prenatal VisitUniversal Prenatal Visit

ImplementationImplementation Funding - $ savings (discussion)Funding - $ savings (discussion) PopulationPopulation

Ohio Medicaid and Self Pay PatientsOhio Medicaid and Self Pay Patients

AdvertiseAdvertise Social Media, Schools, ?Social Media, Schools, ?

Pilot Project – two yearsPilot Project – two years One, preferably Two Sites – validate data One, preferably Two Sites – validate data

sharingsharing

Funding DiscussionFunding Discussion

Primary Preventive High Risk Ob Care Primary Preventive High Risk Ob Care Spend Early, Save Late (NICU, etc.)Spend Early, Save Late (NICU, etc.) Can bill for US and Prenatal LabsCan bill for US and Prenatal Labs Overall less physician visitsOverall less physician visits

SummarySummary

Miami Valley Hospital – DaytonMiami Valley Hospital – Dayton Center for Women’s HealthCenter for Women’s Health

Ob/Gyn Resident clinicOb/Gyn Resident clinic Ohio MC & Self PayOhio MC & Self Pay Approx 2,000 Deliveries/yearApprox 2,000 Deliveries/year

Currently Investigating implementation of Currently Investigating implementation of Pilot ProjectPilot Project Outcomes: Cost, Recurrent PTB, Preeclampsia Outcomes: Cost, Recurrent PTB, Preeclampsia

prior to 34 weeks, Perinatal Mortalityprior to 34 weeks, Perinatal Mortality