1. The State of Ohio Universal Prenatal Booking David S. McKenna, MD, RDMS Maternal-Fetal Medicine Miami Valley Hospital, Dayton OH

2. Outline l Historical perspective of Prenatal care l Current Prenatal Care Schedule l First Trimester Screening u Two examples l Inverted Pyramid l Proposal for Universal 1 st Prenatal Visit

3. Historically l Up to 19 th Century – time of delivery l 20 th Century u High infant and maternal mortality u PNC institutions established l 1929 – UK Ministry of Health u 16 Wks – 1 st visit, then 24 & 28 Wks u “Fortnightly” 28 to 36 weeks u Weekly after 36 weeks l Schedule was not based on science

4. Current Schedule of PNC l ACOG – Guidelines for Prenatal Care (6 th ed, 2007) l 80 years old l Series of Routine Visits l Implies that most complications occur in third trimester; and most adverse outcomes are unpredictable in the 1st or 2nd trimester

5. First Trimester Screening l Pathophysiology present in 1 st trimester: u Preeclampsia, fetal demise, gestational diabetes mellitus, preterm birth, fetal growth restriction and macrosomia l At risk women can be identified: u Ultrasound u Maternal biophysical parameters u Maternal history u Biochemical markers

6. Screening for Aneuploidy l Originally 2 nd Trimester u Poor sensitivity and specificity l 2010 - First Trimester Screen u Combines Ultrasound, age, blood test u Identifies 90% of all major aneuploidies F 5% screen positive rate u Over 20 years experience u Offered to all women regardless of risk

7. Preterm Birth Prediction l 1st TM Screen Model (PTB < 28 Wks) u 15% Maternal History Alone l 22% Mat. History + Characteristics u 82% Add Cervical Length l Treat with Progesterone u Inexpensive, easy, no adverse effects u Reduces risk of Recurrent PTB

8. The Inverted Pyramid of PNC l Early risk estimation l High risk: shift PNC from routine to disease- specific approach l Low risk: reduce number of visits Based on proposal for the UK by Kypros Nicolaides, http://www.fetalmedicine.com/fmf/online-education/08-pyramid-of-care/

9. Universal Prenatal Visit l Ground Rules u Based on Inverted Pyramid u No cost to women u Accessible u Desirable (also cool) u Shared & Secure data

10. Universal Prenatal Visit l Components u Counseling F Diet, Safety, Pregnancy Care F Healthcare Finances u Screen for Risks F History, Maternal Characteristics, Weight F Blood Pressure, Ultrasound, Blood l Low Risk u Schedule for 20 week visit

11. Universal Prenatal Visit l High Risk u Fast track F Ohio Medicaid F Protocols for Focused Prenatal Care F Referral for other resources u Existing clinics at frequent intervals F Timely Interventions

12. Universal Prenatal Visit l Implementation u Funding - $ savings (discussion) u Population F Ohio Medicaid and Self Pay Patients u Advertise F Social Media, Schools, ? u Pilot Project – two years F One, preferably Two Sites – validate data sharing

13. Funding Discussion l Primary Preventive High Risk Ob Care u Spend Early, Save Late (NICU, etc.) u Can bill for US and Prenatal Labs u Overall less physician visits

14. Summary l Miami Valley Hospital – Dayton u Center for Women’s Health F Ob/Gyn Resident clinic F Ohio MC & Self Pay F Approx 2,000 Deliveries/year u Currently Investigating implementation of Pilot Project F Outcomes: Cost, Recurrent PTB, Preeclampsia prior to 34 weeks, Perinatal Mortality