Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum.

BACKGROUND: To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed. OBJECTIVE: This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum. STUDY DESIGN: This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists. RESULTS: A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded. CONCLUSION: The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.

Prenatal Diagnosis of Arhinia.

Arhinia is a rare congenital anomaly that is not typically associated with known genetic mutations and is usually discovered after an affected infant is born. Prenatal diagnosis is important because neonates with arhinia often require specialized respiratory support with creation of an artificial airway. We present a case of isolated arhinia diagnosed on second-trimester ultrasound. A patient presented for routine ultrasound at 18 weeks gestation, and nasal tissues were absent in an otherwise morphologically normal appearing fetus. Cell free fetal DNA was unremarkable. The patient elected to undergo termination of pregnancy by dilation and evacuation. Subsequent genetic analysis confirmed a normal fetal karyotype and microarray, and no examination of fetal structural anatomy was possible. Antenatal diagnosis of arhinia is important to guide maternal-fetal care decisions and requires methodical sonographic evaluation to identify this malformation prior to delivery.

Telemedicine and gynecologic oncology: caring for patients remotely during a global pandemic.

BACKGROUND: Telemedicine uses technology to deliver medical care remotely and has been shown to provide similar patient satisfaction and care outcomes compared with in-person visits. OBJECTIVE: This study aimed to assess the gynecologic oncology patient telehealth experience. STUDY DESIGN: All patients receiving telehealth care between March 23, 2020, to May 14, 2020, from a single institution's gynecologic oncology division were offered postvisit surveys to assess satisfaction. Basic demographic and clinical data were collected and analyzed with descriptive statistics. Patient zip code data were correlated with Community Need Index scores and visualized using heat maps. RESULTS: Of 286 telehealth visits, 112 postvisit surveys (39.2%) were collected. Survey responses demonstrated high patient satisfaction with responders agreeing that privacy was respected (97.3%), diagnosis and treatment options were adequately explained (92%), they could easily ask questions (97.3%), and they established a good rapport with their provider (96.4%). Additional benefits included reduced travel (92.9%), time (83.0%), cost (67.9%), and family interruption (57.1%). Among 11 patients receiving treatment on a clinical trial, 10 (90.9%) were able to continue on trial without disruption. Most responders (87.5%) preferred future visits to occur via telehealth or a mixture of telehealth and in-person visits. No difference in satisfaction was found among patients residing in zip codes associated with higher Community Need Index scores or increased distance from the institution. CONCLUSION: The use of telemedicine in providing gynecologic oncology care was associated with high patient satisfaction and had the benefits of reduced time, cost, travel, and interruption to family time.

Placenta previa in the second trimester: sonographic and clinical factors associated with its resolution.

We identify characteristics that predict resolution of placenta previa and develop a clinical model for likelihood of resolution. We conducted a retrospective study of 366 singleton pregnancies complicated by placenta previa diagnosed with resolution of the previa as the primary outcome. Regression analyses were performed to determine variables associated with resolution and optimal timing for repeat sonographic evaluation. A likelihood of resolution model was created using a parametric survival model with Weibull hazard function. Of the 366 cases, 84% of complete placentae previae and 98% of marginal placentae previae resolved at a mean gestational age of 28.6 ± 5.3 weeks. Only gestational age and distance from the internal cervical os at the time of diagnosis were significantly associated with resolution ( P < 0.01). Likelihood of resolution was not significantly associated with any other variables. Marginal previae diagnosed in the second trimester do not appear to warrant repeat ultrasound evaluation for resolution.

Reframing Telehealth: Regulation, Licensing, and Reimbursement in Connected Care.

Complexity in regulation and reimbursement of telehealth across the United States yields inconsistent use and availability of services. Drivers of this variation stem from existing regulatory, licensing, and payment policy that was designed for face-to-face care. Emerging technology for connected care continues to outpace the rules that govern its use. This article explores the drivers of uncertainty around regulation and payment of remote care services, and provides a roadmap for fulfillment of the benefits of connected care.

The effect of fetal heart rate on the peak systolic velocity of the fetal middle cerebral artery.

OBJECTIVE: To estimate the effect of an increase in the basal heart rate of the fetus on the middle cerebral artery peak systolic velocity (MCA-PSV). METHODS: This was a prospective longitudinal cohort. Patients between 14 and 36 weeks of gestation were enrolled (N=66). Ultrasound examinations were performed monthly. MCA-PSV measurements were assessed at 0-degree angle of insonation at basal fetal heart rate and after application of vibroacoustic stimulation. RESULTS: A total of 514 MCA-PSV measurements were obtained in 66 fetuses. No difference in fetal heart rate before and after vibroacoustic stimulation was noted before 27 weeks of gestation. A significant increase in fetal heart rate after vibroacoustic stimulation was detected from a mean+/-standard deviation gestational age of 27.1+/-1.3 weeks onward. A significant decrease in the MCA-PSV was noted between before vibroacoustic stimulation and after vibroacoustic stimulation measurements for examinations 3,4, and 5 (P<.001 for all). CONCLUSION: Acceleration of the fetal heart rate in the third trimester is associated with a decrease in the middle cerebral artery peak systolic velocity. Assessment of the MCA-PSV for the detection of fetal anemia, particularly in the third trimester, should be undertaken during a period of baseline fetal heart rate to avoid the potential of a false-negative result. LEVEL OF EVIDENCE: II.

Angle correction can be used to measure peak systolic velocity in the fetal middle cerebral artery.

OBJECTIVE: The objective of the study was to compare Doppler ultrasound measurements of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) obtained at a 0 degrees angle of insonation to assessment at 30 degrees and 30 degrees with angle correction. STUDY DESIGN: Patients between 14 and 36 weeks' gestation were enrolled (n = 66). MCA-PSV measurements were assessed at 0 degrees , 30 degrees , and 30 degrees with angle correction. The data were analyzed using a mixed model adjusted for gestational age. Pairwise comparisons of mean MCA-PSV measurements were made using the Tukey multiple comparison test. RESULTS: All measurements were obtained for 50 fetuses (76%). Mean MCA-PSV measurements were statistically different between 0 degrees vs 30 degrees (P = .03 to < .001) but not between 0 degrees vs 30 degrees with angle correction (P = .34-.99) at each of the 5 gestational age groupings. CONCLUSION: Assessment of the MCA-PSV at 0 degrees and 30 degrees with angle correction provides comparable measurements during the second and third trimester of pregnancy.