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.

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.