Dr. Chapa’s Clinical Pearls.

First off, let’s all agree that everyone has a different STYLE of sexual intimacy, and that’s OK. Yep, we all understand that there's always been a lot of sexual act “diversity” in the world… and throughout history. But there is a more recent trend that has increased in popularity, some surveys attribute it to its representation in pornography, that may be dangerous. This was in recent print as of July 3, 2024! This is "sexual choking”. But this term is not accurate because it actually is a form of strangulation. The increase in practice is mostly seen in teenagers and young adults. In this episode, we will discuss a real-world scenario that one of our podcast family members asked me about just the other day. This OBGYN physician was on call and one of her patients, a 21-year-old, non-pregnant, otherwise healthy, and THIN (yes, that was a factor in this case, and we will discuss why) presented with LOC during sex whose partner stated “she had a seizure” during sex. But this was no ordinary seizure. She had no history of epilepsy and was not on any medications. The “seizure” happened after sexual choking. Sexual choking is a big concern as it exposes the brain to recurrent episodes of hypoxia. We now have data showing there are real negative effects from this activity. Plus, we need to discuss this as it may also be a normalization, inappropriately, of sexual violence. In this episode, we will take a look at this alarming data and discuss why we need to ask about these sexual practices in a compassionate, empathic, and open way.

Candida in women is being right? Afterall, vulvovaginal candidiasis during pregnancy is common. Candida species may be isolated from the vagina of 15 %-21% of nonpregnant women; this rate increases to 30% during pregnancy. While it is generally benign and isolated to the vagina clinically, some Candida species have the capacity to be troublemakers. C. Glabrata has the potential to be a bad player, with the possibility of invasive disease. Candida IAI is rare but can lead to neonatal infection, high mortality, preterm prelabor rupture of membranes, and childhood neurodevelopmental impairment. The most prevalent predisposing condition is preterm prelabor rupture of membranes, followed by intrauterine pregnancy with a retained intrauterine contraceptive device, cervical cerclage, diabetes in pregnancy, and pregnancy after in vitro fertilization. Preterm labor is the most common symptom with Candida IAI, and only 13% of cases involved fever. Case reports have also associated C. Glabrata with third trimester stillbirth. Although case reports have documented this since the 1980s, this is still an evolving diagnosis as awareness of the condition increases. Nonetheless, the clinical features of Candida IAI are not well understood, and best management of the condition is unclear. In June 2024, Candida Glabrata was called a “global priority pathogens”. In this episode, we will review this rare but very real clinical conundrum. One of our podcast family members actually managed a patient, s/p IVF, with periviable PPROM found to have Candida Glabrata fungemia. How is this possible? Shall we treat Candida in the urine? We will discuss this in this episode.

Biomarker testing has arrived in Obstetrics. Of course, we have been using some biomarkers for years, like PAMG1 (Amnisure) and AFP+ILGFBP1 (ROM Plus) for ROM evaluation. In May 2023, the FDA cleared Thermo Fisher Scientific's maternal serum biomarker test for prediction of preeclampsia with severe features in hospitalized patients (and we have a prior episode on that). Now, as of July 9, 2024, published data has arrived for a new maternal serum biomarker ratio for the prediction of preterm birth in low-risk patients. This is the PreTRM biomarker test. This is on the path for FDA clearance. In this episode, we will review the AVERT Preterm Trial which utilizes a novel biomarker ratio using IGFBP4/SHBG. What did this study find? There some promising aspects to this, and also some striking limitations. Listen in for details!

Published studies, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PG E1) when used for cervical ripening and labor induction. Based on cumulative data, misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Prostaglandin E2 also has proven efficacy. Plus, we are all aware of the safety and efficacy of mechanical methods of cervical ripening; yes…we know that these options may be used either individually or concomitantly. But what about sequential use? Can cervical balloon be used after misoprostol? Or should it be the other way around? Is there a “best way” to do sequential cervical ripening? This episode topic comes from one of our podcast family members. It's a really good clinical question, and we will dive into the data in this episode. And STAY TUNED IN UNTIL THE END for the real-world clinical implications of the data.

Tuberculosis (TB) was historically called "consumption" due to the dramatic weight loss and wasting away experienced by patients. The modern name "tuberculosis" was first published by J. L. Schönlein in 1832. Today, between 3% and 5% of the U.S. population are estimated to be living with latent TB infection. Contrast that with the worldwide statistics which state that nearly one fourth of the world population has TB infection. In some countries in sub-Saharan Africa and Asia, the annual incidence is several hundred per 100,000 population. In the US, the annual incidence is <3 per 100,000 population, but immigrants from countries with a high TB burden and long-term residents of high-burden countries have a 10× greater incidence of TB than the US national average. Thankfully, only 5–10% of individuals with latent TB infection will progress to active TB disease over their lifetimes. But it is difficult to predict who will progress from latent TB infection to active TB disease. The perinatal period is a good opportunity to screen, diagnose, and treat those at high risk for TB. The ACOG the American Academy of Pediatrics, and the Centers for Disease Control and Prevention (CDC) recommend screening all women who are at high risk for TB at the initiation of antenatal care. In this episode, we will review the epidemiology of tuberculosis, who should be screened, and focus on latent TB infection management in pregnancy. What does the “4R” preferred regimen mean? Listen in and find out.

Approximately 0.5% of all births occur before the 3rd trimester of pregnancy, and very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. Preterm prelabor rupture of membranes (PPROM) is a known risk factor for preterm birth and is responsible for 30–40% of preterm deliveries. While PROM occurs around 8% of all (term) pregnancies, PPROM occurs around 1% of the time. Periviable birth is delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. Women who experience PPROM before 27 weeks have a 10% risk of early PPROM and a 35% risk of preterm delivery in a subsequent pregnancy. Despite improvements in perinatal and neonatal care, infants born at <26 weeks of gestation contribute disproportionately to neonatal mortality and morbidity. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. In this episode, we will review the latest data on previable and periviable PPROM based on a new SMFM Consult Series (#71), released July 15, 2024. Is amnioinstillation of fluid into the uterus an option? What about home outpatient management? Listen in for the data.

Researchers estimate that more than 100 million women in over 120 countries use tampons during their menstrual cycle. Tampons are generally considered safe and healthy menstrual products. However, a new study conducted by researchers at the UC Berkeley School of Public Health has identified the presence of 16 different heavy metals in tampons from 14 different brands purchased in the U.S. and the U.K. This is causing a flurry of on-line commentaries, controversies, and conundrums. Are tampons toxic? In this episode, we will summarize this new publication (set to be officially released Aug 2024) and relate it to some real-world, daily exposures.

It's Summer…and its getting HOT in here! Although the effect of heatwaves in pregnancy has been studied various times, the data remains limited because these studies are observational, with very heterogenous populations, so its hard to prove causation between heat exposure and adverse outcomes. Nonetheless, these associations are indeed concerning. YES…just to be clear, there are past studies that have observed associations between heatwaves and PTB, low birthweight, and in some studies…stillbirth. The most recent review on this was published just last year (June 2023) in the J Mother Child, and the title was “A Comprehensive Review on Hot Ambient Temperature and its Impacts on Adverse Pregnancy Outcomes”. This review of 23 articles did again find an association between heat stress and adverse pregnancy outcomes. PLUS, a new publication released July 3, 2024, now raises new concerns about ambient heat and in-utero childhood cancer programming! That article, from Lancet Planetary Health, is the focus of this episode. BUT WAIT there’s more! We will also look at the relationship between ambient heat and PTB and oligohydramnios. So, grab your ice cooled glass of water and Let’s look at the evidence.

Up to 1 in 10 reproductive-aged women are impacted by endometriosis. Dysmenorrhea is the most common pelvic complaint of adolescents. While most cases of primary dysmenorrhea in adolescents will be primary dysmenorrhea, Endo remains a possibility especially after 2-3 years of progressive symptoms. Although the true prevalence of endometriosis in adolescents is unknown, at least two thirds of adolescent girls with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at the time of diagnostic laparoscopy. Now, as of July 2, 2024, a new diagnostic tool for Endo has received FDA Fast Track designation for development. This is different than FDA APPROVAL, but still represents a novel new option (if/when approved) to make ENDO diagnosis possible by using a molecular/protein ligand tracer. Listen in for details!

Well, sometimes the "traditional", evidence-based recommendations don't have the desired result they are supposed to. When the "usual and standard" ways of doing things fail, its time for "shared-decision making"! In this episode, we will highlight, and give KUDDOS, to an OB care team who exampled thinking outside-the-box in order to care for an acutely ill patient s/p second trimester loss. This is soon to be released in the AJOG, and was released as a journal "pre-proof" July 9, 2024. This is a difficult case of a 19 week septic AB, retained placenta, an overtly abnormal uterus, and the surgical robot! Listen in for details.

RSV season is just around the corner (Fall and Winter months). Newborns are 16x more likely to be hospitalized with serious RSV lung infection than the flu. On August 21, 2023, the FDA approved the first RSV vaccine, Abrysvo, for use in pregnant individuals to protect newborns and infants against severe RSV disease in the first 6 months after birth. The FDA approved the vaccine to be administered between 32 and 36 weeks and 6 days of gestation. Then, on September 22, 2023, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to recommend a single dose of maternal RSV vaccination for pregnant people at 32 through 36 weeks of gestation, using seasonal administration, to prevent RSV lower respiratory tract infection (LRTI) in infants.This resulted in the ACOG’s endorsement, also in September 2023, of Abrysvo in pregnancy. However, the clinical trial resulting in the vaccine’s FDA approval noted “a numerical imbalance” for preterm birth occurrence (1% more) in vaccine recipients. Because of this, there was a call for additional “real world outcomes“ to see if this finding would be replicated outside of the trial. In this episode, we will summarize a brand new (July 8, 2024) publication from JAMA Network Open which provides this data, although some noteworthy study limitations must be acknowledged. Listen in for details!

A substantial collection of evidence indicates that the fallopian tube serves as the primary site of origin for a large portion of high-grade serous ovarian cancers. As a result, clinical practice guidelines (including from the ACOG) recommend salpingectomy for permanent contraception- when necessary- rather than simple tubal ligation. But an August 2023 publication, in JAMA Network Open, stated that women who undergo a salpingectomy are no more or less at risk of ovarian cancer compared to traditional tubal ligation. Why? In this episode, we will summarize this controversial publication and contrast that to a systematic review the following month, in September 2023 in JAMA Surgery, which provides an alternative conclusion. Should we still perform opportunistic salpingectomies (OS) rather than tubal ligations in the average-risk patient? We’ll explain the data and provide clinical pearls for practice at the end of the episode. Thank you, Bret, for this clinical conundrum as a podcast episode recommendation! You ask…we do!

Approximately 20% to 25% of pregnancies end in miscarriage, and there are many medical reasons why it may occur. About half are caused by chromosome aneuploidy. However, less than 5% of women will experience a second first trimester loss, and less than 1% will experience three early losses. The incidence of early spontaneous pregnancy loss increases by maternal age. In this episode, we will highlight an ACOG Clinical Expert Series from May 2024, which discussed the evaluation of recurrent pregnancy loss. Is genetic testing of the POC recommended after the first occurrence, 1st trimester spontaneous loss? If so, which test is the best? What genetic testing applies to parents, and when? Listen in for details.

Happy Independence Day, America! We hope you are enjoying this wonderful, national holiday. Yep...Its a PARTY in the USA! In light of the festivities, here's a clinical question for us: Do fireworks affect the fetus? Even broader than that, do loud sounds in general affect the developing child? The answer is both YES and NO. Listen in to this short- yet fun- episode as we prepare to light the night up in celebration of our nation's independence.

(Here’s a WONDERFUL QI Project for this New Residency Academic Year) With 70.8% of pregnancies among adolescents being unintended, there is a clear need for increased access to contraceptive services. Many adolescents use the emergency department (ED) as their primary healthcare source, highlighting the importance of providing comprehensive sexual health services in this setting. The risk of pregnancy is high among adolescents seeking ED care, indicating an opportunity to expand pregnancy prevention services in this setting. ED clinicians are in a unique position to address pregnancy prevention among adolescents. Novel ED staff training tools kits do exist for brief contraceptive counseling interventions during the ED visit for interested adolescents who present for any chief complaint. Talking to teens about contraceptives in the ED is feasible, acceptable, and allows ED staff to reach youth that may not have access or choose not to access medical care in any other setting. In this episode, we will summarize striking data from a recent publication (June 28, 2024), in JAMA Network Open, which revealed gaps in addressing contraceptive needs among vulnerable adolescent females and gaps in provisions of EC when needed. Additionally, we will propose an easy to adopt strategy to better equip Emergency Department staff for having these conversations.

PROM occurs in approximately 10% of pregnancies and leads to a risk of IAI in women that is 3 times higher than that in non-PROM women. The risk of early-onset sepsis of neonates born to mothers exposed to PROM is 20 times higher than in non-PROM mothers. An increasing time period with PROM increases the risk of infection for both mothers and newborns accordingly. Nonetheless, the ACOG states that there is insufficient evidence to justify the routine use of prophylactic antibiotics with PROM at term in the absence of an indication for GBS prophylaxis (ACOG PB217). HOWEVER, now that the ACOG has provided a clinical practice update on IAI (JULY 2027), emphasizing that the traditional “requirement” of maternal temperature of 38 °C (100.4F) need NOT be present for IAI diagnosis, new data suggests that febrile and infectious morbidity may be increased with PROM after 12 hrs with “low grade” maternal temps. In this episode, we will review the ACOG clinical practice update (briefly, as we covered that previously) in light of a June 11, 2024 AJOG publication analyzing the relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes.

Podcast Family, I hope this episode gives you pause and brightens your day 🌞. Just a quick work and acknowledgement to likley our YOUNGEST podcast family member and his mother, a Co-OBGYN preparing for oral Boards. 👏👏 Let this speak to you as the message spoke to me! (and introducing ​callmestevieray & Connor Price, whose words/song- “GRATEFUL”- always lightens my load). 🎶👏🎶👏🎶

Oral Hormonal contraception gets the blame for a lot of things, including the development of hypothyroidism. Hypothyroidism is one of the most common endocrine disorders affecting 5 to 10 times more women than men, and its prevalence increases with age. This association of OCPs with hypothyroidism comes from a controversial article in BMJ published in 2021, but is still very active in current social media posts. Does combination oral birth control cause hypothyroidism with prolonged use? Are birth control pills responsible for “micronutrient depletion” which negatively affects the thyroid? In this episode, we will explore and dissect this study and look at a January 2024 case-control study that provides an alternative conclusion. Listen in for details.

Podcast Fam, on March 27, 2024 our episode was called "Balloon for PROM: Yea or Nay". Although mechanical cervical balloons for induction were the focus, we also discussed which medication is better (based on published data) for labor induction after PROM. Well, in this episode, we pick up from March with ANOTHER NEW STUDY released today (June 25, 2024) in AJOG MFM. This RCT builds on the evidence that going straight to Pitocin (despite an unfavorable cervix) is the way to go after PROM. Although there are study design limitations, this is reassuring- and validating- information. Listen in for the "I TOLD YOU SO DANCE", and for details.

Anxiety disorders are the most common mental health issue in the United States, affecting nearly 1 in 5 adults, or 40 million people. Another 19 million adults – 8% of the population – has depression. Prenatal mood disturbances are known to affect the fetal brain, and endocrine system. Left amygdalar volumes were smaller in newborns whose mothers had high psychological distress during the COVID-19 pandemic, a small cross-sectional study suggested. Infants of mothers with elevated maternal distress during the pandemic had median reductions in white matter, right hippocampal, and left amygdala volumes compared with neonates whose mothers had low distress levels, this is according to research from the Children's National Hospital in Washington, D.C. This was published in JAMA Network Open on June 20, 2024 and is making the medical headlines. This is fascinating data. BUT, this is NOT new news. In this episode, we will review the concerning effect that maternal mood and stress has on the developing fetal brain, and how maternal stress may even be leading to changes in the child’s puberty! Listen in for details.