Dr. Chapa’s Clinical Pearls.

Welcome to our “OB Smorgasburg” episode, where we have a CORNUCOPIA of topics. Well, maybe not a full cornucopia… But a mini-cornucopia. In this episode, we will address 2 recent publications that really are my “pet peeves“ about medical data! One is from the US Preventive Service Task Force, and the other has to do with “timed intercourse”. You have to listen to this! Then we will get into new data regarding the association of 1 abnormal glucose value on the 3 hour GTT with adverse neonatal outcomes. And lastly, is there such a thing as “organic” 50 g glucose challenge? Let’s get into all this information…Now!

Universal, weekly (surveillance) laboratory screening for expectant management of Hypertensive Disorders in Pregnancy has been routine practice since the release of the ACOG’s Hypertension in Pregnancy executive summary in November of 2013. This plan of care was also recommended in the ACOG Practice Bulletin 222 focused on Gestational Hypertension and Preeclmapsia. But does this actually help prevent maternal morbidity? Does routine weekly lab surveillance, detect worsening disease over clinical presentation alone? In this episode, we will summarize a new study soon to be released in the Green Journal (Obstetrics & Gynecology) which seeks to determine the clinical utility of this outpatient, antepartum management option.

Trichomoniasis has been found in every continent and climate without showing any significant seasonal variability. According to the CDC, trichomoniasis is estimated to be the most prevalent nonviral STI worldwide, affecting approximately 2.6 million persons in the United States. Conditions shown to be associated with T vaginalis infection include: Increased risk of HIV acquisition and transmission, increased prevalence of other sexually transmitted infections, adverse outcomes of pregnancy (eg, preterm delivery, preterm prelabor ROM), pelvic inflammatory disease, and infertility. Nonetheless, despite this potential morbidity, T. Vaginalis remains a non-reportable communicable illness. Why is that? In this episode we will summarize the data and look into the CDC's rationale for that decision.

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women, with a prevalence between 10 to 13%. PCOS has a large component of Insulin Resistance at its core. This is not only a metabolic complication in gynecology, but also has adverse implications for pregnancy. Since metformin is a staple of PCOS care, not only for infertility but also for the metabolic syndrome in adults, a common question is what to do with that medication once conception occurs. Should metformin continue past conception, and if so...should it be stopped at a certain gestational age or continued until delivery. There is data to help with this clinical conundrum. In this episode we will review the data from 2001 up to the most recent ASRM PCOS management guideline for PCOS, which just came out-ahead of print- last month August 2023.

NSAIDs have been shown to be associated with development of VTEs. This data is not new, but is more than 10 years old. Of course, hormonal contraception is also known to potentially increase the risk of VTE depending on the amount of estrogen in the combination product as well as the type of progestin used. So, a reasonable question to ask is whether the use of these two medications TOGETHER synergistically increase the risk of VTE. A recent publication in BMJ (06 Sept 2023) provided some controversial results in this very topic. Could those study results be the result of "indication bias" or protopathic bias? In this episode we will look at the data, summarize the key results, review the study limitations, and provide some real world clinical insights as to what to do with this new info.

Optimal uterine closure remains one of the most studied and controversial aspects of cesarean delivery. Traditionally, a single-layer locking hysterotomy closure has been taught and passes down. Is this evidence based? Is there any advantage to doing a double-layer myometrial closure? We’ll get down to the data in this episode.

A uterine niche is a reservoir-like pouch in the anterior uterine isthmus located at the site of a previous CS scar. First published and describe din 1961, there have been a variety of publications looking at "best practice" at cesarean hysterotomy closure to try to minimize its occurrence. This defect has been linked to abnormal placentation in subsequent pregnancies, CS scar ectopic pregnancies, abnormal uterine bleeding, and dysmenorrhea. While the complete pathogenesis of the niche defect is not completely understood, hysterotomy closure techniques have been implicated in its formation. Should we include the endometrial decidual layer at hysterotomy closure or should we exclude it. Its a debated subject but the data does favor one approach over the other. In this episode, we will examine that data.

SLE can affect people of all ages, including children. However, women of childbearing ages—15 to 44 years—are at greatest risk of developing SLE. Women of all ages are affected far more than men (estimates range from 4 to 12 women for every 1 man). Are you familiar with the 2019 updated diagnostic criteria for SLE? What are some specific concerns regarding this condition in pregnancy? Do patients with anti-SSA/SSB antibodies need serial fetal echocardiograms? And do these patients need early induction of labor? We will cover all this information, and more, in this episode (summary of SMFM, Consult Series # 64; 2023)

Celiac disease is an autoimmune disorder of the small intestine. Celiac disease is the only autoimmune disorder with a single clearly identified environmental trigger...DIET. Although the exact mechanism of the disease development is unknown, celiac disease appears to form after gluten intake from a complex interplay of environmental, immune, and genetic factors. What is Tropical Sprue and how is this different than Tropical Sprue? Does this lead to infertility? How is this linked to a specific dermatologic condition? And what about pregnancy outcomes in Celiac Disease. In this episode, we will cover all this data and more! (For Ana!)

Probiotics may be good for your gut, but does your vagina need them too? Probiotics are in everything from fermented drinks to pills and powders, and in many cases, are being advertised as a way of improving your vaginal health. Is that evidence based? Do oral probiotics help support a healthy vaginal microbiome? What about vaginal probiotics? Can vaginal probiotics augment BV therapy? The answer may surprise you. So…Grab your kombucha and take a seat… We’re going to cover this and much more, in this episode. 😊

We recently provided some additional information regarding the recently approved medication for postpartum depression, Zoranalone. One of the benefits of this medication is it’s rapid mechanism of action. Although not yet approved for major depressive disorder outside of the perinatal interval, there is a separate medication, which was FDA approved last year, which is ultra-fast acting for depression. Oddly enough, one of its main ingredients is a traditional cough suppressant. Have you heard of this medication? In this episode we will review this incredible development AND highlight some cautionary ⚠️ details.

As a true testament that we read each one of our Podcast Facebook messages, this is a “You asked, We answered” episode regarding 3 main recent topics: 1. dose of oral MI for PCOS, 2. Zoranalone for Major Depressive Disorder, and 3. the “shoulder shrug” maneuver for shoulder dystocia. 👍👍👍👍

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder and one of the most frequent causes of infertility in women. It affects 5–20% of women of childbearing age. The pathogenesis of PCOS is still not fully understood; however, insulin resistance (IR) is known to have a central role in its pathogenesis. According to a cross-sectional study, IR is present in 75% of lean and 95% of overweight women with PCOS. This IR seems to have something else behind it: an imbalance in the ratio of 2 vital inositols! In the treatment of PCOS, metformin is the gold standard metabolic treatment. However, metformin may induce mild to severe gastrointestinal side effects such as nausea, diarrhea, and vomiting. So, an evidence-based and data driven alternative is highly welcome…especially one that could be seen as “natural”. Can inositol, specifically myo—inositol, “reverse” some PCOS metabolic derangements? Can it help normalize cycles? The data may surprise you.

In 1990, the ACOG released the “Perinatal Hepatitis B Prevention Program“. OB healthcare workers have doing universal screening for Hepatitis B using HBsAg in each pregnancy, ever since. However, there is a new guidance being released in September 2023 from the ACOG. This new guidance aligns with the national Hep B screening and testing recommendations from the CDC released March 2023. Are you familiar with the “Hep B triple screen”? Is antiviral therapy recommended for Hep B in pregnancy? When should it be used? And is breast-feeding still allowed in mothers with Hep B viral infection? We will cover all of this- and more- in this episode. 🎙️🎙️🎙️

OK, OK…we all get that past history of DVT related to hormonal exposure is a true and persistent contraindication for estrogen birth control. We get that. But what about the incidental presence of lower extremity varicose veins? Are varicose veins a contraindication to estrogen containing birth control? After all, some data has linked superficial varicose veins to the development of DVT. That must mean that estrogen containing BC is contraindicated due to the additional risk of clot formation, right? Is that true? There is some STRANGE information on the internet regarding the association of oral birth control pills and varicose veins. Do combo OCPs cause varicose veins? Do they increase the risk of DVT in those with varicose veins? In this episode we will explore the science, data, and published guidelines related to the prescribing of estrogen containing birth control in patients with varicose veins. PLUS, we will cover which patients- who do by chance develop a superficial venous thrombus in a varicose vein- need anticoagulation.

On August 21, 2023, the FDA approved a new RSV vaccine for maternal use, ideally in the late third trimester. However, there are some nuances and some cautionary notes here! In this episode, we will review the phase 3 data, which fostered the FDA approval and review the nuances to this study. Are we ready for mass incorporation of the maternal RSV vaccine into clinical practice? The answer quite simply is… “No”. We will explain why in this episode.

In 2015, the ACOG released its Committee Opinion on "Endometrial Intraepithelial Hyperplasia", or EIN (CO 631). EIN is of clinical significance because it is often a precursor lesion to adenocarcinoma of the endometrium. Making the distinction between hyperplasia and true precancerous lesions or true neoplasia is super important because their differing cancer risks must be matched with an appropriate intervention to avoid under/overtreatment. As is our podcast tagline, "medicine moves fast"; coming out in September 2023, the ACOG will release a new Clinical Consensus guideline on "EIN-AEH". What are the new changes? Why are we moving from a EIN designation to EIN-AEH? Is a progestin IUS a reasonable therapeutic option for those wishing to preserve fertility after this diagnosis? In his episode, we will answer all these questions and more, focusing on this new Clinical Consensus guideline.

Recently, a horrific and unimaginable birth event made national (USA) news. A case of shoulder dystocia resulted in an extremely morbid and rarely witnessed complication. On August 16, 2023, an extremely important review article was released (ahead of print) in the American Journal of ObGyn. This article summarizes important key aspects and tips for the proper performance of rescue maneuvers for shoulder dystocia, with the aim of keeping both the mother and the baby safe. In this episode, we will review these critical and vital tips for safe resolution of shoulder dystocia. Should the buttocks rotate upwards with McRoberts maneuver? What is the Ruben I procedure? We’ll get to all of this, and more, in this episode.

Access to effective oral emergency contraception is vital, now more than ever. While use of either levonorgestrel or ulipristal is endorsed by the ACOG, pharmacodynamic and clinical data does show that ulipristal has the efficacy advantage. Although the process of ovulation is directed by the LH surge, it is also put into action by prostaglandin resulting from COX2 activity. So, can the addition of a COX2 inhibitor increase the efficacy of Plan B when taken as a combo? A new study published 24 hrs ago in the Lancet provides some exciting data. We will cover this new RCT, and more, in this episode.

Persistent genital arousal disorder (PGAD), now called Genito-Pelvic Dysesthesia, was first described by Leiblum and Nathan in 2001 in a five-patient case series. This is now a well-recognized pelvic floor/genital abnormality with a consensus statement being released in 2019 by the International Society for the Study of Women's Sexual Health. Are you familiar with this condition? It is a source of severe emotional and mental hardship for those affected. In this episode, we will summarize the data on this strange but very REAL condition that is NOT related to sexual desire or sexual arousal.