Dr. Chapa’s Clinical Pearls.

We are definitely a “DIY“ society. And now, consumers can add DIY Insemination to that list! On December 6, 2023 the FDA cleared the first device for at home insemination. This over-the-counter option will be available in 2024. In this episode, we will review this landmark and historic device clearance. We will also clarify the distinction between FDA “approval” and FDA “clearance”. Who is best suited to use this device? Is this considered first-line for unexplained infertility? Lots of interesting questions, but we have the answers. Listen in and find out more.

Amniotic fluid embolism remains one of the most devastating conditions in obstetric practice with an incidence of approximately 1 in 40,000 deliveries. The associated mortality for this condition has been reported to be 20% at the low-end, to 80% at the high-end. The use of atropine (1 mg intravenously [IV]), ondansetron (8 mg IV), and ketorolac (30 mg IV) (AOK) as an adjunctive treatment has been widely discussed by obstetric providers as a treatment option which should be considered to supplement other treatment modalities. In this episode, we will review the pathophysiology of AFE and discuss its first-line treatment regimens, as well as the AOK/AOK – T protocol.

Management of CINI is straightforward, as is management of CIN3. CIN1 allows for observation, and CIN3 requires treatment regardless of the patient’s age as it is a true pre-cancerous lesion. But some “gray zone“ exits for CIN2 management. Population-based data has confirmed a high rate of spontaneous resolution within 2 years after CIN2 diagnosis. Is the rate of cervical cancer higher in this surveillance group compared to immediate LEEP? In this episode, we will highlight 2 separate publications, each originating from the same patient database (Danish population-based cohort). These 2 publications are from the same group of authors with one publication coming from the AJOG (December 2023), and the other one published last month in BMJ (November 2023).

A recent analysis of NHANES data from 2021 found that 40% of US adults aged 18 to 44 are insulin-resistant (IR) based on HOMA-IR measurements. While obesity rates have increased considerably over the past 2 decades, this rapid increase in prevalence was not only associated with increased adiposity. Hypertension, dyslipidemia, and limited physical activity also increased insulin resistance. PCOS and IR are intimately tied, although not all PCOS patients will have clinical or biochemical evidence of IR. And remember this clinical pearl: IR is NOT included in the diagnostic criteria for PCOS. According to published estimates, insulin resistance may be found in 44% to 90% of people with PCOS (the widespread percentage is due to various testing modalities and PCOS phenotypes). Screening for IR is an important aspect of preventative health maintenance in PCOS patients, and all patients deemed high risk. In this episode, we will provide an evidence-based review of the various modalities for IR screening and diagnosis.

On July 30, 2023 we released an episode describing the hypertensive “rule of 55” otherwise known as the physiologic approach to hypertension management. The rule of 55 breaks down hypertension into either hyperdynamic/high cardiac output in origin, or systemic vascular resistance in origin. There is plenty of evidence to support this management approach. Late this evening, on November 30, 2023, Obstetrics and Gynecology released a new research letter ahead of print, providing more insights on the physiologic approach to hypertension management. In this episode, we will briefly cover this brand new publication, released just 2 hours ago, and provide clinical application perspectives.

On July 30, 2023 we released an episode describing the hypertensive “rule of 55” otherwise known as the physiologic approach to hypertension management. The rule of 55 breaks down hypertension into either hyperdynamic/high cardiac output in origin, or systemic vascular resistance in origin. There is plenty of evidence to support this management approach. Late this evening, on November 30, 2023, Obstetrics and Gynecology released a new research letter ahead of print, providing more insights on the physiologic approach to hypertension management. In this episode, we will briefly cover this brand new publication, released just 2 hours ago, and provide clinical application perspectives.

Population based data tells us that 15 to 20% of women will develop an ovarian cyst during their lifetime. Although most ovarian cyst have a low potential for malignancy, their presence causes anxiety for both the patient and the provider. Our typical mental-exercise is balancing the risks of expected management vs choosing surgery prematurely. Which ovarian masses are likely to resolve if given enough time? Do septated ovarian cysts resolve the same as simple cysts? In this episode, we will highlight and summarize a new publication coming out in Obstet Gynecol (Green Journal) in December 2023. We will also review a uniform, standardized approach to reporting and interpreting ovarian masses, originally published in 2020 by the American College of Radiology. This scale is called the O-RADS classification and provides extremely helpful tools for ovarian cyst prognostication and follow up.

The word clitoris comes from the Greek word, “kleitoris” which means “little hill”. In 1559, the clitoris was “discovered” by an anatomist Renaldus Columbus who called it the “love of venus” and concluded that its primary function was strictly for pleasure. It is quite shocking 2 believe, although true, that the first anatomical paper on the clitoris was published only in 1998 and its anatomy, using MRI, fully described in full in 2005. This lack of scientific attention, until recently, to both the anatomical structure and true functioning of the clitoris is equally shameful as it is shocking. It is no wonder that vast misunderstandings of such a vital structure for female sexual well-being persist even today. In this episode, we will review an eye opening, and sad, recent publication released on October 15, 2023 in the Australian and New Zealand Journal of Obstetrics and Gynecology. How well do we truly understand clitoral anatomy? Apparently, not well at all! As Women's Health care providers, we must realize that the results of that study are not only disappointing but that we must also advocate for more information and education pertaining to the mysterious little bean. How is our understanding of the clitoris related to Napolean Bonapart, and to Sigmund Freud? How is the Clitoris-Vaginal Distance related to orgasm? And what is the actual wishbone anatomy of the clitoris? Listen in and find out.

A ruptured uterus is a potentially catastrophic event in which the integrity of the myometrial wall is breached. We all have memorized the usual red flags and contraindications to labor as prior classical cesarean, multiple (more than 2) low transverse cesarean, prior transmural gyn surgery, or grand multiparity. In the absence of previous surgery or multiparity, uterine rupture may go unnoticed, resulting in late diagnosis and considerable mortality and morbidity. Uterine rupture intrapartum has also been reported in primiparous patients, without a history of uterine surgery. Although more likely to go unrecognized and/or underreported, the proposed incidence of rupture in the unscarred uterus has been recently published at less than 0.01% deliveries! Rare right? Well, it’s rare until it happens to you. In contrast, uterine rupture has been reported to occur in 0.2–1% in those with one previous low-transverse scar. Diagnosing this condition in the absence of uterine scar requires a high degree of suspicion and fetal heart tracing abnormalities remain the most common symptom. In this episode, we will look at published data- including a recent review from the Green Journal from April 2023- regarding this terrifying event and review risk factors that may raise the risk of uterine rupture in a patient without the classic historical red flags. And, we will review how 2 GYN diagnoses influence the risk of uterine rupture in labor. Plus, we will review what the published data says regarding characteristic uterine and fetal heart rate patterns in those found to have uterine rupture.

On Tuesday, November 21, we released an episode titled “Optimizing Postpartum HTN Care”. On Wednesday, November 22, I received notification that a new clinical opinion piece will be released in AJOG in December 2023 which also discusses whether or not mag sulfate, should be used in the late postpartum interval in these patients. Amazing timing! Our podcast, and this soon-to-be released clinical opinion, match 100% in the data and recommendations! 🎉🎉🎉 So in this episode, we will highlight the main take-home points from that soon-to-be released clinical opinion regarding whether or not magnesium sulfate should be used in the late postpartum interval for hypertension. This is a perfect and timely supplement to our immediate past podcast. 👏👏👏

Data has shown that more than half of maternal deaths occur past the traditional 6 week postpartum mark. This is why the ACOG recognized the “fourth trimester” in 2018 (ACOG CO 736), reflecting the fact that the patient is still at risk beyond the first 6 weeks after delivery. One of the main areas of focus postpartum is on hypertension care. Growing understanding of the long-term implications of HDP and other medical complications of pregnancy have led to an increasing focus on building transitions from postpartum care to primary care, which will be essential for the long-term wellbeing of women with postpartum hypertension. How many women will develop new onset hypertension more than 6 weeks from delivery? At what blood pressure cut off should anti-hypertensive medication be considered postpartum? Should it be at 150/100 or 140/90? Which medication is preferred for postpartum use? Is magnesium sulfate for severe range blood pressures effective as seizure prevention beyond 7 days postpartum? We will tackle these questions, and more, in this episode.

ACOG’s last practice bulletin on asthma in pregnancy (ACOG PB 90) was back in February 2008. Yep, 2008. Sooo… No advances since then? There’s been big shifts in the management of asthma, of course. That’s why we’re doing this podcast- things move so fast, and it’s often hard for guidelines to keep pace at times. That’s why we’re here. And that’s why it’s important to always stay ahead of the data. are you aware of the new recommendations from the GINA? It has changed the way we view Short Acting B Agonist therapy (SABA) as solo medication. And what about antepartum fetal surveillance? Is that indicated in moderate to severe asthma? Maternal asthma is not listed on the “indications for outpatient fetal surveillance“ from the ACOG‘s 2021 Committee Opinion. Should it be there? Can biologics be used? We’ve got lots to cover in this episode. So take a deep breath in and out… and listen in.

It’s a universal nomenclature… The TPAL system. Despite its traditional and long-standing integration into obstetrical vernacular, there are significant gaps in this system. And, although we use these terms daily, there is controversy about what one of those elements actually means. What is the “L“ actually for? We’ve all learned it as “living children”. But what does that actually mean? Is that live births? Is it number of living children at time of the report? Or does it mean something entirely different? In this episode, Dr. Katie Light joins me as we have a fun time looking into the data. Hang out with us until the end of the episode, because I will give us some practical insights for using the TPAL nomenclature.

This episode is our NEWS BRIEF. Yesterday, on November 15, 2023, the FDA approved the first, patient self-collected, home test kits for GC and Chlamydia. This is a BIG advancement for women's health. But, this is actually not the first at home STI test to be approved. In this episode, we will review this new FDA approved test, the specifics of the product, and why this is not just a "direct to consumer" purchase item.

Recently, we released an episode regarding the limited utility of by BMEs; now, I mean, limited utility as a routine, annual exercise in the low-risk asymptomatic, and non-pregnant patient. And there’s plenty of evidence that has shown that just doing a bimanual exam because “that’s what we’ve always done” -without a real indication- is just not helpful. All to say, we received numerous comments regarding that episode with 99% saying, “this is great”, “thank you for sticking with the evidence”, and “yes, we stopped doing bimanual exams without indication, when the ACOG first put that out several years back”. But of course there’s always that 1% who state something like, “I can’t believe you’re not recommending this exam, this is how we find ovarian cancer, etc”. This is very interesting because the whole episode was how it exactly did NOT help in the early detection of ovarian cancer, but simply increased the ordering of tests and patient anxiety! (Which makes me think, maybe they didn’t even listen to the episode). One of the comments that came in was worth noting. This provider said, “Isn’t the same debate applicable to clinical breast examinations (CBEs)?” What’s the data on that? And how do various medical groups and professional societies agree or disagree with CBEs? Well, that’s exactly why we’re doing this episode! In this episode, we’re going to cover the various guidelines and opinions regarding the utility of clinical breast examinations. Plus, you’ll want to hang out with us until the end of the episode, when we will provide some real, practical applications for daily practice. Yep, let’s “feel the data out” (see what I did there?). 🧐🙂🙂

Trichomoniasis is the most prevalent nonviral sexually transmitted infection (STI) in the United States and is more prevalent than chlamydia and gonorrhea combined. In the US, the southern states share a disproportionate burden of infection, with rates up to 14%. Infection with Trichomonas vaginalis increases risk of human immunodeficiency virus (HIV) acquisition and is associated with adverse perinatal outcomes, including preterm birth, low birth weight, and preterm premature rupture of membranes. Although 80% of infections are asymptomatic, there are no national recommendations for trichomoniasis screening in women who are HIV-negative (including pregnant women who are HIV-negative), except for incarcerated women, where screening is recommended. Plus, there is also perpetual controversy surrounding whether asymptomatic trich should be treated in pregnancy or not. Why is that? Shouldn’t we always treat STIs in pregnancy? The data is a bit confusing for asymptomatic trichomoniasis. We’ll review the data in this episode and we will end with some practical advice for treatment of trich in pregnancy.

The pelvic examination is a standard component of the annual gynecologic visit despite limited evidence supporting its utility. Pelvic examinations can be a source of discomfort and anxiety for some patients seeking routine health care, whereas, for others, they can offer reassurance. In 2018, the ACOG released CO 754 on "The Utility of and Indications for Routine Pelvic Examination". What does the AAFP, ACP, and ACOG say about "routine" pelvic examinations in low-risk, nonpregnant, and asymptomatic women? Why do they say what they do? In this episode, we will summarize a new publication from Obstetrics & Gynecology which was just released yesterday (November 9, 2023) which validates these professional societies' guidelines/stances.

What do think about when I mention to you, Placenta Accreta Spectrum (PAS)? You would probably think placenta previa and prior C-section, right? You should! Those are the two most well-known risk factors. But placenta accrete can happen without either of those 2 factors, although less commonly. I was recently asked to provide insights on a real case of suspected PAS in a primiparous patient who was suspected of having placenta accrete at attempted placenta extraction at time of her primary C-Section performed for failure to progress. Her placenta was fundal. Can a fundal placenta be an accreta? What is the frequency of that? And what is the expected patient morbidity? We’ll examine the data and highlight a recently published case report from September 2023 describing a similar presentation.

I received a very personal and impactful Facebook message today from one of our podcast family members. It was enough to stop me in my tracks, and issue this heartfelt response. For F. L.

The Centers for Disease Control and Prevention, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the World Health Organization all recommend universal topical ocular prophylaxis to prevent gonococcal ophthalmia neonatorum. In the United States, ophthalmia neonatorum caused by N. gonorrhoeae has an incidence of 0.3 per 1000 live births, while Chlamydia trachomatis represents 8.2 of 1000 cases. However, this prophylaxis is not a uniform GLOBAL stance. The Canadian Pediatric Society recommends against universal prophylaxis. Several European countries, including Denmark, Norway, Sweden, and the United Kingdom, no longer require universal prophylaxis, instead opting for a prevention strategy of increased screening and treatment of pregnant women and/or selective use in those delivered without pregnancy screening. But WAIT… it gets even slightly more confusing. According to a 2022 publication from the FROM THE AMERICAN ACADEMY OF PEDIATRICS, the AAP has taken the position that the need for legal mandates for ocular prophylaxis should be reexamined and instead advocates for states to adopt strategies to prevent ophthalmia neonatorum by focusing on maternal treatment, such as compliance with CDC recommendations for prenatal screening and treatment of N gonorrheae and Chlamydia trachomatis. This was also the subject of a recent review published May 2023 in an article titled, “Neonatal ocular prophylaxis in the United States: is it still necessary?”. Confused...don't be. We’ll cover all this information in this episode. So, can erythromycin ophthalmic application be avoided in some cases? Is that safe? And if so, doesn’t that conflict with current US neonatal care expectations? Listen in and find out.