A brief THANK YOU prior to 2025 end.

In 2002, the National Institute of Child Health and Human Development (NICHD) proposed the 3-Tier fetal heart rate (FHR) classification system that was subsequently adopted by many organizations, categorizing tracings into three groups: Category I (normal), Category II (indeterminate), and Category III (abnormal). Recently, our podcast team received an interesting question form one of our podcast family members: “If there is a change in the fetal heart rate tracing intrapartum, but it is still in the normal range (like 120 going to 150)- and variability is normal, is that an abnormality? And what is meant by a ‘ZigZag’ FHT pattern (different than marked variability)?”. That is a fantastically complex question…and we will explain the answer in this episode.1. Zullo F, Di Mascio D, Raghuraman N, Wagner S, Brunelli R, Giancotti A, Mendez-Figueroa H, Cahill AG, Gupta M, Berghella V, Blackwell SC, Chauhan SP. Three-tiered fetal heart rate interpretation system and adverse neonatal and maternal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2023 Oct;229(4):377-387. doi: 10.1016/j.ajog.2023.04.008. Epub 2023 Apr 11. PMID: 37044237.2. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome.Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.3. The 3 Tier System: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ncc-efm.org/filz/NICHD_Reference_from_CCPR.pdf4. Jia YJ, Ghi T, Pereira S, Gracia Perez-Bonfils A, Chandraharan E. Pathophysiological Interpretation of Fetal Heart Rate Tracings in Clinical Practice. American Journal of Obstetrics and Gynecology. 2023;228(6):622-644. doi:10.1016/j.ajog.2022.05.0235. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome. Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.6. Yang M, Stout MJ, López JD, Colvin R, Macones GA, Cahill AG. Association of Fetal Heart Rate Baseline Change and Neonatal Outcomes. Am J Perinatol. 2017 Jul;34(9):879-886. doi: 10.1055/s-0037-1600911. Epub 2017 Mar 16. PMID: 28301895.

Podcast Family, in our immediate past episode we tackled the discrepancy that is often found between a clinical diagnosis of intra-amniotic infection/chorioamnionitis and histological chorioamnionitis. From that episode, we received a fantastic question from one of our podcast family members: Can a patient have IAI without fever? That question is really deep and highlights a gap in the current diagnostic scheme/ criteria from the ACOG. Listen in for details!1. ACOG CO 7122. Sukumaran S, Pereira V, Mallur S, Chandraharan E. Cardiotocograph (CTG) Changes and Maternal and Neonatal Outcomes in Chorioamnionitis and/­or Funisitis Confirmed on Histopathology. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2021. C3. Romero R, Chaemsaithong P, Korzeniewski SJ, et al. Clinical Chorioamnionitis at Term III: How Well Do Clinical Criteria Perform in the Identification of Proven Intra-Amniotic Infection? Journal of Perinatal Medicine. 2015.

Welcome to "Labor & Delivery Debrief," the podcast where we tackle your toughest questions about childbirth and maternal health. Today, we're diving deep into a fascinating and critical topic sent in by one of our listeners, Sarah. Sarah asks: "Is it possible for a clinical diagnosis of chorioamnionitis to not be confirmed by placental histology? And if so, how is that possible?" This is a fantastic question that touches on the complexities of intrapartum clinical diagnosis of intraamniotic infection (IAI), also commonly known as chorioamnionitis. We'll explore the nuances of clinical versus histological findings, the diagnostic criteria, and why these two assessments don't always perfectly align. Get ready for a detailed discussion that will shed light on this important aspect of obstetric care.1. ACOG CO 712; 2017 (2025)2. Romero R, Pacora P, Kusanovic JP, et al. Clinical Chorioamnionitis at Term X: Microbiology, Clinical Signs, Placental Pathology, and Neonatal Bacteremia - Implications for Clinical Care. Journal of Perinatal Medicine. 2021;49(3):275-298. doi:10.1515/jpm-2020-0297.3. Jung E, Romero R, Suksai M, et al. Clinical Chorioamnionitis at Term: Definition, Pathogenesis, Microbiology, Diagnosis, and Treatment. AJOG. 2024;230(3S):S807-S840. doi:10.1016/j.ajog.2023.02.002.4. Oh KJ, Kim SM, Hong JS, et al. Twenty-Four Percent of Patients With Clinical Chorioamnionitis in Preterm Gestations Have No Evidence Of either Culture-Proven Intraamniotic Infection Or intraamniotic Inflammation. AJOG. 2017;216(6):604.e1-604.e11.

Depo-Provera was approved in 1992 by U.S. regulators. About 1 in 4 sexually active women in the United States have used the shot at some point, according to the U.S. Centers for Disease Control and Prevention (CDC). Meningiomas are common intracranial tumors with a female predominance. In fact, they are the most common primary brain tumor in women, with an incidence of approximately 12.76 per 100,000 in the general female population. The vast majority of these tumors are benign (World Health Organization [WHO] grade 1) while 15% to 20% of these tumors can behave atypically (WHO grade 2) and rarely, in 1% to 2% of cases, these tumors can be malignant (WHO grade 3). We covered the relationship between Depo-Provera, as a contraceptive agent, and brain meningiomas back in March 2024. With the increase in data, the ACOG released a patient centered counseling tool titled, “Counseling Patients on Birth Control Injection and Meningioma”. The most recent update on this story comes from the FDA, which has granted a medication label change to Depo-Provera (Pfizer) warning of this association. Even though association does not prove causation, the association between depo and meningiomas seems strong (with new data from the US). Does this warning extend to other progestins? Listen in for details. 1. https://podcasts.apple.com/us/podcast/dr-chapas-obgyn-clinical-pearls/id1412385746?i=10006508795722. ACOG’s “Counseling Patients on Birth Control Injection and Meningioma” 3. https://www.statnews.com/pharmalot/2025/12/17/fda-pfizer-contraception-cancer-preemption-depoprovera/4. Xiao T, Kumar P, Lobbous M, et al. Depot Medroxyprogesterone Acetate and Risk of Meningioma in the US. JAMA Neurology. 2025;82(11):1094-1102. doi:10.1001/jamaneurol.2025.3011.5. de Dios E, Näslund O, Choudhry M, et al.Prevalence and Symptoms of Incidental Meningiomas: A Population-Based Study.Acta Neurochirurgica. 2025;167(1):98. doi:10.1007/s00701-025-06506-7.6. Schaff LR, Mellinghoff IK.Glioblastoma and Other Primary Brain Malignancies in Adults: A Review. JAMA. 2023;329(7):574-587. doi:10.1001/jama.2023.0023.7. BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-078078 (Published 27 March 2024) Cite this as: BMJ 2024;384:e078078

The second stage of labor, characterized by active pushing and the descent of the fetal head, can be a challenging and prolonged phase for both mother and baby. Various interventions have been explored to optimize this stage, and one such technique involves the application of vaginal lubricants. The rationale behind this approach is to reduce friction between the fetal head and the birth canal, potentially leading to smoother and faster delivery. Does this seemingly simple technique work? Does the ACOG mention this in the CPG 8 from January 2024? What does the latest research tell us about its effectiveness in assisting or speeding up the birthing process? Listen in for details.1. Yang Q, Cao X, Hu S, Sun M, Lai H, Hou L, Wang Q, Wu C, Wu Y, Xiao L, Luo X, Tian J, Ge L, Shi L. Lubricant for reducing perineal trauma: A systematic review and meta-analysis of randomized controlled trials. J Obstet Gynaecol Res. 2022 Nov;48(11):2807-2820. doi: 10.1111/jog.15399. Epub 2022 Aug 16. PMID: 36319196.2. ACOG: First and Second Stage Labor Management Clinical Practice Guideline Number 8: January 20243. Aquino CI, Saccone G, Troisi J, Zullo F, Guida M, Berghella V. Use of lubricant gel to shorten the second stage of labor during vaginal delivery. J Matern Fetal Neonatal Med. 2019 Dec;32(24):4166-4173. doi: 10.1080/14767058.2018.1482271. Epub 2018 Jun 27. PMID: 29804505.4. Beckmann MM, Stock OM. Antenatal Perineal Massage for Reducing Perineal Trauma. The Cochrane Database of Systematic Reviews. 2013;(4):CD005123. doi:10.1002/14651858.CD005123.pub3.

Within the last few days, there has been breaking news regarding the war on gonorrhea. Nuzolvence (zoliflodacin) was FDA approved on December 13, 2025, and Blujepa (gepotidacin) was FDA approved on December 11, 2025.These new oral treatments are particularly important given the global rise in gonococcal drug resistance and the convenience they offer over injectable options, potentially improving patient adherence and public health outcomes. Listen in for details. ​ FDA News Release. FDA Approves Two Oral Therapies to Treat Gonorrhea. fda.gov​ Innoviva Specialty Therapeutics. U.S. FDA Approves NUZOLVENCE® (zoliflodacin), a First-in-Class, Single-Dose Oral Antibiotic, for the Treatment of Uncomplicated Urogenital Gonorrhea in Adults and Adolescents. innovivaspecialtytherapeutics.com​ CNN. New gonorrhea treatments approved by FDA for first time in decades. ​ The New York Times. F.D.A. Approves Two New Drugs to Treat Gonorrhea. ​ STAT. FDA approves zoliflodacin, a gonorrhea pill marketed as Nuzolvence. ​ Fierce Pharma. FDA endorses another gonorrhea treatment, blessing Innoviva’s Nuzolvence. https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

It’s so interesting to see how medical evidence evolves, and changes, over time. The result of course is that clinical practice evolves and changes as well. The story of umbilical cord management at time of delivery highlights this very issue very well. The ACOG first recommended delayed cord clamping (DCC) in 2012, for preterm infants, as data showed marked improvement in neonatal outcomes in that population. In this episode, we will briefly walk through the timeline from 2012 to the latest update on DCC which came from the AAP in October 2025, just one month after the ACOG had their DCC update. This story also exemplifies how professional medical societies don’t always have the SAME recommendations, with small tweaks, in their guidance. So, Dr Chapa and I will summarize these key updates…Listen in for details!1. ACOG 2012: DCC for preterm infants only 2. ACOG 2016: ACOG Recommends Delayed Umbilical Cord Clamping for All Healthy Infants, including term: https://mdedge.com/obgynnews/article/121349/obstetrics/acog-supports-delayed-umbilical-cord-clamping-term-infants3. ACOG Dec 2020, CO 814: Delayed Umbilical Cord Clamping After Birth4. ACOG Obstet Gynecol. January 2022; 139(1): 121–137. doi:10.1097/AOG.0000000000004625. Management of Placental Transfusion to Neonates After Delivery5. ACOG (ePUB July ) Sept 2025: ACOG releases a Clinical Practice Update: An Update to Clinical Guidance for Delayed Umbilical Cord Clamping After Birth in Preterm Neonates6. AHA/AAP Oct 2025 Update: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Podcast Family, we have covered PCOS on this show many times in the past; and yet- again, there is new information! A new publication from AJOG (Gray journal) describes a new meta-analysis on preconception/continued metformin use in the first trimester. Is this helpful? How does this contrast with the 2023 international guidance update on PCOS? Listen in for details. 1. ASRM: Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (2023)2. Cheshire J, Garg A, Smith P, Devall AJ, Coomarasamy A, Dhillon-Smith RK. Preconception and first-trimester metformin on pregnancy outcomes in women with polycystic ovary syndrome: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025 Dec;233(6):530-547.e8. doi: 10.1016/j.ajog.2025.05.038. Epub 2025 Jun 3. PMID: 40473092.3. Løvvik TS, Carlsen SM, Salvesen Ø, et al. Use of Metformin to Treat Pregnant Women With Polycystic Ovary Syndrome (PregMet2): A Randomised, Double-Blind, Placebo-Controlled Trial. The Lancet. Diabetes & Endocrinology. 2019;7(4):256-266. doi:10.1016/S2213-8587(19)30002-6.4. Teede HJ, Tay CT, Laven J, et al. Recommendations From the 2023 International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Fertility and Sterility. 2023;120(4):767-793. doi:10.1016/j.fertnstert.2023.07.025.

Major health organizations, including the CDC and ACOG, recommend universal Hepatitis C Virus (HCV) screening for all pregnant women during each pregnancy and at time of delivery. Ideally, pregnant women should be screened for hepatitis C virus infection at the first prenatal visit of each pregnancy. If the antibody screen result is positive, hepatitis C virus RNA polymerase chain reaction testing is done to confirm the diagnosis. The risk of perinatal transmission of HCV is up to 9%, with at least one-third of transmissions occurring antenatally. While antiviral therapy is recommended for Hepatitis B in pregnancy with a viral load greater than 200,000 international units/mL to decrease the risk of vertical transmission, the same is not the case for Hep C. According to the ACOG CPG #6 from September 2023, there are no standard treatment protocols for Hep C in pregnancy but a new publication from the PINK journal (7 Dec 2025) is calling for a change. That new publication is, “Hepatitis C Treatment During Pregnancy: Time for a Practice Change”. Listen in for details. 1. ACOG CPG #6; Sept 20262. Bhattacharya D, Aronsohn A, Price J, Lo Re V. Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2023;:ciad319. doi:10.1093/cid/ciad319.3. Chappell CA, Kiser JJ, Brooks KM, et al. Sofosbuvir/¬Velpatasvir Pharmacokinetics, Safety, and Efficacy in Pregnant People With Hepatitis C Virus. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2025;80(4):744-751. doi:10.1093/cid/ciae595.4. Reau N, Munoz SJ, Schiano T. Liver Disease During Pregnancy. The American Journal of Gastroenterology. 2022;117(10S):44-52. doi:10.14309/ajg.0000000000001960.5. Dutra, Karley et al. Hepatitis C Treatment During Pregnancy: Time for a Practice Change. American Journal of Obstetrics & Gynecology MFM, Volume 0, Issue 0, 1018656. Society for Maternal-Fetal Medicine Consult Series #56: Hepatitis C in Pregnancy-Updated Guidelines: Replaces Consult Number 43, November 2017. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Dotters-Katz SK, Kuller JA, Hughes BL. American Journal of Obstetrics and Gynecology. 2021;225(3):B8-B18. doi:10.1016/j.ajog.2021.06.008

Welcome to the no spin podcast. In today's episode, we're tackling a subject that's gaining traction but carries significant risks: the freebirth and wildbirth movement. We'll explore the rising trends of unassisted childbirth, where individuals choose to forgo professional medical care during labor and delivery- or during the prenatal period altogether, and the potential devastating outcomes associated with these practices. Join us as we unpack the motivations behind these choices, the lack of evidence supporting their safety, and the serious harms that can arise for both parent and baby. We'll be examining medical guidelines, and real-world consequences to provide a comprehensive and nuanced understanding of this complex issue. It’s a balance between patient autonomy, advocacy, and potentially allowing an atrocity. Listen in for details. 1. Apr 20, 2020 ACOG Statement on Birth Settings: https://www.acog.org/news/news-releases/2020/04/acog-statement-on-birth-settings2. Planned Home Birth ACOG CO 6973. https://www.theguardian.com/world/ng-interactive/2025/nov/22/free-birth-society-linked-to-babies-deaths-investigation4. https://birthguidechicago.com/wp-content/uploads/2018/07/home_births_rcog_rcm0607.pdf

In 2024, the ASCCP updated their guidance to include DualStain technology as part of primary HPV cervical cancer screening. Now, on December 4, 2025, the ACS has updated their guidance regarding patient self-collectionof vaginal specimens for primary HPV screening. This is fascinating and proves medicine moves fast! Should a negative self-collection test result have a repeatscreen in 1, 3 or 5 years, or later? Listen in for details.1.     Self-collected vaginal specimens for humanpapillomavirus testing and guidance on screening exit: An update to theAmerican Cancer Society cervical cancer screening guideline2.     https://open.spotify.com/episode/5x4J3TQJPdkHtV9RLTUi5oSTRONG COFFEE PROMO:https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In the original Løvset maneuver (described for breech presentations), the fetus is rotated in one direction to facilitate arm delivery. For shoulder dystocia, the reverse Løvset applies rotation in the opposite direction—specifically rotating the posterior shoulder toward a "belly down" position through up to 180 degrees of rotation. These maneuvers were first described by Norwegian obstetrician Jørgen Løvset in the 1940s. Now, in the current November 2025 AJOG, this maneuver is back in the spotlight. In this episode, we will review the reverse Løvset maneuver for shoulder dystocia and review its effectiveness. Which maneuver is more likely to result in fetal brachial plexus injury? Listen in for details. 1. A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia, March 2024; AJOG. https://www.ajog.org/article/S0002-9378(23)00022-4/fulltext2. Grindheim, Sindre et al.Reverse Løvset maneuver for shoulder dystocia, American Journal of Obstetrics & Gynecology, Volume 233, Issue 5, 505.e1 - 505.e43. Leung TY, Stuart O, Suen SS, Sahota DS, Lau TK, Lao TT. Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres: a retrospective review. BJOG. 2011 Jul;118(8):985-90. doi: 10.1111/j.1471-0528.2011.02968.x. Epub 2011 Apr 12. PMID: 21481159.4. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205(6):513−517.STRONG COFFEE PROMO CODE:https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Misoprostol, as an E1 prostaglandin, is primarily used in obstetrics for cervical ripening (when the Bishop Score is under 6) and/or for labor INDUCTION (to begin labor). IV oxytocin is the principal agent used to augmentlabor, as needed, once labor has begun. In the US, misoprostol is not typically used after 4-6 cm cervical dilation. However, in a patient who requires augmentation,and who declines Pitocin while asking or oral misoprostol, can that be used? Is that evidence-based? The data may surprise you. Listen in for details. 1.     SOGC Guideline No. 432c: Induction of Labour Robinson,Debbie Campbell, Kim Hobson, Sebastian R. MacDonald, W. Kim Sawchuck, DianeWagner, Brenda et al. Journal of Obstetrics and Gynaecology Canada , Volume 45, Issue 1, 70 - 77.e32.     Bracken H, Lightly K, Mundle S, et al. OralMisoprostol Alone Versus Oral Misoprostol Followed by Oxytocin for Labour Induction in Women With Hypertension in Pregnancy (MOLI): Protocol for a Randomised Controlled Trial. BMC Pregnancy and Childbirth. 2021;21(1):537.doi:10.1186/s12884-021-04009-8.3.     Bleich AT, Villano KS, Lo JY, et al. OralMisoprostol for Labor Augmentation: A Randomized Controlled Trial. Obstetrics and Gynecology. 2011;118(6):1255-1260. doi:10.1097/AOG.0b013e318236df5b.4.     Ho M, Cheng SY, Li TC. Titrated Oral MisoprostolSolution Compared With Intravenous Oxytocin for Labor Augmentation: A Randomized Controlled Trial. Obstetrics and Gynecology. 2010;116(3):612-618. doi:10.1097/AOG.0b013e3181ed36cc. STRONG COFFEE PROMO CODE:https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Actinomyces species are considered part of the normal vaginal and urogenital tract flora. The percentage of Pap smears containing Actinomyces-like organisms varies but is most commonly reported as approximately 7% among women using IUDs. That number is supported by multiple sources, including the Infectious Diseases Society of America guideline and several clinical studies. The incidence can be higher or lower depending on the type of IUD; for example, copper IUDs have been associated with rates up to 20%, while levonorgestrel-releasing IUDs show lower rates around 2.9%. In women with an IUD, who are found to have this finding on their liquid-based Pap smear, what is the appropriate management? In this episode, which comes from one of our podcast family members, we will discuss this topic and it’s management in both symptomatic and symptomatic (pelvic pain) IUD wearing women. 1. McHugh KE, Sturgis CD, Procop GW, Rhoads DD. The Cytopathology of Actinomyces, Nocardia, and Their Mimickers. Diagnostic Cytopathology. 2017;45(12):1105-1115. doi:10.1002/dc.23816.2. Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstetrics and Gynecology. 2017;130(5):e251-e269. doi:10.1097/AOG.0000000000002400.3. Miller JM, Binnicker MJ, Campbell S, et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2024; ciae104. doi:10.1093/cid/ciae104.5. Carrara J, Hervy B, Dabi Y, et al. Added-Value of Endometrial Biopsy in the Diagnostic and Therapeutic Strategy for Pelvic Actinomycosis. Journal of Clinical Medicine. 2020;9(3):E821. doi:10.3390/jcm9030821.

Recurrent pregnancy loss (RPL) affects approximately 5% of couples and is an emotional burden on those affected. There is some evidence that vaginal progesterone supplementation may be considered in patients with recurrent pregnancy loss who are experiencing vaginal bleeding during the first trimester. But what about prophylactic low dose aspirin in the first trimester, or preconceptionally, for unexplained RPL? Is that evidence-based? A new publication from the SMFM’s journal Pregnancy has examined this. Listen in for details. 1. 22 November 2025: Low-dose aspirin in unexplained recurrent pregnancy loss: A systematic review and meta-analysis (Pregnancy): https://obgyn.onlinelibrary.wiley.com/doi/10.1002/pmf2.700992. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, T. Flint Porter, Cynthia Gyanff-Bannerman, Tracy Manuck. Low-Dose Aspirin Use During Pregnancy. American College of Obstetricians and Gynecologists (2018)3. Naimi AI, Perkins NJ, Sjaarda LA, et al. The Effect of Preconception-Initiated Low-Dose Aspirin on Human Chorionic Gonadotropin-Detected Pregnancy, Pregnancy Loss, and Live Birth : Per Protocol Analysis of a Randomized Trial. Annals of Internal Medicine. 2021;174(5):595-601. doi:10.7326/M20-0469.4. Lee EE, Jun JK, Lee EB.Management of Women With Antiphospholipid Antibodies or Antiphospholipid Syndrome During Pregnancy. Journal of Korean Medical Science. 2021;36(4):e24. doi:10.3346/jkms.2021.36.e24.5. de Assis V, Giugni CS, Ros ST. Evaluation of Recurrent Pregnancy Loss. Obstet Gynecol. 2024 May 1;143(5):645-659. doi: 10.1097/AOG.0000000000005498. Epub 2024 Jan 4. PMID: 38176012.

Having data is sometimes different than having clinically applicable data. This is exactly the issue with the proposed plan to reduce surgical site infection (SSI) by changing surgical gloves after placental delivery at C-Section. Just 24 hours ago, we received the question from a PGY4 OBGYN resident asking whether the practice of changing surgical gloves at C-Section after placental delivery to reduce SSI was evidence-based. So, in this episode, we will review the data - which is timely since this was recently published on November 13, 2025 in the J Hospital Infection. This study follows a statement on this practice released by FIGO in September 2025. It’s an interesting proposal, and there is clearly data in support of this, yet the ACOG and CDC do not recommend this practice as of Nov 2025. Is there a disconnect? Listen in for details. 1. FIGO: https://www.figo.org/news/new-ijgo-review-provides-comprehensive-framework-preventing-post-caesarean-sepsis (International Journal of Gynecology & Obstetrics)2. Stanberry B, Jordan L, Pullyblank A, Hargreaves J. Glove change during caesarean birth: impact on maternity service budgets and capacity. J Hosp Infect. 2025 Nov 13:S0195-6701(25)00354-8. doi: 10.1016/j.jhin.2025.10.033. Epub ahead of print. PMID: 41241232.3. Narice BF, Almeida JR, Farrell T, Madhuvrata P. Impact of Changing Gloves During Cesarean Section on Postoperative Infective Complications: A Systematic Review and Meta-Analysis. Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(9):1581-1594. doi:10.1111/aogs.14161.4. Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection (ChEETAh): A Pragmatic, Cluster-Randomised Trial in Seven Low-Income and Middle-Income Countries.NIHR Global Research Health Unit on Global Surgery. Lancet (London, England). 2022;400(10365):1767-1776. doi:10.1016/S0140-6736(22)01884-0.5. Gialdini C, Chamillard M, Diaz V, Pasquale J, Thangaratinam S, Abalos E, Torloni MR, Betran AP. Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. EClinicalMedicine. 2024 May 19;72:102632. doi: 10.1016/j.eclinm.2024.102632. PMID: 38812964; PMCID: PMC11134562.

Muscular dystrophy (MD) is a group of genetic diseases that affect about 16 to 25 per 100,000 people in the US, with the most common childhood form being Duchenne muscular dystrophy (DMD) and the most common adult form being myotonic dystrophy. The prevalence of DMD is estimated at around 1 in 3,500 live male births. Prenatal carrier screening for this is part of the ACMG Tier 3 expanded carrier panel. This is different from spinal muscular atrophy (SMA). As we recently had a patient who was a MD carrier, with affected male children, who we cared for, we decided to do a quick review of muscular dystrophy: its prevalence, genetics, and evaluation of asymptomatic maternal carriers.1. https://www.mda.org/disease/duchenne-muscular-dystrophy/causes-inheritance2.https://www.nichd.nih.gov/health/topics/musculardys/conditioninfo/causes3. https://www.nhs.uk/conditions/muscular-dystrophy/4. ACMG: https://thednaexchange.com/2022/03/30/acmg-carrier-screening-guideline-the-hypothetical-tier-3-panel/#:~:text=The%20goal%20of%20this%20ACMG,1%20in%2040%2C000%20or%20higher.

Regional anesthesia, typically with a spinal or epidural, haslong been favored for cesarean births due in part to concerns about the effects that general anesthesia (GA) may have on newborns at delivery. However, data has shown that up to 1 in 6 women may experience pain with a “topped-off”labor epidural, during the cesarean. A new publication in the journal Anesthesia is now being interpreted as implying that general anesthesia may be a valid alternative electively. Is that what this new study found? Has GA been linked to postpartum depression? What about later child neurodevelopmental delays? This is a fascinating topic…Listen in for details. 1.     Langer, Sarah M.D.1; Lim, Grace M.D., M.Sc.2;Qiu, Yue M.D.3; Biaesch, Jingyuan D.O.4; Neuman, Mark D. M.D., M.Sc.5. NeonatalOutcomes with Regional versus General Anesthesia for Cesarean Delivery: AMeta-analysis of Randomized Controlled Trials. Anesthesiology():10.1097/ALN.0000000000005785, November 12, 2025. | DOI:10.1097/ALN.00000000000057852.     Guglielminotti J, Monk C, Russell MT, Li G.Association of General Anesthesia for Cesarean Delivery with PostpartumDepression and Suicidality. Anesth Analg. 2025 Sep 1;141(3):618-628. doi:10.1213/ANE.0000000000007314. Epub 2024 Dec 4. PMID: 39630595; PMCID:PMC12134152.3.     Chen, YC., Liang, FW., Tan, PH. et al.Association between general anesthesia for cesarean delivery and subsequentdevelopmental disorders in children: a nationwide retrospective cohort study.BMC Med 23, 119 (2025). https://doi.org/10.1186/s12916-025-03886-64.     https://www.pennmedicine.org/news/new-study-challenges-fears-about-general-anesthesia-during-c-section

The US has no shortage of lidocaine patch television commercials. Topical lidocaine has a role for local, topical, minor aches and pains. What about lidocaine patches for post-op cesarean section pain? Is there data for that? A brand-new meta-analysis in AJOG-MFM (Nov 13, 2025) looks at this option. However, there has been 3 prior reviews on the same topic from 2019, 2022, and 2023. Do they all arrive at the same result? Listen in for details!1.     Smoker J, Cohen A, Rasouli MR, Schwenk ES. TransdermalLidocaine for Perioperative Pain: A Systematic Review of the Literature. Current Pain and Headache Reports.2019;23(12):89. doi:10.1007/s11916-019-0830-9.2.     Koo CH, Kim J, Na HS, Ryu JH, Shin HJ. TheEffect of Lidocaine Patch for Postoperative Pain: A Meta-Analysis of Randomized Controlled Trials. Journal of Clinical Anesthesia. 2022;81:110918.doi:10.1016/j.jclinane.2022.110918.3.     Wu X, Wei X, Jiang L, et al. Is Lidocaine PatchBeneficial for Postoperative Pain?: A Meta-Analysis of Randomized Clinical Trials. The Clinical Journal of Pain. 2023;39(9):484-490. doi:10.1097/AJP.00000000000011354.     Parisi, Nadia et al.Lidocaine patches aftercesarean delivery: a meta-analysis of randomized controlled trials. American Journal of Obstetrics & Gynecology MFM, Volume 0, Issue 0, 101832

Podcast Family, we have covered the subject of Measles previously on this show (links below). Those episodes were a preview of what has now been released ahead of print as a narrative review in the Green Journal! In this episode, we will summarize the KEY points of measles infection in pregnancy and re-state the “rule of 4” and the importance of the number 10 regarding this.1. Feb 24, 2025: Measles 101: https://open.spotify.com/episode/4lXrpqKTJPdDcTXPxpEmcb2. April 27, 2019: Measles!! ACOG Practice Advisory: https://creators.spotify.com/pod/profile/dr-hector-chapa/episodes/MEASLES---ACOG-practice-advisory-e3s1p43. Joseph, Naima T. MD, MPH. Measles in Pregnancy: Clinical Considerations and Challenges. Obstetrics & Gynecology ():10.1097/AOG.0000000000006126, November 14, 2025. | DOI: 10.1097/AOG.0000000000006126

The term "hypnosis" was first described in 1843 byScottish surgeon James Braid, who published the book Neurypnology. He coined the term "hypnosis" from the Greek word for sleep to describe the trance-like state induced by focusing on a bright object. Self-hypnosis has nowbeen shown to aid in menopausal hot flash reduction! In this episode, we will review this brand new publication from JAMA Network which confirmed via a multicenter RCT that a simple daily hypnosis audio session was effective forsymptom relief. The study is the first to compare self-guided hypnosis with an active control condition (i.e. sham white noise control group). Listen in for details. 1.     Elkins G, Arring N, Morgan G, Lorenz T, Muniz V,Lafferty C, Scheffrahn K, Alldredge C, Barton D. Self-Administered Hypnosis vsSham Hypnosis for Hot Flashes: A Randomized Clinical Trial. JAMA Netw Open.2025 Nov 3;8(11):e2542537. doi: 10.1001/jamanetworkopen.2025.42537. PMID:41217756.2.     https://interestingengineering.com/health/hypnosis-lowers-menopause-hot-flashes

Well, from time to time we cover RANDOM tidbits of information which cover RANDOM questions and/or RANDOM patient care issues that we encounter. In this episode we will cover one OB issue related to recurrent pregnancy loss, one GYN issue related to unilateral breast swelling in a patient with SLE, and one RANDOM life perspective response from a mock interview that I participated in for a residency candidate. Listen in fordetails!1.     Viviana DO; Giugni, Claudio Schenone MD; Ros, Stephanie T. MD, MSCI. Factor V and recurrent pregnancy loss: de Assis, Evaluation of Recurrent Pregnancy Loss. Obstetrics & Gynecology 143(5):p 645-659, May 2024. | DOI: 10.1097/AOG.0000000000005498Unilateral Breast Swelling with SLE: 2.     Voizard B, Lalonde L, Sanchez LM, et al. LupusMastitis as a First Manifestation of Systemic Disease: About Two Cases With a Review of the Literature. European Journal of Radiology. 2017;92:124-131. doi:10.1016/j.ejrad.2017.04.023.3.     Kinonen C, Gattuso P, Reddy VB. Lupus Mastitis:An Uncommon Complication of Systemic or Discoid Lupus. The American Journal of Surgical Pathology. 2010;34(6):901-6. doi:10.1097/PAS.0b013e3181da00fb.4.      Summers TA, Lehman MB, Barner R, Royer MC. Lupus Mastitis: A Clinicopathologic Review and Addition of a Case. Advances in Anatomic Pathology.2009;16(1):56-61. doi:10.1097/PAP.0b013e3181915ff7.5.     Jiménez-Antón A, Jiménez-Gallo D,Millán-Cayetano JF, Navarro-Navarro I, Linares-Barrios M. Unilateral Lupus Mastitis.Lupus. 2023;32(3):438-440. doi:10.1177/09612033221151011.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On August 15, 2025, we reviewed the data from an FDA expert panel calling on the FDA to remove the exiting Black Box warning on commercial HRT options for menopausal care. In a historic decision, this happened today. Listen in for details! 1. https://www.cbsnews.com/video/fda-chief-explains-changes-to-black-box-warnings-on-some-hormone-therapies-for-menopause/2. https://www.hhs.gov/press-room/hhs-advances-womens-health-removes-misleading-fda-warnings-hormone-replacement-therapy.html

The ACOG acknowledges that maternal obesity affects labor curves and recommends allowing more time for cervical dilation before diagnosing labor arrest in obese patients. This approach aims to avoid unnecessary interventions, such as premature cesarean delivery, which may occur if standard labor curves are strictly applied to obese women. In this episode, we will review a new study from the AJOG (08 Nov 2025) which describes labor progression and duration according to maternal body mass index, validating the need (possibly) for a BMI -based labor curve. Has there been advocates of a BMI-based labor curve? Listen in for details.1. Edwards, Sara et al. Characterizing Labor Progression and Duration According to Maternal Body Mass Index. American Journal of Obstetrics & Gynecology, Volume 0, Issue 02. Lundborg L, Liu X, Åberg K, et al. Association of Body Mass Index and Maternal Age With First Stage Duration of Labour. Scientific Reports. 2021;11(1):13843. doi:10.1038/s41598-021-93217-5.3. Kominiarek MA, Zhang J, Vanveldhuisen P, et al. Contemporary Labor Patterns: The Impact of Maternal Body Mass Index. American Journal of Obstetrics and Gynecology. 2011;205(3):244.e1-8. doi:10.1016/j.ajog.2011.06.014.4. Norman SM, Tuuli MG, Odibo AO, et al. The Effects of Obesity on the First Stage of Labor.Obstetrics and Gynecology. 2012;120(1):130-5. doi:10.1097/AOG.0b013e318259589c.

Do you routinely order prophylactic antibiotics at time ofsecond-degree laceration repair? Is there data for that? While the use of prophylacticantibiotics “is reasonable” (per ACOG PB 198) for OASIS lacerations, what doesthe data look like for second degree lacs? Well, the answer is both supportiveAND non-supportive of that practice! In this episode, we will cover a brand newpublication (RCT) from BMJ on this very issue, and also highlight a meta-analysisfrom Plos One (May 2025) that also examined this question. Listen in fordetails!1.     ACOG PB 1982.     Armstrong H, Whitehurst J, Morris RK, HodgettsMorton V, Man R; CHAPTER group. Antibiotic prophylaxis for childbirth-relatedperineal trauma: A systematic review and meta-analysis. PLoS One. 2025 May9;20(5):e0323267. doi: 10.1371/journal.pone.0323267. PMID: 40344566; PMCID:PMC12064200.3.     Risk of infection and wound dehiscence after useof prophylactic antibiotics in episiotomy or second degree tear (REPAIR study):single centre, double blind, placebo controlled randomised trial. BMJ 2025; 391doi: https://doi.org/10.1136/bmj-2025-084312 (Published 29 October 2025): BMJ2025;391:e084312

On March 29, 2023, we released an episode titled, “The 4 PCOS Phenotypes”. That was in 2023! Now, on 29 October 2025, in the journal Nature Medicine, researchers have published, “Data-driven (FOUR) subtypes of polycystic ovary syndrome and their association with clinical outcomes”. PCOS is not ONE condition: is a constellation of metabolic, endocrine, and ovulatory dysregulation. We covered these 4 phenotypes back then. Is this what the “new data” found? Or what it something else? And how does these affect IVF or pregnancy outcomes? Listen in for details!1. Gao, X., Zhao, S., Du, Y. et al. Data-driven subtypes of polycystic ovary syndrome and their association with clinical outcomes. Nat Med (2025). https://doi.org/10.1038/s41591-025-03984-12. Mar 29, 2023; SPOTIFY: https://creators.spotify.com/pod/profile/dr-hector-chapa/episodes/The-4-PCOS-Phenotypes-e217vv0/a-a9ipgjsSTRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Taking folic acid prior to conception and during pregnancy can help protect the unborn baby from developing abnormalities. Supplements are particularly important for women who have epilepsy, as anti-seizure medication (previously known as anti-convulsants or anti-epileptic drugs) can lead to a deficiency in folic acid. Until 2023, high doses of 4-5 mg per day were recommended. However, this has changed as the data has changed. Did you know the SMFM no longer recommends “high dose” folic acid preconceptionally for patients on seizure medications? This is also highlighted in a recently released epub from Obstetrics and Gynecology (Green Journal) on October 31, 2025. Listen in for details. 1. Mokashi, Mugdha MD, MPH; Cozzi-Glaser, Gabriella MD; Kominiarek, Michelle A. MD, MS. Dietary Supplements in the Perinatal Period. Obstetrics & Gynecology ():10.1097/AOG.0000000000006098, October 31, 2025. | DOI: 10.1097/AOG.00000000000060982. Asadi-Pooya AA. High dose folic acid supplementation in women with epilepsy: are we sure it is safe? Seizure. 2015 Apr;27:51-3. doi: 10.1016/j.seizure.2015.02.030. Epub 2015 Mar 7. PMID: 25891927.3. https://aesnet.org/about/aes-press-room/press-releases/guideline-issued-for-people-with-epilepsy-who-may-become-pregnant4. Turner C, McIntosh T, Gaffney D, Germaine M, Hogan J, O'Higgins A. A 10-year review of periconceptual folic acid supplementation in women with epilepsy taking antiseizure medications. J Matern Fetal Neonatal Med. 2025 Dec;38(1):2524094. doi: 10.1080/14767058.2025.2524094. Epub 2025 Jun 30. PMID: 40588438.5. https://www.aan.com/PressRoom/Home/PressRelease/5170#:~:text=The%20guideline%20recommends%20that%20people,and%20possibly%20improve%20neurodevelopmental%20outcomes.6. https://aesnet.org/about/aes-press-room/press-releases/guideline-issued-for-people-with-epilepsy-who-may-become-pregnant

Back on August 9, 2024, we released an episode (link in the show notes) reviewing the renewed interest in transfusing whole blood for PPH rather than component therapy. Now, in O&G open, authors from my Alma Mater (UT Southwestern) have published new data bolstering the use of whole blood for PPH. Listen in for details.1. Clinical Pearls Episode 2024: https://open.spotify.com/episode/0ZhqoIE9wMcAboDlevq9OW?si=rM32uK8ER8uuWmq4mf5dzA2. Ambia, Anne M. MD; Burns, R. Nicholas MD; White, Alesha MD; Warncke, Kristen MD; Gorman, April MS; Duryea, Elaine MD; Nelson, David B. MD. Whole Blood in the Management of Postpartum Hemorrhage. O&G Open 2(5):e130, October 2025. | DOI: 10.1097/og9.00000000000001303. ACPG PB 183STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Elinzanetant, sold under the brand name Lynkuet, receivedapproval from the U.S. Food and Drug Administration (FDA) on October 24, 2025, for the treatment of moderate to severe hot flashes due to menopause.  How is this different than Fezolinetant, which was approved in 2023? Listen in for details. 1.   Menegaz de Almeida, Artur MS; Oliveira, Paloma MS; Lopes, Lucca MD; Leite, Marianna MS; Morbach, Victória MS; Alves Kelly, Francinny MD; Barros, Ítalo MS; Aquino de Moraes, Francisco Cezar MS; Prevedello, Alexandra MD. Fezolinetant and Elinzanetant Therapy for Menopausal Women Experiencing Vasomotor Symptoms: A Systematic Review and Meta-analysis. Obstetrics & Gynecology 145(3):p 253-261, March 2025. | DOI: 10.1097/AOG.00000000000058122.     Pinkerton JV, Simon JA, Joffe H, Maki PM, NappiRE, Panay N, Soares CN, Thurston RC, Caetano C, Haberland C, Haseli Mashhadi N, Krahn U, Mellinger U, Parke S, Seitz C, Zuurman L. Elinzanetant for the Treatment of Vasomotor Symptoms Associated With Menopause: OASIS 1 and 2 Randomized Clinical Trials. JAMA. 2024 Aug 22;332(16):1343–54. doi: 10.1001/jama.2024.14618. Epub ahead of print. PMID: 39172446; PMCID: PMC11342219.3.     Cardoso F, Parke S, Brennan DJ, Briggs P,Donders G, Panay N, Haseli-Mashhadi N, Block M, Caetano C, Francuski M, Haberland C, Laapas K, Seitz C, Zuurman L. Elinzanetant for Vasomotor Symptomsfrom Endocrine Therapy for Breast Cancer. N Engl J Med. 2025 Aug 21;393(8):753-763. doi: 10.1056/NEJMoa2415566. Epub 2025 Jun 2. PMID: 40454634.STRONG COFFEE PROMO: 20% Off Strong CoffeeCompany https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On January 18, 2020, we released an episode called “Vaginal Vit C for BV? Yep, it’s DATA”. That was 5 years ago! Now, in the Green Journal, a new systematic review and meta-analysis is examining this subject….AGAIN. Plus, this is not the only systematic review to investigate this; a similar review was published in Acta Obstétrica e Ginecológica Portuguesa earlier this year (2025) in March. So, did we get it right 5 years ago? Can vaginal Vit C help in eliminating BV? Listen in for details!1. Khaikin, Yannay MD; Elangainesan, Praniya MD, MSc; Winkler, Eliot MD, MSc; Liu, Kuan PhD, MMath; Selk, Amanda MD, MSc; Yudin, Mark H. MD, MSc. Intravaginal Vitamin C for the Treatment and Prevention of Bacterial Vaginosis: A Systematic Review and Meta-analysis. Obstetrics & Gynecology ():10.1097/AOG.0000000000006092, October 23, 2025. | DOI: 10.1097/AOG.0000000000006092; https://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=9900&issue=00000&article=01389&type=Fulltext2. Acta Obstétrica e Ginecológica Portuguesa (March 2025): chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://scielo.pt/pdf/aogp/v19n1/1646-5830-aogp-19-01-40.pdf3. Chapa Clinical pearls 2020: https://podcasts.apple.com/gh/podcast/vaginal-vit-c-for-bv-yep-its-data/id1412385746?i=1000463002444

Here is a real-world clinical case with a tricky differential: Our team recently readmitted a patient 6 days postpartum/post C-section (which was done for ICP and fetal macrosomia at close to 4500 grams, with A2GDM). She had elevated blood pressures, a frontal headache, some midepigastric pain/RUQ discomfort. Pretty clear picture right: sounds like preeclampsia (PreE) with severe features based on BP elevation and symptoms. So, we started her on mag-sulfate per protocol. Well, her transaminases were in the 400-600s, which was significantly higher than they were at delivery. They then peaked the next day at 900! OK, it still meets criteria for PreE with severe features. But could this also be postpartum Acute fatty Liver of Pregnancy (AFLP)? The clinical picture of these 2 conditions may overlap but there are distinct differences here. AFLP is potentially fatal, so we have to get that diagnosis correct. How can we distinguish AFLP from PreE with severe features or HELLP? Listen in for details.1. https://www.preeclampsia.org/the-news/health-information/acute-fatty-liver-of-pregnancy-can-be-confused-with-preeclampsia-and-hellp-syndrome2. Yemde A Jr, Kawathalkar A, Bhalerao A. Acute Fatty Liver of Pregnancy: A Diagnostic Challenge. Cureus. 2023 Mar 26;15(3):e36708. doi: 10.7759/cureus.36708. PMID: 37113350; PMCID: PMC10129069.3. Maalbi O, Elachhab N, Elkabbaj A, Arfaoui M, Hindi S, Lahbabi S, Oudghiri N, Tachinante R. Management of Acute Fatty Liver of Pregnancy: A Retrospective Study of 12 Cases Compared With Data in the Literature. Cureus. 2025 Jun 11;17(6):e85753. doi: 10.7759/cureus.85753. PMID: 40656400; PMCID: PMC12247011.4. Siwatch S, De A, Kaur B, et al. Safety and Efficacy of Plasmapheresis in Treatment of Acute Fatty Liver of Pregnancy-a Systematic Review and Meta-Analysis.Frontiers in Medicine. 2024;11:1433324. doi:10.3389/fmed.2024.1433324.5. Sarkar M, Brady CW, Fleckenstein J, et al.6. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases.Hepatology (Baltimore, Md.). 2021;73(1):318-365. doi:10.1002/hep.31559.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

I was recently asked to OPINE on the labor management for a patient who was receiving IV Pitocin for augmentation, who experienced a placental abruption. One physician stated that in "his opinion", Pitocin increased the risk of placental abruption intrapartum, a point which the original treating physician refuted. So, I was asked to be the "referee" on the play. IV Pitocin can result in some maternal-fetal complications but is abruption one of them as a stand-alone complication. Was the first reviewer's opinion correct? Listen in for details.1. Ben-Aroya Z, Yochai D, Silberstein T, Friger M, Hallak M, Katz M, Mazor M. Oxytocin use in grand-multiparous patients: safety and complications. J Matern Fetal Med. 2001 Oct;10(5):328-31. doi: 10.1080/714904358. PMID: 11730496.2. Morikawa M, Cho K, Yamada T, et al. Do Uterotonic Drugs Increase Risk of Abruptio Placentae and Eclampsia? Archives of Gynecology and Obstetrics. 2014;289(5):987-91. doi:10.1007/s00404-013-3101-8.3. ACOG: First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8. Obstetrics and Gynecology. 2024;143(1):144-162. doi:10.1097/AOG.0000000000005447.4. Pitocin. FDA Drug Label. Food and Drug Administration Updated date: 2024-08-125. Litorp H, Sunny AK, Kc A. Augmentation of Labor With Oxytocin and Its Association With Delivery Outcomes: A Large-Scale Cohort Study in 12 Public Hospitals in Nepal.Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(4):684-693. doi:10.1111/aogs.13919.

Current guidelines recommend universal collection of a vaginal-rectal swab for GBS colonization at 36-37 weeks and 6 days for the identification of patients who require intrapartum IV antibiotic coverage to prevent early onset neonatal GBS infection/sepsis. Recently, we had a patient in clinic whose GBS culture at 36 weeks was negative. Good right? Well, the patient was on amoxicillin at the time for pharyngitis. Did that course of oral PCN based therapy affect the GBS culture result? Should we believe that culture or could it be a false negative, demanding rescreen after therapy completion? There is currently a GAP here in the guidance. In this episode we will cover this controversial scenario, look at the data, and provide a real-world implementable approach to this case.1. Kim DD, Page SM, McKenna DS, Kim CM. Neonatal Group B Streptococcus Sepsis After Negative Screen in a Patient Taking Oral Antibiotics. Obstetrics and Gynecology. 2005;105(5 Pt 2):1259-61. doi:10.1097/01.AOG.0000159040.51773.bf.2. ACOG CO Number 797 (Replaces Committee Opinion No. 782, June 2019.); 20203. Mackay G, House MD, Bloch E, Wolfberg AJ. A GBS culture collected shortly after GBS prophylaxis may be inaccurate. J Matern Fetal Neonatal Med. 2012 Jun;25(6):736-8. doi: 10.3109/14767058.2011.596961. Epub 2011 Aug 1. PMID: 21801141.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On March 7, 2025, we released an episode summarizing key aspects of a NEJM publication regarding male partner therapy for women with recurrent BV. Although that study had limitations, the results were very surprising. Now, on 10/16/25 (7 months later), the ACOG has a new Clinical Practice Update (CPU) on this very issue. In this episode we will briefly summarize that March 2025 NEJM publication and highlight the TWO updated clinical recommendations from the ACOG regarding male partner therapy for the prevention of BV in women. PLUS, we will briefly discuss why although male partner therapy should be considered, partner EPT is “not recommended” at this time by the ACOG. 1. ACOG CLINICAL PRACTICE UPDATE: Concurrent Sexual Partner Therapy to Prevent Bacterial Vaginosis Recurrence Obstetrics & Gynecology ():10.1097/AOG.0000000000006102, October 16, 2025. | DOI: 10.1097/AOG.00000000000061022. Chapa Clinical Pearls March 2025 Episode: https://open.spotify.com/episode/4sW9tTe9CdYVQsCRBjqQQP3. Vodstrcil LA, Plummer EL, Fairley CK, Hocking JS, Law MG, Petoumenos K, et al. Male-partner treatment to prevent recurrence of bacterial vaginosis. N Engl J Med 2025;392:947–57. doi: 10.1056/NEJMoa2405404STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Podcast family, as we have said on many previous occasions, we get episode suggestions from either real-world patient encounters, from things that are hot in press, and/or from podcasts family member suggestions. Recently, one of our podcast family members asked me about the utility ofperforming pelvic floor muscle therapy (PFMT) antepartum. Is this evidence-based? Does performing PFMT help with postpartum urinary incontinence? Not all PFMTs are Kegel exercises! In this episode, we will review peripartum urinary incontinence and answer the question, “Is there value in teaching antepartum PFMT?”. We will summarize key concepts from the Oct 2025 Narrative Review on thissubject from the Green Journal (Obstet Gynecol).1.     Siddique, Moiuri MD, MPH; Hickman, Lisa MD;Giugale, Lauren MD. Peripartum Urinary Incontinence and Overactive Bladder.Obstetrics & Gynecology 146(4):p 466-472, October 2025. | DOI:10.1097/AOG.00000000000059932.     Woodley SJ, Lawrenson P, Boyle R, et al. PelvicFloor Muscle Training for Preventing and Treating Urinary and Faecal Incontinence in Antenatal and Postnatal Women. The Cochrane Database of SystematicReviews. 2020;5:CD007471. doi:10.1002/14651858.CD007471.pub4.3.     Pelvic Floor Muscle Training to Prevent andTreat Urinary and Fecal Incontinence in Antenatal and Postnatal Patients. AmericanAcademy of Family Physicians (2021). Practice Guideline STRONG COFFEE PROMO: 20% Off Strong CoffeeCompany https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In the 09/1/2018 Society for Academic Specialists in General Obstetrics and Gynecology’s (SASGOG’s) Pearls of Exxcellence publication, “Management of Preeclampsia at Term”, it states: “If hypertension management requires acute IV treatment, it is often prudent to initiate oral labetalol or EXTENDED-release nifedipine to maintain blood pressures below the severe range. Intrapartum blood pressure management and consultation should not delay progress towards delivery. Fetal monitoring should be continuous.” In the original ACOG CO 692 from 2017, oral nifedipine was first referenced as an alternative to IV meds GIVEN INTRAPARTUM, stating, “Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available.” This may be given orally as 10mg, 20mg, and 20 mg separated in time by 20 minutes per dose. Notice it says “immediate release oral nifedipine”. But what about EXTENDED release nifedipine intrapartum as stated by the SASGOG? Is that an option after immediate attentive and therapy has been given with IV anti-hypertensives? Listen in for details.1. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period: Committee Opinion, Number 692. Obstetrics & Gynecology 129(4):p e90-e95, April 2017. | DOI: 10.1097/AOG.00000000000020192. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260. doi: 10.1097/AOG.0000000000003891. PMID: 32443079.3. Cleary EM, Racchi NW, Patton KG, Kudrimoti M, Costantine MM, Rood KM. Trial of Intrapartum Extended-Release Nifedipine to Prevent Severe Hypertension Among Pregnant Individuals With Preeclampsia With Severe Features. Hypertension. 2023 Feb;80(2):335-342. doi: 10.1161/HYPERTENSIONAHA.122.19751. Epub 2022 Oct 3. PMID: 36189646.STRONG COFFEE PROMO: 20% Off Strong Coffee Company ⁠https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Fetal gastroschisis is a congenital defect of the abdominal wall, typically located to the right of a normally inserted umbilical cord, through which the fetal intestines and sometimes other abdominal organs herniate directly into the amniotic cavity. This condition is usually isolated, not associated with other major anomalies, and is reliably diagnosed prenatally by ultrasound. Does this require antenatal fetal surveillance? In this episode, we will cover the prevalence, diagnosis, classification, and management of this congenital anomaly. 1. Ferreira RG, Mendonça CR, Gonçalves Ramos LL, de Abreu Tacon FS, Naves do Amaral W, Ruano R. Gastroschisis: a systematic review of diagnosis, prognosis and treatment. J Matern Fetal Neonatal Med. 2022 Dec;35(25):6199-6212. doi: 10.1080/14767058.2021.1909563. Epub 2021 Apr 25. PMID: 33899664.2. Pontes KFM, Muniz TD, Caldas JVJ, Acácio GL, Lapa DA, Rolo LC, Araujo Júnior E. Fetal Gastroschisis: Review From Diagnosis to Delivery. J Clin Ultrasound. 2025 Jun;53(5):1122-1130. doi: 10.1002/jcu.23976. Epub 2025 Mar 28. PMID: 40152061.3. Muniz TD, Rolo LC, Araujo Júnior E. Gastroschisis: embriology, pathogenesis, risk factors, prognosis, and ultrasonographic markers for adverse neonatal outcomes. J Ultrasound. 2024 Jun;27(2):241-250. doi: 10.1007/s40477-024-00887-8. Epub 2024 Mar 29. PMID: 38553588; PMCID: PMC11178761.STRONG COFFEE PROMO: 20% Off Strong Coffee Company ⁠https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On October 9, 2025, the ACOG released a clinical practice update (CPU) regarding Zouranolone and brexanolone. As postpartum depression is an area of continued research and need for therapeutics, any new clinical practice update on the subject is welcome. So what's new in this update?! Well…the answer will surprise you. Listen in for details on the CPU, and a mini-review of the concerns for Zuranolone. 1. ACOG CPU Oct 9, 2025: Zuranolone and Brexanolone for the Treatment of Postpartum Depression 2. ACOG PA Aug 2023: Zuranolone for the Treatment of Postpartum Depression 3. Clinical Practice Guideline No. 5, Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum (Obstet Gynecol 2023;141:1262–88)STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Sometimes you hear something that makes you just stop and say, “What did you say?!”. Yep, in this episode we will give evidence-based answers to three questions that I heard TODAY that made me stop and ask, “What did you say?”. In this episode we will cover: 1. Umbilical cord blood collection from a monochorionic twin gestation, 2. Predictability of the mBPP compared to full BPP, and 3. Breastfeeding during postpartum cannabis use (this last one is not so intuitive as you would think, and there is new ACOG guidance on this which we will review). Listen in for details!1. ACOG PB 229; 20212. ACOG CC #10: Cannabis Use During Pregnancy and Lactation3. Kaufman DA, Lucke AM, Cummings JJ. Postnatal Cord Blood Sampling: Clinical Report.Pediatrics. 2025;155(6):e2025071811. doi:10.1542/peds.2025-071811.4. Simpson L, Khati NJ, Deshmukh SP, et al. ACR Appropriateness Criteria Assessment of Fetal Well-Being. Journal of the American College of Radiology : JACR. 2016;13(12 Pt A):1483-1493. doi:10.1016/j.jacr.2016.08.028.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In July 2023, the ACOG released a Practice Advisory stating, “Based on data on the benefit of adjunct HPV vaccination, ACOG recommends adherence to the current Centers for Disease Control and Prevention (CDC) recommendations for vaccinations of individuals aged 9–26 years, and to consider adjuvant HPV vaccination for immunocompetent previously unvaccinated people aged 27–45 years who are undergoing treatment for CIN 2+”. The possible beneficial effect of peri-treatment HPV vaccination goes back to the early 2010s. But science is always changing, and MEDICINE MOVES FAST. In September 2025, the Lancet’s Obstetrics, Gynecology, and Women’s Health journal published the VACCIN trial to test that guidance. These authors found that, “Although previous studies, including meta-analyses and observational studies, have shown that adjuvant HPV vaccination reduces the recurrence of cervical dysplasia after surgical treatment, our trial suggests that adjuvant HPV vaccination is not effective in reducing the recurrence of CIN 2–3 lesions, contradicting the conclusions of previous works”. They have also called for a REVISION to prior guidance. This is FASCINATING. Listen in for details. 1. ACOG PA July 2023, “Adjuvant Human Papillomavirus Vaccination for Patients Undergoing Treatment for Cervical Intraepithelial Neoplasia 2+”2. Adjuvant prophylactic human papillomavirus vaccination for prevention of recurrent high-grade cervical intraepithelial neoplasia lesions in women undergoing lesion surgical treatment (VACCIN): a multicentre, phase 4 randomised placebo-controlled trial in the Netherlands: https://www.sciencedirect.com/science/article/pii/S305050382500007X#:~:text=To%20our%20knowledge%2C%20this%20is,the%20conclusions%20of%20previous%20works.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

FYI

A breakthrough discovery in the 1970s was the determination of alpha-fetoprotein levels in the serum of pregnant women to detect fetuses with neural tube defects. In the case of high AFP values in maternal serum, amniocentesis was performed to determine the levels of AFP and acetylcholinesterase (AChE) in the amniotic fluid to confirm the diagnosis. Currently, the ACOG states that high-quality, second-trimester fetal anatomy ultrasonography is an appropriate screening test for NTDs where routinely performed for fetal anatomic survey at 18 to 22 weeks. If optimal images of the fetal spine, intracranial anatomy, or anterior abdominal wall are not obtained (eg, fetal position or maternal obesity), MSAFP should be performed to improve detection of NTDs (ACOG Practice Bulletin No. 187: Neural Tube Defects. Committee on Practice Bulletins Obstet Gynecol. 2017). Some clinicians (as we do in our practice) order both fetal anatomy ultrasound and msAFP concurrently. What are the implications when the msAFP is elevated with a normal fetal anatomical survey? Where is this msAFP coming from? Listen in for details.1. ACOG Practice Bulletin No. 187: Neural Tube Defects. Committee on Practice Bulletins Obstet Gynecol. 20172. Pregnancy Outcomes Regarding Maternal Serum AFP Value in Second Trimester Screening. Bartkute K, Balsyte D, Wisser J, Kurmanavicius J. Journal of Perinatal Medicine. 2017;45(7):817-820. doi:10.1515/jpm-2016-0101.3. Głowska-Ciemny J, Szmyt K, Kuszerska A, Rzepka R, von Kaisenberg C, Kocyłowski R. Fetal and Placental Causes of Elevated Serum Alpha-Fetoprotein Levels in Pregnant Women. J Clin Med. 2024 Jan 14;13(2):466. doi: 10.3390/jcm13020466. PMID: 38256600; PMCID: PMC10816536.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

The only structure of fetal gastrointestinal tract (GIT) which is seen on routine second trimester anomaly scan is the fetal stomach. Under normal conditions, the fetal stomach "bubble" is seen on the left side of the fetal abdomen. This is a normal finding on an ultrasound and indicates the stomach's normal position. There are two functions of the fetal GIT: 1. Propulsive action by peristalsis which takes the swallowed amniotic fluid up to the small bowel; 2. Absorption – the amniotic fluid is absorbed through the fetal small bowel. When the stomach is found prenatally to be located on the right side, it is called dextrogastria. Today in our high-risk prenatal clinic, we encountered a patient whose fetus was found to have this rare condition dextrogastria. Is this an isolated issue? What does this mean for clinical outcomes. Listen in for details.1. Versteegh HP, Adams SD, Boxall S, Burge DM, Stanton MP. Antenatally diagnosed right-sided stomach (dextrogastria): A rare rotational anomaly. J Pediatr Surg. 2016 Feb;51(2):236-9. doi: 10.1016/j.jpedsurg.2015.10.060. Epub 2015 Nov 4. PMID: 26655213.2. A Case Report Of An Isolated Dextrogastria Diagnosed In First Trimester Ultrasound Screening: https://hjog.org/?p=35403. Docx MKF, Steylemans A, Govaert PIsolated dextrogastria in a newbornArchives of Disease in Childhood - Fetal and Neonatal Edition 2015;100:F513.4. https://www.researchgate.net/publication/43349867_Isolated_dextrogastria_A_case_report5. Aziz, S., König, S., Noor, H. et al. Isolated dextrogastria with eventration of right hemidiaphragm and hiatal hernia in an adult male. BMC Gastroenterol 22, 56 (2022). https://doi.org/10.1186/s12876-022-02127-x

Did you know that C-Section birth is referenced in Shakespeare’s Macbeth? Cesarean Section is the most common laparotomy in the world, and yest we are still learning surprising facts about it. This episode we will summarize 2publications which have recently been released. One is from the American Journal of Perinatology (September 2025 ) and the other is from the AJOG (August 2025 ). Does a primary C-section on a laboring uterus have a different risk of PAS in the subsequent pregnancy compared to a non-labored uterus? And what is the percentage of patients who experience “pain” at time of C-section? Listen in for the surprising data.1. Kashani Ligumsky L, Lopian M, Jeong A, Desmond A, Elmalech A, Many A, Martinez G, Krakow D, Afshar Y. Impact of Labor in Primary Cesarean Delivery on Subsequent Risk of Placenta Accreta. Am J Perinatol. 2025 Sep 16. doi: 10.1055/a-2693-8599. Epub ahead of print. PMID: 40957594.2. Somerstein, Rachel. I feel pain, not pressure: a personal and methodological reflection on pain during cesarean delivery. American Journal of Obstetrics & Gynecology, Volume 0, Issue 0 (EPub Ahead of Print)

Just today in clinic, we had a patient, who was well into her third trimester, come to her regular scheduled appointment with new onset left-sided facial droop. Yeah, that’s concerning! A complete history and physical was performed and the diagnosis was made of Bell’s palsy. This is not a rare event and it can be extremely stressful for the affected mother to be because everybody knows facial droop is not normal! And we have recent data regarding this. In July 2025 in the Journal of Plastic, Reconstructive, and Aesthetic Surgery, authors confirmed that Bell’s palsy can have real negative functional and psychosocial implications for those affected. So, in this episode, we are going to discuss Bell’s palsy in pregnancy. How do we differentiate this from the more serious differential, which is a stroke? What about treatment? Listen in for details. 1. Wesley, Shaun R. MD; Vates, G. Edward MD, PhD; Thornburg, Loralei L. MD. Neurologic Emergencies in Pregnancy. Obstetrics & Gynecology 144(1):p 25-39, July 2024. | DOI: 10.1097/AOG.00000000000055752. Vrabec JT, Isaacson B, Van Hook JW. Bell's Palsy and Pregnancy.Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2007;137(6):858-61. doi:10.1016/j.otohns.2007.09.009.3. Evangelista V, Gooding MS, Pereira L.Bell's Palsy in Pregnancy.Obstetrical & Gynecological Survey. 2019;74(11):674-678. doi:10.1097/OGX.00000000000007324. JPRAS (July 2025): https://www.jprasurg.com/article/S1748-6815(25)00328-6/fulltextSTRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Maternal perception of decreased fetal movement at term occurs in up to 15% of pregnancies and is a cause for maternal and provider concern. All maternal concerns of decreased fetal movement require an assessment of fetal wellbeing. But what about the patient with recurrent episodes of reduced fetal movements at term? Routine induction of labor is not supported solely for decreased fetal movement in a non-growth-restricted fetus, as increased intervention rates (including induction of labor and early term birth) have not demonstrated improved perinatal outcomes and may increase neonatal morbidity, such as respiratory distress and NICU admission. Some international sources (ISUOG) have recognized the cerebroplacental ratio (CPR) as a possible ultrasound tool to investigate possible early placental insufficiency before fetal growth restriction occurs. Is CPR helpful for decreased fetal movements at term? A new publication from the Lancet’s new journal- Obstetrcis, Gynecology, and Women’s Health- states that it is. Is the CPR ultrasound assessment recognized by the ACOG or SMFM? Listen in for details. 1. The cerebroplacental ratio: a useful marker but should it be a screening test? (2025): https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.29154#:~:text=The%20ISUOG%20guidelines%20recommend%20using,after%2038%20weeks'%20gestation44.2. Turner JM, Flenady V, Ellwood D, Coory M, Kumar S.Evaluation of Pregnancy Outcomes Among Women With Decreased Fetal Movements.JAMA logoJAMA Network Open. 2021;4(4):e215071. doi:10.1001/jamanetworkopen.2021.5071.3. Cerebroplacental ratio-based management versus care as usual in non-small-for-gestational-age fetuses at term with maternal perceived reduced fetal movements (CEPRA): a multicentre, cluster-randomised controlled trial. https://www.sciencedirect.com/science/article/pii/S30505038250000204. Hofmeyr GJ, Novikova N. Management of Reported Decreased Fetal Movements for Improving Pregnancy Outcomes. The Cochrane Database of Systematic Reviews. 2012;(4):CD009148. doi:10.1002/14651858.CD009148.pub2.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In the 1960s, continuous electronic fetal monitoring was introduced as a way to better capture and document the fetal response to labor and uterine contraction pattern. Since then, it has become a fully integrated component of intrapartum care despite its limited ability to prevent neonatal long term neurological complications and fetal death. We have covered intrapartum fetal heart rate patterns several times on this show, and this episode now VALIDATES those prior episodes. In this episode, we will summarize THREE key points from the October 2025 upcoming ACOG CPG #10 on “Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management”. Is there a place for intermittent fetal auscultation intrapartum? What about maternal O2 for fetal resuscitation? Are we ready for “AI fetal heart racing interpretations”? Listen in for details.1. ACOG CPG 10: Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management (Oct 2025)2. ACOG PB 205: Vaginal Birth After Cesarean DeliverySTRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In 2023, we released 2 episodes on obstructive sleep apnea (OSA) and adverse pregnancy. Now, on September 16, 2025, a new publication from JAMA Network Open adds more insights to disturbed sleep and adverse pregnancy outcomes. How does insomnia affect pregnancy? And is there any data on night shift work and its altered circadian rhythms on adverse pregnancy outcomes? Listen in for details. 1. Ross N, Baer RJ, Oltman SP, et al. Ischemic Placental Disease and Severe Morbidity in Pregnant Patients With Sleep Disorders. JAMA Netw Open. 2025;8(9):e2532189. doi:10.1001/jamanetworkopen.2025.321892. Cai C, Vandermeer B, Khurana R, et al. The Impact of Occupational Shift Work and Working hours during Pregnancy on Health Outcomes: a systematic Review and Meta-Analysis.American Journal of Obstetrics and Gynecology. 2019;221(6):563-576. doi:10.1016/j.ajog.2019.06.051.3. Dominguez JE, Cantrell S, Habib AS, Izci-Balserak B, Lockhart E, Louis JM, Miskovic A, Nadler JW, Nagappa M, O'Brien LM, Won C, Bourjeily G. Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology Consensus Guideline on the Screening, Diagnosis, and Treatment of Obstructive Sleep Apnea in Pregnancy. Obstet Gynecol. 2023 Aug 1;142(2):403-423. doi: 10.1097/AOG.0000000000005261. Epub 2023 Jul 5. PMID: 37411038; PMCID: PMC10351908.4. Kader M, Bigert C, Andersson T, et al . Shift and Night Work During Pregnancy and Preterm Birth-a Cohort Study of Swedish Health Care Employees. International Journal of Epidemiology. 2022;50(6):1864-1874. doi:10.1093/ije/dyab135.STRONG COFFEE PROMO: 20% Off Strong Coffee Companyhttps://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Brain-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) levels originate from the cardiac cells in response to cardiac strain. This may come from a pulmonary embolus, an acute severe infection (sepsis), or cardiomyopathy. But what is the relationship between these 2 cardiac biomarkers and preeclampsia? Can preeclampsia with severe features result in an abnormal rise in these 2 proteins exclusive to heart failure. Listen in to this real case scenario which our on call team cared for. 1. Serum Levels of N-Terminal Pro-Brain Natriuretic Peptide in Gestational Hypertension, Mild Preeclampsia, and Severe Preeclampsia: A Study From a Center in Zhejiang Province, China. Zheng Z, Lin X, Cheng X. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. 2022;28:e934285. doi:10.12659/MSM.934285.2.Evaluation of B-Type Natriuretic Peptide (BNP) Levels in Normal and Preeclamptic Women. Resnik JL, Hong C, Resnik R, et al. American Journal of Obstetrics and Gynecology. 2005;193(2):450-4. doi:10.1016/j.ajog.2004.12.006.3.Increased B-Type Natriuretic Peptide Levels in Early-Onset Versus Late-Onset Preeclampsia. Szabó G, Molvarec A, Nagy B, Rigó J. Clinical Chemistry and Laboratory Medicine. 2014;52(2):281-8. doi:10.1515/cclm-2013-0307.4. Association of N-Terminal Pro–Brain Natriuretic Peptide Concentration in Early Pregnancy With Development of Hypertensive Disorders of Pregnancy and Future Hypertension.5. Hauspurg A, Marsh DJ, McNeil RB, et al. JAMA logoJAMA Cardiology. 2022;7(3):268-276. doi:10.1001/jamacardio.2021.5617.STRONG COFFEE PROMO: 20% Off Strong Coffee Companyhttps://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Stroke (CVA) is very common in women, who have a higher risk than men over their lifetime; one in five women between the ages of 55 and 75 will experience a stroke. Stroke is a significant concern for women's health, being the third leading cause of death and causing more deaths than breast cancer. While systematic estrogen containing menopausal HT has been considered contraindicated in those with prior CVA history, is local/vaginal E2 therapy safe? A new population-based study gives us some insights. Listen in for details.1. Recurrent Ischemic Stroke and Vaginal Estradiol in Women With Prior Ischemic Stroke: A Nationwide Nested Case-Control Study; https://www.ahajournals.org/doi/10.1161/STROKEAHA.125.0509862. NAMS 2022 Position Statement; chrome-https://menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf3. Stroke News & Brain Health | Published: August 21, 2025; https://newsroom.heart.org/news/vaginal-estrogen-tablets-may-be-safe-for-postmenopausal-women-who-have-had-a-stroke4. https://www.obgproject.com/2022/11/21/north-american-menopause-society-releases-2017-hormone-therapy-statement/5. https://www.goredforwomen.org/en/know-your-risk/risk-factors/risk-of-stroke-in-women-infographic#:~:text=Stroke%20in%20U.S.%20Women%20by,risk%20decreases%20in%20women%20who:

Mastalgia is a common breast complaint in reproductive aged women. Mastalgia can be separated into three categories: 1) cyclical, 2) noncyclical, and 3) extramammary. Vitamin B6 is often cited as a homeopathic (non-prescription/pharmacological) remedy for simple mastalgia. Does the published data support its use? A newly published meta-analysis sheds light on the subject.1. Sharifipour, F., Siahkal, S.F. & Bagherinia, M. The effectiveness of vitamin B6 in reducing mastalgia: a systematic review and meta-analysis. BMC Women's Health 25, 421 (2025). https://doi.org/10.1186/s12905-025-03991-x2. ACOG PB 164; reaffirmed 2023

We are delaying today's program, as stated in this message. We will resume our program as soon as possible. Remembering Charlie Kirk.

We have a wonderful podacst community! Within 24 hours of our immediate past episode release, one close friend- and fellow OBGYN, Dr. Eric Colton (OB Hospitalist Group) reached out and shared valuable words of wisdom regarding a potentially deadly complication of the CS-scar defect...the CS scar ectopic pregnancy. Listen in for Dr. Colton's cameo and details. 1. Ban, Yanli MD, PhD; Shen, Jia MD; Wang, Xia MD; Zhang, Teng MD, PhD; Lu, Xuxu MD; Qu, Wenjie MD; Hao, Yiping MD; Mao, Zhonghao MD; Li, Shizhen MD; Tao, Guowei MD, PhD; Wang, Fang MD, PhD; Zhao, Ying MD, PhD; Zhang, Xiaolei MD, PhD; Zhang, Yuan MD, PhD; Zhang, Guiyu MD, PhD; Cui, Baoxia MD, PhD. Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstetrics & Gynecology 141(5):p 927-936, May 2023. | DOI: 10.1097/AOG.0000000000005113

On Sept 10, 2023, er released an episode titled, “CS Ut Closure: Decidua or No Decidua?”. We highlighted the importance of AVOIDING the decidua at hysterotomy closure at CS. Now, in Sept 2025, in Obstetrics and Gynecology (the Green Journal), there is a new systematic review and meta-analysis on this very topic. Does this new study CONFIRM or REFUTE what we explained 2 years ago? Listen in for details. 1. Sept 10, 2023 Chapa Clinical Pearls Podcast: CS Ut Closure: Decidua or No Decidua?2. Lino GM, Galvão PVM, da Silva MLF, Conrado GAM. Not Closing Compared With Closing the Endometrial Layer During Cesarean Delivery: A Systematic Review and Meta-analysis. Obstet Gynecol. 2025 Jun 12;146(3):e55-e63. doi: 10.1097/AOG.0000000000005974. PMID: 40505112.

According to the J Am Acad Orthop Surg Glob Res Rev. (2024), the incidence of pelvic ring injuries is 34.3 per 100,000 with trauma being the most obvious causation. Women account for approximately 69.7% of these injuries, 23% of which occur in women of childbearing age. In this specific patient population, concern is raised about one's future reproductive capability and method of delivery. The normal bony pelvic movements that occur during vaginal delivery are crucial for accommodating the passage of the fetus through the birth canal; this allows for the normal cardinal phases of labor to occur. These movements involve the widening and shifting of various pelvic joints and bones, primarily influenced by hormonal changes and the mechanical forces exerted by the baby. So, it is reasonable to ask if a patient with pelvic fractures and fixation can safely allow a trial of labor. Is a history of pelvic fractures with surgical fixation an indication for primary cesarean section? If it’s not, in what scenario would a primary c-section be best after a pelvic fracture? Listen in for details. 1.Pelvic Fractures in Women of Childbearing Age.Cannada LK, Barr J. Clinical Orthopaedics and Related Research. 2010;468(7):1781-9. doi:10.1007/s11999-010-1289-5.2.Birth Outcomes Following Pelvic Ring Injury: A Retrospective Study. Hsu CC, Lai CY, Chueh HY, et al. BJOG : An International Journal of Obstetrics and Gynaecology. 2023;130(11):1395-1402. doi:10.1111/1471-0528.17487.3.Pregnancy and Delivery After Pelvic Fracture in Fertile-Aged Women: A Nationwide Population-Based Cohort Study in Finland. Vaajala M, Kuitunen I, Nyrhi L, et al. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022;270:126-132. doi:10.1016/j.ejogrb.2022.01.008.4.Pregnancy Outcomes After Pelvic Ring Injury.Vallier HA, Cureton BA, Schubeck D. Journal of Orthopaedic Trauma. 2012;26(5):302-7. doi:10.1097/BOT.0b013e31822428c5.5.Caesarean Section Rates Following Pelvic Fracture: A Systematic Review. Riehl JT. Injury. 2014;45(10):1516-21. doi:10.1016/j.injury.2014.03.018.6.Unstable Pelvic Fractures in Women: Implications on Obstetric Outcome. Davidson A, Giannoudis VP, Kotsarinis G, et al. International Orthopaedics. 2024;48(1):235-241. doi:10.1007/s00264-023-05979-4.7.Management of Pelvic Injuries in Pregnancy.Amorosa LF, Amorosa JH, Wellman DS, Lorich DG, Helfet DL. The Orthopedic Clinics of North America. 2013;44(3):301-15, viii. doi:10.1016/j.ocl.2013.03.0058.Effect of Trauma and Pelvic Fracture on Female Genitourinary, Sexual, and Reproductive Function.Copeland CE, Bosse MJ, McCarthy ML, et al. Journal of Orthopaedic Trauma. 1997 Feb-Mar;11(2):73-81. doi:10.1097/00005131-199702000-00001.9. The Rate of Elective Cesarean Section After Pelvic or Hip Fracture Remains High Even After the Long-Term Follow-Up: A Nationwide Register-Based Study in Finland. Vaajala M, Kuitunen I, Liukkonen R, et al.European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022;277:77-83. doi:10.1016/j.ejogrb.2022.08.10. Bajerová M, Hruban L. Movements of the pelvic bones of expectant mothers during vaginal delivery. Ceska Gynekol. 2024;89(4):335-342. English. doi: 10.48095/cccg2024335. PMID: 39242210. 11. Lewis AJ, Barker EP, Griswold BG, Blair JA, Davis JM. Pelvic Ring Fracture Management and Subsequent Pregnancy: A Summary of Current Literature. J Am Acad Orthop Surg Glob Res Rev. 2024 Feb 6;8(2):e23.00203. doi: 10.5435/JAAOSGlobal-D-23-00203. PMID: 38323930; PMCID: PMC10849384.12. Childbirth after Pelvic Fractures: Debunking the Myths: https://ota.org/sites/files/legacy_abstracts/ota09/otapa/OTA090132.htm13. Davidson A, Giannoudis VP, Kotsarinis G, Santolini E, Tingerides C, Koneru A, Kanakaris NK, Giannoudis PV. Unstable pelvic fractures in women: implications on obstetric outcome. Int Orthop. 2024 Jan;48(1):235-241. doi: 10.1007/s00264-023-05979-4. Epub 2023 Sep 15. PMID: 37710070

Traditionally, we have learned that any imbalance in the estrogen: progesterone relationship can trigger irregular uterine bleeding. That makes sense, right? During anovulation, prolonged unopposed estrogen can result in HMB. In such a case, we give progesterone as both a therapeutic as well as diagnostic intervention. On the contrary, with progestin only contraception, we consider estrogen predominant products when progesterone breakthrough bleeding (BTB) occurs to restore endometrial stabilization. But a new RCT (AJOG) adds credence to adding MORE progesterone in cases of progesterone associated BTB. Listen in for details.1. Zigler RE, Madden T, Ashby C, Wan L, McNicholas C. Ulipristal Acetate for Unscheduled Bleeding in Etonogestrel Implant Users: A Randomized Controlled Trial. Obstet Gynecol. 2018 Oct;132(4):888-894. doi: 10.1097/AOG.0000000000002810. PMID: 30130351; PMCID: PMC6153077.2.ANDRADE MCR, et al. Norethisterone for Prolonged Uterine Bleeding Associated with Etonogestrel Implant (IMPLANET): A Randomized Controlled Trial, American Journal of Obstetrics and Gynecology (2025), doi: https://doi.org/10.1016/j.ajog.2025.08.029.

Routine vaginal examinations (VEs) are a standard component of intrapartum care, traditionally performed at regular intervals to monitor cervical dilation, effacement, and fetal station, which are indicators of labor progression. Yet, the American College of Obstetricians and Gynecologists states that there is insufficient evidence to recommend a specific frequency for cervical examinations during labor, and examinations should be performed as clinically indicated. Now, a recently published RCT form AJOG MFM is adding additional credence to that. Can we space out clinical exams in otherwise “low-risk” laboring women to 8 hours? Listen in for details. 1. AJOG MFM: (08/18/25) Routine Vaginal Examination Scheduled At 8 vs 4 Hours In Multiparous Women In Early Spontaneous Labour: A Randomised Controlled Trial https://www.sciencedirect.com/science/article/abs/pii/S25899333250016122. Nashreen CM, Hamdan M, Hong J, et al.Routine Vaginal Examination to Assess Labor Progress at 8 Compared to 4 h After Early Amniotomy Following Foley Balloon Ripening in the Labor Induction of Nulliparas: A Randomized Trial. Acta Obstetricia Et Gynecologica Scandinavica. 2024;103(12):2475-2484. doi:10.1111/aogs.14975.3. First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8. Obstetrics and Gynecology. 2024;143(1):144-162. doi:10.1097/AOG.0000000000005447.4. Moncrieff G, Gyte GM, Dahlen HG, et al. Routine Vaginal Examinations Compared to Other Methods for Assessing Progress of Labour to Improve Outcomes for Women and Babies at Term. The Cochrane Database of Systematic Reviews. 2022;3:CD010088. doi:10.1002/14651858.CD010088.pub3.5. Gluck, O., et al. (2020). The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study. [BMC Pregnancy and Childbirth]6. Pan, WL., Chen, LL. & Gau, ML. Accuracy of non-invasive methods for assessing the progress of labor in the first stage: a systematic review and meta-analysis. BMC Pregnancy Childbirth 22, 608 (2022). https://doi.org/10.1186/s12884-022-04938-y

Breast cancer is an hormone responsive malignancy, meaning it may use estrogen and progesterone, reduced in high quantities during a pregnancy, for growth. However, as medical evidence evolves quickly, physicians have come to understand that breast cancer diagnosis during pregnancy doesn't always mean worse prognoses. While older studies- including meta analysis-reflected worse prognoses for pregnancy related breast cancer compared to non-pregnancy related cases, these studies either included studies from the 1960s and 70s when diagnosis and treatment were radically different, had inconsistent definitions of PABC, and/or were poorly age and staged matched. Therefore, as stated in the new UK (Aug 2025) guidance, “the applicability to modern day practice of the findings from these reports is limited”. The more updated clinical stance is that, “By using diagnostic and treatment pathways for women with {pregnancy related breast cancer} which are as close as possible to women with non-pregnancy related breast cancer, similar outcomes can be achieved” (RCOG Green Top recommendations No 12). In this episode, we will summarize key points from the recently released Green Top Guidance No 12 (25 Aug 2025) which has shifted the perspective on treating breast cancer DURING pregnancy. 1. Cubillo A, Morales S, Goñi E, Matute F, Muñoz JL, Pérez-Díaz D, de Santiago J, Rodríguez-Lescure Á. Multidisciplinary consensus on cancer management during pregnancy. Clin Transl Oncol. 2021 Jun;23(6):1054-1066. doi: 10.1007/s12094-020-02491-8. Epub 2020 Nov 16. PMID: 33191439; PMCID: PMC8084770.2. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/pregnancy-and-breast-cancer-green-top-guideline-no-12/3. Sundermann AC, Cate JM, Campbell AK, Dotters-Katz SK, Myers ER, Federspiel JJ. Maternal morbidity and mortality among patients with cancer at time of delivery. Am J Obstet Gynecol. 2023 Sep;229(3):324.e1-324.e7. doi: 10.1016/j.ajog.2023.06.008. Epub 2023 Jun 7. PMID: 37295633; PMCID: PMC10593119.

YEP…Its another episode of You Asked, We Answered! In this episode, we will look at the data to answer 2 questions that came into the show within the last 24 hrs: 1. Is oral or topical therapy best for first treatment of uncomplicated vulvovaginal candidiasis? (We have new data- AJOG, Sept 2025, to answer that), and 2. Is urine PCR testing for UTI diagnosis a “routine practice”? (We will look at 4 sources of information to answer that one). Listen in for details. 1. Gardella, Barbara et al. Treatment of uncomplicated vulvovaginal candidiasis: topical or oral drugs? Single-day or multiple-day therapy? A network meta-analysis of randomized trials. American Journal of Obstetrics & Gynecology, Volume 233, Issue 3, 152 - 1612. Invited Commentary: JAMA Netw Open: Published Online: November 26, 20242024;7;(11):e2446711. doi:10.1001/jamanetworkopen.2024.467113. March 2025 (AAFP): Are the Advantages of Urine PCR Testing Worth the Higher Costs? https://www.aafp.org/pubs/afp/afp-community-blog/entry/are-the-advantages-of-urine-pcr-testing-worth-the-higher-costs.html4. July 2025: PALTmed: https://paltmed.org/news-media/paltmed-calls-providers-stop-using-routine-pcr-urine-tests-utis5. https://pathnostics.com/limitations-of-pcr-only/

In the last 2 episodes we covered new updates in menopausal hormone therapy. However, we did not address TESTOSTERONE use. This episode idea comes from one our podcast family members and good friend, Eric. Eric is 100% correct: Testosterone replacement, when done correctly, has come along way. When is this indicated? Is this endorsed by professional medical/endocrine groups? What’s the dose? We have fun stuff to review, so listen in!1. Davis SR, Baber R, Panay N, Bitzer J, Perez SC, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019 Oct 1;104(10):4660-4666. doi: 10.1210/jc.2019-01603. PMID: 31498871; PMCID: PMC6821450.2. Sharon J. Parish, James A. Simon, Susan R. Davis, Annamaria Giraldi, Irwin Goldstein, Sue W. Goldstein, Noel N. Kim, Sheryl A. Kingsberg, Abraham Morgentaler, Rossella E. Nappi, Kwangsung Park, Cynthia A. Stuenkel, Abdulmaged M. Traish, Linda Vignozzi, International Society for the Study of Women’s Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women, The Journal of Sexual Medicine, Volume 18, Issue 5, May 2021, Pages 849–867, https://doi.org/10.1016/j.jsxm.2020.10.0093. Levy, Barbara MD, MSCP; Simon, James A. MD, MSCP. A Contemporary View of Menopausal Hormone Therapy. Obstetrics & Gynecology 144(1):p 12-23, July 2024. | DOI: 10.1097/AOG.00000000000055534. NAMS The 2022 hormone therapy position statement of The North American Menopause Society: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf

This is a requested follow up to our most recent episode. Menopausal hormone therapy (HT) prescribing practices have evolved over the last few decades guided by the changing understanding of the treatment’s risks and benefits. We know that dose, route of administration, and choice of agent (estradiol versus a more synthetic option, and micronized progesterone over other progestins.) alter the risk benefit ratio. Compared to natural progesterone, synthetic progestins have 10-100- fold greater activity. Synthetic MPA is vasoconstrictive while natural progesterone and drospirenone cause vasodilation and lower blood pressure. Micronized progesterone is bioidentical to the hormone made endogenously and has efficient oral absorption. Progestogens come in oral and transdermal forms, and it can also be given vaginally. Is there data that micronized progesterone is safer for the breast for a menopausal hormone therapy? This podcast topic recommendation comes from one of our podcast family members. Listen for details. 1. Gompel A. Micronized progesterone and its impact on the endometrium and breast vs. progestogens. Climacteric. 2012 Apr;15 Suppl 1:18-25. doi: 10.3109/13697137.2012.669584. PMID: 22432812.2. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018 Apr;21(2):111-122. doi: 10.1080/13697137.2017.1421925. Epub 2018 Jan 31. PMID: 29384406.3. Eden J. The endometrial and breast safety of menopausal hormone therapy containing micronised progesterone: A short review. Aust N Z J Obstet Gynaecol. 2017 Feb;57(1):12-15. doi: 10.1111/ajo.12583. PMID: 28251642.4. Asi N, Mohammed K, Haydour Q, Gionfriddo MR, Vargas OL, Prokop LJ, Faubion SS, Murad MH. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Syst Rev. 2016 Jul 26;5(1):121. doi: 10.1186/s13643-016-0294-5. PMID: 27456847; PMCID: PMC4960754.5.AHA J Circulation: Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? 2023

There’s a lot of fear and misinformation around HRT, and one of the biggest myths is that HT is a highly significant cause of breast cancer. That is not the case. This is a remnant concept from 2002, with MANY caveats. Calls for the removal of the black box warning on hormone replacement therapy (HRT) stems primarily from the outdated and limited nature of the data from the Women's Health Initiative (WHI) study published in 2002. The WHI, while groundbreaking at the time, focused predominantly on a specific formulation of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) in older, postmenopausal women, leading to concerns about its generalizability to the broader population of women considering HRT. This is why on July 17, 2025, the FDA met with a panel of experts, in open forum, to hear the petition of removing the black box warning on hormone replacement therapy. Listen in for details. 1. Writing Group for the Women's Health Initiative Investigators. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA.2002;288(3):321–333. doi:10.1001/jama.288.3.3212. Manson JE, Crandall CJ, Rossouw JE, Chlebowski RT, Anderson GL, Stefanick ML, Aragaki AK, Cauley JA, Wells GL, LaCroix AZ, Thomson CA, Neuhouser ML, Van Horn L, Kooperberg C, Howard BV, Tinker LF, Wactawski-Wende J, Shumaker SA, Prentice RL. The Women's Health Initiative Randomized Trials and Clinical Practice: A Review. JAMA. 2024 May 28;331(20):1748-1760. doi: 10.1001/jama.2024.6542. PMID: 38691368.3. NAMS: The 2022 hormone therapy position statement of The North American Menopause Society (Menopause)

Well, I hate to say it, but I'm going to say it: "I Told You So". Back in 2019, we released an episode called "Mycoplasma genitalium: An Overlooked STI". Then, in Sept 2023, we released an episode called, "The Neglected STI", referring to trichomoniasis. Well, on July 22, 2025, a new commentary was released in the AJOG which is making the case why both Trich and MGen SHOULD be reportable STIs, yet they are currently not reportable. Listen in for details and a quick summary/reminder on therapy. 1. https://www.ajog.org/article/S0002-9378(25)00498-3/fulltext2. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm3.https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm

Thank goodness for William Morton and Horace Wells- pioneers in anesthesia. Anesthesia has come a long way since them and there is even a professional medical society for OB anesthesia called SOAP. Today, August 07, 2025, there is a new Clinical Expert Series which was just released in the Green Journal. That publication (which is ahead of print) is titled, Key Management Considerations in Obstetric Anesthesiology, is our episode focus. Can you safely have an epidural placed if the patient has platelets under 100K? Can labor epidurals cause pyrexia alone? Do labor epidurals slow labor? Listen in for details. 1. Clinical Expert Series, Key Management Considerations in Obstetric Anesthesiology. Obstet Gynecol; ePub 08/07/2025. 2. ACOG PB 2017; 20193. Adams AK. Tarnished Idol: William Thomas Green Morton and the Introduction of Surgical Anesthesia. J R Soc Med. 2002 May;95(5):266–7. PMCID: PMC1279690.4. Hegvik, Tor-Arne et al. Labor epidural analgesia and subsequent risk of offspring autism spectrum disorder and attention-deficit/hyperactivity disorder: a cross-national cohort study of 4.5 million individuals and their siblings.American Journal of Obstetrics & Gynecology, Volume 228(2): 233.e1 - 233.e125. https://med.stanford.edu/news/all-news/2021/04/Epidural-use-at-birth-not-linked-to-autism-risk-study-finds.html

EMDR (Eye Movement Desensitization and Reprocessing) therapy is a recognized and effective treatment for postpartum PTSD, particularly when related to a traumatic birth experience. EMDR helps individuals process traumatic memories and reduce the associated distress, allowing for a more adaptive way of remembering the event. On Aug 4, 2025, a new publication was released in AJOG pertaining to this therapy. What’s this latest randomized controlled trial data saying? Listen in for details.     1. Hendrix YMGA, van Dongen KSM, de Jongh A, vanPampus MG. Postpartum Early EMDR therapy Intervention (PERCEIVE) study forwomen after a traumatic birth experience: study protocol for a randomizedcontrolled trial. Trials. 2021 Sep 6;22(1):599. doi: 10.1186/s13063-021-05545-6.PMID: 344888472.     Sajedi, S.S., Navvabi-Rigi, SD. & Navidian,A. Midwifery-led brief counseling on the severity of posttraumatic stresssymptoms of postpartum hemorrhage: quasi-experimental study. BMC PregnancyChildbirth 24, 729 (2024).3.     8/4/25: Treatment of Traumatic Birth Experiencewith Postpartum Early Eye Movement Desensitization and Reprocessing Therapy:Hendrix, Yvette M.G. A. et al.4.     A Randomized Clinical Trial. American Journal ofObstetrics & Gynecology, Volume 0, Issue 0

Edwards syndrome (trisomy 18) affects approximately 1 in 5,000 to 6,000 live births. Patau syndrome (also known as Trisomy 13) is even less common, occurring in about 1 in 8,000 to 12,000 live births. About 20% of cases of Patau syndrome are caused by translocation. On the other hand, approximately 10% of Edwards syndrome cases are caused by a genetic translocation. Both conditions result in a wide range of birth anomalies including the heart, kidneys, and brain as well as cognitive limitations. Both of these conditions are part of maternal cell free fetal DNA testing (NIPTs). Prenatal counseling for expectant parents whose fetus was found to have T13 or T18 once focused exclusively on options for pregnancy termination or postnatal comfort care, on the presumptive basis that all affected infants died. However, examination of contemporary outcomes for these infants suggests that death in the neonatal period is not universal, particularly for infants who receive intensive medical and surgical care after birth. Although severe cognitive and motor impairment and shortened lifespan are anticipated for all survivors, some infants with these disorders live for 1 year or more, and some attain social and interactive milestones, with positive quality of life noted by their caregivers. This has led to newly updated guidance released by the AAP on July 21, 2025. This is a marked shift in counseling for parents of an affected child. Here, we will review what this new guidance is, and what it isn’t. Listen in for details.1.https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2025-072719/202649/Guidance-for-Caring-for-Infants-and-Children-With Guidance for Caring for Infants and Children With Trisomy 13 and Trisomy 18: Clinical Report | Pediatrics | American Academy of Pediatrics

Delayed (AKA deferred) Cord Clamping (DCC) is extremely beneficial for both the preterm and term neonate. In September 2025, a new Clinical Practice Update (CPU) will be released by the ACOG regarding the amount of time DCC should be done for preterm newborns. This updates data from a Clinical Expert Series which was released in 2022, called “Management of Placental Transfusion to the Neonate”. Is the recommended amount of DCC 30 sec, 45 sec, or at least 60 seconds for preterm newborns? We will highlight this data in this episode. PLUS, we will very quickly summarize a separate yet related publication from JAMA Pediatrics regarding the use of supplemental O2 (100% PP face mask) during DCC for babies born at 22- 28 weeks. Listen in for details.1. ACOG CPU, Sept 2025: “An Update to Clinical Guidance for Delayed UmbilicalCord Clamping After Birth in Preterm Neonates”2. ACOG Clinical Expert Series, Management of Placental Transfusion to the Neonate”; 2022. 3. JAMA PEDIATRICS (July 21, 2025): https://jamanetwork.com/journals/jamapediatrics/article-abstract/2836681

Podcast family, in this episode we will reply to 2 questions raised by our 2 of our podcast family members. The first pertains to a real world, HORRIBLE tragedy of hepatic rupture in pregnancy (no identifiable information released). We will review how and why this happens and what is the single, 5-letter, clinical diagnosis that makes this a possibility. Secondly, we will answer this question: Can MagSo4 ALONE lead to pulmonary edema. The answer is YES. Listen in for details.1. ACOG PB 222;20202. COMMONLY USED MAGNESIUM SULFATE UNCOMMONLY CAUSING PULMONARY EDEMAVYATA, VISHRUTH et al.CHEST, Volume 162, Issue 4, A10293. Singh Y, Kochar S, Biswas M, Singh KJ. Hepatic Rupture Complicating HELLP Syndrome in Pregnancy. Med J Armed Forces India. 2009 Jan;65(1):89-90. doi: 10.1016/S0377-1237(09)80072-5. Epub 2011 Jul 21. PMID: 27408207; PMCID: PMC4921511.4. Escobar Vidarte MF, Montes D, Pérez A, Loaiza-Osorio S, José Nieto Calvache A. Hepatic rupture associated with preeclampsia, report of three cases and literature review. J Matern Fetal Neonatal Med. 2019 Aug;32(16):2767-2773. doi: 10.1080/14767058.2018.1446209.

Polyhydramnios may be due to excess urine production or impaired fetal swallowing. The ACOG CO 831 states that mild, idiopathic polyhydramnios may be delivered at 39 weeks and 0 days and thereafter, but there is no specific mention regarding moderate to severe poly. In this episode we will cover delivery of moderate to severe poly. Is that data in SMFM consult series 46 (Evaluation and management of polyhydramnios)? The answer is both YES and NO. Listen in for details.1. ACOG CO 8312. SMFM CS 463. https://med.uc.edu/docs/default-source/obstetrics-and-gynecology-docs/ob-mfm-protocols/a-d/isolatd-amniotic-fluid-disorders.pdf?sfvrsn=75dc58e4_4

What’s best for skin closure at C-Section? Staples or suture? This debate has raged for over 20 years. Past data has shown greater odds of wound complications with metal staples compared to suture. But new a meta-analysis from June 2025 is challenging the prior results. In this episode, we will explore the data from 2010 to present day. PLUS, we will summarize a separate meta-analysis examining if wound dressing removal is tied to any wound complication. This was just published July 15, 2025 in the “Pink” journal. Listen in for details. 1. 2010: Basha SL, Rochon ML, Quiñones JN, Coassolo KM, Rust OA, Smulian JC. Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet Gynecol. 2010 Sep;203(3):285.e1-8. doi: 10.1016/j.ajog.2010.07.011. PMID: 20816153.2. 2015: Mackeen AD, Schuster M, Berghella V. Suture versus staples for skin closure after cesarean: a metaanalysis. Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. PMID: 25530592.3. Jan 2025: Gabbai D, Jacoby C, Gilboa I, Maslovitz S, Yogev Y, Attali E. Comparison of complications and surgery outcomes in skin closure methods following cesarean sections. Arch Gynecol Obstet. 2025 Jul;312(1):125-129. doi: 10.1007/s00404-024-07911-6. Epub 2025 Jan 25. PMID: 39862268; PMCID: PMC12176926.4. June 2025: Post-cesarean skin closure with metal staples versus subcuticular suture in obese patients: A systematic review and meta-analysis of randomized controlled trials. Luis Sanchez-Ramos et al (Univ Florida). https://onlinelibrary.wiley.com/doi/pdf/10.1002/pmf2.700615. DRESSING REMOVAL: July 15, 2025: Leshae A Cenac, Serena Guerra, Alicia Huckaby, Gabriele Saccone, Vincenzo Berghella. Early Wound Dressing (soft gauze/tape dressing) Removal after Cesarean Delivery: A Meta-Analysis of Randomized Trials: Short title: early wound dressing removal after cesarean, American Journal of Obstetrics & Gynecology MFM, 2025; https://doi.org/10.1016/j.ajogmf.2025.101739.6. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

We have covered Low Dose Aspirin (LDA) for pre-natal preeclampsia prevention MANY times before. But here's a good clinical question: Since preeclampsia can also pop-up in the first 6 weeks postpartum (pp), should we continue it in the immediate pp interval? There is a new publication, an RCT, in the AJOG that looked to answer this- and we will highlight that publication in this episode. PLUS, we will briefly summarize a separate publication from the American J Perinatology back in 2023 that also provided some clinical insights on this topic. Listen in for details.1. The association between postpartum aspirin use and NT-proBNP levels as a marker for maternal cardiac health: a randomized-controlled trial; July 2025 (AJOG): https://www.sciencedirect.com/science/article/pii/S00029378250047522. Christenson E, Stout MJ, Williams D, Verma AK, Davila-Roman VG, Lindley KJ. Prenatal Low-Dose Aspirin Use Associated with Reduced Incidence of Postpartum Hypertension among Women with Preeclampsia. Am J Perinatol. 2023 Mar;40(4):394-399. doi: 10.1055/s-0041-1728826. Epub 2021 May 3. PMID: 33940641.3. Mendoza M, Bonacina E, Garcia-Manau P, et al. Aspirin Discontinuation at 24 to 28 Weeks’ Gestation in Pregnancies at High Risk of Preterm Preeclampsia: A Randomized Clinical Trial. JAMA. 2023;329(7):542–550. doi:10.1001/jama.2023.0691

Amniotic Fluid Sludge (AFS) has been theorized to be sonographic evidence of an underlying infection/inflammation. Others have proposed it may represent an organized clot from the placental surface. At the same time, the finding of AFS may be more common as a benign finding especially at/after 40 weeks as the amniotic fluid accumulates shed skin cells, vernix, and possibly meconium past 41 weeks. What can be tell the patient when we identify AFS in the early second trimester? What do we do with this? In this episode, we will summarize the data on second trimester AFS and review the evidence-based “next steps” in care. Does this require empiric antibiotic therapy in the asymptomatic patient? Listen in for details. 1.     Zimmer EZ, Bronshtein M. Ultrasonic features ofintra-amniotic "unidentified debris' at 14-16 weeks' gestation. UltrasoundObstet Gynecol. 1996 Mar;7(3):178-81. doi: 10.1046/j.1469-0705.1996.07030178.x.PMID: 8705409.2.     Luca S-T, Săsăran V, Muntean M, Mărginean C. AReview of the Literature: Amniotic Fluid “Sludge”—Clinical Significance andPerinatal Outcomes. Journal of Clinical Medicine. 2024; 13(17):5306. https://doi.org/10.3390/jcm131753063.     Sapantzoglou I, Pergialiotis V, Prokopakis I,Douligeris A, Stavros S, Panagopoulos P, Theodora M, Antsaklis P, Daskalakis G.Antibiotic therapy in patients with amniotic fluid sludge and risk of pretermbirth: a meta-analysis. Arch Gynecol Obstet. 2024 Feb;309(2):347-361. doi:10.1007/s00404-023-07045-1. Epub 2023 Apr 25. PMID: 37097312;

Podcast family, we are in process of an exciting rebrand! Dr. Chapa's Clinical Pearls will soon become our legacy show as we change names and channels to, "Dr. Chapa's OBGYN No Spin Podcast". This will allow us to better align with our mission. Listen in for details and FIND US, as Dr. Chapa's OBGYN No Spin Podcast!!

Intrahepatic Cholestasis of Pregnancy (ICP) has dichotomous effects: Benign for the mother (although the itching it causes may be a qualify of life issue, yet potentially devasting for the child in-utero. In 2021, SMFM released Consult series 53 on the subject. This, together with the ACOG 's CO 831 (Medically Indicated Late Preterm and early term delivery) also from 2021 provide management options for ICP. However, this month- July 2025- Dr. Cynthia Gyamfi-Bannerman et al published a new proposed ICP classification and management schema that is easy to follow. Listen in for details. ​ SMFM CS #53,2021​ ACOG CO #831, 2021​ Sarker M, Ramos GA, Ferrara L, Gyamfi-Bannerman C. Simplifying Management of Cholestasis: A Proposal for a Classification System. Am J Perinatol. 2025 Jul;42(9):1229-1234. doi: 10.1055/a-2495-3553. Epub 2024 Dec 4. PMID: 39631774

Stillbirth is one of the most devastating adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In March 2020, the ACOG released OCC #10, "Management of Stillbirth". Now, formally released July 2025, the SMFM has an updated checklist for stillbirth care, published in the journal Pregnancy. In this episode, we will highlight some nuances in this list. Listen in for details.​ SMFM Special Statement (July 2025): Society for Maternal-Fetal Medicine Special Statement: Checklists for management of pregnancies complicated by stillbirth.​ ACOG OCC 10; March 2020

PPH is terrible. PPH must be assessed quickly via the “4Ts” and acted upon in a timely manner. And listen to this: new data from the Journal of Maternal-Fetal & Neonatal Medicine (June 24, 2025 ahead of print) finds an association with PPH and adverse outcomes years later: the odds of cardiovascular disease (CVD) and thromboembolism disease are increased in patients with postpartum hemorrhage (PPH), to a magnitude of 1.76 fold. That’s why these authors recommended "proactive postpartum care". That’s what we’re gonna talk about in this episode. Control of PPH includes bladder drainage, uterine massage, medications as appropriate, and mechanical methods of bleeding control. So… Vacuum uterine contraction works, and a balloon works. Even a simply 24 Fr foley has efficacy data in this setting as a uterine tamponade tool. But, in an attempt to have a LOW-COST, HIGHLY EFFECTIVE, and easy to use alternative to the Jada and Bakri- could we just use an intrauterine foley catheter and connect that to vacuum suction? JADA is effective but it limited based on uterine (EGA) size, or in cases of uterine anomaly. But most importantly…JADA and Bakri are expensive! Well, we now have data that this approach, using a low-cost, easy to use alternative, may be a consideration. It is FOCUS. This idea comes from one of our podcast family members, Dr. Frank Jackson- an MFM fellow- who has published his experience with this and already has a new publication on this technique (FOCUS), which was released as we were recording this very episode! Listen in for details.

Severe nausea and vomiting in pregnancy/hyperemesis gravidarum (HG) takes a toll on patient, and the healthcare system. According to a June 2024 ACOG Clinical Expert Series on the subject, GFD15 and IGFBP7 both play important roles in placentation, appetite, and cachexia that are linked to hyperemesis gravidarum. Specifically, LOW pre-pregnancy GFD15 is associated with increased frequency of HG as GFD15 levels spike post pregnancy in an otherwise "naive" system. Since metformin increases GFD15, can this be a pre-pregnancy, chemoprophylactic option in high risk women? New data just released (June 2025; AJOG) provides some eye-opening insights. Listen in for details.

OASIS (3rd and 4th degree perineal lacerations) occur at a rate of 4-11% (average around 5.5%). OASIS lacerations have both short term and ling term potential morbidities. Practice Bulletin 198, from 2018, briefly discusses counseling patients following OASIS on subsequent mode of delivery options. Now, in a soon to be released AJOG publication, authors have provided a wonderful and comprehensive review on "patient-centered" guidance regarding mode of delivery in a subsequent pregnancy following OASIS. This is a detailed episode, so listen in for the update!

Ladies and gentlemen, welcome back to another addition of “You asked, We answered”! In this brief episode, we will tackle 2 very appropriate clinical questions:1. Why do cervical psychology reports still state the presence or absence of endocervical cells/TZ component if it does not change management, and 2. Does continued magnesium sulfate infusion during C-section increased blood loss? We have done similar “you asked, we answered” episodes in the past and we will continue to do them as questions arise. Listen in for details.

The Bishop Score was originally developed in 1964 by Dr. Edward Bishop and remains the central assessment tool for determining the appropriateness of cervical ripening for labor induction. We have covered pharmacologic and mechanical methods of cervical ripening for labor induction many times in prior episodes. Ut now, in July 2025, there will be a new clinical practice guideline (#9) from the ACOG which has some notable items. Does the ACOG recognize COMBINATION mechanical and pharmacologic agents for cervical ripening for labor induction? What about outpatient cervical ripening? What are the recommended protocols for oral and vaginal prostaglandins? Listen in for details.

Second and/or Third trimester vaginal bleeding is a common reason for L&D Triage patient assessment. The evaluation starts with determining the status of maternal hemodynamic stability. This together with IV access are key first steps. This is followed by an assessment of fetal-placental status. Typically this includes bedside ultrasound for fetal position, visual confirmation of FHTs, amniotic fluid determination, and placental location. At the same time, lab data is obtained to guide care: CBC, fibrinogen, type and RH, and possibly type and cross. Do you order a KB test as part of the STANDRAD evaluation for suspected placental abruption? In this episode, we will review a new study released ahead of print on June 8, 2025 in the European J of Obstetrics, Gynecology, and Repro Biology. Listen in for details.

Antenatal Corticosteroids (ACS) for Fetal Lung Maturation (and more) is an ever evolving saga. This is how science and medicine evolve, by always seeking more information. The effect of antenatal corticosteroids on neonatal/child neurodevelopmental outcomes is controversial and may be influenced by the gestational age at which exposure occurred. In this episode we will highlight TWO recent publications, one from May 2025 (JAMA Netw) and the other from June 2025 (Obstet Gynecol). The first adds data to the "Dose to Delivery interval" question for ACS benefit, and the second article relates to neurodevelopmental outcomes after exposure. Listen in for details.

Innovation in medicine is happening. In our immediate past episode, we summarized how AI is improving standard mammography to now PREDICT breast cancer rather than just diagnosing it once it was appeared. In a past episode, we covered a new and novel “first in class” oral medication for uncomplicated UTIs in women called Blujepa. This is innovation! Well now, as of June 10, 2025, the FDA has granted a New Drud Application for a new and noval oral antibiotic against gonococcal (GC) infection! In this episode, we will review the current CDC treatment protocols for GC and highlight what this new medication’s MOA is and what to expect from this FDA process.

Each year, more than 2.3 million women worldwide are diagnosed with breast cancer—including over 370,000 in the United States alone. For more than 60 years, mammograms have saved lives by detecting early-stage cancers. Now, advancements in AI have lead to a first of its kind breast imaging algorithm that can PREDICT future (5-year) breast cancer risk in the patient (CLARITY BREAST). This is GROUNDBREAKING. Yes, there has been other new tools, like the recent contrast enhanced mammography data, for early detection of breast cancer, but this is the first technology to help PREDICT it in the future. Nonetheless, questions remain. Listen in for details. (CLARITY is not a sponsor)

It’s interesting how, at times, different medical societies can look at the same data and arrive at different recommendations. It happens! In April 2025, the Society of Family Planning (SFP) released its new clinical recommendations for the medical management of early pregnancy loss (EPL), AKA miscarriage. This clinical guidance has 4 remarkably interesting differences when compared to the ACOG practice bulletin # 200 on early pregnancy loss. In this episode, we will review these 4 key differences and summarize the latest recommendations for the medical management of miscarriage. Listen in for details.

The white-coat effect is a measure of blood pressure change from before to during the visit in office/clinic when the blood pressure is recorded by a physician or nurse; this was first described in 1983 by Mancia et al, and was initially thought to represent a benign process. But it was unclear what this actually meant for pregnancy. Ambulatory blood pressure monitoring (ABPM) has been used in pregnancy for about 20 years now. Use of this monitoring option has revealed a subgroup of patients who have persistently high blood pressure (BP) in the presence of health care providers, but a normal ambulatory or self-measured BP. This phenomenon has been termed “White Coat Hypertension” (WCH). In 2013, The International Society for the Study of Hypertension in Pregnancy (ISSHP) published the revised classification for hypertensive disorders in pregnancy, that included WCH, not previously included. The ISSHP guidelines also emphasize that a diagnosis of white coat hypertension in pregnancy should only be considered before 20 weeks of gestation. We now know that WCH, outside of pregnancy, is not an entirely benign process. The role of metabolic risk factors in patients with white-coat hypertension was first outlined in 2000 by Kario and Pickering. When metabolic risk factors are present in association with white-coat hypertension, the increased risk of target organ damage is determined not only by the blood pressure characteristics but also by the metabolic abnormalities. Recognizing the potential risks of white coat hypertension was also published in a commentary in 2016 out of the European Society of Cardiology. That article’s title was, “White-coat hypertension: not so innocent”. But what is the latest data on WCH in pregnancy? Is WCH linked to poor obstetrical outcomes? Does WHC need medication therapy? We have data from 2024 to help us. Listen in for details.

Uterine incarceration in pregnancy, is a rare but troublesome complication. This occurs when a retroverted uterus becomes trapped in the pelvic cavity during pregnancy. This happens when the uterus fails to move forward as it grows, becoming stuck between the sacral promontory and pubicsymphysis. It's more common in women with prior pelvic issues or uterine anomalies. Urinary retention is the most common symptom that occurs because of elongation of the urethra by displacement of the cervix, loss of the urethro-vesical angle, and mechanical compression of the bladder neck. It is estimated to occur in 1 in 3000 patients. How do we release an incarcerated uterus? Is laparoscopy an option? And how can an ultrasound probe help (April 2025publication)? Listen in for details.

In May 2024, the FDA approved vaginal self-collection for HPV as a cervical cancer screening tool. This was limited to health care settings. While this self collection option can help address some of the emotional deterrents to a speculum examination, it fails to overcome the remaining substantial clinic access barriers cited among those who are underscreened, including time off work, arrangement of child or elder care, and transportation. Then, the FDA approved the first at-home cervical cancer screening test on May 9, 2025. This test, called the Teal Wand (FDA-approved prescription device), allows individuals to self-collect vaginal samples at home to test for Human Papillomavirus (HPV). But is at-home testing valid? Does this work? A new publication in JAMA Network Open (May 19, 2025) answers this important question. Listen in for details.

In the US, an estimated 70-75% of women who give birth use an epidural for pain relief during labor. Epidural anesthesia during labor can affect bladder function by delaying the return of bladder sensation and potentially leading to urinary retention. This can be due to the nerves that control bladder function being affected by the epidural, reducing the sensation of bladder fullness and the urge to urinate. Intrapartum, there is no universal guidance regarding bladder management with labor epidural analgesia (LEA). Does one method of bladder care intrapartum affect mode of delivery more than the other? Is it better to have an indwelling catheter or to perform intermittent caths. What about patient self-voiding with a bedpan. Let’s summarize the data.

At the end of April 2025, we released an episode summarizing the ERAS update for 2025. In that episode/update, we summarized the data on extended spectrum prophylactic antibiotics at cesarean section in patients living with obesity. The ERAS protocol recognized the value of oral cephalexin and metronidazole for 48 hours in patients with obesity who receive single agent Cephalosporin prophylaxis preop. Now, a new (RCT) publication soon to be released in the Green Journal, evaluates whether using dual agent pre-op prophylaxis (ancef and zithromax) together with post op oral cephalexin and metronidazole has benefit in reduction of SSI composite risk. Does this help? When is too much prophylactic antibiotics, just too much? Listen in for details.

We have covered menopause on this show on various occasions. That’s fitting and non-surprising as we are a women’s health education podcast! While vaginal dryness and hot flashes get most of the attention in menopause, and they should, less attention often is given to skin changes. Nonetheless, these dermal manifestations of perimenopause and menopause can be just as disturbing to those affected. Estrogen helps skin produce oil and hold onto water, so extremely dry skin during menopause is common. Plus, according to the American Academy of Dermatology, collagen production drops 30% in the first 5 years of menopause and approximately 2% each year for about the next 20 years. Collagen gives skin its plumpness and structure. The direct-to-consumer market is replete with a variety of over-the-counter estrogen containing products, formulated as facial creams, which are meant to fight the battle of skin aging. But is topical estrogen applied to the face effective? What are the data? You’d be surprised to learn that there is published data on this- even level I data. Are there any safety concerns? We will summarize it in this episode. PLUS, as a “two-for one” special, we will also briefly highlight a brand new publication in the journal JAMA Network Open regarding antenatal corticosteroid dose to delivery interval and fetal benefits.

In 2014, the International Society for the Study of Women's Sexual Health together with the North American Menopause Society introduced the term “Genitourinary syndrome of menopause” to replace the prior term vulvovaginal atrophy. Ten years after that, in 2024, a related term “Genitourinary Syndrome of LACTATION, was introduced to better capture the genitourinary issues lactating women may experience. A new systematic review, soon to be released in the journal obstetrics and gynecology, provides new data on GSL prevalence and characteristics. This is a good reminder for any clinician who evaluates postpartum/lactating women to ask about GSL. How does sexual dysfunction fit into this question? Listen in to the next episode of Dr. Chapa’s Clinical Pearls Podcast for more details.

Endometriosis is a prevalent gynecologic condition that affects approximately 10–15% of women of reproductive age worldwide. For endometriosis related pelvic pain, continuous combination birth control pills have long been the first-line pharmacologic intervention of choice. But new data published May 15, 2025 (ahead of print) in Obstetrics and Gynecology is challenging that tradition. In this episode , we will summarize the key findings of this brand new network systematic review and metanalysis. Plus, we will also review what is missing from the ACOG PB 114 regarding the management of endometriosis. Listen in for details.

In August 2024, the CDC updated its MEC. This included a recommendation for local anesthesia for IUD/S placement and also had guidance regarding misoprostol for that procedure. Coming up in July 2025, the ACOG will officially release a new clinical consensus on “Pain Management for In-Office Uterine and Cervical Procedures”. Are these recommendations similar to the CDC’s? What about misoprostol? Was the non-use of local anesthesia for these office-based procedures rooted in racism and sexism? Listen in for details.

Asthma is more prevalent in adult women than in adult men. Specifically, data from the National Health Interview Survey (NHIS) indicates that 9.7% of adult women had asthma, compared to 5.5% of adult men. This higher prevalence is observed across various racial and ethnic groups within the adult female population. At the end of April 2025, new population-level data was published (UK) describing an alarming association between progastrin only pills and asthma exacerbations. Is this a new finding? Recently, it seems that there has been a barrage of negative press towards progestin only contraceptives: depo provera and brain tumors, progestin releasing IUS and breast cancer, and the progestin IUS and rosacea. What is happening here?! We'll break it all down in this episode.

Female Genital Mutilation (FGR) is condemned by the WHO, Unicef, and the US. Nonetheless, it is still being performed worldwide, and in North America. In this episode, we will recently published data (April 2025) from BMC regarding this practice. This episode's topic was brought to me by one of our podcast family members who currently has a pregnant patient with FGR. Does this patient require a cesarean section? What are the 4 types (classifications) of FGR? Listen in for details.

(Topic Requested): Serum Magnesium and Calcium have an intimate and complex relationship best described as “love-hate”. One of our podcast family members sent me this fascinating question: “Should we be following serum calcium levels in patients undergoing IV Mag Sulfate use in obstetrics, in order to identify dangerous hypocalcemia?...Should we be giving these patients prophylactic calcium?” Thera are indeed published case reports of hypocalcemia induced tetany in patients. However, are there national guidelines which call for “calcium surveillance”? Do you remember what the Chvostek's and Trousseau's signs are? Listen in for details.

Some debates in medicine and in OBGYN are “the same ol’ thing”. Like the debate on when to remove the urinary catheter after a “routine” cesarean section. In the original 2019 ERAS publication, the authors stated that “immediate” removal of the urinary catheter was “strongly recommended”. This drew concern and criticism as being too early in the recovery process. Not, in the UPDATED ERAS guidelines (as of end of April 2025), this recommendation has once again changed! In this episode, we will review the new guidance from the ERAS Society regarding post cesarean section care focusing on when to stop IV fluids and urinary drainage.

The term "genitourinary syndrome of menopause" (GSM) was introduced in 2014 by the International Society for the Study of Women's Sexual Health and the North American Menopause Society (now the Menopause Society). This new term was created to replace older terms like vulvovaginal atrophy, urogenital atrophy, and atrophic vaginitis, and it encompasses the range of symptoms related to hormonal changes in the vulvovaginal and urinary tract areas that can occur during menopause. Recurrent UTIs are more likely in postmenopausal women not on vaginal estrogen therapy. IN this episode, we will highlight new data from the recent AUA meeting which looked at surprising benefits on postmenopausal vaginal estrogen in women with recurrent UTIs. Nonetheless, questions on the data remain. Listen in for details.

The ERAS (Enhanced Recovery After Surgery) concept was initially developed for colorectal surgery in 1997 to standardize surgical protocols. The ERAS Society then first published a guideline for cesarean section (ERAC) in 2018-2019. Now, as of April 28, 2025, the ERAS Society has released a NEW UPDATE for ERAS-CS. In this episode we will focus on 2 main areas: 1. Vaginal prep at CS, and 2.Extended antibiotic prophylaxis in patients with obesity! Medicine moves fast, and this data exemplifies that. PLUS, we will relate these 2 points back to the ACOG PB 199 which focused on prophylactic antibiotics at cesarean section.

I know this sounds braggadocious, but I'm going to say it anyway: I work with some incredible people! We recently released a podcast on updated TOLAC uterine rupture data. One of our former residents reached out to me with a question about this: “Did they include interdelivery interval in their assessment?” You see, I work with really smart people! There's an answer to that question, and we're going to cover that in this episode. PLUS, a current resident, Spencer, had a great question about proof of immunity to rubeola (measles) in pregnancy. Can we assume that if a patient is rubella immune that she is also immune to rubeola? That's a great question, and we will explain in this episode!

Spontaneous twin pregnancies occur in about 1 out of every 250 pregnancies. A real world clinical question has to do with dating a spontaneous twin gestation: Do we use the smaller crown rump length or the larger for dating in the 1st trimester? Do we use the smaller or larger measurement of biometry in the 2nd trimester? We had this discussion today in our prenatal clinic, and in true form and fashion, I turned it into an episode! PLUS, there is practice guidance from Jan 2025 (ISUOG) to settle the debate. Listen in for details.

In the ACOG Practice Bulletin 205 (Reaffirmed August 2025), the stated risk of uterine rupture with TOLAC is stated as 0.7% (after 1 prior LTCS). However, as our podcast tag list holds true, "Medicine Moves Fast". In an new upcoming publication from Obstet Gynecol (The Green Journal), May 2025, authors looked at the rate of uterine rupture with TOLAC over a 12 year interval. The rate of uterine rupture was NOT close to the national quoted rate in the Practice Bulletin. This information, which was also presented at the Jan-Feb 2025 Pregnancy Meeting, can be very helpful in counseling patients desiring TOLAC. Listen in for details.

As healthcare professions we are often pulled in different directions ALL AT ONCE. It happens. We "multitask" every day. Or do we? Neuroscience actually states that we don't multitask at all; rather, we "task-switch" and that may lead to increased physiologic and mental stress and patient error. Yep, there is a MYTH about multitasking. In this brief episode, we remind ourselves that its OK to put somethings off, as able, until one task is completed. As the famed stoic philosopher Publilius Syrus wrote, "To do two things at once is to do neither". Listen in for details.

I love my home state of TEXAS. I am definitely full of Texas pride. We have Texas barbecue, Texas, hospitality, and of course, the Texas music scene! Our state definitely has some issues to improve on, mainly access to maternity care. We have a HUGE state and 50% of our counties are maternity care deserts. It’s a vast vast Land to cover! Texas has also received a lot of criticism regarding its heartbeat law originally named SB8, which was passed in 2021. Commentaries since then have stated that OBGYNs are leaving the state by the droves! Is that accurate? A new publication from JAMA network open (April 21, 2025) seems to contradict these commentaries. Listen in for detail details.

There have been various publications and commentaries published on “evidence-based” cesarean section techniques. Still, one of the persistent controversies on abdominal wall closure relates to the rectus. With transverse fascial entries, should we close/reapproximate the rectus or not? In June 2025, a new RCT looking at this very issue will be printed in the European J Obstetrics Gynecology and Reproductive Biology. Listen in for details.

On December 13, 2022, we released an episode describing a new concept in prenatal care, called the PATH model. This was to “redesign” prenatal care, as needed, for those who may have limitations for the “traditional” model of prenatal care visits. Well, what we covered 2.5 years ago is NOW an OFFIICAL guidance from the ACOG and will be out in May 2025. Similarly, the SMFM released their vision for redesigned maternal care teams on 16 April 2025 (J Pregnancy). We will BRIEFLY summarize these 2 publications in this episode.

Pelvic congestion syndrome is a controversial entity that does not currently have validated diagnostic criteria. In the ACOG PB 218 (2020), it states, “Pelvic congestion syndrome is a proposed etiology of chronic pelvic pain related to pelvic venous insufficiency. Although venous congestion appears to be associated with chronic pelvic pain, evidence is insufficient to conclude that there is a cause-and-effect relationship. In addition, there is no consensus on the definition of this condition, and diagnostic criteria are variable. Further research is needed to establish greater consistency in diagnosis and homogeneity in treatment studies”. Is that it? Is that all there is? NO! There has been great interest in the diagnosis of this enigmatic condition and in potential new treatment options. The last publication on this was just released in March 2025 as a “pilot study”. In this episode, we will combine multiple sources and explain this controversial condition and offer hope to patients who may indeed have this real disorder.

On Monday April 7, 2025, the UK’s publication The Guardian wrote, “Surgeons are hailing an ‘astonishing’ medical breakthrough as a woman became the first in the UK to give birth after a womb transplant. Grace Davidson, 36, who was a teenager when diagnosed with a congenitally absent uterus, said she and her husband had been given ‘the greatest gift we could ever have asked for’. Grace’s sister donated her own womb during an eight-hour operation in 2023. Davidson said she felt shocked when she first held her daughter, who was born by planned NHS caesarean section on 27 February. She was first UK womb transplant recipient to give birth”. Since the first successful uterine transplant in 2011, there have been over 70 live births worldwide. These births have occurred following more than 100 uterine transplant procedures. This episode, we will review the fascinating history of this procedure. We will also answer some questions regarding uterine transplant like can the patient has vagina sex after this? How is this procedure done? Are these babies born vaginally? And which location in TEXAS become a world-renowned uterine transplant center? Listen in for details.

On March 19. 2025, The American College of Clinical Pharmacy published, "A review of antibiotic safety in pregnancy- 2025 Update". In this episode, we will review some of the confusion surrounding aminoglycosides, sulfa, and nitrofurantoin in pregnancy. Its interesting how different professions view certain medications in pregnancy. Does ACOG say you can use Sulfa in the third trimester? Can you use nitrofurantoin in the first trimester? Listen in for details. (SHOUT OUT to our partner podcast, CLINICAL PEARLS LATINO, for the topic idea. GRACIAS AMIGOS)

Well Podcast Family, in this VERY BRIEF episode, we will highlight a patient's perspective on IUS insertion with lidocaine jelly pre-insertion prep. As we have stated in past episodes, I am a BIG ADVOCATE of lidocaine jelly for IUD/IUS insertion. This patient agreed to share her experience of the EASY BREEZY IUS placement. (NOTE: HIPAA protected, patient agreed to participate in this episode).

Animal bites in humans are a common problem in the United States, with two to five million occurring each year. The vast majority of animal bites are caused by dogs (85 to 90 percent), with the remainder caused by cats (5 to 10 percent) and rodents (2 to 3 percent). Children are bitten more often than adults. The most feared complication of an animal bite is rabies, although skin infection is the most common complication. In our community high risk clinic, we recently saw a pregnant patient, who also has diabetes, who had a “cat bite” reported to our nursing staff. On examination, it was more like she was mauled by the cat! Both her feet had significant scratches and bite marks. Are you up to date in your animal bite care algorithm? It's one of those occurrances that are low frequency but have potential high morbidity. So in this episode I thought we would review the care plan for a patient who has suffered a cat bite, or animal bite in general. Meow Meow.

VVC is second to BV in vaginitis type, here in the USA. data indicate that 75% of women have experienced at least one episode of genital candida throughout their lives . VVC is currently classified as uncomplicated (sporadic infection with mild-to-moderate clinical symptoms in non-immunocompromised women) or complicated (recurrent or clinically severe infection that eventually affects immunocompromised women or is caused by non-Albican species). What is the best course of action for these patients? Topical therapy or oral? Single or multiple dosages? In this episode, we will highlight a new publication from the AJOG which was just released ahead of print that looks at this issue. PLUS, we will revisit a 2001 multicenter study on single Diflucan vs sequential dosing every 3 days. As a little bonus, as the AJOG new publication is Italian, we will have sporadic interludes from ITALIA's best! Listen in for details.

Postural Orthostatic Tachycardia Syndrome (POTS), first described in the 1940s, is a heterogeneous and often debilitating condition affecting the autonomic nervous system, estimated to affect between 0.3% and 1% of the U.S. population. Its incidence is believed to be rising among people with a prior COVID-19 infection, as a likely component of so-called long COVID. The condition is characterized by chronic orthostatic intolerance in the absence of orthostatic hypotension manifested as excessive increased heart rate upon standing. The etiology is not well understood but is thought to be complex. One recent publication described the complex etiology of POTS as, “A multitude of pathophysiologic mechanisms including but not limited to disproportionate sympathoexcitation, volume depletion, autoimmune dysfunction, cardiac and physical deconditioning point to a heterogeneously complex etiology”. Other POTS symptoms include fatigue, headaches, cognitive impairment, palpitations, chest pain and gastrointestinal symptoms. These symptoms can significantly reduce quality of life. Interestingly, most people with POTS are under age 50. In this episode we will review POTS in pregnancy. What therapies are available? Does anxiety have a role within this process? Listen in for details.

Hematuria remains one of the most common urologic diagnoses, estimated to account for over 20% of urology evaluations. Women with hematuria have been especially prone to delays in evaluation, often due to practitioners ascribing hematuria to a urinary tract infection (UTI) or gynecologic source, resulting in inadequate evaluation and delay in cancer diagnosis. In this episode, we will review the recently released joint guidance form the AUA and SUFU regarding microhematuria. What defines this condition? If a UTI is also diagnosed, does that end the investigation? And what are the 3 risk profiles for microhematuria? Listen in for details!

HOT HOT HOT Off the News CycleL The FDA has just approved (1 hour ago) a new at-home STI test kit. Does this work? What is the data on accuracy? What does this test for? This is a developing story... Listen in for details!

Metabolic syndrome (MetSyn) is a cluster of conditions, such as increase in waist circumference, dyslipidemia (elevated triglyceride levels and reduced HDL), increased blood pressure, and increased fasting blood sugar levels that is related to insulin resistance, diabetes, and elevated risk of cardiovascular disease. Women with PCOS have a significantly higher prevalence of metabolic syndrome (MetS) compared to the general population, with studies indicating a prevalence of around 43-47% in PCOS women. PLUS, there is a high prevalence of moderate to severe depressive symptoms and depression in adults and adolescents with PCOS; therefore, screening for depression in all adults and adolescents with PCOS is encouraged. In this episode, we will review a new publication for the J Clinical Endo & Metabolism discussing this combination (PCOS and depression/anxiety) and the MetSyn, and we will review the EXPANDED indications for metformin for metabolic syndrome prevention/treatment according to the 2023 PCOS updated guidance.

Throughout their lifetime, over 50% of women experience uUTIs, with recurrent infection reported in approximately 30%. Today, on March 25, 2025, the FDA approved a new first-in-class oral antibiotic for uncomplicated UTIs in women! This is Blujepa! In this episode, we will review the EAGLE clinical trial data and review the main side effects reported in the study population. How does this new antibiotic work? Will it be approved for pregnancy? And, what other genital condition could it likely be approved for? Listen in for details!

Medicine has traditionally been practiced “in silos”. But compartmentalization of medical practice/interventions can leave gaps in patient care. Patients win when they have increased access to a variety of medical therapies or contraceptive options. In this episode, we will review a brand new publication (released ahead of print) from the AJOG. We've decided to call this episode, “Internists, IUDs, and Inspiration”. Listen in for details.

TWICE BEFORE, we have covered Pitocin use intrapartum: 1. On Oct 24, 2022 we covered, “Save the Pitcoin! Safe to Stop Pit Once in Active Phase?”, and 2. On Sept 24, 2024 we covered, “Labor Hacks: Pit Breaks”. Nonetheless, today's episode yet again focuses on pitocin in labor. On March 18, 2025, a new systematic review and meta-analysis was released ahead of print in the AJOG. This looks at cesarean delivery rates with discontinuation of pitocin in the active phase. Although the title of this new publication states, “Reduced risk of cesarean delivery with oxytocin discontinuation in active labor”, the devil is in the details! There's lots to review here, so listen in for details.

Fresh off the heels of our immediate last episode, we bring you a perspective from the trenches! Sarah, a Clinical Pearls podcast family member, is a health professional who works with autistic individuals. Sarah has provided clear and evidence-based data which helps to explain the rise of autism in the US over the last decades. Our podcast community is Incredible! Her noted and data driven perspective are the core concepts highlighted in this episode. Listen in for details.

Autism Spectrum Disorder (ASD) has an alarming trend of rise in the US. Currently, 1 in 36 (or 1 in 40 in some reports) have an ASD diagnosis. For this reason, ASD remains in the spotlight as researchers remain dedicated in explaining its origin. Over the last few years, there have been publications suggesting a link between one of the most common symptoms of pregnancy (nausea and/or nausea together with vomiting) and autism spectrum in the child. This is obviously a point of concern for those suffering with nausea slash vomiting in pregnancy. Is this association solid? What does the data show? It's controversial, but we will drive through it in this episode. PLUS, we will also highlight 2 recent publications (January 2025, February 2025 ) that provide some comfort for those suffering with these common symptoms. Listen in for details!

Fasting during the lunar month of Ramadan (Feb 28 to March 30, 2025) is a core practice for Muslims across the world. During Ramadan, Muslims abstain from food and drink from dawn to sunset. However, during a singleton pregnancy, the ACOG recommends adding approximately 340 extra calories per day in the second trimester and 450 extra calories per day in the third trimester. Does fasting during Ramadan have negative perinatal outcomes due to the potential caloric restriction? In this episode, we will highlight a Clinical Opinion publication from AJOG (June 2023) to examine the data.

Infants born by vaginal birth are exposed to maternal vaginal bacteria, which are one of the contributing influences on the subsequent development of the infant’s microbiome. This process is altered by cesarean delivery, which changes the initial microbiome of the neonate. It is theorized that infants born by cesarean delivery have an increased risk of chronic inflammatory conditions due to altered early-life microbiome colonization, with associated aberrant immune and metabolic development. Vaginal seeding is the practice of inoculating an infant born by cesarean section with a sampling of fluid, with the use of a guaze, from the vagina of the mother over the child’s face, mouth, and nares. This is performed to introduce the neonate to the mother’s vaginal flora for presumed better health outcomes. Although cautionary statements have been published about this practice, it remains very popular. In Feb 2025, a “viewpoint” was published in JAMA Pediatrics which has brough vaginal seeding back into the limelight. Does this work? What are the official statements about this from the ACOG and AAP? Is there a way to do this “safely”? We will cover this new publication, review the official professional society’s statements….and more, in this episode.

On Feb 24, 2025, the FDA granted approval for MIUDELLA®, a hormone-free, low-dose copper IUD developed by US manufacturer Sebela Women's Health Inc (Georgia) for contraceptive use in females of reproductive potential for up to 3 years. MIUDELLA® utilizes a small, flexible nitinol frame and contains less than half the copper of currently available copper IUD. Where have we seen nitinol before?? How does this compare with the traditional ParaGard IUD? Can this be used for emergency contraception? In this episode, we will review this novel design, low-dose copper IUD with a summary of its new published article released March 2025 (Contraception).

BV is a vaginal dysbiosis resulting from replacement of normal hydrogen peroxide and lactic-acid producing Lactobacillus species in the vagina with high concentrations of anaerobic bacteria. Recurrent BV can occur in 50-70% of women after an initial diagnosis. The concept of treating the male partner for BV recurrence prevention is not new, and the results have been conflicting. However, a new publication from Australia (released 03/5/25, in NEJM) has sparked new interest and new conversations about male partner BV therapy. Listen in for details!

Thank you to our GREAT podcast family members who fixed by history regarding "Hollyweird" ! And thank you DANNY Thomas for your legacy at SJCRH. Go Memphis!

Screening for spinal muscular atrophy (SMA) should be offered to all women who are considering pregnancy or are currently pregnant. SMA is an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. Once identified, oral therapy may be started in the neonatal interval for those with the most severe phenotype (SMA-1). However, on Feb 19, 2025, a medical team piloted an investigational PRENATAL protocol as treatment starting in utero! While more data is needed, the results have been incredible. In this episode we will highlight this fascinating therapy which was "parent proposed". Listen in for details!

Vitamin D gets a lot of attention, and it should, mainly for its known role in bone stability. However, vitamin D has significant additional roles in physiology. Vit D, and its metabolites, also functions as modulator of inflammatory and immune responses. According to a number of recent studies, this important micronutrient plays a complex role in numerous biochemical pathways in the immune system and disorders that are associated with them. In pregnancy, the association of Vit D deficiency and adverse perinatal outcomes has been controversial with conflicting data. Nonetheless, in August 2024, the Endocrine Society published its recommendation (J Clin Endocrin Metabol) for routine supplementation for children, adults older than 75 years, pregnant women, and adults with prediabetes. In this episode, we will review a new publication (Feb 2025) from the Am J Clinical Nutrition regarding low vit D levels in the first trimester and PTB. Could vit D supplementation be the answer for preterm birth prevention? The answer may surprise you! Listen in for details.

According to published estimates, the prevalence of an NSAID allergy (hypersensitivity) in the general population is estimated to be between 0.5% and 2%, with some studies reporting a range of 1-3% of people experiencing a reaction to NSAIDs; however, this rate can be significantly higher in individuals with conditions like asthma, nasal polyps, or chronic urticaria, where it may reach up to 20-30%. Genetic and epigenetic backgrounds are implicated in various processes of NSAID-induced hypersensitivity reactions. Aspirin is a type of NSAID and may result in some cross sensitivity in NSAID allergic people. Well, as low dose aspirin is currently the only pharmacological recommended prophylactic agent for HDP, what can we do for these patients? In a new publication (ahead of print, 2/17/2025), clinicians from Singapore provide helpful insights- and an easy to adopt protocol- for aspirin desensitization in pregnancy. Listen in for details.

Its BACK. While the current outbreak is in western Texas and Eastern NM, it is expected to spread to other States. Measles is an acute viral respiratory illness characterized by fever, malaise, cough, conjunctivitis, a pathognomonic enanthema (oral lesions), followed by a maculopapular rash. In pregnancy, this could lead to significant maternal and fetal morbidity. What are Koplick Spots? What is the "Rule of 4" with measles, and what is important about the number 10? Listen in for this QUICK RECAP of Measles 101!

The ACOG's PB 205 (2019; reaffirmed Aug 2024) states that "when compared with spontaneous labor, induced labor is associated with a lower likelihood of achieving VBAC". Additionally, that guidance states, "Several studies have noted an increased risk of uterine rupture in the setting of induction of labor in women attempting TOLAC". These are important observations to review with a patient. However, according to a study soon to be published in March 2025, based on US Vital Statistics birth certificate data, that may not be the case. YEP...Medicine Moves Fast. Listen in for details.

Funic presentation, the umbilical cord presenting as the leading feal component seen on ultrasound, may be a transient phenomenon and is usually considered insignificant until ~32 weeks. However, its persistence beyond that gestational age raises the possibility of cord prolapse intrapartum as cervical dilation progresses. Cord prolapse is a mostly unpredictable obstetric emergency, in which the umbilical cord comes through the cervical os in advance of (overt prolapse – usually palpable or even visible within the vagina) or alongside the fetal presenting part in the presence of ruptured membranes (occult prolapse). The reported incidence of umbilical cord prolapse ranges from 1 to 6 per 1000 pregnancies. Though rare, cord prolapse is associated with high perinatal mortality and morbidity as cord compression and umbilical artery vasospasm may occur preventing blood flow. Consequently, expert opinion recommends CS when funic presentation is detected INTRAPARTUM. But WHEN is delivery recommended a funic presentation is found in the late third trimester? Does that need a CS? Funic presentation is notably absent from the ACOG CO 831 on medically indicated late preterm and early term deliveries. Listen in for details.

One in five women in the U.S. have a BMI of 30 or more at the START of pregnancy. Around 1 in 5 women gain more than 40 pounds during pregnancy, which is more than any woman should gain. Only about one-third of women gain the recommended amount of weight during pregnancy. Gaining too much weight during pregnancy can increase the risk of HDP, GDM, fetal macrosomia, and can cause complications of birth, such as shoulder dystocia or preterm birth. Excessive weight gain during pregnancy can also increase the likelihood of postpartum weight retention. But what about stillbirth risk? Does excessive maternal weight gain during pregnancy increase still birth risk? The ACOG recommends antepartum fetal surveillance based on pre-pregnancy BMI. Why is maternal weight during pregnancy not an indication for an antepartum fetal surveillance? The data may surprise you! Listen in for details.

Estimates of Postpartum Urinary Retention (PUR) incidence vary widely from 1.5% to 17.9%, with undiagnosed cases making the true incidence difficult to determine. A postvoid residual (PVR) volume of

In 2013, The ACOG’s Hypertension Task Force suggested that NSAIDS not be used in postpartum patients with hypertensive disorders of pregnancy due to theoretical concerns on BP aggravation. But “medicine moves fast”. In 2020, the ACOG “green lighted” ibuprofen use postpartum in these patients if no evidence of renal insufficiency was present. In episode, we will review a brand-new publication (soon to come out), in AJOG, released ahead of print on February 10, 2025. This study is a randomized trial also evaluating the effect of ibuprofen on blood pressure control in those with hypertensive disorders of pregnancy. Did they find something new? This highlights the importance of going through an entire study’s materials and methods focusing on the years of patient recruitment to properly interpret results. Listen in for details!

(We were made aware that this original posting had the last section DROPPED accidentally)...here is the full episode! Ahhh...TECHNOLOGY! *This is why AI will likely replace our production team...Just kidding production team, just kidding).Episode Details:Well, we typically focus on ONE or maybe TWO publications to highlight and review. However, in this episode, which we have decided to call, “Survey said…!”, we will go through some common and REAL WORLD “mental battles”regarding what is and what is not part of a diagnostic criteria. These are every day OBGYN things that we KNOW, but when asked to define them…we can easily get ourselves confused. We are going to clear these up…Game Show style!  First, when only one abnormal value is found in the two-step, 100-gram GTT,  it is called borderline GDM, or impaired glucose tolerance. But what is it called when there is an abnormal (failed) 1-Hour 50 gram, but completely normal 3-Hr 100-gram GTT? Is this also called “impaired glucose tolerance”? We….the Survey Said…! (Yep, we’ll get to that). Secondly, does the criteria for Preeclampsia with Severe Criteria include platelets of 100,000 or not? The Survey Said…! (Yep, we’ll cover that). We will also review the numbers for MVP oligo, for a “normal” postmenopausal ES, and MORE! Listen in for details!

Well, we typically focus on ONE or maybe TWO publications to highlight and review. However, in this episode, which we have decided to call, “Survey said…!”, we will go through some common and REAL WORLD “mental battles” regarding what is and what is not part of a diagnostic criteria. These are every day OBGYN things that we KNOW, but when asked to define them…we can easily get ourselves confused. We are going to clear these up…Game Show style! First, when only one abnormal value is found in the two-step, 100-gram GTT, it is called borderline GDM, or impaired glucose tolerance. But what is it called when there is an abnormal (failed) 1-Hour 50 gram, but completely normal 3-Hr 100-gram GTT? Is this also called “impaired glucose tolerance”? We….the Survey Said…! (Yep, we’ll get to that). Secondly, does the criteria for Preeclampsia with Severe Criteria include platelets of 100,000 or not? The Survey Said…! (Yep, we’ll cover that). We will also review the numbers for MVP oligo, for a “normal” postmenopausal ES, and MORE! Listen in for details!

Yep, its an area of debate and confusion. Controversy surrounds the diagnosis of CHTN with severe BPs vs superimposed preeclampsia with severe features. Do you need “new onset proteinuria” for the diagnosis of superimposed preeclampsia over CHTN? What about “with severe features”? This is something that is very clear to understand, yet muddy; there is well defined guidance here which is grey! Yep, we will cover this controversy and give PRACTICAL insights for the care of CHTN with severe BPs in the third trimester.

According to the ACOG, eclampsia is a low frequency, high acuity emergent condition. The rate of an eclamptic seizure is 1/200 in those with preeclampsia without severe features but is 4 fold higher ( 4/200 ) in those with preeclampsia with severe features. Traditionally, “textbook eclampsia” management did not include cranial imaging. However, that consensus is changing! In this episode, we will review data making the case for a standardized approach to eclampsia, which includes universal non-contract cranial CT after eclampsia. We will highlight a Clinical Expert Series ACOG publication from July 2024 as well as an upcoming publication from Pregnancy Hypertension in March 2025 which makes the strong case for this radiological diagnostic tool. Listen in for details.

Well, in this episode we have a “3-in-1” subject review. Often in medicine, we find ourselves with some data to guide us, but definitely not a “predominance of evidence”. So in caring for our patients, we often come to the conclusion that doing a course of action can possibly help, and can't hurt... and therefore our plan “sounds reasonable”. That's the focus of our episode today! We're going to have fun with this one and cover three topics where we do have some data to guide us, but not our predominance of data that the dot leaving us to conclude that a plan of action “sounds reasonable”. 1. Can nitrous oxide be used for IUD/IUS insertion? 2. Should we follow total serum bile acids serially for ICP (new Jan 2025 data)? 3. And if IM Ceftriaxone is recommended as first-line RX for gonorrhea, can we give expedited partner therapy as an oral medication? Listen in for details!

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is responsible for 9–30% of pregnancy-related mortality in high resource countries and remains a significant, increasing cause of severe maternal morbidity. Peripartum, 50% of VTE events occur in the postpartum interval, which has a 6-fold higher risk compared to antepartum. There is wide variation in LMWH pharmacological postpartum prophylaxis guidance. The RCOG, for example, recommends 10 days of LMWH for all postop CS patients unless it was elective, and additional risk factors exist. The ACOG uses a more selective approach. However, on Jan 16, 2025, a new multicenter retrospective study from the US is raising questions about the efficacy of postpartum VTE pharmacologic therapy. Is there really no need for pp VTE pharmacologic therapy? Or does the answer lie in the reality of VTE as a “low frequency, high acuity” event? Listen in for details!

This- is-CNN. No, that THAT CNN...This is Chapa News Network! WE have late-breaking news developments on 2 fronts: 1. The ACOG has released a clinical update (ACOG ROUNDS) in response to a recent study associating the RSV vaccine and GBS (we covered this study in a past episode). 2. The FDA has EXPANDED the label for an intranasal therapy for Treatment Resistant depression (TRD). Listen in for details.

Around a third of a person’s life is spent asleep. Previous studies have reported an association between sleep disordered breathing, like OSA, and pregnancy complications such as pre-eclampsia, gestational diabetes, and preterm birth. We recently discussed a stillbirth bundle from Australia which includes patient education on sleeping practices and stillbirth risk. Does maternal sleeping position ready influence stillbirth risk? Some data says NO, but there’s a catch to those. Other population level data says YES. Why the difference? And why is the position the mother STARTS to sleep very important here? Listen in for details as we walk down the timeline of data from 2011 to present day.

Internal manual aortic compression is a procedure that may be used intraoperatively in the management of massive pelvic bleeding. But what about EXTERNAL aortic compression? In February’s 2025 AJOG (Grey Journal), under their Surgeon’s Corner section, there will be a very nice video recap of an easy to adopt maneuver which may “buy time” in OB hemorrhage cases as surgical intervention is being planned. This is called the EAC maneuver. First described in 1994, this technique has regained the spotlight as rates of PPH have been on the rise. How is EAC done? Does it work? If so, why is this not part of the OB Hemorrhage bundle? Listen in for details.

Mesenchymal stem cells (MSCs) are multipotent adult stem cells which can differentiate into multiple cell types. MSCs can be isolated from the bone marrow, umbilical cord blood, adipose tissue, muscle, and dental pulp. However, the use of these MSCs involves a number of barriers. Human umbilical cord is limited to collection at birth. Bone marrow and fat biopsy are painful and requires general anesthesia. If only there was an easily obtainable method to collect these MSCs, like maybe even once a month, collectable in a little cup, without biopsy. WHAT… use menstrual blood you say?! Menstrual blood-derived mesenchymal stem cells (MenSCs) were first described by Meng et al. in 2007, as a novel source of MSCs. Most of the MenSC are produced by the endometrium. With the potential of multi-directional differentiation, this has spurred a list of preclinical and animal studies looking into the collection of menstrual blood for MSC processing. Men SCs have been investigated for use in Alzheimer’s disease, Stroke, Spinal Cord Injury, Type I DM, wound healing, endometriosis therapy, infertility, and even Muscular Dystrophy. Is there a miracle med in menses? Listen in for details.

Tachycardia in pregnancy is common and distinguishing between physiological and pathological causes can be a challenge. Plus, until recently, there had not been a well-defined or universally accepted definition of the upper limit of normal for heart rate in pregnancy. But a study published in 2020 from the Green Journal, from the NHS in London has shed light on this issue. The finding of persistent tachycardia beyond a certain rate (and we’ll discuss that rate in this episode), regardless of symptoms, should prompt a search for potential etiologies and at least some basic investigations. Of course, any tachyarrhythmia in pregnancy causing hemodynamic instability requires urgent cardioversion as per adult life support guidelines. In 2023, The Heart Rhythm Society (HRS) developed expert consensus guidelines in collaboration with the American College of Cardiology (ACC), the ACOG, and the AHA to address arrhythmias in pregnancy. In this episode we will focus on and review maternal tachycardia. Does HR really increase by “10-20%” in pregnancy as we all were taught? What heart rate is generally considered evaluable? And what’s the suggested evaluation? Listen in for details.

The stillbirth rate in the US is considerably higher than in many countries with similar resources. In 2021, the United States stillbirth (loss before birth at ≥20 weeks’ gestation) ratio was 5.73 per 1000 births or 1 in 175 pregnancies with 21,000 stillbirths occurring annually. Contrast that to the rate in Japan which is 1.6/1000! The UK and Australia have both implemented stillbirth prevention bundles which have proved worthwhile. It is long past due for the US to have its won national stillbirth prevention bundle. In this episode we will review a publication from Aug 2024 (AJOG) describing this bundle proposal and highlight a letter to the editor from January 9, 2025 in the AJOG in response to that August publication. Listen in for details.

Guillain-Barré syndrome (GBS) is a rare disorder that causes muscle weakness and sometimes paralysis. It's caused by the body's immune system damaging nerves. While most cases are triggered by respiratory or gastrointestinal infections, vaccinations have also been linked to GBS pathogenesis. GBS can last from weeks to years, but most people start to recover within a few weeks. The earlier symptoms improve, the better the outlook. Physical therapy is important to prevent muscle contractures and deformities. Some people may experience long-term weakness, numbness, fatigue, or pain. A small percentage of people with GBS may have a relapse, which can cause muscle weakness years after symptoms end. On Jan 7, 2025, the FDA required and approved UPDATED safety labeling changes to the Prescribing Information for Abrysvo (Respiratory Syncytial Virus Vaccine) manufactured by Pfizer Inc. and Arexvy (Respiratory Syncytial Virus Vaccine, Adjuvanted) manufactured by GlaxoSmithKline Biologicals. Specifically, FDA has required each manufacturer to include a new warning about the risk for Guillain-Barré syndrome (GBS) following administration of their Respiratory Syncytial Virus (RSV) vaccine. Who is most at risk for GBS? Where pregnant women affected? This is important information….listen in for details.

Sometimes you read a new study and you just have to say, "You Don't Say?!" In this episode, we will highlight 2 publications which were released Dec 26. 2024 and Jan 6, 2025 which make you say just that. This is a brief, fun, YET STILL EDUCATIONAL, episode...Listen in for details.

In this episode, we will cover 2 topics: the first is brand new in print (01/06/2025 ), and the second is just weird. In the “new” portion we'll summarize a new randomized study published in JAMA Network dealing with gestational diabetes. Should we add glyburide to metformin for GDM control? Listen in for details. In the second portion, we'll focus on unilateral ovarian absence not related to previous removal. Yep! This is why it's very important to check the adnexa at “routine” C-section or “routine” gynecological surgery. It is possible to be missing an ovary…and its weird! Listen in for details!

Preterm infants, especially those born at periviability, are at inherent risk of a variety of short-term neonatal complications- depending on their gestational age- including sepsis, respiratory distress, IVH, and have an overall higher mortality compared to term born infants. Well known interventions are intended to reduce these complications; these include antenatal corticosteroids, magnesium sulfate for CNS protection, and antibiotics for latency in PPROM. This is an even bigger issue for those born in the periviable interval. That group is a unique population. But does mode of delivery matter? Cesarean delivery is currently not recommended before 25 weeks' gestation unless for maternal indications, even in the setting of malpresentation. We’ll cover recently stated guideline in this episode. These recommendations are based on a lack of evidence of improved neonatal outcomes and survival following cesarean delivery and the maternal risks associated with cesarean delivery at this early gestational age. Plus, for non-vertex presenting fetuses, C-section has been reported to reduce risk of neonatal mortality, but what about vertex presenting preterm/periviable babies? In this episode, we will review the mode of delivery and neonatal outcomes in preterm birth with a special focus on those born in the periviable interval, like 22- and 23-weeks gestation. There’s lots to cover here…so listen in for details.

In most regions of the United States, RSV season starts in the fall and peaks in the winter. In September 2023, the ACOG released a Practice Advisory recommending a single dose of Pfizer’s RSV vaccine (Abrysvo) for eligible pregnant individuals between 32 0/7 and 36 6/7 weeks of gestation who do not have a planned delivery within 2 weeks, using seasonal administration, to prevent RSV lower respiratory tract infection (LRTI) in infants. This is recommended from September to January. Currently, the US recommendation is for this to be given once, with subsequent deliveries receiving neonatal Beyfortus in RSV season. The recommendation from NICE is to have this vaccination with every pregnancy. The prescribing information for Abrysvo includes a warning to inform patients that a numerical imbalance in preterm births in Abrysvo recipients (5.7%) occurred compared to those who received placebo (4.7%). This imbalance was only seen in trial participants residing in low- to middle-income countries with no temporal association to vaccination or association with other adverse events in the mother or the newborn. Now, that phase 3 clinical data has gone through peer review and is a new publication. This is the MATISSE global study and will be officially published in the Green Journal February 2025…but we will summarize the results NOW in this episode! Listen in for details.

In August 2024, researchers at Columbia University published a study that found measurable concentrations of 16 metals in multiple brands of tampons. The study evaluated levels of metals like cadmium, manganese, and arsenic in 30 tampons across 14 different brands. The study concluded that using tampons may be a potential source of metal exposure. We covered this publication in JULY 2024 before it was released! In response to the study, the FDA launched an investigation that includes 3 parts: 1. An independent literature review to learn more about data available regarding the presence of chemicals in tampons and possible health effects , 2. A laboratory study to evaluate metals in tampons and potential exposure people may experience when using them, and 3. Toxicity testing to identify potentially harmful substances and assess the risk of those substances being absorbed by the body. The literature review has been completed and was released by the FDA on Dec 23, 2024. Listen in for details.

Low-dose aspirin (LDA), typically prescribed at a dosage of 81 mg daily, is primarily used during pregnancy to prevent or delay the onset of preeclampsia. However, the question of whether to continue LDA postpartum is less clear and requires careful consideration of the benefits and risks associated with its use in the postpartum period. After all, the American College of Cardiology and American Heart Association recommend that low-dose aspirin use (75 to 100 mg/d) might be considered for the primary prevention of atherosclerotic CVD among select adults ages 40 to 70 years at higher CVD risk but not at increased risk of bleeding. Meanwhile, the 2022 US Preventive Services Task Force (USPSTF) recommendation notes that the decision to initiate daily aspirin therapy for primary prevention of cardiovascular disease (CVD) should be made on a case-by-case basis for adults ages 40 to 59 with a 10% or greater 10-year CVD risk. The recommendation applies to those without signs or symptoms of clinically evident CVD who are not at an increased risk of bleeding. So, does continuation of LDA after delivery reduce the persistence of, or development of, chronic hypertension. Is that evidence-based? The answer is both YES and NO. Listen in for details.

Somethings in medicine are pretty cut and dry. Others...not so much. Such is the case with obstetrical management of PPROM with a cervical cerclage in place. Should it be removed, or left in place? While the ACOG has some guidance from March 2020, there has been additional publications released, including one from SMFM. PLUS, a November 2024 review on the topic (AJOG MFM) has suggested a practical approach to this clinical scenario. Listen in for details.

In late 2024, the CDC updated their MEC on contraception in those with medical co-morbidities. Obesity (BMI >/= 30) was also referenced in that revision. NOW, coming out officially in 2025, The Society of Family Planning has released their committee statement on "contraception and body weight". Is there a certain BMI class where a type of BC is contraindicated? Does BC make you fat?! Listen in for details.

We have made SIGNIFICANT progress in our ability to screen for fetal RH factor using cell free DNA from maternal blood. Cell-free DNA to determine the fetal RHD genotype from the maternal circulation was first described in 1993. We have come so far since them. In March 2024, the ACOG released a Practice Advisory stating, “the use of NIPT to prioritize use of RhIg and conserve RhIg supply is a reasonable consideration”. Two U.S. companies have introduced cell-free DNA assays for RHD as part of their noninvasive prenatal testing assays. These assays use next generation sequencing to determine the presence of fetal RHD DNA. These tests are NEAR perfect in accuracy (we will review the latest data here). So, how can it be possible to detect the RHD gene (when truly present), yet the fetus ultimately be found to have RH negative blood? In other words, how do we explain the occurrence of genotype/phenotype discrepancy? The science is clear. In this episode, we will review this unusual phenomenon and summarize a recent (November 2024) clinical validation study on the use of cell free DNA test testing to look for this “genomic variance”. This article was also on the Green Journal’s “Spotlight on Fetal RHD” on 12/16/2024. Is this common? And which patient population is more likely to have this? Listen in for details.

The saying says, “The Devil is in the details”. This idiomatic phrase that means even the grandest project depends on the success of the smallest components. So is the case with low dose ASA for preeclampsia prevention. Currently, the ACOG states, “Low-dose aspirin (LDA) (81 mg/day) prophylaxis is recommended in women at high risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery” (ACOG CO 743; 2018). But the DOSE of LDA is controversial with mounting data that the minimal dose should be 100mg, with leading commentaries pushing for 162 mgs here in the US. We have covered this MANY times on our show. But there is a separate issue here that is often missed. Does it matter WHEN in the day this is taken? Is taking LDA first time in the morning best? What about after lunch? At bedtime? There is data here to guide us. In this episode, we will review the CHRONOBIOLOGIC response of LDA in pregnancy. Yes, that is a real term! This is also reflected in the March of Dimes data. Plus, there is Level I data supporting the best time to take aspirin- and it is fascinating. Listen in for details.

EVERYTHING CHANGES! So true. And now, the USPSTF has changed (UPDATED) their recommendations for cervical cancer screening in regards to HPV primary screening. This is BRAND NEW, within the last 24 hours. Primary HPV screening for cervical cancer has gained a lot of steam and is progressing quickly. The FDA approval of “dual stain” testing of hrHPV positive results, the recent FDA approval for patient self-collection for HPV vaginal samples in a clinical setting, and now this new draft recommendation from the USPSTF. What did they update? How is that controversial? Listen in for details!

Well, in this episode we have 2 very interesting and challenging clinical situations. These come from real world clinical encounters so we thought we would share these with you because they are brain teasers and should be discussed. They both have to do with OB ultrasound. First, is there a “minimal” CRL to estimate gestational age? In other words, is there a CRL that is too small to be accurate? It’s an intriguing question and we will give an answer! Second, in women with regular and predictable menstrual cycles that are every 21 or 35 days, how to we “reconcile” a CRL EGA since that CRL algorithm is based on a “typical 4-week cycle”? How can we? Should we adjust the sono dating? WE will review in this episode. PLUS, we will review the latest data on how AI can greatly impact gestational age calculation via ultrasound. So, we have 2 questions, and we will give 2 answers (2 x2)…Listen in for details.

Acetaminophen (Paracetamol) is a common over-the-counter medication that has gained substantial media attention regarding its use by pregnant women. Although estimates vary considerably, most studies and surveys report that around 40–65% of women take acetaminophen sometime during their pregnancy. Historically considered safe, concern was initially raised back in 2014 with a JAMA Pediatrics publication stated that use in pregnancy lead to ADHD in the offspring. Seven years later, in 2021, a consensus statement published in Nature Reviews Endocrinology suggested that acetaminophen use in pregnancy might increase the risk of neurodevelopmental and urogenital tract abnormalities in offspring and called for “precautionary action”. This lead tgo an ACOG response back in Sep 29, 2021 (we will review). This is very controversial. Today, Dec 5, 2024, a new clinical perspective was published in Obstetrics & Gynecology adding another flavor to the mix. Is acetaminophen a direct cause of fetal harm? Listen in for details!

In November 2013, ACOG issued the Hypertension in Pregnancy Task Force Report recommending daily low-dose aspirin (81mg) beginning in the late 1st trimester for women with a history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks, or for women with more than one prior pregnancy complicated by preeclampsia. The following year, the USPSTF published a similar guideline, although the list of indications for low-dose aspirin use was more expansive. Since then, the ACOG has issued new guidance on low-dose aspirin, in 2018 and 2021. Nonetheless, while criteria for use has evolved, the dosage recommended has remained as 81 mg. But MEDICINE MOVES FAST, and a new Expert Review in the AJOG MFM is making a case for 162mg. Are we underdosing low-dose aspirin for prevention of preeclampsia? A litany of data says YES. Listen in for details.

The first successful births from frozen eggs were twins, born in Australia in 1986. IVF serves a valuable role for those with persistent infertility issues or other conditions where natural conception is hindered. Although oocyte cryopreservation was initially used as a fertility preservation strategy for medical indications, currently, it is increasingly used to circumvent age-related infertility. This process of elective egg retrieval and cryopreservation- targeting women in their 20s- has gotten out of hand! Mainly due to social media, Gen Z women are panicking about their fertility. Should They Be? For decades, the age of 35 has been seen as a “demarcation line” for female fertility. Before 35, the theory often goes, most women will have little trouble conceiving, but at that point, fertility falls off a cliff. This misunderstanding of natural fertility processes, spurred on by false information on social media, has led to 20-somethings calling for egg retrieval and egg freezing. The dread of age 35 is so pervasive that its effect bleeds backward in time, with women in their early 30s—and yes, sometimes even in their late 20s—already feeling as if they are behind in the race against their “biological clock.” But the reality of fertility “loss” is much more complicated then just “falling off a cliff” and should be viewed more as of a natural “slope” rather than a “cliff”. About a decade after it shed its “experimental” label from the ASRM, oocyte retrieval and cyropreservation has become ubiquitous in our social media culture and has ballooned in popularity, with over a million frozen eggs or embryos stored in the United States today. It has done little, however, to materially change women’s lives. The ASRM has an ETHICS COMMITTEE OPINION (2024) on this very thing. Is 35 really a fertility cliff? Or it it 32? Is egg freezing in late or early 30s the best way to go for delayed fertility? Listen in for details as we set the record straight.

Introducing one of our Senior Residents, Dr. Mauldin: Dr. Mauldin just told me of a real patient encounter she had just today, that I felt we HAD to share with everyone. This real encounter is WHY we are passionate about EVIDENCE-BASED medicine! PLUS, we will introduce our NEXT episode which will focus on "elective egg harvesting and freezing" for young women who may have "delayed fertility" due to career path. The social media influence on what has come t be called "social egg harvesting" by some, has gotten out of hand! Listen in to her personal history and perspective on this!

In the United States, more than 400,000 babies are born prematurely each year, which is about 1 in 10 babies. Over the last several decades, multiple studies have shown a link between poor oral health and increased occurrence of preterm birth. Researchers have looked at various ways to improve dental health during pregnancy, including doing a “deep-teeth cleaning” (also called ‘scaling and planing’), which involves removing plaque and tarter on the teeth and below the gum line. However, despite improving periodontitis, deep teeth cleaning approaches have not proven to be effective in the prevention of preterm birth. But now new data has discovered an easy and inexpensive way to improve oral health and potentially reduce preterm births. This data was originally presented at the annual Pregnancy meeting at SMFM, but now it is a peer reviewed publication. In this episode, we will review how chewing xylitol gum has promising results for preterm birth reduction. Nonetheless, some important limitations must be reviewed. Listen In for details.

The U.S. Preventive Services Task Force and the World Health Organization recommend primary HPV screening, starting at age 25, as an option (some as preferred) for cervical cancer screening. Although primary HPV screening is as effective as cotesting at detecting cervical cancer, primary HPV screening decreases the number of lifetime screenings needed. The primary HPV screening tests approved by the U.S. Food and Drug Administration (FDA) are the Roche Cobas and BD Onclarity tests. HPV results for the Roche and BD tests can be reported as a pooled result. This means the physician receives a result of negative or positive, in which positive indicates that at least one, but possibly more, types of high-risk HPV were identified in the sample. HPV genotyping options differ by manufacturer. Roche Cobas reports HPV 16 and 18 individually and groups 12 other types (i.e., positivity means at least one of the 12 types triggered the positive result). BD Onclarity reports six individual HPV types (16, 18, 31 [the highest risk going immediately to colposcopy], 45, 51, and 52), and combined types (33/58), (35/39/68). Now, as of March/April 2024, the ASCCP has recognized another important and clinically useful HPV and co-test TRIAGE tool, the DUAL STAIN. This pertains only to the ROCHE COBAS HPV test. In this episode, we will review this latest ENDURING GUIDELINES update to the 2019 ASCCP management algorithms (already updated in the ASCCP app).

With an estimated 3.8 million breast cancer survivors in the United States, OBGYNs and other women's healthcare providers often are on the front lines of addressing survivorship issues, including the hypoestrogenic-related adverse effects of cancer therapies or early menopause in survivors. Although systemic and vaginal estrogen are used widely for symptomatic relief of genitourinary syndrome of menopause in the general population, among individuals with a history of hormone-sensitive cancer, there is uncertainty about the safety of hormone-based therapy, leading many individuals with bothersome symptoms to remain untreated, with potential negative consequences on quality of life. The term genitourinary syndrome of menopause (GSM) is the term used to describe to a constellation of symptoms that relate to hypoestrogenic effects on the genital epithelium, such as genital dryness, burning, and irritation; potential downstream effects of vulvar and vaginal atrophy such as dyspareunia; urinary symptoms such as urgency or dysuria; and recurrent urinary tract infections. Is vaginal estrogen or estrogen-like therapies safe in these patients? What about in those using aromatase inhibitors? A new Meta-Analysis (AJOG) provides insights. Listen in for details.

Yep! We have definitely covered the evolving saga and controversy regarding antenatal corticosteroids in the late preterm/early term interval. It's like Dorothy in the Wizard of Oz: "Lions and Tigers and Bears, Oh My!" More fitting for our discussion, its "Steroids, and Studies, and Shared-Decisions, Oh My!" In this episode we will highlight TWO pieces of literature coming out in DECEMBER 2024 in the Green Journal on this topic. The article is by Clapp et al and the associated editorial piece will be the core part of our episode. Listen in for details!

Well, in the last 4 weeks there have some interesting developments in the sphere of OBGYN medical news. In October 2024, out of the American Society of Anesthesiologists, came a study on the possibility of using serum FAR to predict preeclampsia with severe features in admitted patients (don’t worry, we’ll discuss what FAR is!). PLUS, some exciting, although preliminary, data has been published out of Baylor College of Medicine raising the possibility of a non-invasive test for endometriosis using…POOP! Yep, poop. And on October 31, 2024 a new clinical perspectives article was published in the Green Journal “CHALLANGING” the recent ACOG’s Clinical Practice Update regarding screening for pregestational DM in early pregnancy. Intrigued? You should be….we will cover these 3 tidbits of OBGYN news in this episode!

The ARRIVE was published in the New England Journal of Medicine on August 8, 2018 1. This study was a large unmasked multicenter trial conducted from March 2014 to August randomized 6,106 nulliparous women to either IOL or expectant management at full term. The trial was conducted at 41 facilities across the United States. This validated that eIOL at 39 weeks, in that patient population, had the ability to reduce cesarean sections and rates of hypertensive diseases of pregnancy. Since that time, elective IOLs have INCREASED at 39 weeks as some messaging was distorted implying that IOL was the BEST way to go over expectant management. Has other data since 2018 found the same thing? Or were the results of the ARRIVE trial an aberration? The ACOG has JUST RELEASED a new CPU which provides additional insights to this. Listen in for details!

Urinary tract infections (UTIs) are a leading cause of health care visits in the USA and around the world. In the US, they have a cost burden of $3.5 billion annually. Half of women experience at least one UTI in their lifetime, and approximately 25% of these women develop recurrent UTIs! On October 31, 2024, a study was published in Obstetrics Gynecology (the Green Journal) looking at UTI treatment trends in nonpregnant women. With the increased use of tele-visits, there is now a conundrum between allowing easier access to care (tele-visit) and treatment of UTIs online balanced against contributing to antibiotic resistance. Is urine culture recommended prior to antibiotic use for uncomplicated UTI? That depends on who you read! We will discuss this issue in this episode. PLUS, we will briefly discuss a NEW oral antibiotic for uncomplicated UTI in women; this was just FDA approved on October 25, 2024.

Everyone understands that VTE (DVT and/or VTE) requires life-saving anticoagulation. That's simple. No controversy there. But what about pregnancy-associated superficial thrombophlebitis (AKA superficial venous thrombosis) in an extremity? Does that need anticoagulation? We have been traditionally taught that superficial venous issues are benign and do not require LMWH. Is that correct? The answer is NOT as straightforward as you would think. In this episode, we will review the 2018 ASH guidelines and contrast them to the 2022 published consensus statement from the Balkan Working Group. Plus, we will highlight a May 2023 Danish population based study from the Lancet Hematology that reminds us that superficial venous disease is not always benign in its course. Listen in for details,

According to the UK’s National Institute for Health and Care Excellence (NICE; 2024), women who are S/P scheduled CS and recovering well, who are afebrile, and do not have complications, should be discharged early (after 24 h) and followed at home because this is not related to the readmission of the baby or mother. However, the first 24 hours after a C-section can be challenging, with many of the same challenges as a vaginal delivery PLUS the usual post-surgical issues: The mother will be adjusting to new parenthood, attempting breastfeeding, and fielding visitors; the incision will be sore, and pain may increase as anesthesia wears off. Is this postop plan coming to the USA? A soon to be published systematic review and meta-analysis (Dec 2024) in the AJOG MFM seems to favor that. Is this the new progression of the postop ERAS protocol? Listen in for details.

Welcome Back to another episode of "You ask, We Answer"! As Abrysvo (RSV vaccine) now has some time on the market, some women may find themselves with a subsequent pregnancy after first receiving the injection in the prior pregnancy. Is another RSV vaccine recommended with each pregnancy, like TDap? The answer to that question depends on where you live. We will discuss in this episode. PLUS, have you heard of CLITOXIN? Its a little botulinum toxin injected into the clitoris for "enhanced sexual response". Is that evidence-based? Is there data for that?! Listen in for details.

Ultrasound assessment of placental volume has been proposed as an important aspect of prenatal care. It involves measuring the size and volume of the placenta, which may provide critical information regarding fetal health and development. Abnormal placental volume can be associated with various complications such as FGR, preeclampsia, and other pregnancy-related conditions. Some advocates suggests the volume and vascularity of the first trimester placenta may be linked to the most devasting adverse pregnancy outcomes which is stillbirth. Social Media posts have been advocating and endorsing the measurement of placental volume antenatally as a stillbirth prevention strategy. Is this evidence-based? It’s very controversial. Nonetheless, we have principles from the AIUM. ISUOG, ACOG, and SMFM to guide us here. Listen in for details.

Stroke is also a leading cause of adult-onset disability; among individuals who survive 6 months, almost half are dependent in at least 1 activity of daily living. In October 2024, the AHA/ASA released their 2024 Primary Prevention of Stroke guidance. This document has a striking focus on women's health, namely adverse pregnancy outcomes and certain gynecological conditions (Endometriosis, POI, PCOS). Listen in for details.

Several observational studies have suggested that women with endometriosis have a slightly increased risk for preterm birth. The cause seems to be related to factors associated with pathogenesis of endometriosis, such as inflammation, reactive oxygen species, progesterone resistance, and alterations in the junctional zone of uterus leading to the shallow invasion of the placenta and to preterm birth. But is this association firmly established? It is actually more an enigma than solid evidence. In October 2024, a new cohort study in Fertility Sterility is questioning this relationship. These results are a contrast to the findings of a meta-analysis published in January 2022, which itself conflicted with results of a French observational study published the following month, February 2022. It’s the perpetual problem and enigma of whether endometriosis is associated with PTB, or not! Listen in for details.

In November's Green Journal, Drs Amy Valent and Linda Barbour will publish their Clinical Expert Series (CES) on insulin management in GDM and Type 2 DM in pregnancy. This is a FANTASTIC document and is our subject matter in this episode. Here, we will give clinical pearls for insulin initiation in pregnancy based on 3 regimens (NPH/Reg; NPH/RAAs; Basal-Bolus) and their initiation in an easy to follow format. Congratulations to Drs Valent and Barbour on a wonderful CES.

The relationship between hormonal birth control and sexual orientation has been a topic on social media channels and threads; it is a discussion of controversy. It is essential to clarify that the hormonal birth control pill itself does not determine or change an individual's sexual orientation. While there is evidence to suggest that hormonal birth control can influence sexual desire and partner preferences, there is insufficient data to support the idea that it can change a person's sexual orientation. Sexual orientation is a complex interplay of biological, environmental, and social factors, and current scientific consensus does not support the idea that hormonal contraceptives influence one's sexual orientation. Where did this concept come from? Are there large-scale studies which address this? Listen in for details.

Early pregnancy failure (EPF), pregnancy loss in the first trimester, is a common pregnancy complication, with 15 to 20% of clinically recognized pregnancies ending in the first trimester. It is not uncommon for women with one or more cesarean sections, or myomectomies, to present with EPF. Options for treatment of early pregnancy failure include expectant management, surgical management (D&C), or medical management with medications such as misoprostol (miso). However, the limited information available regarding miso with EPF in those with prior uterine surgery may complicate the counseling of these women. What does the ACOG say about misoprostol use in the first trimester for these patients? Is misoprostol safe for EPF in women with 2 prior cesareans? In this episode, we will explore the data for miso use in these cases with a focus on the first trimester, but also review the data for miso use in the early second trimester in those with a scarred uterus.

The SMFM, ACOG and RCOG all recommend screening for Antiphospholipid Antibody Syndrome (APS) in women with Recurrent Pregnancy Loss (RPL). However, once identified, there has been controversy historically regarding the best TIME to initiate low dose aspirin and prophylactic LMWH. The main controversy regarding this is whether to begin treatment before a confirmed pregnancy, right after a positive pregnancy test, or only after an ultrasound confirms a viable fetus; with some studies suggesting potential benefits from starting earlier, while others debate the optimal timing due to lack of conclusive evidence and potential risks associated with early anticoagulation. Nonetheless, we DO HAVE current guidance here to make an evidence-based plan of care for these patients. In this episode, we will summarize a recent Clinical Expert Series from the ACOG (May 2024) and the RCOG (June 2023). PLUS, we will highlight some persistent controversies surrounding APS and RPL.

Cannabinoid Hyperemesis Syndrome (CHS): Yep, this is definitely an issue and has been in recent print. This was just covered in an expert commentary in J Gastroenterology in May 2024, and CMS was featured as a JAMA Patient Page on October 10, 2024 in JAMA Network. PLUS, we actually covered this back in Feb 10th, 2020! Yep…M-O-R-E information just keeps coming, including a new study in the OCT 2024 Green Journal, which shows that rates of THC in pregnancy are still increasing. This study, again from THIS MONTH, tells us that the prevalence of prenatal cannabis use increased from 5.5% in 2012 to 9.0% in 2022 among pregnant individuals, at least according to the database from Northern California ( Kaiser Permanente Northern California). In this episode, we will update our previous discussion on CHS (from back in 2020) based on these new publications.

Proper hydration is important for physiology whether male or female, and if female… hydration in pregnancy is important for proper uterine blood flow and proper amniotic fluid production. Interestingly, water recommendations do not specify differential water needs or hydration status recommendations by pregnancy month or trimester, nor do they take into account body composition, knowing that overweight and obesity increase the probability of being underhydrated. During pregnancy, dehydration is thought to contribute to Braxton-Hicks contractions possibly due to lactic acid buildup in the myometrial cells or via reflex secretion of ADH (vasopressin). But this is theoretical. Here is where IV hydration comes into clinical practice. What's hoped for in administering intravenous (IV) hydration is that the fast fluid volume increase will stop uterine activity and hence avert cervical change. Theoretically, hydration may reduce uterine contractility by increasing uterine blood flow and by decreasing pituitary secretion of antidiuretic hormone and oxytocin. Does mild-moderate dehydration lead to preterm labor? Is IV hydration a way to prevent preterm birth. There has been data since the 1980s up until 2021 which says, “No”. Listen in for details.

Eczema is also known as a form of Atopic Dermatitis (AD). Males and females are not equally affected by AD, and studies have shown that AD is more common among males during infancy and childhood. However, around puberty, there is a shift towards more females than males having AD and this female predominance continues into adulthood. Eczema can impact any women during pregnancy. In fact, it is the most common prenatal skin condition. A majority of women with eczema in pregnancy have never it previously diagnosed. Actually, approximately 60%–80% of prenatal eczema patients have no prior history of the condition. Eczema in pregnancy may occur because of changes in hormones and the immune system. During pregnancy, the body’s immunity shifts a bit and this shift in immunity can make the mother more sensitive to allergens and dermal manifestations vis inflammatory mediators. Those with preexisting common hay fever or other allergies before pregnancy may be at higher risk of developing eczema during pregnancy. Eczema isn’t just about “itchy skin”, for some it has severe skin manifestations and affects quality of life. While biologics are generally not initiated in pregnancy except for very severe cases, some women may be on this medication when ENTERING pregnancy. Are they safe to use? We have new SURPRISING data from September 2024 which will help us in our shared-decision making with our patients. Listen in for details.

Hurricane Helene has caused massive devastation for a part of the US, and now we are bracing again for Milton, set to affect Florida within the next 24 hours. Baxter, one of the country's leading manufactures for IV fluid bags has closed its plant for an unknown amount of time as it was affected by Helene. On October 4, 2024, the SMFM released a news brief on IVF conservation intrapartum. Listen in for details.

BRCA1 mutations dramatically increase the lifetime risk of breast, ovarian, pancreatic, and other cancers, yet most BRCA1-positive patients are not identified until after they have been diagnosed with cancer. At prenatal visits, women often undergo obstetrical prenatal carrier screening that can identify hundreds of genetic mutations which can be passed on to offspring and results in an inherited condition — however, BRCA1 and other autosomal dominant mutations are not included on these screening panels. However, a recent publication (September 2024) and related commentaries have brought this screening possibility to the limelight. There is also new data about endorsing offering the HPV vaccine during the immediate postpartum admission. Is pregnancy becoming a “one-stop shop” ( a “window of opportunity”) for women’s care? OK podcast family I think I've set it up enough, now…let's get to it.

The ACOG defines Fetal Growth Restriction (FGR) as fetuses with an estimated fetal weight or abdominal circumference that is less than the 10th percentile for gestational age. Currently, the ACOG, SMFM, FIGO, and the ISUOG do not recommend maternal bed rest for this condition. However, a recent publication from the AJOG (May 2024) concluded that strict maternal bed rest could in fact reverse FGR in a short two-week interval! Is this possible? In this episode, we will dissect this controversial, retrospective study and give it proper perspective with real world clinical implications.

In the ACOG practice bulletin 203, the ACOG states that, “Traditionally, the diagnosis of hypertension (HTN) in pregnancy has been 140/90, on 2 occasions at least 4 hrs apart“. The keyword there is… “Traditionally”. In 2017, the ACC/AHA redefined hypertension with Stage I HTN being 130/80. Do some societies recommend the use of this lowered blood pressure criteria in pregnancy? It’s a complicated answer. Does aspirin help prevent preeclampsia in women with Stage I (130/80) hypertension? The answer may surprise you! In this episode, we will do a deep dive into ACOG PB 203, the ACOG practice advisory from 2022 in response to the CHAP trial, and discuss the CLIP 2021 published data. This is a story of CHIP, CHAP, and CLIP… And we will give clear clinical implications of each in this episode!

Dysphoric Milk Ejection Reflex (D-MER) is an abrupt emotional "drop" that occurs in some women just before milk release and continues for not more than a few minutes. Although research is still evolving, one study Published in 2019 (Breastfeeding Medicine) states that up to 9% of breastfeeding women may experience dysphoric milk ejection, although the true incidence is still unknown. The brief negative feelings range in severity from wistfulness to self-loathing. In Arch Gynecol Obstet, in July 2024, authors published, “Dysphoric milk ejection reflex – a call for future trials”. This is gaining interest in the published literature. The etiology of this is unclear but a new (soon-to-be-released) publication in the AJOG provides some interesting insights into this. This was just accepted for publication on September 18, 2024 and the official release is pending. Haven’t heard about D-MER? Due to a lack of awareness, this phenomenon is easily misdiagnosed as postpartum depression and aversion by many healthcare professionals. A July 2024 Harvard Review in Psychiatry publication called D-MER, “A Novel Neuroendocrine Condition with Psychiatric Manifestations”. This condition is a physiologic tale of oxytocin, milk- let down, dopamine and prolactin, and the fight and flight response. Listen in for details.

Podcast Family, every once in a while we need a little reminder that we are all wired for community. Despite differences in geographic locations, cultures, and family history, we really do have a lot in common. In this episode, I'll share with you 3 examples which prove that we really do live in a very small world. I hope this brings a smile to your face and encourages you! PLUS, of course, we will provide one main clinical pearl regarding CS-Hysterotomy closure while keeping with our "small world" theme. Listen in for details!

The LNG-IUS has been on the U.S. market since 2001. Since 2005, there have been several studies examining the association (if any) of LNG-IUS users and the diagnosis of breast cancers. This is a controversial and conflicting story. In this episode, we will highlight a soon to be released publication (OCT 2024) from the AJOG looking into this relationship. PLUS, we will very quickly walk down history’s timeline starting in 2005 and ending in October 2024 looking at the cumulative data on the subject. Does the ACOG has a statement on it? Listen in for details!

We all what to win in life, right? That’s why we have life hacks…to beat the system. Sometimes those tricks are tremendously successful while some other random hack can be- well, just WACK. Such is the case for LABOR HACKS! We all want our inductions and augmentations of labor to be successful, and there have been some labor hacks promoted throughout the years. But is there evidence of their effectiveness? Is a Pitocin break effective at kickstarting the uterus back up? We will cover that in this episode. PLUS, we will highlight two new publications, both from AJOG MFM which have just been released (September 2024; October 2024): Can “pretreatment” with calcium help with labor? What about the use of propranolol? Listen in for details.

On May 22, 2024, we summarized a then soon-to-be-released ACOG CPU on Screening for GDM in Pregnancy and Postpartum. That CPU was officially released July 2024. That update endorsed the possibility of immediate postpartum GTT testing with a 75-gram OGTT. Now, on September 19, 2024, authors from UT Houston have published a systematic review/meta-analysis on this subject. In this episode, we will review what this data is and what it isn't. Listen in for details.

Magnesium Sulfate for preeclampisa can be traced back to the work of Horn in 1906! Yet, despite such a long history of use, there are still questions about mag sulfate use that we just don’t have good answers for, and that’s indicative of the all the continued articles and commentaries on the subject that are still being released. For example, there are still sparse data regarding the ideal dosage of magnesium sulfate for preeclampsia with severe features. Even the therapeutic range of 4–8 mEq/L quoted in the literature is questionable. What to know where that statement comes from? That’s in the ACOG PB 222 from 2020! So is the case for mag duration…you know, the 24-hour infusion tradition. The ACOG states in that same PB, “For women requiring cesarean delivery (before onset of labor), the infusion should ideally begin before surgery and continue during surgery, as well as for 24 hours afterwards. For women who deliver vaginally, the infusion should continue for 24 hours after delivery.” But this 24-hour mark, while TOTALLY OK, is more traditional than hard data driven. YES…its true, MOST if not ALL of would give mag for 24 hrs. in cases of eclampsia, and that is SUPER fitting and reasonable since they are the highest to have a recurrent seizure, but what about preeclampsia with severe features, without eclampsia or neurological symptoms. That’s where the 24-hour use can get into a greyer zone; can mag be used for less than 24hrs? Can we use diuresis as a clinical marker to stop mag? Two systematic reviews and meta-analyses looking at PP Mag duration were just published in July 2024 and in September 2024. We will summarize these findings- and more- in this episode.

Filet Mignon, Pork Loin, Rib-Eye….all delicious (unless you are vegetarian)! If you are a meat- eater, be aware of AGS. Alpha-gal syndrome (AGS), also known as Red Meat Allergy, is a potentially life-threatening allergic reaction that can occur after a tick bite from a Lone Star tick or other tick species. While clustering within the US, Alpha-gal syndrome is found on every continent except Antarctica. With the tick bite, the tick transfers alpha-gal, a sugar molecule found in most mammals, into the person's bloodstream. The body then produces antibodies to fight the alpha-gal, which can trigger an allergic reaction when the person eats meat from a mammal or is exposed to other products containing alpha-gal. It's named for a molecule, galactose-α-1,3-galactose, that's found in most mammals but not in humans. According to the CDC, the overall prevalence is increasing. In this episode, we will review this allergic condition, the animal-based foods that may trigger it, and what the implications are during pregnancy.

Today, 9/12/24, the FDA released a SAFETY COMMUNICATION regarding Veozah. As you may recall, we have been following this novel medication since March 2023. This episode is NOT our regularly planned episode- that topic will come out as scheduled tomorrow AM 9/13/24! This is a SPECIAL REPORT episode in response to the FDA's communication released today. Listen in for important information regarding fezolinetnet.

Back in January 2024, we summarized the SFP's position statement on RH IG use (or rather non-use) under 12 weeks IUP gestations. Then, in February 2024, we released an episode summarizing the more conservative stance from the SMFM. Well now, 7 months after that episode, we have a new Clinical Practice Update from the ACOG on this very issue. That is the focus of this episode...and as we have said better, WORDING matters. We will discuss in this episode.

In our last episode we tackled random questions with specific answers. After that episode went live, one of our nurses asked about the value of antibiotics with a Bakri balloon in place. This conversation happened as we were placing the balloon for PPH in a patient on Mag-Sulfate for Preeclampsia with Severe Features. That's antibiotic question is another random question that needs to be answered! So in this episode we will examine the data on prophylactic antibiotics with Bakri balloon for metritis prevention. Is there data for that? The ACOG has a statement on that very issue from back in 2018. Additional information has come to print since then, and we will review it. PLUS, as our patient was on Mag-Sulfate, we will also throw in this additional question as a FREEBEE: Is Mag-Sulfate an independent risk factor for PPH? The answer may not be what you think. Listen in for details.

Welcome to this episode of "Random Questions: Specific Answers"! In this episode we will (surprise) answer random questions- with specific answers- from our podcast family members: 1. Can administration of IV Calcium at intrapartum CS reduce QBL?, 2. What are the 4 classes of CS performance urgency? and 3. If a normal MVP for amniotic fluid is 2-8cm on ultrasound, does an MVP of >8cm still get "2-points" at mBPP or full BPP? Listen in for details!

on 09/02/2024, we released an episode called, "Do SSRIs Raise PTB Risk?". In that episode, we highlighted a new publication from the AJOG (August 30. 2024) which indicated that SSRIs may raise PTB risk. This is in contrast to a separate cohort study released Feb 2024. This is a classic case of "He Said, She Said". But now we have a REFEREE on the field to settle the score. This new systematic review and metanalysis comes from the September 2024 O&G Open release. Listen in for details.

Tubal sterilization goes back to the 1880s. The first collaborative review of sterilization effectiveness was the CREST study published in 1996 in the AJOG. But that was with prior sterilization techniques. As a way to update the data researchers looked at the national survey for family growth (NSFG) from 2002 to 2015 to determine failure rates after more modern methods of tubal sterilization. This was published in NEJM Evidence on August 27, 2024. The results... Surprising! In this episode, we will review this new data and contrast it to the landmark CRESTstudy. Also, are you aware that the ACOG endorsed a mathematical formula to allow a patient to undergo tubal sterilization, until 1969? It's true! Listen in for details.

Depressive disorders during pregnancy are common, with estimated prevalence ranging from 11% to 16%. Accordingly, antidepressant drugs, most commonly selective serotonin reuptake inhibitors (SSRI), are used by approximately 3–4% of pregnant women worldwide, with a higher prevalence in the United States compared to Europe. As antidepressants cross the placenta and the fetal blood-brain barrier, exposure during pregnancy raises concerns of potential risks of adverse pregnancy outcomes. On August 30, 2024, a new study was released ahead of print in the AJOG. This confirmed the reduction in preterm birth risk with effective mental health counseling approaches; HOWEVER, it also concluded that “use of antidepressants during pregnancy was associated with an increased 31% risk of pre-delivery independent of underlying depression “. Do SSRI meds increase preterm labor risk by 31%?! This is indirect contrast to a separate publication published just six months earlier, in February 2024 in a separate journal. In this episode, we will discuss this very important topic of SSRI use in pregnancy and the preterm birth risk.

Just when we thought we had put coronavirus in our rearview mirror for the most part, here comes mPOX again. We covered that in a previous episode. Unfortunately, that is not the only pathogen to be concerned about. Enter: OROPOUCHE VIRUS (OROV). This virus was first reported in 1955, but it is making news today due to a rapid increase in cases. Coming from the Amazon Basin, and even Cuba, there have been 21 cases in the USA diagnosed in US travelers. This virus is a concern for pregnant women. Information gaps still exist but things are moving quickly here: On August 16, 2024, the Centers for Disease Control and Prevention issued a Health Alert Network (HAN) Health Advisory to notify clinicians and public health authorities of an increase in Oropouche virus (OROV) disease, originating from endemic areas and in new areas in South America and the Caribbean. Then, on August 22, 2024, SMFM released its alert on the virus. Today, the ACOG released its Practice Advisory (August 29, 2024) on this very issue. Listen in for details.

Polycystic ovary syndrome (PCOS) was first described in 1935 by Irving Freiler Stein and Michael Leo Leventhal at the Central Association of Obstetricians and Gynecologists. Since that time, it has gone through several name changes: Stein-Leventhal syndrome, PCOD, and currently PCOS. Nonetheless, proponents and scientists are still recommending yet another name change for this syndrome, one that better incorporates the multi-metabolic dysregulation that it incorporates. PCOS is not simply a gynecological issue. It is a metabolic issue with implications for adverse obstetrical outcomes. In this episode we will review 2 recent publications, one from July 2024 and the other from August 27th, 2024. These two studies, in two separate journals, each a month apart, validate what others have previously reported: PCOS doesn't just affect gynecological health but it also impacts obstetrical health. Listen in for details.

Our immediate past episode focused on the “C-section scar pregnancy”. In that episode we discussed the ultrasound markers of early pregnancy (first trimester). Now – today – HOT 🔥🔥OFF THE PRESS- is a new publication in the AJOG, which is “A Lexicon For First Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations“. This consensus statement is through a MOU through the ACR, ACOG, AIUM, SMFM, ASRM, SFP, and the ACEP. For the first time, we have a proposed universal lexicon for ultrasound markers in the first trimester. This also discusses the cesarean scar topic pregnancy. Listen in for details!

Cesarean scar pregnancy (CSP) occurs when an early pregnancy implants on the cesarean scar defect (CSD), myometrial tissue previously disrupted by cesarean delivery. The first case of CSP was reported in 1978 in a patient with a previous cesarean section (CS) who had heavy bleeding and abdominal pain after uterine curettage for a suspected miscarriage at 6 weeks. Eventual laparotomy revealed erosion of a major vessel in the scar sacculus by the products of conception which was successfully obliterated with subsequent revision of the previous surgical site. This was published in the South African Med Journal. Early ultrasound evaluation is crucial for detecting this condition. These are very complicated situations with increased rates of antepartum and postpartum hemorrhage, uterine rupture, PAS, preterm birth, and massive transfusion. Perhaps because of high worldwide cesarean delivery rates, there seems to be increased incidence and recognition of this condition over the past 2 decades. The clinical presentation is variable, and many are asymptomatic at presentation. In this episode, we will review the diagnosis and management of this unique and challenging high-risk pregnancy.

(DISCLOSURE: Sexual Content) Back in April 2023, we released an episode on the “Jade Vaginal Egg” and vaginal weights for vaginal tightening. While we tackled the Jade Egg successfully, we now have a new player on the field: the VAGINAL TIGHTENING STICK. This over the counter “sex aid” can lead to chemical burns and severe vaginal dryness/agglutination. Marketed to improce vaginal laxity, some of these sticks have the real potential to cause tissue damage and scarring- as one of our podcast family members saw firsthand with a patient. Its an interesting market place out there! Listen in for details.

The IUD is a very safe and supremely effective contraceptive method. Given its increasing rate of use, practitioners are bound to see its relatively infrequent complications with greater regularity. Typical complications are considered “lost strings“, uterine perforation at placement, and expulsion. But there is another complication, device FRACTURE at removal. This can cause distress to the patient and can lead to additional interventions. Fracture of an intrauterine device (IUD) upon removal is a very rare complication, with a prevalence rate of 1–2%. However, the numbers have been rising since 2021, causing the FDA to track these complications. There has even been a bizarre case report of the copper coils being found in the pelvis WITHOUT device fracture! How?? In this episode, we will describe and review this relatively recent issue, its diagnosis, ways to minimize its occurrence at removal, and management strategies.

In 1958, James et al. first described umbilical cord blood gas analysis to evaluate the fetus's metabolic condition at the time of delivery. It's recommended by both the British and American Colleges of Obstetrics and Gynecology for all high-risk deliveries. Cord blood gas provides the most accurate and objective evidence of fetal acidosis at the time of birth. Still, there is no universal agreement on when to perform umbilical artery gas analysis, or cord gas, for babies. Some suggest that all babies should have their umbilical artery and vein sampled immediately after birth, while others recommend only sending a sample if you think you need one, or in high-risk pregnancies. Should we collect umbilical cord gases universally- in all deliveries? And what about umbilical cord lactate levels? Is that helpful in predicting adverse newborn outcomes? Listen in for details.

According to the National Institutes of Health, almost 13,000 women in the United States are diagnosed with cervical cancer each year, resulting in around 4,000 deaths, with most of the deaths occurring among under-screened women. Now, there is potentially a barrier-breaker. As of August 15, 2024, self-collection kits for cervical cancer screening may be available in doctor's offices and other clinical sites, ready for use. The kits allow patients to collect their own vaginal sample for HPV testing in a health care setting, as an alternative to a Pap smear. The FDA approved the kits on May 15, 2024. This is different from the OTC at-home HPV test kits. The tests, which are FDA cleared, are not yet available for people to use at home. The FDA's approval of these tests aims to increase access to HPV screening and reduce barriers to sample collection. Roche and BD both plan to consider offering at-home options in the future. Although a variety of companies currently offer at-home HPV tests, the Food and Drug Administration (FDA) has not yet approved at-home HPV tests. Listen in to today’s episode for details.

The rise of home testing for STIs/HIV started long before the recent pandemic (the FDA approved its first HIV home test collection kit way back in 1996), but COVID-19 seems to have accelerated the popularity of getting tested from the comfort of our homes. In Nov 2023, the Food and Drug Administration granted marketing authorization, the first of its kind, for an at-home test for chlamydia and gonorrhea. The test kit, called Simple 2, is available online through various offerings. Chlamydia and gonorrhea are the most common STIs in the U.S. Of course, syphilis has also been on the move. And now, as of August 2024, The FDA has granted new clearance to NOWDiagnostics (not a sponsor) for the first at-home, over-the-counter syphilis screening test. So now we have gonorrhea, chlamydia, and syphilis at home testing options. At home HPV swabs are also seeking entrance into the marketplace. While these options remove barriers to care and allow testing in the privacy of one’s own home, there are inherent problems balancing out each of these promises. In this episode, we will review the pros and cons of at home testing for STIs and we will discuss why this is still caveat emptor, “buyer beware”, in this new healthcare marketplace option.

The World Health Organization declared on 8/14/24 that the increasing spread of Mpox in Africa is a global health emergency, warning the virus might ultimately spill across international borders. Mpox, also known as monkeypox, was first identified by scientists in 1958 when there were outbreaks of a “pox-like” disease in monkeys. Until recently, most human cases were seen in people in central and West Africa who had close contact with infected animals. In 2022, the virus was confirmed to spread via sex for the first time and triggered outbreaks in more than 70 countries across the world that had not previously reported Mpox. Unlike in previous Mpox outbreaks, where lesions were mostly seen on the chest, hands and feet, the new form of Mpox causes milder symptoms and lesions on the genitals. That makes it harder to spot, meaning people might also sicken others without knowing they’re infected. In this episode, we will review the pathophysiology of this virus and describe its implications during pregnancy. Does Monkeypox cause adverse pregnancy issues? It’s cesarean section indicated for those affected? And is there any available treatment for active infection? Listen in for details.

On July 26, 2024, Boar’s Head issued its recall of 7 million pounds of ready-to-eat meat and poultry products that might be contaminated with the potential harmful bacteria, listeria. Sporadic listeria outbreaks are nothing new; in June 2024, chicken-based products were recalled for the same concern in Canada. The US recall includes more than 70 products — including liverwurst, ham, beef salami and bologna. Listeriosis is reportable to the local health department of the county in which the patient resides. Listeria can be very serious for 3 groups of people: pregnant women, people older than 65, and people with weakened immune systems. Pregnant women are about 13 times more likely than the general population to get listeriosis. Maternal infection may manifest as a nonspecific, flu-like illness with fever but can result in severe fetal and neonatal infection, leading to fetal loss, preterm labor, neonatal sepsis, meningitis, and death. Yep, we’ve been here before. There have been episodic outbreaks of listeria monocytogenes in the past. In 2014, the ACOG released its medical guidelines for the management of presumptive exposure to listeria monocytogenes (reaffirmed in 2023). In this episode, due to the recent outbreak and listeria concerns, we will review the pathophysiology, diagnosis, and therapy of L. Monocytogenes in pregnancy.

Our tagline, “Medicine moves fast“, is the absolute truth! Historically, identification of fetuses at risk of hemolytic disease of the fetus/newborn (HDFN) required amniocentesis for determination of the Delta OD450, Liley Curve. This was the first screen, which would then trigger cordocentesis for determination of the fetal hematocrit. We’ve now moved on to middle cerebral artery (MCA) doppler of the fetus for identification of those at risk. Additionally, we now have an ability to ascertain antigens on the fetal red blood cells through the maternal serum (cell free DNA). That’s amazing! Nonetheless, despite these wonderful advances, HDFN can still exist. But Medicine moves fast… In this episode, we will present brand new data from the NEJM. This Phase 2 international study, published on 8/7/24, describes the use of a monoclonal antibody (Nipocalimab) to block maternal IgG passage to the child. This is a revolution in HDFN prevention. Yep, medicine moves fast! Listen in for details.

Prior to the 1970s, when component therapy became the preferred method of resuscitation, whole blood (WB) was the resuscitative medium of choice for hemorrhagic shock. In modern medicine, sometimes it turns out that the old way is better than the new…and using whole blood for transfusions is one example. Research is emerging that shows whole blood works better for these patients than fractionated components of blood. Beginning in 2017, multiple stakeholders within the Southwest Texas Regional Advisory Council for Trauma- as well as others in different states, collaborated to incorporate cold-stored low-titer O RhD-positive whole blood into all phases of their trauma system, including the prehospital care via EMS. Although the program was initially focused on trauma resuscitation, it was expanded to include non-traumatic hemorrhagic shock patients that may benefit from whole blood resuscitation when MTP is needed. What about Low Titer O Pos whole blood use for maternal MTP resuscitation? Is there data there? And what about the risk with using type O whole blood as a donor. In this episode, we’ll dive into the details.

MEC CHANGES ARE HERE! During January 2022, the CDC held virtual scoping meetings that included 27 participants with expertise in contraception, adolescent health, and thrombosis, as well as representatives from partner organizations, to solicit their individual input on the scope for updating both the 2016 U.S. MEC. The 27 invited participants represented various types of health care providers and health care provider organizations. This led to a subsequent expert meeting held during January 2023 which reviewed the scientific evidence for updating the MEC recommendations. This MEC update is now official (8/6/24). There are updates to the MEC guidelines, replacing the 2016 version. This is good news! In this episode, we will summarize the 129 PAGE MMWR report & review the most clinically applicable updates for patient counseling. Has migraine with aura and CHC been moved out of category 4? Are there changes to IUD/IUS recs? Listen in for details!

In May 2023, the FDA approved fezolinetant (Veozah), an oral medication that's the first neurokinin 3 (NK3) receptor antagonist to treat moderate to severe hot flashes caused by menopause. Now, a separate oral medication which blocks the NK 1 and 3 receptor iis on the scene. Although not yet FDA approved, the published phase 1, 2, and 3 data make this approval very likely. Bayer, the manufacturer of elinzanetant, has just submitted a New Drug Application for its approval. In this episode, we will review this new up and coming medication option for moderate to severe VMS due to menopause.

Artificial Intelligence (AI) has arrived. Machine Learning is a form of AI which is being investigated/used for improving maternal outcomes. The UK has already launched the TOMMY APP (through the RCOG) for use to reduce PTB and stillbirths in the UK. In this episode we will highlight a new systematic review which assessed Machine Learning’s ability to predict stillbirth. Did this work? This is a hot topic, especially since the passage of the Maternal and Child Stillbirth Prevention Act here in the US. Its fascinating how far AI has come and how it has found a “home” in OBGYN. Listen in for details.

We all are aware that multiple adverse obstetrical outcomes have been linked to maternal obesity, such as stillbirth, preterm birth, NICUs admission, and congenital anomalies. But once delivery and hospital discharge occurs uneventfully, a new cohort study is raising the alarm for another possible adverse event up until the child’s first year of life: Sudden Unexpected Infant Death (SUID). SUID is devastating. In this episode we will review this new publication, which is making medical headlines. This was published on July 29th, 2024 in JAMA Pediatrics. We'll put this association between maternal obesity and SUID in perspective and summarize the key findings of this alarming data.

Our immediate past episode summarized a validation study of cell-free DNA (cfDNA) isolated from maternal plasma for fetal RBC genotyping in alloimmunized patients. And now, in this episode, we will highlight a BRAND NEW ACOG Clinical Practice Update on this very subject! YEP... we now have new ACOG guidance regarding using maternal derived cfDNA for fetal RBC antigen detection as an option for care in alloimmunized pregnancies. This is how "medicine moves fast"! Listen in for details.

In September 2022, a cell-free DNA assay using next-generation sequencing and quantitative counting tech for fetal antigen status determination became clinically available in the USA. This allowed maternal screening for fetal RBC genotypes for RH negative patients. This test was recognized by thre ACOG in March 2024 as one option to “triage” anti-D immunoglobulin in RH negative women. But can this technology be trusted in alloimmunized patients? In women with antibodies against foreign antibodies, this cell free DNA fetal screening option MUST get it right. We now have that data. In this episode, we will summarize remarkable results, published ahead of print on July 25, 2024 in the Green Journal. This study is a win for science and prenatal care. Listen in for details (BillontoOne, Inc is not a sponsor for this podcast).

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

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

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.

Respect for patient autonomy is a fundamental part of the clinician-patient relationship and discussion of healthcare interventions. Some patients decline transfusion of blood products, either for religious or non-religious reasons, but most frequently as part of the Jehovah’s Witness faith. Acceptance of, and decision-making, surrounding blood products and human blood derived medications is complex, however, and some patients who decline certain blood products may still accept other interventions. Because childbirth can be associated with excess blood loss and need for resuscitation, it is important before delivery to clearly delineate which blood products will be accepted or declined, realizing that the patient can change her preferences at any time. One way proposed to address blood loss at cesarean section is the use is intraoperative cell saver (IOCS) for autologous infusion (re-infusion of blood). Is it appropriate to use cell savers to collect and re-infuse blood during a C-section? Does ACOG mention this as an option? And what about the use of erythropoietin antepartum to increase RBC capacity? These questions are the focus of this episode.

"HSDD" as a diagnosis has been gone for some time. According to the ACOG, the DSM-V defines the combined entity of female sexual interest/arousal disorder as a complete lack of or a substantial decrease in at least three of the following symptoms for at least six months: interest in sexual activity and sexual or erotic thoughts or fantasies. This is the most common sexual dysfunction in women, affecting an estimated 5.4–13.6% of women, based on who you read. It is most prevalent in women between the ages of 40–60 and in women who have undergone surgical menopause. Now, a new publication from the Green Journal (June 18, 2024) provides a potential “new”therapeutic option for women, although the data for this actually first came out June of 2023. Can topical sildenafil help with Female Sexual Arousal Disorder? There is already an over the counter cream like this!Let’s take a look at this June 2024 RCT. PLUS, we will also briefly discuss the EROS device for female sexual arousal.

Hypertensive disorders of pregnancy (HDP), including chronic hypertension, gestational hypertension, and pre-eclampsia, are increasingly common in the United States, complicating close to 15% of births, and the incidence is continuing to rise! On this show we have addressed medical management of urgent hypertension in pregnancy and in the immediate postpartum interval. This topic continues to EVOLVE, with a brand new study which has gained a lot of medical news attention. This new study was published in JAMA CARDIOLOGY on June 12, 2024 and is helping redefine the "BP cut off" for medication use in the pp interval. AND...this is evolving within the ACOG as well! We have LOTS of late breaking news to cover here....so listen in!

At time of post cesarean discharge, most providers prescribe a fixed number of opioid tablets. However, past data has shown that most patients don't use all the opioids they are prescribed. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion. In this episode, we will highlight a new publication from the Green Journal (Obstet Gynecol) exemplifying an adoptable strategy using a individualized opioid prescribing protocol (IOPP). While this was published ahead of print on June 10, 2024, the concept of IOPP is not "new" at all. Listen in for details.

Podcast Family, this episode has 2 parts: 1. First, a "non-medical" little life lesson that I heard recently which I will share with you...I hope it ENCOURAGES you, and 2. The MEDICAL part, which comes from Paul- one of our podcast family members. Paul had a GREAT question regarding the data covered in our immediate PAST episode on TOLAC....listen in for details!

After a primary CS, the decision to undergo trial of labor after cesarean (TOLAC) or schedule a repeat cesarean birth is one in which a patient’s values and preferences should be prioritized in a process of shared decision making. Some clinicians elect to utilize a TOLAC calculator as part of the shared decision-making process, while others use a more generalized counseling approach. Once TOLAC is decided upon, which is better: elective induction at 39 weeks, or expected management? Does elective induction at 39 weeks increase the rate of uterine rupture compared to expected management? Older observation data has suggested that very thing. In this episode, we will review a brand new publication from the AJOG (released on June 7, 2024) that provides valuable information in counseling patients on either IOL or expectant care at 39+ weeks for TOLAC.

Hemorrhagic disease of the newborn (HDNB) was first identified over a century ago, and presents as unexpected bleeding, often with gastrointestinal hemorrhage, ecchymosis and, in many cases, intracranial hemorrhage. In newborns, HDNB is typically caused by vitamin K deficiency as neonates are innately deficient in vitamin K secondary to very little vitamin K transferred through the placenta to fetuses in utero, limited liver storage of vitamin K, and low amounts of vitamin K in breast milk. IM administration of vitamin K for prevention of vitamin K deficiency bleeding (VKDB) has been a standard of care since the American Academy of Pediatrics recommended it in 1961. Despite the success of prevention of VKDB with vitamin K administration, the incidence of VKDB appears to be on the rise. This increase in incidence of VKDB is attributable to parental refusal as well as lowered efficacy of alternate methods of administration. Can parents decline this injection for their babies? In this episode, we will review IM Vit K neonatal administration and discuss the controversial data regarding Vit K oral supplementation.

Proving that our podcast tagline, “Medicine Moves Fast” is true… this episode highlights something that is, once again, 🔥🔥🔥 Off the Press! on June 4, 2024, the ACOG released a new Practice Update regarding the determination of paternal and fetal RBC genotyping in pregnancies affected by alloimmunization. This builds upon and updates PB #192 from 2018. There are 3 big areas of change here… And we will highlight each one!

June is CMV awareness month. And that’s the keyword there… Awareness! The way we prevent CMV transmission is by awareness. It would be great to have a vaccine against this virus, but we just don’t…yet. Until a safe and effective CMV vaccine is clinically available, primary prevention of cCMV relies on patient education and hygiene measures. In this episode, will take a look at this strategy and see what the data has to say about it. Will also discuss the very controversial (and non-ACOG recommended) use of antiviral medication’s for primary, perinatal CMV.

In 2011, Congress passed a resolution naming June "National CMV Awareness Month," to raise awareness about the most common congenital infection in the US, affecting 1 of 200 live births. It is the leading VIRAL cause of IUFD & miscarriage & the leading cause of neonatal hearing loss, second only to genetic causes. Furthermore, cCMV is more common than many other neonatal conditions, such as spina bifida and fetal alcohol syndrome. Neonates affected by the virus can experience a wide array of symptoms, from none to severe neurodevelopmental disability, & even death. However, public and healthcare provider awareness remains low. In this episode, which is Part 1, we will cover the presentation, transmission, and work up of CMV in pregnancy.

(VACAY EDITION) Recently in our high-risk OB clinic, I saw a patient who was disappointed that she “had to stop breastfeeding” as she entered her 3rd trimester with her 2nd child. Her first pregnancy was via vaginal birth, at term, with no complications. This situation is not frequently addressed and is a clinical dilemma. First, when nursing coincides with pregnancy, there is frequently a significant cultural taboo leading many women to wean their infants when they become pregnant again. Secondly, there is the concern for potential maternal “nutritional depletion” and thirdly, there is a fear of triggering preterm birth due to oxytocin release with breastfeeding. Nonetheless, there are mothers who wish to breastfeed throughout their subsequent pregnancy. This practice is known as breastfeeding during pregnancy (BDP). Is there data that shows that BDP increase miscarriage risk? What about FGR? Does it increase the risk of PTB? In this episode, we will review the latest data on this not too frequent- but real world- occurrence.

In our podcast archive, we have an episode titled, “TikToc’s #IUD is Killing a Good LARC”. In that episode, I discussed our protocol of using viscous lidocaine applied topically to the cervix, cervical canal, and coating the IUD device for placement. This works! In this episode, we will build on that concept by reviewing a publication released on May 23, 2024 in the AJOG. Could this be the remedy for painful IUD insertion? Plus, have you heard of the CAREVIX device? Listen in for details.

It definitely is interesting how published data tends to have sporadic “groupings” in print. For example, last week 2 publications were released which could be placed under one “group”: prediction/prevention of spontaneous preterm birth. One publication (AJOG MFM) presented a systematic review and meta-analysis on universal cervical length screening. The second publication, SMFM’s consult series # 70, pertains to the management of a short cervix in individuals without a history of spontaneous preterm birth. In this episode, we will review these 2 similar, yet different, publications and make sense of all! 👍👍👍

It’s exciting to know that we are practicing a type of medicine that is alive and ever-evolving! Such is the case regarding our clinical practice/management of gestational diabetes. In this episode, we will review brand new (as of May 21, 2024) clinical guidance from the ACOG regarding gestational diabetes. Should we be screening for diabetes before 24 weeks? Is there one diagnostic threshold which is suggested for use over the other (CC versus NDDG)? And is it possible to screen for postpartum DM as early as 2 days after delivery?😳 Listen in and find out.

The United States began adding fluoride to community water supplies in 1945. At that time, Grand Rapids, Michigan became the first community in the world to add fluoride to tapwater. Over the last several years, with an increase in reporting and media stories over the last 3 months, fluorinated drinking water has come under scrutiny and controversy. Does fluoride in drinking water affect children in the womb? Is this a cause of altered neurocognitive development? Does this lower IQ scores? This is a very HOT topic and there’s more fuel towards this fire with a publication which was released on May 20, 2024 in JAMA Network Open. In this episode, we will lay out the facts of this study, and why this must be interpreted with more than just face value. So grab your favorite fluorinated water beverage, and listen in!

Podcast family, this episode is recorded on the last day of the ACOG ACSM. Wanted to share with you some encouragement that I received from our podcast family members over these last 2 to 3 days. AND of course, in typical style, I’ll share with you a brand new publication which was released on May 17, 2024 in the AJOG (GRAY Journal) regarding “optimal dose of antenatal corticosteroids”. And lastly, I’ll share 3 Special Announcements, as an FYI.

We all can agree that we need a new ally against the foe of pre-term birth. With the disappointing results regarding the (lack of) efficacy of progesterone in reducing preterm birth, the search is out for a new, effective tool to reduce pre-term birth rates. Enter: the Lioness(tm) device. In this episode, we will review a new “safety and efficacy” study published today (May 16, 2024) in the AJOG. Is this ready for prime time? And how does this device work? Listen in for details.

Unbelievable timing! In our immediate past episode, we discussed the controversy surrounding pharmacoprophylaxis for antepartum inpatients. Just 3 days from that episode, a new RCT has been published in the Green Journal (Obstet Gynecol) discussing this very subject! This new RCT (published May 14, 2024) investigates the “best dose” of unfractionated heparin (UFH) during antepartum admissions? is there an advantage to “gestational – age based” dosing? Or should standard UFH dosing be used?

All of us can agree that the rates of obesity are progressively climbing, not just in the US, but globally. Obesity is a known independent risk factor in pregnancy for VTE. Several professional societies (ACOG, CMQCC, RCOG, SMFM) have clear recommendations for VTE pharmacoprophylaxis in patients considered at high risk. These include having a high risk thrombophilia, having a personal history of VTE, or having multiple risk factors. But these recommendations address POSTPARTUM prophylaxis. The ACOG does not specifically address inpatient prophylaxis during the antepartum interval. However, in cases of prolonged antepartum admission, where ambulation may be slightly limited, there is concern that the hypercoagulable state of pregnancy, together with obesity, may raise the risk of VTE in these antepartum patients. To be clear, no professional organization or guidelines recommend strict bedrest for pregnancy complications. Is VTE pharmacoprophylaxis endorsed in these admitted antepartum patients? The answer is both YES and NO. The use of heparin based agents in this group is controversial, with published expert opinions having a dichotomy of thought. Plus, recent data (2023) has raised questions regarding pharmacoprophylaxis’ efficacy in the postpartum interval. nonetheless, at the end of the episode, will provide some common sense approaches to VTE prevention in the admitted antepartum, obese patient. (With a special shout-out to our podcast family in Australia.).

Bacterial vaginosis (BV) is known as a normal vaginal microbiota resulting in low lactobacilli; it affects one-quarter to one-third of reproductive-age women. The BV treatment landscape has not appreciably changed in decades: in the US, metronidazole and clindamycin are recommended as first-line treatments for symptomatic BV, and secnidazole and tinidazole are used as alternatives. Although these treatments are effective in the short term, up to 60% of women experience BV recurrence within 1 year of treatment. Some have more frequent recurrences. Suppressive vaginal metronidazole fails for 25% of patients and leads to secondary vulvovaginal candidiasis (VVC) in up to 40%, and many patients have BV recurrence after stopping suppressive therapy. But now a “new” therapeutic option has been in print and is attracting a lot of attention. DQC has been available in other parts of the world for decades, and recently published results from a new European clinical investigation (May 2024) adds more reassuring date. This has led many in the United States to call for trials in this country to begin FDA approval. Listen in for details.

Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety. Plus, more than 90% of the data regarding tocolytic use comes from patients with threatened preterm labor with intact membranes, with (according to the WHO) only 9% of available data is regarding patients with ruptured membranes. But in May 2024, a new publication adds further information to this subset of patients. In this episode, we will review this ongoing controversy regarding the benefits of tocolytic therapy, and when they may provide the most efficacy. And yes, of course, we will provide the ACOG guidance as well.

Haemorrhage, hypertensive disorders, and sepsis are responsible for more than half of maternal deaths worldwide. Further, it is estimated that for every death, there are 50 pregnant people with life-threatening morbidity from sepsis. Heartbreakingly, the incidence of puerperal sepsis has risen over the last decade, in some cases doubling, with increasing rates of severe sepsis contributing to mortality. Underlying this trend is increasing virulence of group A streptococcal (GAS) infection. This is suspected to be due to the predominance of emm1 and emm28 genotypes, which have higher associations with mortality, as well as increasing maternal risk factors for infection such as obesity and DM. PLUS, certain GAS antibiotic resistance is on the rise. Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are Important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome. In this episode, we will highlight this alarming rise of Group A strep in the peripartum period including the most recent 2021 International Society for Infectious Disease in Obstetrics and Gynecology (ISIDOG) guidelines regarding GAS in pregnancy. Listen in for details.

Menopausal HRT is getting a big, big facelift! Get ready for new research trials, physician education programs, and patient awareness campaigns on menopause! Since the WHI study was released in 2002, the world of menopausal HRT has gone through some major changes. WHI initially led to confusion and fear regarding the use of menopausal HRT. But now, 30 years later, where do we stand? In this episode, we will highlight 2 brand new publications released on May 1, 2024, which prove that we are finally digging out of the hole of WHI. Plus, there’s a Hollywood actress behind the new menopause awareness campaign… and we’ll tell you who that is, and more, in this episode. 😊😊😊

Just the other day in my University clinic, in one single morning, I had 3 separate patients with three very interesting histories; these became the basis of this episode. It’s amazing what’s out there in daily practice! So, we will dive into these 3 main questions which arose from these 3 patient encounters: 1. What single test is recommended before initiation of combination birth control pills? And if this is recommended, how do online pharmacies prescribe prescription birth control? 2. Does PCOS cause other hormone (Prolactin? HCG?) disturbances? And 3., Is treatment of acne within the wheelhouse of women’s healthcare providers? We’ve got lots to cover in this episode…so let’s get started, NOW.

Well, once again… Late breaking news! Today, April 30, 2024, the USPSTF released its updated recommendations for breast cancer screening (mammography) in average risk patients. This follows a firestorm of controversy and backlash over the last 1 to 2 years as the USPSTF continued to recommend initiation of mammogram at age 50, despite the increased incidence of breast cancer in women in their 40s. In this episode, we will review this brand new recommendation and summarize the ACOG response from ACOG President, Dr. Hicks.

Traditionally, clinical guidance has incorporated maternal fever as a required criterion for suspected intraamniotic infection. That is exactly what is stated in the ACOG committee opinion #712 from 2017. However, not all patients with clinical IAI have fever! Having fever as a required part of the diagnostic criterion may result in delayed administration of appropriate antibiotics intrapartum. This has now been addressed by the ACOG! Today, on April 29, 2024, the ACOG released a practice update regarding the criteria for the diagnosis of suspected intra-amniotic infection. This is hot of the press, and we will break it down for us all in this episode. 🔥🔥🔥🎙️🎙️🎙️👍👍🙏

Regenerative Medicine is definitively a HOT and marketable offering across a variety of medical disciplines. But it is equally as controversial. The most well known type of regenerative medicine is the use of Platelet Rich Plasma (PRP). This has been proposed as a novel care therapy for musculoskeletal pain disorders, and a variety of GYNECOLOGICAL applications- including POI, pelvic floor dysfunction, uterine infertility treatment, and even some forms of vaginal fistulas. AND YES... RPR is even being used as a type of cosmetic fascial (with a new CDC health investigation underway!). In this episode, we will review the concept of Regenerative Medicine in gynecology, summarizing some key points from a brand new narrative review of the subject published in the Green Journal (Obstetrics Gynecology).

WOW. There has been a lot of new developments in the ObGyn world within the last 48 hours. In this episode, we will highlight 3 big developments/alerts regarding women’s healthcare: 1. the FDA’s approval of a new oral antibiotic for UTIs in females; 2. The updated ACOG practice advisory regarding maternal cell-free fetal RHD testing; and 3. The FDA’s recent (within last 24 hours) clearance of a new digital app for postpartum depression (MAMMALIFT). Special shout out to Dr. Colton for bringing MAMMALIFT to my attention.

(With Resident Co-Host Dr Taylor Apley) Menstrual synchrony is often reported by all-female living groups and by mothers, daughters and sisters who are living together. Is this real? Is this a pheromone issue? Is there biological signaling occurring here? The answer may surprise you! How does this work? Or does it work at all? And…what is the “MALE Effect”?? Where did this concept come from? This topic of menstrual synchronization is still getting its share of publications, like from November 2023- which we will review. Yep, we’re going to get into this fun topic in this episode. PLUS…DON’T say the “Q” word when all is still in L&D, or the ER. Or the OR! Saying the word QUIET is a sure-fire way to increase hospital admissions and patient pass through, right?! Can you believe there is an RCT that actually studied this? YEP…we’ll check out this issue as well: Fact or FICTION? Listen in, and find out.

Our regular podcast family members know that we have been following the antenatal corticosteroid story (especially in the late pre-term/early term interval) for several years now. A variety of countries have now pulled back from recommending corticosteroids in the late pre-term/early term interval due to concerns of adverse child neurodevelopment, especially when the children deliver at term. But today, April 24, 2024, a new publication from JAMA has provided some reassuring information. Is this data truly reassuring? Or is there more to the story? In this episode, we will dive into this brand new publication, released today, which provides follow-up from the original ALPS Study. This issue of steroids in the late pre-term/early term interval is hot hot hot 🔥🔥🔥. Listen in to get the latest information!

Breast cancer is the second most common cancer among women in the United States (with skin cancer are the most common). About 9% of all new cases of breast cancer in the United States are found in women younger than 45 years of age. Unfortunately, breast cancer is being diagnosed in women under 40 at an increased rate. This was recently published in a Jan 2024 JAMA population-based, cross-sectional study using data from Surveillance, Epidemiology, and End Results database. Every year, more than 1,000 women under age 40 die from breast cancer. Nearly 80% of young women diagnosed with breast cancer find their breast abnormality themselves. Breast cancer is the most common form of cancer in women who are pregnant or have recently given birth. According to US statistics, Breast cancer occurs about once in every 3,000 pregnancies, with some reports stating it may be as high as 1 in 1,000. For those under the age of 40, most are diagnosed between the ages 32 to 38 years. Because many women are choosing to delay having children, it is likely that the number of new cases of breast cancer during pregnancy will increase. In this episode, we’re going to look at breast cancer in reproductive age women with a focus on gestational breast cancer. Is MMG contraindicated in pregnancy? Can chemotherapy be used during pregnancy? What about radiation therapy? And is it better to have a complete mastectomy or breast conservation, during pregnancy? Listen in for details.

Historically, colostrum was expressed by women mid- to late-pregnancy with the intent to avoid engorgement and breast trauma in the postnatal period, but it was not stored for use after birth. But storing colostrum antepartum for newborn feeding has gained attention in social media channels. Is antenatal milk expression, also called colostrum harvesting, evidence-based? Are there benefits to this? Does this run the risk of initiating labor? Are there published studies? In this episode, we will “milk” the data- including a RCT from 2023 – and present some key points to consider about what it is and what it isn’t.

From 2012 to 2021, congenital syphilis cases in the United States increased by 755%. According to the CDC, 88% of congenital syphilis cases in 2022 could have been prevented with timely screening and treatment. Despite repetitive messaging about the need to identify syphilis early in pregnancy, with appropriate treatment, gaps remain. A new publication in the Green Journal (4/17/24) provides shocking information about gaps in diagnosis and treatment. In this episode, we will review that original research as well as summarize the new ACOG Practice Advisory (April 2024) regarding screening for syphilis in pregnancy.

There is a STRONG debate within the medical community as to whether testosterone should be prescribed to women during menopause and the time before and after it. Social media influencers and other media personalities are touting testosterone as a cure-all for mood, sex drive, cognitive changes, fatigue, reduced muscle strength, and other symptoms associated with menopause. In fact, the number of testosterone prescriptions for women has risen within the last five years in the United States and internationally. But is that evidence-based? The answer is both YES and NO. In this episode, we will focus on testosterone replacement for female low sexual interest. We will highlight the position statements from a large international coalition in 2019, a separate 2021 position statement, and the opinion of the ACOG. We have LOTS to cover here, so go lather up with your testosterone cream (JK) and listen in!

While the importance of optimizing a woman's hemoglobin level during the peripartum period has been emphasized in recent guidelines by the Society for Obstetric Anesthesia and Perinatology, the ACOG, and the Enhanced Recovery After Surgery Society, postpartum anemia remains a real issue in both the developed and developing world. Postpartum anemia has been associated with depression, fatigue, impaired lactation, and impaired cognition. This may lead to impaired maternal-child bonding. Additionally, severe anemia during the antepartum interval is an important predictive factor of PPH! This relationship was shown in a published meta-analysis in 2021. Postpartum, IV Fe has been proven to be of value for asymptomatic anemia. Packed RBC transfusion may be recommended for women with postpartum hemoglobin levels

Amnioinfusion was first described in 1976 using a rhesus monkey model. In that landmark study, the authors reported that variable decelerations occurred when amniotic fluid was removed from the uterine cavity and resolved when it was replaced. Although this experiment established that variable decelerations related to oligohydramnios and cord compression could be corrected by amnioinfusion, the technique did not achieve clinical application until 1983, when a novel approach to the relief of variable or prolonged decelerations was described. Amnioinfusion is mainly utilized in the rescue of recurrent fetal variable decelerations intrapartum. But what if the patient has suspected IAI? Is that a relative contraindication for amnioinfusion? Is that safe? In this episode we will examine the data and provide some clinical insights.

In 2014, a publication out of JAMA Pediatrics raised questions regarding the safety of acetaminophen in pregnancy describing a possible “association” with later neurodevelopmental and cognitive delays in children. What followed was a string of controversial publications (observational) with mounds of conflicting data. This led to a controversial international consensus opinion in 2021 calling for “caution for use” regarding acetaminophen in pregnancy. The ACOG had a strong rebuttal to that statement at that time. But now, as of April 9, 2024, we have new data on acetaminophen/paracetamol use in pregnancy and possible neurodevelopmental affects in children. This new study was published out of JAMA network and followed 2.4 million children with sibling pairs out of Sweden. This is making a lot of news within the last 24 hours and it is hot off the press 🔥🔥🔥. Listen in, and find out more.

It has been stated that “Trauma is in the eye of the beholder”. Healthcare providers must be aware that a woman makes experience a birth as traumatic, even if she and her infant are healthy. The ACOG has highlighted perinatal PTSD in several publications, which we will review in this episode. Perinatal PTSD has definitely been in the OB/GYN and psychology literature with an increased frequency just over the last 3 months. In this episode, we will review the very real and devastating condition of perinatal PTSD, its diagnosis, and discuss interventions to reduce its development. We will also review new data on “service dogs“ detecting PTSD in people with trauma histories? NOTE: We will also highlight a real world account of a traumatic birth event from one of our podcast listeners (Deidentified, and shared with permission).

In July 2023 and again in November 2023, we discussed the “Rule of 55“ and its role in the management of hypertensive disorders of pregnancy. The Rule of 55 has been mainly applied in the selection of appropriate antipretensive medications when urgent/emergent hypertension is present. Does the Rule of 55 also work for antihypertensive management of gestational hypertension or preeclampsia without severe features? A new publication (April 1, 2024) from the AJOG MFM gives us that answer! In this episode, we will cover the newly released PYTT study from Italy.

On April 8, 2024, parts of the United States will be within the Path of Totality for the total solar eclipse. The state of Texas has already declared a state of emergency as visitors flock to the state to witness the event. This is a fascinating celestial occurrence that is not scheduled to happen again until August 2044. Does the eclipse have a negative effect on pregnancy? Do lunar cycles affect birth rates? What does the data say? Does NASA have a statement on this? And what are neutrinos?! Listen in… And find out. 🌖🌗🌑

Today, April 3, 2024, the ACOG released a clinical practice update to practice bulletin# 222 (gestational hypertension eclampsia). This is in direct response to a recent FDA approved biomarker test for risk stratification for preeclampsia. On May 19, 2023, the FDA cleared a novel biomarker serum test for the risk stratification for severe preeclampsia in hypertensive pregnant women. This clearance is the first given to any blood-based biomarker test for assessing preeclampsia risk. The company is Thermo Fisher Scientific (no disclosures). This new clinical practice update puts this test into proper perspective and gives clinicians some valuable insights of what it can, and what it cannot, do. Listen in for this “off the press” clinical practice update. 🔥🔥🔥🔥

According to the CDC, as well as worldwide data, the percentage of individuals categorized as overweight or obese is rising. First released in 1990 by the IOM, the guidelines for expected weight gain in pregnancy-based on pre-pregnancy weight (BMI)- have been controversial. These guidelines were revised in 2009. Now, a new publication from the Lancet (28 March 2024), is questioning the validity of the “minimal weight gain” recommended for patients with obesity. In this episode, we will review this controversy. Additionally, we will highlight a separate publication from the AJOG MFM (systematic review and meta-analysis) discussing NPWT use at C-section for patients with obesity.

The current dose and schedule for antenatal corticosteroids (ACS) follows the original publication by Liggins and Howie in 1972. That dose and schedule was based on sheep models from the 1960s. The dose in current use had never been evaluated to minimize exposures while assuring efficacy. New pharmacokinetic and pharmacodynamic data is calling into question whether the current dose and schedule is necessary. Translational research in animal models indicate that a constant, low concentration fetal exposure to ACS is sufficient for lung maturation, resulting in lower fetal exposures. In this episode, we will summarize a new clinical commentary published in AJOG in March 2024 highlighting the current state and controversies regarding ACS for threatened preterm labor.

Meningiomas are common intracranial tumors with a female predominance. The vast majority of these tumors are benign (World Health Organization [WHO] grade 1) while 15% to 20% of these tumors can behave atypically (WHO grade 2) and rarely, in 1% to 2% of cases, these tumors can be malignant (WHO grade 3) Their etiology is still poorly documented. The role of sexual hormones has long been proposed, but data have been conflicting across studies. However, a dose-dependent relationship between the incidence and growth of meningiomas and hormonal treatment with the synthetic progestin cyproterone acetate (CPA) has been recently established (2021). Now, a new observational study from France (BMJ) has raised the warning flag for a similar association with a common birth control option, depo medroxyprogesterone acetate. Does Depo-Provera cause brain tumors? It's very important to put this study into proper context. We’ll explain all of this, and more, in this episode.

According to the ACOG, pre-labor rupture of membranes (PROM) complicates 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality. What is the best course of action when patients present with PROM with a “unfavorable cervix”? Should it be a pharmacological method of ripening, or a mechanical? What does the data say? In this episode, we will do a deep dive into published data from the 1980s up to 2023. We will also explain why the Bishop score “is irrelevant“(SOGC) in patients at term with PROM. 😳. The literature does favor one pharmacological agent in cases of PROM. Curious? Listen in and find out more.

Obstetrical vacuum and forceps are incredible tools, when used correctly, to assist vaginal delivery. Appropriately selected and used, they can be pivotal in reducing the number of unnecessary cesareans and potentially decreasing certain fetal and maternal complications. However, there are several pearls of wisdom to remember when using them. In this episode, we will focus on a rare – but potentially fatal – complication of vacuum use: subgaleal hemorrhage. Although subgaleal hemorrhage can occur following normal birth processes, and even cesarean section, vacuum use is the strongest independent factor for its occurrence. In this, we will review these pearls of wisdom and the importance of detecting neonatal subgaleal hemorrhage quickly.

Ovarian preservation by autologous transplantation has given hope to patients desiring future fertility after certain gonadotoxic therapies for malignant conditions. But now, the same procedure is being promoted as a “natural cure” for menopause. Can ovarian tissue-based therapies really be the female, endocrine “fountain of youth”? In this episode, we will highlight a recent publication from the AJOG describing the potential of this procedure. We will also discuss the history of ovarian autotransplantation and why this procedure for menopause prevention has more questions than answers.

Since the late 1990s, the standard practice for GDM care has been to measure postprandial glucose values. For patients with pre-gestational diabetes, whether type I or type II, the ACOG recommends multi-level glucose checks (fasting, pre-meal , postprandial, and nighttime). But what about in the immediate postpartum interval? In patient’s with pre-existing diabetes, should blood sugars be checked pre-meal (qAC) or postprandial while still in the hospital, and after discharge? The topic for this episode comes from one of our podcast family members who had this clinical dilemma? In this episode, we will review the data and recommendations from the American Diabetes Association, the ACOG, and CDC. So grab your sugar-free drink of choice, and listen in!

Is breastfeeding with Hepatitis C safe? The answer: Yes! But confusion persists today mainly surrounding the serum hepatitis C viral load. That’s the topic and focus of the new publication released March 2024 in the Green journal, Obstetrics and Gynecology. We will highlight this new study in this episode. Yep, we have learned a lot about hepatitis C, and HIV, and breast-feeding. In this episode, we will review: the different hepatitis C genotypes and their implications, current breast-feeding guidelines for women with hepatitis C, the updated guidelines for breast-feeding with HIV, how some may be spontaneously “cured” of hep C postpartum, and why viral load matters for one of these conditions – but not the other!

It has been estimated that up to 4.4% of the US adult population has been diagnosed with ADHD. Use of ADHD medication is increasing among pregnant women. In the last several years, there’s been a litany of publications looking at the effects of pregnancy on ADHD, as well as the effects of medication on the pregnancy. In this episode, we will highlight a new publication released March 2024 (Archives Women’s Mental Health) examining prenatal outcomes in women who continued dexamphetamine in pregnancy. We will also summarize the data regarding the effect of ADHD medication on congenital anomalies and neurodevelopmental outcomes in the children.

Four years, the US National Vital Statistics System has reported an abnormally high maternal mortality rate in the United States, showing it to be nearly doubled from 17.4 in 2018 to 32.9 per 100,000 live births in 2021. The United States’s maternal mortality rate has been on the media radar for many years because of this. But that rate is completely WRONG. How is it that maternal mortality rates are more than 2 to 3 times higher than other developed countries despite our vast progress in obstetrical care? The answer? It is a statistical error! In this episode, we will review a brand new publication from the AJOG published on March 12, 2024 that is making media headlines. We have known that this reporting system is greatly flawed for several years, and now it is getting the attention it deserves. Although this is reassuring news for the country overall, there is still ONE patient demographic where we need to dramatically reduce the maternal mortality rate. Curious? Listen in and find out more.

The ACOG, CDC, and WHO currently do not recommend universal screening for thrombophilia in the general population before starting oral contraceptive pills. However, a new publication in AJOG (March 2024) is challenging that stance. In this episode, we will review this new prospective population-based study to see if it makes the case for universal screening for thrombophilia variants before starting OCPs. In this episode, we’ll also discuss high-risk versus low-risk thrombophilia, discuss relative risk versus absolute risk of VTE on the combination pill, and give clear clinical implications for patient management.

Gestational Diabetes (GDM) is vastly more prevalent in pregnancy compared to pre-existing diabetes. In 2009, the ACOG states that 7% of all pregnancies were complicated by a diabetes diagnosis, with 86% being GDM. The prevalence of GDM keeps rising in the US and globally. Metformin is increasingly prescribed in pregnancy, yet its long-term effect on the neurocognitive development of the offspring remains incompletely described. However, newly published data (March 6, 2024; AJOG) has changed that! In this episode, we will summarize and review a systematic review and meta-analysis of childhood neurodevelopmental outcomes after in utero exposure to metformin. Additionally, does some evidence suggest that metformin may be superior to insulin in pregnancy for perinatal outcomes? We will discuss all this and more, in this episode. This information will be helpful as we counsel and educate our patients on metformin use in pregnancy.

On this podcast, we have been following this story of the OPill for several months. Previous episodes on the subject can be found in our podcast library. As expected, this first ever daily use progestin only pill is now available over-the-counter in the US. 👏👏. On Wednesday, March 6, 2024, the ACOG released its Practice Advisory presenting some key reminders for clinicians regarding this new over-the-counter contraceptive option. In this episode, we will summarize this practice advisory and answer some real-world questions patients may have regarding this: does the OPill help with acne? Is this approved for endometriosis pain? What happens if a patient misses the next dose at the scheduled time? Listen in for these answers and more.

Use of second-line noninsulin diabetic medications, like Glucagon-like peptide 1 (GLP-1) agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors, is rapidly increasing for treatment of T2D and other indications. As these drugs are being used by an increasing group of fertile women, it is expected that a few of them will get pregnant and data on their safety when used in the first trimester is needed. Is periconceptional use of glucagon-like peptide 1 (GLP-1) receptor agonists associated with increased risk of major congenital malformations? In this episode, we will look at the available data (although limited) regarding these medications, focusing on specific GLP1 options.

Using mechanical options as a way to prime/ripen the cervix for labor is nothing new. Balloon catheters have been used for labor induction as far back as the 1890s. Embrey and Mollison reinvigorated the method in 1967 using it in combination with extraamniotic prostaglandins. Since then numerous studies have been performed worldwide, mostly using the Foley catheter. Then, in 1990, the double balloon catheter was introduced by Atad; this paved the way for the Cook Balloon. But what is the best way to use a balloon for cervical ripening? Should be a single balloon or a double balloon? If single balloon, does volume of the balloon matter? Should it be used alone or with combination with a second agent? Can it be used safely as an outpatient procedure? In this episode, we will present new data regarding traction vs no-traction for single balloon cervical ripening therapy. This new study was published on March 1, 2024 in Obstetrics and Gynecology (the Green Journal).

It’s very important to stay up-to-date and current with new data. But sometimes you read something that is hot-off-the press and it makes you just stop and say, “hmmm”. In this episode, we will discuss the new USPSTF position statement on screening/treating iron deficiency anemia in pregnancy. We will also review the ACOG August 2023 clinical consensus #4 regarding UTI in pregnancy. In doing so, we present 2 things that “make you go hmmm”.

The “traditional“ Parkland management protocol for GDM included the immediate initiation of medical therapy for those with abnormal fasting blood sugar, in addition to another additional value, on the 3 hour GTT. These patients were automatically labeled as A2 GDM at time of diagnosis, rather than waiting the 1 to 2 weeks of nutritional/diet therapy. Does fasting hyperglycemia on the 100g GTT truly predict the need for subsequent medical therapy? In this episode, we will summarize new data on this subject from AJOG MFM published on February 17, 2024. Does immediate medical therapy after GDM diagnosis improve overall maternal/neonatal outcome? It’s a complicated answer, and we will review it in this episode.

Yes, the subject of RhoGAM/RHIG administration to RH negative patients under 12 weeks gestational age is a continuously controversial issue. We have covered this issue in past episodes, most recently- last month- on January 4, 2024. Today, February 26, 2024, the SMFM released their position statement on the subject. As you would guess, the controversy continues! In this episode, we will review this brand new, hot off the press, position statement regarding RHIG administration, or avoidance, under 12 weeks gestation.

February 2024 has seen its share of medical and mainstream media stories highlighting hypertensive disorders in pregnancy. While some of this can be considered “old news”, there is “new news” and new developments on the horizon. We have covered hypertensive disorders in pregnancy on several past episodes; however, in this episode, we are going to pick up where we left off and review what the current state of understanding is for AHA/ACC Stage 1 hypertension in pregnancy. Does stage I hypertension in pregnancy require medication? What about antepartum fetal surveillance? What are these patients at risk for? Listen in as we simplify the latest data and summarize the latest evidence regarding serum biomarkers for hypertensive disorders in pregnancy.

Hyperemesis Gravidarum (HG) has a reported incidence of approximately 0.3–3% of pregnancies. Without prompt recognition and treatment, severe maternal dehydration, electrolyte abnormalities, cardiac arrhythmias, and potentially altered fetal neurodevelopment may result. Recently, HG made medical and general media news as new data has pinpointed 2 likely culprits of its origin- and neither one is estrogen. In this episode, we will discuss these 2 protein markers, and how researchers are looking to develop a genetic test for patients to predict HG. We will also summarize a new publication from Obstetrics & Gynecology (which was published on February 1, 2024) as an ACOG Clinical Expert Series on the inpatient management of HG.

Women whose fetuses are in the occiput posterior head position at the time of delivery are known to have longer second stages of labor and more complicated deliveries, including more operative assisted births, more 3rd and 4th degree lacerations, PPH, and in some studies lower Apgar scores and lower umbilical cord arterial pH. At what point in labor should the healthcare provider attempt to rotate the fetal head: first stage or second stage of labor? Recent intrapartum studies using ultrasound to verify fetal head position has provided new insights regarding the cardinal phases of labor. In this episode, we will tackle the fetal occiput posterior position and manual rotation. Should this be a 1st or 2nd stage of labor practice?

The ACOG has long-held that shoulder dystocia is “unpreventable and unpredictable”. Nonetheless, as it is a devastating obstetrical occurrence, researchers have attempted to identify a reproducible mathematical formula using ultrasonographic, anthropometric factors to better predict it. What is the data behind these math models? Does the ACOG recognize their use? What is their positive predictive value? In this episode, we will examine the data – going back 40 years – and we will end the episode with the current stance from the ACOG regarding these mathematical calculations for shoulders dystocia prediction.

The ACOG has consistently recommended universal screening for gestational diabetes between 24 and 28 gestational weeks. Although controversial, the ACOG does endorse earlier screening for GDM in patients with additional risk factors. But what about patients who present for prenatal care after the 28th or 29th week? Should screening for GDM be done in the 3rd trimester? And if we do screen in the then, what is the reference range for “normal “or “abnormal”? Is it the same interpretation as when it is done between 24 and 28 weeks? Does 3rd trimester screening impact parental outcome? In this episode, we will examine the data and provide a recommendation of when testing for gestational diabetes in the 3rd trimester may have the most impact.

On February 6, 2024, a new publication in the Lancet Planetary Health received national and international headlines. This study, funded through the NIH, revealed a striking association between certain chemicals in our environment and preterm birth. But is this data really new? We have known that certain chemical components, called phthalates, have a strong association with preterm birth for over 10 years now. Nonetheless, it is always a good reminder to reduce or avoid exposures to potentially dangerous substances which are ubiquitous in today’s culture. What exactly are phthalates? What did this new data reveal? In this episode, we will dive into the data and put things into proper perspective. PLUS, at the end of the episode, I’ll review 10 common-sense things that we can all do daily to try to reduce our exposure to these“forever chemicals”.

YES, it’s true… Not even Super Bowl Sunday 🏈🏈can stop us from getting our podcast episode up and out! In this episode, we will summarize the key findings of a newly released RCT (ahead of print, Obstetrics and Gynecology) that is yet another “nail in the coffin” for late pre-term/early term steroids. This is perfect timing, as we just covered this topic on a separate episode last week. So listen in as we summarize this newly released, triple-blind RCT with eye-opening results.

We are still in an opioid crisis. The number of women with opioid-related diagnoses at delivery has increased by 131% over the last several years (CDC, Data and Statistics, 2023). The ACOG has recommended the use of opioid agonist pharmacotherapy for MOUD during pregnancy. Traditionally, medically supervised withdrawal has not been endorsed for pregnancy. However, some patients may elect to discontinue opioid therapy in favor of an opioid antagonist like naltrexone. In this episode, we will review a new systematic review just released ahead-of-print in Obstetrics and Gynecology. This systematic review evaluates OB and neonatal outcomes following naltrexone use during pregnancy. And listen in until the END of the episode for one of the “issues” with naltrexone as a MOUD option.

It is completely natural, and part of the human experience, to have some anticipatory concern about an upcoming delivery/childbirth. However, when that concern becomes overwhelming, it can develop into a debilitating phobia called Tokophobia. First coined as a term in 2000, there’s been growing awareness of this specific type of anxiety disorder/phobia. Even though it was first described in 2000, this extreme fear of pregnancy and childbirth has, of course, been part of the human experience For centuries. This is now considered a sub-type of PTSD when it happens after a traumatic childbirth experience. The idea for this episode originated from a real patient encounter that one of our residents had just yesterday. Have you heard of Toca phobia? How prevalent is it? And what are the “4 Rs” of trauma informed care? Will cover this, and more, in this episode.

In 1972, Liggins and Howie published their landmark study on the benefits of antenatal corticosteroids (ACS) regarding their reduction of prematurity’s morbidity and mortality. This led to the weekly administration of ACS until 34 weeks. Weekly courses of steroids are no longer given, but the steroid story keeps evolving. In 2016, the ALPS trial demonstrated reduction in short-term respiratory morbidity when steroids were given in the late pre-term interval. Many professional societies and organizations endorsed this intervention shortly thereafter. But since then, there have been renewed commentaries and debates regarding steroids in the late pre-term interval, and steroid exposure in-utero for babies born late pre-term/term. several professional organizations, no longer endorse steroids in the late pre-term interval. In this episode, we will review this complicated and ever evolving debate, highlighting a recent systematic review and meta-analysis from August 2023.

On January 28, 2021, a non-inferiority RCT was published in the NEJM, “Levonorgestrelvs Copper T Device for Emergency Contraception”. This study concluded that the LNG 52mg IUD was “noninferior” to the CopperT IUD for emergency BC up to 120 hours after ill-protected intercourse. Since that time, use of the LNG 52mg IUS has remained controversial with some organizations endorsing its use as EC while others take a more cautionary stance. Now, as a February 1, 2024, a new commentary in the Green Journal (Obstet Gynecol) is raising eyebrows regarding this. What’s the controversy surrounding this? Is the LNG 52 mg IUS a reasonable option for emergency contraception? What does non-inferiority mean? In this episode, we will go through all of the data and put things in proper perspective. While gaps in evidence remain… There is plenty to draw an evidence-based opinion on. Curious? Listen in and find out more.

On January 18, 2024, the FDA cleared a novel new device for osteopenia treatment. This is a vibrating belt (wearable device) that transmits low-amplitude, high-frequency (20 to 40 Hz) vibration to the spine and hips. This belt is called Osteoboost. Osteoboost previously received a breakthrough designation from the FDA in Dec 2020. This FDA clearance has already generated a lot of commentaries regarding the single RCT results. In this episode, we will review the results critically and explain why there is a difference in “per protocol” RCT results and “intend to treat” RCT results. Is Osteoboost a game changer? Listen in and find out.

Bacterial vaginosis (BV) is the most common vaginal aberrant condition in women, in the general population. Even still, the majority of women with BV are asymptomatic. If BV is found at time of elective IUD/S placement, can the device still be inserted? Or is it an independent risk factor for upper tract infection? What category in the CDC MEC is vaginitis/vaginosis for IUD placement? There definitely is some confusion about this in clinical practice, highlighted by the 3 different clinicians which were interviewed in this episode! So…. IUD placement with BV: test and place, or test and differ placement? Listen and find out.

Hypertensive Disorders of Pregnancy (HDP) affect 5 to 15% of women worldwide, and their increasing incidence is likely related to the growing levels of obesity, metabolic syndrome and advancing maternal age. It is widely accepted that women who have preeclampsia are at increased risk of future hypertension, cardiovascular disease, stroke, chronic kidney disease, and even diabetes in later life. But what is the association between HDP and dementia? In this episode, we will review the latest data from a systematic review and meta-analysis published on January 24, 2024 in the AJOG.

Uterine wall perforation at time of IUD placement has been published to occur, in general, about 1-2/1,000 cases. It happens! While there are some risk factors for uterine perforation (very antiflexed, retroflexed, recent postpartum state, lactating), sometimes uterine perforation can happen even with the best of technique and no risk factors. While most providers are concerned about immediate short-term gynecological complications like infection and bleeding, we don’t really consider the possibility of any potential future OB complications. Is a patient at higher risk of future adverse OB issues after perforation during IUD placement? It’s an interesting question, with an even more fascinating answer! In this episode we will dive into the data, and make sense of published case reports and clinical opinions which help us arrive at the answer to that question.

Yep, Medicine moves fast! On Friday, January 5, 2024, I participated in a medical news report published in “The Guardian”. In that news commentary I stated that “Bicillin-LA is the only medication approved for syphilis during pregnancy”. We’ve all heard that statement, and it is a true statement. However, 5 days later on January 10, 2024, the FDA announced the importation allowance of “Extencillin” to combat the Bicillin-LA shortage. Yep, Medicine moves fast. Now we have this medication available as an option until Bicillin-LA increases its availability. But what about Linezolid? In this episode, we will also discuss a recent non-inferiority trial of Linezolid for early syphilis, which was published in “The Lancet”. Although that study had disappointing results, there are some caveats which need explaining. Listen in to find out more.

If you had 5 reproductive age women, all late on their menstrual cycle, who were having unprotected sex, and all have a positive pregnancy test… What would be your diagnosis? The most likely diagnosis would be that there are five pregnancies! Right?! But what if 1 of those patients had end stage renal disease (ESRD), on hemodialysis. Is there anything else to consider? While ruling out pregnancy is priority #1, it is possible that this HCG is a phantom result. This is a slippery slope discussion and one that could easily lead down the rabbit hole. In this podcast, we will highlight this clinical conundrum, based on a real case from our practice, and summarize some fascinating reports from the literature.

Periodically, we respond to podcast family members’ questions as data is available. In this episode, we will cover 3 very clinically relevant questions from our podcast listeners. The first question is regarding our immediate past podcast topic, which was propranolol as a labor stimulant. The question is, “Does the ACOG have a statement on adjuvent propranolol use during labor?“. We’ll answer that question in this episode. The second question is whether the placebo/pill-free interval of combination birth control pills is linked to anxiety/depression. This is a COMPLICATED issue but there is brand new data that helps answer that exact question, and we will cover that in this episode. The final question is whether or not “HPV booster vaccination“ is indicated after CIN2+ treatment in patient who had previous vaccination. Lots of data to help answer these questions… and we will summarize it here.

It has been well reported that rates of elective induction have risen nationally and internationally since the adoption of the ARRIVE trial. But as medicine is at times controversial, some studies have suggested an increase in cesarean section rates with elective induction of labor at 39 weeks. While we will briefly discuss those studies, they are not the focus of this episode. However, as induction of labor becomes more common place, there has been renewed interest in use of adjuvant medications to augment induction success. One of those medication is propranolol. Can giving a beta-blocker help with uterine contractility? The data is conflicting with recent evidence saying “No!“. In this episode, we’re going to put the evidence on trial and present both arguments: one as plaintiff, and one argument as the defense for our shared client, which is propranolol. Is propranolol guilty of its charges of being a labor stimulant? Or is it innocent of all charges? Let’s let the data decide.

On New Year’s Eve 2023 we released “LUST for TOLAC”. LUST stands for lower uterine segment thickness. This is a very enticing, and controversial, approach to TOLAC counseling and direction. I encourage you to go back and listen to that episode, if you have not yet, before listening to this one as this is more data to support those conclusions. In this episode, we will highlight a multi-center, cluster-randomized trial out of Canada, the PRISMA study. This fantastic investigation sheds more light on the application of LUST for prediction of TOLAC uterine rupture.

The gestational age boundary termed viability has shifted dramatically during the past 50 years, and more so in the last 15 years. In 1971, a widely used neonatology textbook stated that, “The lower limit of viability is probably around 28 weeks, at which time most infants weigh two pounds, four ounces (1000 g).” Today, the most immature infants routinely cared for by neonatologists in some parts of the world are born at 22 weeks of gestation, with many weighing around 500 grams. While most studies reporting on neonatal resuscitation at 22 weeks give a main outcome as “alive at discharge”, there are other potential long-term morbid conditions which cannot be ignored. The ability to perform neonatal resuscitation at 22 weeks and 0 days has led to many powerful ethical debates and published commentaries. In this episode we will take a look at the complexities of neonatal resuscitation at 22 weeks focusing on the potential long morbidity after hospital discharge.

This is NOT our regularly scheduled episode. Based on an incredible comment from Rachel – one of our podcast family members, which I received just moments ago, this was too good to not put out. A brief clarification on NIPTS and “46XX or 46XY”. (This is a supplement to our immediate past episode.) 😊😊🧐🧐

NIPT is a prenatal SCREENING method that involves analysis of cell-free fetal DNA (cfDNA) in maternal blood. Prenatal screening for sex chromosome aneuploidies (SCAs) has become readily available through expanded non-invasive prenatal testing (NIPT). NIPTs became commercially available in 2011 and has since been introduced in more than 60 countries around the world and is now part of mainstream obstetrical practice. Initially offered as a secondary screen for pregnancies with a high probability of a fetal chromosomal anomaly, NIPT is now often offered and recommended as a first-line screening test for the main chromosomal aneuploidies. Initially, NIPT was available to screen for fetal trisomies 21 (Down syndrome), 18 (Edwards syndrome) and 13 (Patau syndrome). This has expanded of course to include (separately) fetal sex chromosome aneuploidy (SCA) screening. However, there are some VERY important points we must remember when seeing an “atypical sex chromosome” NIPT result. What is the PPV of a SCA found on NIPT? In this episode we will highlight a recent NIPT atypical sex chromosome result from our practice and review what this may and may not actually mean, and review why NIPT screening for SCA is actually VERY controversial with some potential ETHICAL concerns, with some countries recommending AGAINST ordering it. Lots to cover here….so listen in.

We take pride as healthcare providers in being “evidence based“. But sometimes things that we do, even in 2024, sound, reasonable and sound practical, but actually are NOT evidence-based. But lacking evidence means 2 things: 1. Studies have proven something does not work, or 2. Studies have not been done to confirm or refute the intervention. In this episode, we will discuss 2 common interventions that are recommended in pregnancy that actually don’t have the evidence behind them. First is the “test of cure” urine culture after treatment of ASB or cystitis, and the second is certain physical activities like specific yoga positions/Miles circuit as preparation for labor. I believe in both of these interventions- although we don’t have STRONG data for either. I will explain in this episode. That’s why I am calling this, “No data, No problem!”.

Before the 1960s, there was no method available to prevent Rh sensitization during Rh-incompatible pregnancies. Then, in 1968, the FDA approved the use of RhoGAM to help prevent Rh immunization. This was a landmark move in the field of Obstetrics. More recently, ever evolving data and medical genomic technology has brought new insights to RHD alloimmunization care. Can maternal RH typing be avoided with early pregnancy loss (under 12 weeks)? Why about in cases of pregnancy termination? Is that safe? And what is the UNITY non-invasive prenatal test? How can it be used to decrease unnecessary Rhogam administration? Well cover all this new data in this episode (NOTE: UNITY is not a sponsor of this podcast nor of this episode).

Historically a range of psychiatric and medical conditions have been erroneously attributed to 2 gynecological organs/function. During the time of Hippocrates, the “wandering womb” theory blamed emotional disturbances in women on this condition. Not only was that erroneous, it was nonsensical. However, certain gynecological conditions can indeed manifest with neuro-behavioral disturbances. One of these syndromes can be triggered by the presence of an ovarian dermoid. Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis is a paraneoplastic limbic syndrome which may be caused by ovarian teratomas containing neural components. Neural tissue in a teratoma can trigger the production of anti-NMDA-R antibodies, which causes neuronal dysfunction and loss by altering the neuronal cell-surface NMDA receptors in the limbic system. This syndrome presents with a range of psychiatric, neurological and autonomic features and if not promptly recognized and treated may be associated with long-term morbidity and mortality. Rare…yes. But it is out there in the community and patients are at HIGH risk of misdiagnosis. In this episode we will discuss this “Brain on Fire” syndrome and highlight a real case contributed by one of our podcast family members (HIPPA protected).

This is our last episode for 2023! A podcast family member reached out to me notifying me of a thread on social media discussing ultrasound measurements of “lower uterine segment thickness” (LUST) for TOLAC candidates. I consider myself pretty social media friendly, but was unaware of this comment thread. Should we be measuring lower uterine segment thickness in the late 3rd trimester as a discriminatory tool for TOLAC approval/denial? Is this evidence-based? Where did this concept originate? Is this supported by the ACOG? The answer to all of this is both YES and NO. We will explain in this episode.

It’s no surprise and understatement to say that the US maternal/neonatal morbidity and mortality rates have to improve. As a way to increase maternal supportive care, an increasing number of states are turning to cover Doula services. Despite this forward thinking, there are still misperceptions, misunderstandings, and “boundary” issues regarding Doulas which must be addressed. Are Doula interventions evidence based? Are Doula services related to improved maternal and neonatal outcomes? What is the position from the ACOG? Does the March of Dimes have a position statement? We will answer all of these questions and explain why 2024 may be the “Year of the Doula” in this episode.

On May 8, 2023, we released an episode called “Slowed Fetal Growth Trajectory and Neonatal Outcome”. That episode highlighted data that slowed fetal growth was an independent risk factor for stillbirth. This is true even though the composite EFW remained above 10 percentile. Now, there is new data which validates this concept and provides a working model which may help predict fetuses with slowed fetal growth who are at risk of stillbirth. PLUS, we will describe a free online fetal growth trajectory calculator (UK) that helps with patient education and prognostication.

On August 26, 2023, we summarized the ACOG update on viral hepatitis in pregnancy and discussed new concepts regarding Hep B viral infection. To follow that up, the SMFM has now released its Consult Series #69 (Hepatitis B in Pregnancy: Updated Guidelines) which was published on December 21, 2023. In this episode, we will reinforce some topics originally discussed back in August 2023 and emphasize key management issues regarding Hep B in pregnancy based on this Consult Series… both for the infected, and the non-infected/non-immune patient. Is antepartum fetal surveillance indicated in these patients? Is C-section a way to prevent perinatal transmission? What’s the viral load cut-off to begin antiviral medication? Is it safe to administer hepatitis B vaccine during pregnancy for those who need it? Listen in for details.

The average height for men in the U.S. is about 5 feet 9 inches. For women, it’s about 5 feet 4 inches. Height stature has been correlated with some interesting health conditions at a population level: Some research shows that a below-average height may mean you have lower odds of getting some types of cancer. For example, a study of more than 100,000 women in Europe and North America showed that shorter women are less likely to get ovarian cancer. Also, although researchers can’t explain why, studies show that the shorter you are, the less likely you are to have a VTE. People who are 5 feet or shorter have the lowest chances of getting one. Those are good correlations to being short! BUT, short stature has also been linked to higher stroke risk, coronary heart disease, and diabetes. It is theorized that individuals at/around the 5 foot mark- outside of simple race/genetics- may have been imprinted for smaller growth trajectories either in utero or in early childhood which metabolically predisposes them to these future issues. What about short stature and pregnancy? Are there any correlations there? Is maternal short stature an independent OB risk factor for negative outcomes? And why do we only have ONE main EFW chart (Hadlock) in pregnancy vs population specific ones? We’ll get to the tall and short of it…in this episode.

Sex has always had its share of misinformation, even as it relates to some medical conditions- like epilepsy. "Coitus brevis epilepsia est" ("Sex is a brief seizure") is an ancient proverb attributed to Galen, the influential Greek physician and philosopher in the Roman Empire. Then, in the 18th and 19th centuries, some physicians, including Samuel-Auguste Tissot and Edward Sieveking, argued that excessive masturbation could cause epilepsy! At the time, castration and clitoridectomy (removal of the clitoris) were reportedly performed on people with severe epilepsy. Terrible! Thankfully we now are all SURE that sex does not CAUSE epilepsy, but sexual release (orgasm) and seizure like activity are indeed similar. Can orgasm trigger epilepsy? And is the reverse possible: can seizures give orgasm like effect? How is PNES related to this? We will review this fascinating clinical conundrum in this episode.

BIG. BIG. BIG Update. In March 2014, the ACOG/SMFM released OCC #1 (Safe Prevention of the Primary C-section) which redefined the labor curve. That document has now been WITHDRAWN. It is being replaced with Obstetrical Care Consensus #8 coming out January 2024. In this episode, we will highlight key points from this updated guidance including: 1. ACOG’s new language surrounding the length of latent phase, 2. the role of “early” amniotomy in labor induction, and 3. clarification on 2nd stage of labor management.

It’s really amazing how fast medical information and discovery happens. For decades, we blamed nausea and vomiting of pregnancy/hyperemesis gravidarum on either estrogen or high levels of HCG. While these 2 hormones definitely have some association with that condition, new evidence has pointed to a separate compound as the likely offender. In this episode, we will review data just published on December 13, 2023 from an international research think tank. This group has likely pinpointed the origin of nausea and vomiting of pregnancy. This discovery opens up a new area of therapeutics aimed at targeting this chemical messenger, rather than simply treating the symptom of nausea. Are you familiar with GDF-15? In this episode, will review this incredible little molecule, and summarize key findings from this recent publication.

According to ACOG’s CO 773 from 2019, “Currently, serum antimüllerian hormone levels are not part of the accepted diagnostic criteria for polycystic ovary syndrome (PCOS)”. But medicine moves fast, and that statement is no longer valid, at least it isn’t valid from the ASRM July 2023 Standpoint. Yep, once considered experimental, AMH has now entered the PCOS diagnostic algorithm. Nonetheless, some important limitations and facts must be understood for its use in this way. In this episode, we will highlight the recommendations from the 2023 international, evidence-based guideline for the assessment and management of polycystic ovary syndrome, focusing on the role of AMH. We will also discuss the condition in adolescents and why this diagnosis is DIFFERENT in this group, and the update to the number of follicles per ovary (FNPO) recommended for the diagnosis. This guideline has been co-published in Fertility and Sterility, Human Reproduction, European Journal of Endocrinology, and The Journal of Clinical Endocrinology and Metabolism.

We thought we had endometriosis all figured out. After all, we know it’s a chronic pain syndrome that’s hormone responsive. But there’s more to it than that. Within the last few years, including this year 2023, we have grown even more in our understanding of this pelvic pain condition. We now have new data explaining the link between endometriosis and migraine attacks. Are you familiar with CGRP? While most attention has focused on this biochemical messenger’s role in migraines, CGRP is also related to endometrial implants. In this episode, we will do a deep dive into the shared pathophysiology of endometriosis and migraine headaches. We will look at the role that CGRP and TRPV1 play in both of these pain conditions.

Advances in obstetrical and neonatal care have allowed for increased survival rates in babies born at extremely premature gestational ages. However, extreme prematurity brings its own set of issues and problems. One of these issues is intraventricular hemorrhage (IVH). Intraventricular hemorrhage is not simply a neonatology issue, but is something that all obstetrical providers should be familiar with. Does the mode of delivery impact the rates of intraventricular hemorrhage for extremely preterm vertex babies? Do corticosteroids help reduce the rate of IVH? And at what gestational age is umbilical cord milking not associated with the risk of intraventricular hemorrhage (Nov 2023 Data)? In this episode, we will do a deep dive into the pathogenesis and behavior of IVH and discuss common obstetrical interventions that may mitigate its occurrence. We will also discuss how magnesium sulfate works for fetal neuroprotection and discuss the importance of neonatal vitamin K administration in extremely pre-term neonates.

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.

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.

On September 26, 2023 we released an episode titled “LDA in Preg: the SAGA Continues”. Well, it continues still. In this episode, we will review a brand new publication (a Narrative Review) released ahead-of-print yesterday on November 2, 2023 covering “Aspirin in Pregnancy” (Obstet Gynecol). We will focus on 2 main areas: 1. Dose of aspirin best suited for preeclampsia prevention, and 2. support for universal adoption. PLUS, we will throw in one other clinical pearl regarding continuation until delivery. As a reminder, the ACOG is still in the draft stages of revising its “low-dose aspirin for preeclampsia prevention” consensus guideline. Listen in to see which way the data is leaning regarding this common prophylactic treatment plan.

Recurrent vulvovaginal candidiasis (RVCC) is a highly burdensome, long-lasting medical condition that heavily compromises the activities of women and their quality of life. Recently, the prevalence of RVVC has increased, partly due to a rise in VVC caused by non-albicans species. Here's a real-world clinical dilemma (from a real case): What would you offer a patient who is allergic to fluconazole and terconazole, has taken 3 doses of Brexafemme, has used boric acid, and even tried vaginal probiotics? Oh- and vaginal Gent Violet is not available (in this case). In this episode, we are going to review 3 alternative vaginal therapies that could be very helpful in cases where that darn yeast will not go away.

In 2017, the ACOG released committee opinion (CO) 712 which described the 3 categories of intrapartum fever. One of those categories was “isolated intrapartum fever”. In that CO, the ACOG stated that practitioners “should consider” the use of antibiotics in patients with isolated intrapartum fever. However, there was no evidence to support or refute that. But that evidence has now arrived. In this episode, we will discuss an upcoming publication from the AJOG (November 2023) providing important insights into the treatment of “isolated, intrapartum fever”.

DiGeorge syndrome… what a complicated condition for such a little area of a single chromosome being affected. The condition’s descriptive and preferred name is 22q11.2. This is called a microdeletion. Along with microduplications, microdeletions are collectively known as copy number variants. Copy number variants can lead to disease when the change in copy number of a dose-sensitive gene or genes disrupts the ability of the gene(s) to function and affects the amount of protein produced. Other examples of microdeletion syndromes include Prader- Willi, (which is a deletion on 15q), and Cri du chat syndrome which results from a microdeletion on 5p. In this episode, we will review the varied penetrance of DiGeorge syndrome and review its genetic basis. What are some suggestive features found on prenatal ultrasound? What are the associated abnormalities/phenotypes? And how is this condition managed after birth? And why is this also known as CATCH22. We will answer all of these questions, and more, in this episode.

For years, herbalists have touted bee pollen as an exceptionally nutritious food. They've even claimed it is a cure for certain health problems. Bee pollen does contains vitamins, minerals, carbohydrates, lipids, and protein. It comes from the pollen that collects on the bodies of bees as they fly from one flower to another. Bee pollen may also include bee saliva. This is NOT the same as natural honey, honeycomb, bee venom, propolis, or royal jelly. These other products do not contain bee pollen although there are combination products that contain one or more of these substances. A recent Social Media trend has propagated the idea that bee pollen can help breasts grow. Can it? Can it really boost your immunity and longevity? And what is the recommendation for use during pregnancy or breastfeeding? And speaking of pregnancy, can pregnant women eat RAW honey? We’ll get to the “sweet spot” of the data!

Although there were some early reports of sickle cell disease (SCD) in the late 19th century, the 1st time that the disease was referenced in literature was in 1910. Then in 1957, a doctor studying protein chemistry in England discovers that a single genetic mutation causes the abnormal hemoglobin found in patients who inherit SCD. And our knowledge of SCD continues to grow. In this episode, we will review a soon-to-be released new SMFM Consult Series # 68 highlighting the data on management of SCD and pregnancy. Are routine, prophylactic blood transfusions in pregnancy recommended? What about hydroxyurea? What is the dose of folic acid recommended for these patients? Is antepartum fetal surveillance recommended? We will answer all of these questions, and more, in this episode.

In November 2023, the ACOG will release Clinical Consensus #6, “Compounded Bioidentical Menopausal Hormone Therapy”. We have covered bioidentical hormones in past episodes. However, this ACOG clinical consensus sheds new light on an old topic. Is there ever a role for bioidentical hormone therapy? What about postmenopausal testosterone use? What does the College say about the marketing of these compounded options? And, were you aware that for the first time ever there is now a novel, bioavailable estrogen in a combination oral contraceptive? That same estrogen (E4) is now being considered as another option for bioidentical hormone use. In this episode, we will review this new estrogen, estetrol (E4), answer the questions posed, and provide other high yield facts from the clinical consensus.

On June 27, 2023, researchers published a population based analysis of the prevalence of Iron Deficiency and Iron-Deficiency Anemia in Females in the US who were aged 12-21 Years. This study spanned from 2003 to 2020. What they found was staggering: Almost 40% of American teenage girls and young women had iron deficiency. This was published in JAMA. It's the first research to look at iron deficiency in young women and adolescent girls. Iron deficiency and iron-deficiency anemia are both common, underappreciated conditions with significant morbidity and mortality despite widespread availability of effective treatment. Iron deficiency is the most common micronutrient deficiency worldwide and is the most frequent cause of anaemia. Historically, the focus of screening has been preschool-aged and pregnant females. The CDC-P recommends anemia screening for nonpregnant female adolescents and women every 5 to 10 years, whereas the USPSTF does not address screening for these populations. Ands that’s for anemia, not iron-deficiency alone. Oh, and that CDC recommendation is from 1998! That’s right, no update since 1998. Also, guidelines from the ACOG focus only on anemia during pregnancy. But now, and here’s a clinical pearls: This year, for the first time in its history, the International Federation of Gynecology and Obstetrics issued a recommendation that all women and girls who menstruate should regularly be screened for iron deficiency, not just for anemia and not just during pregnancy. This was recently picked up as a story in the New York Times, being published on October 17, 2023. And here’s another clinical pearl… It is completely possible for someone with normal hemoglobin levels to still have iron deficiency. So in this episode, we’re going to address the new FIGO guidelines and review why a “screening CBC“ just does not have the sensitivity to detect iron deficiency in reproductive age women. We will also review the appropriate screening test for this condition, as well as review basic iron physiology.

In 2009, the ACOG released practice bulletin 106 which introduced the 3- tier fetal heart rate classification system. This was followed up in November 2010 with its sister practice bulletin, number 116, “Management of Intrapartum Fetal Heart Rate Tracings”. Yet now, 13 years later, management of the category II tracing remains a conundrum. How long can you watch/observe a category II tracing? Can category II tracings predict fetal acidemia? And what is a step-by-step, evidence-based algorithm for category II management? In this episode, we will cover all of these questions, and summarize a new systematic review/meta-analysis from the AJOG (October 2023) focused on this very condition.

In April 2023, both the ACOG and SMFM released their clinical updates regarding the use of progesterone for preterm birth prevention. While 17-OHP is gone, vaginal progesterone remains an option in the appropriate patient, with some slight differences between the opinions from ACOG and SMFM. A new expert commentary from October 2023 in the AJOG -MFM is calling for a reappraisal of those opinions. Is vaginal progesterone for PTB prevention coming back to treat ALL patients with a history of PTB, not just those with a short cervix? That depends on how you look at the data. And, where does cerclage fit in? Listen in for all this...and more.

Finding a nuchal cord (NC) at delivery is not rare. NCs occur anywhere from 25-30% of all deliveries. When encountered at time of vaginal delivery, the first line maneuver should be an attempt to "reduce" the loop of cord around the fetal head by gently pulling the cord up and around the presenting part. However, if the NC is tight, an attempt at reduction may not be successful- or may risk inadvertent cord rupture withs subsequent fetal blood loss. Historically, the next move described was the +clamp and cut" maneuver. However, this interrupts the vital communication of oxygenated blood to the child from the placenta prior to the fetal body delivery. This prevents the beneficial and physiologic placental blood transfusion to the child immediately after the body delivers. That's why the fetal somersault maneuver has benefits when encountering a tight fetal NC. First described in 1991, this maneuver often gets overlooked as a viable option. In this episode, we will summarize the basis for and technique (the 4 Fs) of the fetal Somersault Maneuver.

Hypertensive Disorders in Pregnancy/Preeclampsia is a persistent problem, world-wide. Over the last decade, studies have highlighted the role of vitamin D in modulating several mechanisms associated with hypertensive disorders of pregnancy, including but not limited to vessel compliance, the maternal immune response, the renin angiotensin response, and placental implantation and angiogenesis. There has also been published concern that maternal vitamin D deficiency may be associated with childhood neurodevelopmental issues including autism. However, the last ACOG CO on UNIVERSAL SCREENING for vitamin D in pregnancy was in 2011…this stated that UNIVERSAL screening is just not recommended (FYI, this was reaffirmed 2021, and is currently being reaffirmed by the OB committee). But this is different than targeted screening. Since the ACOG stance in 2011, despite RCTs of vitamin D supplementation in pregnancy, everything has changed and yet nothing has changed regarding the approach to screening for vitamin D deficiency. Should vitamin D levels be assessed? Are the cutoffs for vitamin D insufficiency and deficiency the same in pregnant patients? Who is the ideal pregnant patient for vitamin D intervention? How can the intervention be optimized? And what’s that link between maternal vit D deficiency and the child’s neurodevelopmental outcomes? There is data to answer these questions, and we will lay it all out in this episode.

The FDA’s approval of the first oral hormonal contraceptive pill, Enovid, in 1960 launched a revolution in women’s reproductive healthcare. From that one initial pill sprang a plethora of oral contraceptive choices, representing estrogen-progestin combinations in standard dose to ultra-low dose options, progesterone only pills, and cyclic or continuous use pre-packaged formulations. According to a survey conducted from 2017 to 2019 by the Centers for Disease Control and Prevention (CDC), around 65% of women aged 15-49 use some form of birth control, with the pill being the most common birth control method used by younger women. Around 20% of women aged 15-29 use oral contraceptives. Similarly, the FDA’s approval of levonorgestrel-based (LNG) emergency contraception (EC) in 1998, and its subsequent approval of the selective progesterone receptor modulator-based option in 2010 (ullipristal acetate or UPA), provided another layer of contraceptive protection during times of unprotected or ill-protected sexual intercourse. More recently, this revolution in medical control over reproductive ability has resulted in the FDA’s approval of the first over-the-counter, norgestrel-only oral contraceptive, the Opill. This move allows the Opill to be available in a variety of venues, from online to local pharmacies and grocery stores. Nonetheless, despite this major success in women's contraception, some suspicions remain. In this episode we will review latest data on Opill and its plan for release in 2024. This has already lead to the potential for a combination OTC pill coming out soon. Have you heard of it? And...does your state already offer OTC hormnal BC? Listen in and find out more.

Here.

There is no controversy regarding the definition of the 2nd stage of labor: it is the phase of labor from 10 cm until complete delivery of the child. However, there has been persistent controversy about what defines a prolonged 2nd stage of labor. In other words, are the hour limits stated by the ACOG “active pushing” or “total duration” in 2nd stage? 🤔 Historically, this has been a very gray area. Even though we have guidance on this going back to 2014 with the ACOG Obstetric Care Consensus 1, “Safe Prevention of the Primary C-Section”, certain phrases within that document caused confusion. Does the ACOG make a distinction between active vs passive 2nd stage of labor? Listen in and find out. 🎙️🎙️🎙️

Mirror Syndrome also known as “triple edema” or Ballantyne syndrome, is a rare disorder affecting pregnant women. Mirror Syndrome is often underdiagnosed or misdiagnosed due to a general unawareness of the condition, and sometimes its preeclampsia-like manifestations. However, until now, the characteristics of Mirror Syndrome have not been fully elucidated. But medicine moves fast, and we now have a better understanding of its presentation, likely contributing factors, and outcomes. Still, some knowledge gaps remain. In this episode we will summarize the data on this terrible, potentially life threatening, obstetrical emergency. Our centerpiece for discussion will be a recent systematic review published in September 2023 in the AJOG with authors from my home state of Texas.

Incorrect delivery technique can lead to fetal birth trauma. However, sometimes – despite proper technique and care – fetal birth injuries occur. As I was taught as an intern, “Mal-occurrences don’t always mean Mal-practice“. Does that rule hold true for fetal clavicular fracture? What about Erb’s palsy found at birth? Can these issues occur as part of normal labor and delivery? And at time of cesarean section, does meticulous surgical technique always prevent immediate postop bleeding complications? In this episode, we’re going to review the data on 3 perinatal adverse events that may occur despite proper care: clavicular fracture, Erb’s palsy, and post-operative, rectus sheath bleeding/hematoma.

The ACOG released Clinical Consensus #4 in August 2023, covering Urinary Track Infections in Pregnancy. Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies. These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. In this episode we will summarize some the key points from this monograph, and we will tackle 3 common myths/misperceptions related to OB Pyelonephritis. Are most people who claim a PCN allergy truly allergic? Can an anaphylactic PCN response decrease over time? What antibiotic is recommended for OB Pyelo if patients do have a real anaphylactic PCN history? Can OB Pyelo present without fever? Listen in and find out.

The age at which couples have children in the United States continues to increase. While it is well documented and known that maternal age directly impacts fetal and child outcomes, less attention has been given to advanced paternal age (APA). Medical and Genetic commentaries have stated that limited APA principles have been advocated for or disseminated into the medical communities and the general population. There may be considerations for the development and application of a couple-centered strategy counseling on age-related genetic risks. Is APA a real issue? What age defines that? And what has APA been associated with? Listen in and find out!

A quick clarification about Beyfortus neonatal protection against RSV. Thank you Katie for bringing this to my attention! What a wonderful podcast community we have. ❤️❤️❤️

We have been following this developing story on the Maternal RSV vaccine, Abrysvo. In the recent podcast, we stated that we would let you know when the ACOG releases its “Practice Advisory”, which is its clinical guidance update. This is now out! In this episode will provide the summary, high-yield points regarding this vaccine’s use in pregnancy. Can this be co-administered with other vaccines? What did ACOG say about the preterm birth “numerical imbalance” among study trial participants who received this vaccine? And which option provides a stronger and longer lasting immune response in the child: maternal vaccination, or newborn vaccination? Listen in and find out.

Low Dose Aspirin has been a routine aspect of preeclampsia prevention since first mentioned by the ACOG’s Hypertension in Pregnancy Task Force report, back in November 2013. Since that time, there has been several revisions of the criteria of who qualifies for low-dose aspirin in pregnancy. Nonetheless, there are calls and expert opinions challenging this “risk factor based” approach, favoring a more universal adoption. Additionally, the DOSE of low-dose aspirin has also come under recent critique. Is 81 mg the correct dose to use? Does aspirin have the potential to reduce preterm birth? In this episode, we will review a soon-to-be released clinical commentary from the AJOG (October 2023) which addresses these matters.

According to the CDC’s press release from September 2022, the leading underlying causes of pregnancy-related death include mental health conditions (including deaths to suicide and overdose/poisoning related to substance use disorder), accounting for 23% of cases. The top 2 perinatal, mental health conditions are anxiety and depression. And, although much more rare with an incidence of 1–2/1,000, postpartum psychosis is a major cause of self-harm an infant harm. In this episode, we will review “The College’s” recent clinical practice guidelines on mental health therapies in the perinatal interval. Do you know which 2 classes of medications are most preferred for treating anxiety/depression in the perinatal period? Are SSRIs a leading cause of PPHN? Is Lithium allowed in pregnancy? And what is “neonatal adaptation syndrome”? We will cover all these questions, and more, in this episode.

It’s pretty standard of an evaluation… TVUS for postmenopausal bleeding. It’s well accepted that an endometrial thickness of 4 mm (5 mm in some studies) should trigger further endometrial tissue analysis in women with postmenopausal bleeding. But is there a cut-off endometrial thickness at which endometrial tissue should be evaluated in a postmenopausal patient WITHOUT bleeding, where this was found incidentally? There is definitely an evidence-based recommendation, and we will cover that in this episode.(With a special guest host 😊…. “Anything for SELENAs”)

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.

The definition of recurrent pregnancy loss (RPL) in the US is 2 or more consecutive failed clinical pregnancies documented by ultrasound or histopathology, while, in the United Kingdom, the definition is as having 3 or more consecutive early pregnancy losses. Up to 50 percent of cases of recurrent pregnancy loss lack a clear etiology. Where do we stand, in 2023, in regards to our understanding of the effects of inherited thrombophilias on recurrent pregnancy losses? Do they cause recurrent ABs? Does LMWH help? In this episode, we will summarize a June 2023 publication in the Lancet that provides a clear answer.

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%! Obstetrical lacerations of all degrees can lead to significant physical and even psychological morbidity, and have been identified as an independent risk factor for sexual dysfunction- which could last up to 18 months after delivery. Can perineal massage help reduce the rate of obstetrical trauma at time of vaginal birth? In this episode, we will summarize a new publication from the AJOG which was released on Aug 10, 2023 (first released as an ePub at the end of 2022) and compare the results covered in that publication with a separate systematic review and meta-analysis published in Feb 2023 in a separate journal. Does antepartum perineal massage help? What about intrapartum perineal massage? The answer depends on who you ask/read? Listen in, and find out why.

In 2019, brexanolone, better known as Zulresso, became the first postpartum depression (PPD) drug to receive FDA approval. While we have previously discussed this IV medication for PPD in other episodes, there is now a novel oral version of this antidepressant which has made the news as of last week (ie, early august 2023). That medication was known as SAGE 217 during the clinical trials, but it is now known as zuranolone (ZURZUVAE™). YEP.. in the first week of August 2023, the US Food and Drug Administration approved the medication zuranolone for the treatment of postpartum depression – making it the first FDA-approved oral pill in the United States specifically for postpartum depression. Do you know how this medication works? What’s the data on it? Does ACOG have an opinion on this? And what’s the special FDA warning that ended up as a BLACK BOX on the approval? In this episode, we will learn the ins and outs of Zurzuvae.

In our most recent episode on vaginal prep at C-section, we referenced a parallel topic where individual data pieces seem to be contradictory: prophylactic TXA at time of cesarean section. In that past episode, we referenced a systematic review and meta-analysis that showed prophylactic TXA was indeed beneficial. Well… we are going to build on that data regarding prophylactic TXA in this quick/targeted episode that we call our NEW DATA BLURB. In this episode, we will highlight a fantastic, brand new, systematic review and meta-analysis published by one of our very own podcast family members out of Arizona. Dr. “KC”… Great job and congratulations to you and your co-authors on a wonderful publication. 👏👏👏👏

With improvements in the screening & treatment of Breast Ca, the number of female survivors continues to rise, with a reported 5-year survival rate of up to 90%. However, several of the systemic treatments for breast cancer, including endocrine therapy, chemotherapy, and radiotherapy, can result in a new or worsened hypoestrogenic state. Up to 70% of postmenopausal women will develop symptoms of genitourinary syndrome of menopause (GSM). With an estimated 3.8 million breast cancer survivors in the US, women’s healthcare providers are on the front lines of addressing survivorship issues, including these hypoestrogenic-related adverse effects of cancer therapies or early menopause. This isn’t simply bothersome vaginal dryness, but this also affects sexual intimacy, and may even be linked to recurrent UTIs. Although nonhormonal vaginal agents are traditionally considered first-line for patients with a history of breast cancer, there’s been evolving data on the efficacy and safety of vaginal, low-dose estrogen therapy for genitourinary syndrome of menopause in breast cancer survivors. In this episode, we will highlight pivotal pieces of data starting from 2021 and ending with a new publication just released on August 3, 2023 revealing very impactful and clinically applicable insights reffing vaginal E2 in breast cancer patients.

CS is the most important risk factor for postpartum infection with a 20-fold increase compared to the vaginal delivery route. For post-cesarean section metritis, infection is considered to be primary due to ascending bacteria from the vagina. Although antibiotic prophylaxis is thought to reduce postoperative infections, it has little effect on bacterial colonization of the vagina. Over the past 20 years, multiple randomized clinical trials have investigated the effect of preoperative vaginal preparation/disinfection (including povidone-iodine, chlorhexidine, metronidazole gel, etc.) on postoperative infection, but the conclusions have not been consistent. Actually, a publication from June 2023, which we summarized in a prior episode back in Dec 2022 when it was released ahead of print, concluded that vaginal pre- CS prep with povidone-iodine did NOT prevent infectious morbidity over standard infectious precaution use (abdominal prep and standard IV antibiotics). But as of August 2023, there is new data that seeks to provide a more definitive recommendation. In this episode, we will summarize this new systematic review and meta-analysis (AJOG MFM) examining the effectiveness of vaginal cleaning with either povidone-iodine or chlorhexidine acetate in the prevention of post CS infectious morbidity.

Venous thromboembolic events (VTE) are among the top three causes of maternal death in developed countries and prevention with thromboprophylaxis has been identified as the most readily implementable means of reducing maternal mortality from VTE. Most guidelines address VTE prophylaxis after cesarean section, and/or in those with thrombophilias- not after vaginal delivery alone. The ACOG does not directly address inpatient pharmacologic thromboprophylaxis during antepartum admission nor after vaginal deliveries for patients without a known thrombophilia or without a personal history of a VTE event. Guideline recommendations regarding thromboprophylaxis strategies for women with more commonly occurring risk factors- such as Preeclampsia with severe features- vary widely, leading to uncertainty regarding the optimal strategy for prevention. Do you order pharmacoprophylaxis for postpartum (SVD) patients with “minor risk factors”? What about the patient whose BMI is 40? Have you heard of the recommendations from the NPMS and the CMQCC regarding VTE prevention after vaginal birth? In this episode we're going to review VTE prophylaxis after vaginal delivery and take a look at the data.

We are still in an opioid crisis state in the US. Have you heard of Kratom? It is likely at your neighborhood health food store or even on the counter at your local gas station. A derivative of the coffee plant, Kratom is making national headlines. Whether Kratom, a legal, widely available herbal supplement, should be classified as an opioid is contentious. Although the US Food and Drug Administration has recently addressed this controversy, Kratom continues to be marketed as an over the counter, nonopioid, "natural" remedy for a variety of conditions- including pain, anxiety, mood, and opioid withdrawal. YES.. its use is increasing in the United States. and it is now getting new attention from both medical as well as governmental authorities for its possible adverse effects during pregnancy and its association with NAS. In this episode, we will discuss this novel OTC herbal supplement which has now earned the watchful eye of the FDA. Kratom: wonder supplement or dangerous herb? Let’s discuss.

In 2019, the ACOG released CO 767 discussing “Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period”. currently, 3 meds are recommended for the treatment of emergent hypertension in pregnancy: oral nifedipine, IV, labetalol, and IV hydralazine. But which one is “better” at normalizing blood pressure? A new meta-analysis, published on July 24, 2023, provides one answer. However, this meta-analysis did not take into account the most crucial factor determining success of antihypertensive medication: “The Rule of 55”. In this episode, we will review this new meta-analysis from the journal of Mat-Fetal Neonatal Medicine, and review the petition by hypertension experts to tailor antihypertensive treatments based on the “hemodynamic expression” of the hypertensive disorder in pregnancy.

We have learned so much about the natural progression of HPV induced cervical abnormalities. In 2019/2020, the ASCCP published its updated guidance using a “risk-based” algorithm for management of cervical intraepithelial neoplasia. Traditionally, HPV vaccination was considered ineffective once cervical dysplasia already was present. But recent data has proven this concept incorrect! In this episode, we’re going to summarize a brand new ACOG practice advisory released today, on July 28, 2023, related to this “adjuvant HPV vaccination” for patients undergoing treatment for CIN2 or more.

There are, indeed, FDA indicated applications for purified, amniotic membrane (wound healing). Is there also a role for the use of purified amniotic fluid as a “regenerative medicine” treatment option? Can amniotic fluid injections help repair osteoarthritis and aching joints? Can it be used as EYE DROPS for dry eyes? The subject is trendy on certain social media channels and on certain websites. But this concept of injecting amniotic fluid into various body locations has landed one Texas healthcare professional in hot water. Specifically, the US Department of Justice, has pressed charges. 😳 In this episode we will discuss this whole issue of “regenerative medicine” and the legitimate an illegitimate use of amniotic products, AND we also review the inherent qualities of amniotic membranes and fluid which makes them attractive for "regenerative" uses. 💉💉💉

Skin conditions can't affect pregnancy outcomes, right? After all, the skin is just the skin. WRONG! As a chronic inflammatory disease, hidradenitis suppurativa (HS) exemplifies the link between integumentary and comorbid systemic disease through shared inflammatory pathways. Patients have double the comorbidity burden compared with the general population, and hidradenitis suppurativa has independent associations with several individual comorbid diseases. During pregnancy, HS also is associated with some specific pregnancy related morbidities. Successful management of hidradenitis suppurativa is challenging and at times requires comprehensive care from a coordinated team of health care professionals, including dermatologists, general or plastic surgeons, experts in pain management and wound care. In this episode, we ill summarize the pathogenesis of HS, its treatment, and its affect on pregnancy and vice-versa.

In Feb 2023, the USPSTF recommended that clinicians “screen for hypertensive disorders of pregnancy”. Specifically, they stated that “measuring blood pressure at each prenatal visit is the best approach”. Mind blowing I know. 😳😊 But sarcasm aside, a new publication- set to be released next month in AJOG (Slade LJ et al; Aug 2023)- validates this recommendation…not that it needed validation, for frequent BP monitoring during pregnancy. This has to do with the “sensitivity” of BP results in pregnancy compared to the “specificity”. Ahhh…intrigued? In this episode, we will review this upcoming publication aimed at evaluate whether the definition of gestational HTN should be revised according to the 2017 ACC and AHA criteria, and whether or not there is an association between adverse maternal and perinatal outcomes based on those lower BP levels. And as always, you’ll want to stay with us until the end of the episode as we pass on real world clinical implications of these findings.

On April 5,2023 the U.S. FDA withdrew its approval of Makena and generic forms of 17-a hydroxyprogesterone caproate for the prevention of recurrent preterm birth. Having the only medication which had been FDA approved for the prevention of preterm birth taken away, has left clinicians investigating other possible strategies that can cause a dent in preterm birth rate. As Bacterial vaginosis (BV) is the most common vaginal abnormality in reproductive age women, naturally the spotlight would fall on the treatment of BV for preterm birth prevention. After all, BV is a well-known risk factor for preterm birth. There’s been new advances in the diagnostic tools for vaginal infections, so BV is back in the hot seat as a possible intervention for PTB prevention. Yes, this has been investigated in the past. But in this episode, we’re going to highlight 2 recent publications- one from March 2023, and one from July 17th 2023- which help to solidify the answer to this question: “can treatment of BV help prevent preterm birth?” Let’s talk about that… now.

FYI. We just released our episode for today, July 14, 2023, and will be out until July 23!

Its hard to be pregnancy in the late third trimester, especially in a HOT state like TEXAS in the summer. Pregnant individuals will try just about anything "to just get this baby to come out already!" Historically, walking, spicy foods, and SEX have been "employed" to get the labor process going. Does it work? In this episode we will look at the data examining whether labor can induce spontaneous labor. Is this a myth or a real thing? What about CURB WALKING?! That works, right? Lots to cover and explain in this one...so let's get our walking shoes on and get to it.

There’s no such thing as a “false positive syphilis confirmation test”, is there? After all… It’s right there in the name, CONFIRMATION test! Well, not all positive confirmation tests are true positives, especially when that test is the FTA-ABS. Yes, it’s true, the specificity for this is very good between 95 to 98%. But there are cases of BFPs (Biologic False Positives), which have been reported and published in the literature. This is why putting the test results in clinical context is very important. In this episode, we will highlight a real clinical scenario where a “low level“ confirmation test did not fit the clinical picture (asymptomatic, monogamous, low risk patient). Is there something else going on here? What about autoimmune conditions? Can pregnancy itself cause a false positive FTA-ABS? And more importantly… What are the options for management in this case? We’ll discuss all of this, and also review the “reverse syphilis algorithm” in this episode.

The Bandl Constriction Ring. It is real. It exists. Its true incidence is unclear as it lacks uniform reporting when found at time of cesarean. As labor guideline are more permissive of slowed labor progress, some fear that the incidence of Bandl's Band may rise. What is this ring? What is the pathophysiology of this abnormal uterine response? Can ultrasound detect this labor abnormality? In this episode we will cover the fascinating and controversial history of the Bandl Band and review some key publications describing its potential morbidity.

Just a little description of what happens “behind the scenes“! Enjoy. 😊😊❤️❤️😩😩

Gestational diabetes (GDM) is a risk factor for adverse perinatal outcomes. Currently, the ACOG recommends early screening for GDM for women “at risk”. However, other experts disagree with this approach. On October 6, 2022 we released a podcast episode called “Early GDM Screening: Evidence-based?”. In that episode we covered the controversy regarding early GDM screening, in other words- screening under 24 weeks. We have been following this story and debate for over 2 years now; we first released the episode investigating the utility of early screening back on May 7, 2021 with an episode called “early GDM screening: Does it matter?”. The controversy surrounds maternal and neonatal outcomes… does it improve with early screening? Well… we have more data now! YEP.. looks like we were vindicated in our prior messages covering this! In this episode, we will summarize key findings from a recent June 2023 publication in the NEJM titled, “Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy”. The lead author is Simmons. So…should we be doing early screening for GDM? We’ll highlight the data.

Well, Well, Well, this is very interesting. Back in May 10, 2023, we released an episode on "OSA (Obstructive Sleep Apnea) in Pregnancy: Time to Screen?". In that episode, we summarized the impressive data on OSA in pregnancy and its association with some adverse perinatal sequelae. Spring forward to July 6, 2023, the ACOG has now released a brand new Consensus Statement on OSA in pregnancy. This statement is a joint guideline from the Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology. Seems that we were ahead of the curve on this one. So, should we screen for OSA in pregnancy? The answer is YES and NO. Is CPAP really safe in pregnancy? We'll explain in this episode.

The headline from CNN Health form June 28, 2023 reads, "HRT use by younger women linked to dementia, study says". That is FRIGHTENING to any patient using hormone therapy for menopausal symptoms. Does HT cause dementia? Or is HT a "easy suspect"? The question of HT and cognitive function has been a subject of controversy for many years. In this episode we will summarize the NAMS position statement on HT for cognitive issues (2022) as well as summarize this new June 2023 publication from BMJ causing quite a stir among menopauses' medical experts. PLUS, we will provide a likely reason, which is the proverbial "elephant in the room", for this new study's conclusions.

First published in 1952, the Apgar Score has remained unchanged over 70 years and is entrenched in current OB/Pediatric/Neonatal care. The ACOG highlighted the Apgar Score in 2015 in CO 644. In that release, the ACOG reminds us that although it provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed, it has important limitations: A. The healthy preterm infant with no evidence of asphyxia may receive a low score only because of immaturity, B. The incidence of low Apgar scores is inversely related to birth weight, and C. a low score cannot predict morbidity or mortality for any individual infant. Most importantly, it is inappropriate to use an Apgar score alone to diagnose asphyxia. It has been previously shown that not all items of the conventional Apgar score are of equal importance. However, Virginia Apgar did not differentially weigh or remove individual items since it was her intention to have a score that can be “determined easily and without interfering with the care of the infant”. Accordingly, use of the score has been found to have important use limitations across babies whose skin color has more pigmentation, leading to more NICU admissions in some despite other more objective measures of neonatal status. As the United States and many other countries have become more racially and ethnically diverse, embedding skin color scoring into basic data and decisions of health care may propagate unintentional race-based medicine. In this episode we will discuss the data leading some to call the traditional Apgar score “antiquated” and are calling for a change.

Listen to this! According to recent US statistics from both consumer reports and statista.org: 26% of Americans used CBD in 2022, 24% of people owning pets use CBD for their animals and themselves, 33% of Americans have used CBD products at least once, 64% of Americans have used CBD for pain, 49% of Americans use it for anxiety and stress, and 42% of Americans have used it for sleep and insomnia. CBD is super common, and it is super unregulated. CBD, or cannabidiol, is one of the numerous cannabinoids found in cannabis plants. After THC, CBD is the second most active substance found in the plant. THC produces the euphoria that users feel when consuming it through various methods. CBD differs in that it doesn't produce a high, is non-psychoactive, and like THC, isn't physically addictive. Although CBD has shown promise in migraine care, chronic pelvic pain, fibromyalgia, and cancer associated pain, it is NOT benign. CBD contains several terpenes that are all oil-based. These are known to cause some disturbances in the body's immune system. Other things like lethargy, sedation, and increases in liver enzymes are possible when used regularly. Things like malaise, weakness, heavy fatigue, diarrhea, and a skin rash may occur. Nonetheless, as CBD is viewed as “natural”, many pregnant women look to this as an alternative medication for pregnancy aches and pains. Is this safe? We know that THC is problematic, but what about CBD? We have learned much more about CBD in pregnancy since the ACOG’s CO 722, first released in 2017 and reaffirmed in 2021…and even the term has changed! In this episode we will review the data on CBD use in pregnancy from 2018 (since the last ACOG CO) onward and let you know why one word in particular is no longer favored.

This episode subject was requested by Emily, one of our podcast family members. She has noticed the reporting of “large placental, venous lakes” on antepartum ultrasound. Placental lakes are enlarged spaces in the placenta filled with maternal blood. These spaces are also called intervillous spaces because they are found between the placental villi the finger-like projections of the placenta that contain fetal blood vessels . The placental villi float in the intervillous spaces and absorb oxygen and nutrients from the maternal blood. The blood-filled placental lakes appear nearly black on ultrasound because they do not reflect soundwaves back to the ultrasound machine. Placental lakes can be seen within the placenta or on the fetal surface of the placenta bulging into the amniotic cavity. Slow swirling blood flow may be seen within the spaces, and the shape of the spaces tends to change with uterine contractions. These features may help to distinguish a placental lake from a thrombus. Well, why is this even supposed to be an issue? How can venous lakes affect the fetus, after all…maternal blood is normally found in the intervilluous spaces between the chorionic villi which house the placental vessels for gas exchange. Well, the theory is that these large placental lakes may affect blood redistribution in the chorionic fetal vessels, leading to increased incidence of placental growth abnormalities or fetal distress in labor. Are these placental sono findings a harbinger of bad things to come or are they simply benign findings? Let’s look at the data!

We recently had a patient in our OB high-risk community clinic whose maternal carrier screen result was either late or lost. Thinking the test may be lost, another resident ordered hemoglobin electrophoresis. The electrophoresis was NEGATIVE (that is, no abnormal hemoglobin was found at detectable levels)…by the way, good for that resident! After calling the lab for the genetic screen and not getting a clear answer from that location, they had the self- initiative in ordering a back-up test. AND TURNS OUT: this was a GREAT educational opportunity as the results from these two tests were discordant: the maternal carrier screening panel returned the day after and was POSITIVE for alpha thalassemia trait. So, which is better? Hgb electrophoresis (once considered the clinical gold standard over CBC with indices) or molecular testing? Let’s explore the data in this episode.

Desquamative inflammatory vaginitis (DIV) made its debut in the medical literature in 1965, by the hands of Gray and Barnes. In that paper, they presented their findings on 478 women complaining of vaginal discharge. Then, in 2002, Donders et al. described a new entity, referred to as aerobic vaginitis (AV). This term emphasized the clear contrast with the far more common and acknowledged form of dysbiosis: bacterial vaginosis (BV). These 2 clinical conditions are now thought to exist on a clinical continuum of presentations with AV being the "milder form" and "DIV" manifesting as a more severe condition. Recently, I received three separate questions regarding aerobic vaginitis (AV) and the potential role of GBS in its etiology...which lead to the research for this episode. Can GBS cause vaginitis (AV)? Or is it simply a "colonizer", and not a pathogen? This topic and the role of GBS in it has been a hot debate for 40 years PLUS! However, new data published in March 2023 by the ISSVD has contributed to: the credibility of AV as a cause of vaginitis, the pathogenesis of this DIAGNOSIS OF EXCLUSION, and resulted in a guideline for therapy. We will cover all this- and more- in this episode.

The word placenta, first used in a 1638 anatomy textbook, was borrowed from the New Latin phrase placenta uterina, meaning "uterine cake", because the circular, flat shape of the organ was thought to resemble a traditional Roman flat cake. Circumvallate is another Latin derived term meaning the "encircled placenta, by a rampart". Circumvallate placentas are a form of extrachorial placenta where the basal plate extends past the margins of the chorion plate resulting in the chorion and amnion folding over one another onto the fetal surface. Is a circumvallate placenta an incidental finding or is it a harbinger of adverse outcomes? The answer to that question depended, until recently, on who you asked and WHEN you asked. In this episode, we will summarize and highlight a new publication from the American Journal of Perinatology from May 2023 which serves to offer a more definitive answer to this question. So, is the circumvallate placenta Maleficent or Meh? Listen in and find out!

Over the past decade, there’s been about a 700% increase in the cases of congenital syphilis in the United States. That’s 700%! Rates of congenital syphilis, meaning the number of cases for every 100,000 live births, are highest in the South and Southwest, in states such as Arizona, New Mexico, Louisiana, Mississippi and Texas. Individual states have seen increases that are even more astounding. From 2016 to 2021, cases shot up 3,300% in Mississippi, nearly 3,000% in Oklahoma, more than 2,200% in Hawaii, more than 1,800% in Washington, more than 1,600% in New Mexico, according to CDC data . "Clinical Pearls" has covered screening and diagnosis of maternal syphilis in past episodes; one past episode focused on the traditional and the now-favored reverse sequence algorithms. You can find that episode in our archives from July 03, 2022. Do you know what the CDC calls “inadequate treatment” for congenital syphilis prevention? Having recently had concern for a child born at high risk of congenital syphilis, in this episode we will focus on the vertical transmission of syphilis and congenital syphilis (CS) and provide several clinical pearls related to this subject.

LARCS provide remarkable contraception. The IUD and the IUS are both HIGHLY effective, although they do not have the same typical-use failure rates. While it is common knowledge that active mucopurulent cervicitis is a contraindication for IUD/IUS placement, what about the presence of bacterial vaginosis (BV)? BV has been identified for years as an independent risk factor for Pelvic Inflammatory Disease. Is placement of an IUD/IUS in a patient with current BV contraindicated? What do the guidelines say? Listen in and find out.

Endometriosis is caused by endometrial-like tissue containing endometrial glands and extensive fibrotic tissue growing outside the endometrial cavity, most often in the pelvic peritoneum or ovaries, resulting in chronic pelvic pain and infertility. It is reported to affect 10 to 15% of women of reproductive age, with an unknown percentage of women who go on undiagnosed or misdiagnosed. For decades, Sampson's Theory has survived as the most "likely" to explain the pathogenesis of endometriosis. But why do some women with retrograde menstruation go on to develop endometriosis while others do not? That has been the big UNKNOWN for decades....until NOW. Could the answer be because of the uterine microbiome? Its highly possible! If so, certain combination of antibiotics may reduce and/or reverse some of the pathology of endometriosis. In this episode, we will summarize a brand new study (from 06/14/23) that is SHAKING UP gynecology! Listen in...and find out what this data is about, its clinical applications, and the gaps that still remain in this story.

The world of "Hypertension (HTN) in Pregnancy" is an ever-evolving environment! Many clinicians have adopted patients' home monitoring of blood pressure (BP) in their management of hypertensive disorders in pregnancy. Do you recommend home BP monitoring in your OB patients? On May 4, 2022 we summarized the results of 2 RCTs examining whether home BP monitoring during antepartum care prevents HTN morbidity and mortality. These were BUMP1 and BUMP2 (JAMA). We will again summarize the key findings from those 2 RCTs in this episode. PLUS, we will highlight a brand new publication from Obstet Gynecology (the Green Journal) which was just released on June 13, 2023 (Steele et al) which examines the effectiveness of POSTPARTUM home BP monitoring in patients with hypertensive disorders of pregnancy. Does that reduce postpartum HTN morbidity? Its completely acceptable to be "medically conservative" and have patients self-monitor their BPs at home...but is that also data-driven? And which antihypertensive seems to work the best in the immediate postpartum interval: labetalol, nifedipine, or is it furosemide? Listen in and find out!

Just a quick clarification regarding a previous statement, on an earlier episode, regarding MSAFP….thank you Maggie Rey! ❤️❤️❤️this community.

Does the combination birth control pill cause depression? This has been a controversial subject for over 2 decades. While some observational studies have described a possible association, randomized clinical trials have shown little to no connection. On June 12, 2023, a new population-based cohort study from the UK sought to evaluate this possible association. This resulted in some interesting claims! These results, just within 24 hours, have now made their way to major news outlets and social media circles. In this episode, we will summarize the key findings as well as the key limitations to this “hot-off the press" publication.

I recently received a message from one of our podcast family members requesting more gynecological topics...that was perfect timing, since the NAMS just released its 2023 Position Statement on "NonHormonal Therapies" for vasomotor symptoms on June 1st. In this episode we will summarize this 18 page monograph. The NAMS expert working work critically evaluated the published literature on all nonhormonal therapies for hot-flashes and grouped them into 5 categories: lifestyle modifications; mind-body techniques; prescription therapies; dietary supplements; and acupuncture-other treatments-and technologies. In this episode we will cover each of these categories to keep you informed, up to date, and evidence-based. Is yoga recommended for hot-flash relief? What about cannabinoids? Can chiropractic adjustments help with hot-flashes? Listen in and find out!

Welcome back to part 2. In this episode we will wrap up our discussions on dermatoses of pregnancy, focusing on atopic eruptions of pregnancy and ICP. Do you know what the 3 comorbidities are which may follow a diagnosis of ICP? We’ll cover that here. AND we’ll throw in a weird one as our final discussion point, one that is considered by some to be the 5th dermatosis of pregnancy. This is the Triple P: Pustular Psoriasis of Pregnancy.

I’ve said this many times before: I ❤️ our podcast community. This podcast topic idea comes from Jerry, an OBGYN Resident in Virginia. 👏👏 Jerry writes, “I wanted to know if you could do a topic on the Dermatoses of Pregnancy. My program has had some interesting cases recently and most of what I could find was in UpToDate. I couldn’t find a specific PB or CO on the topic, so I wanted to reach out.” Honestly, I hadn’t even thought of this topic…and it is a good one! We do see patients with these complaints very frequently. So, in this episode we are going to not just scratch the surface—see my dad joke there? “Scratch the surface”, as we talk about dermatoses—anyway…we will be taking a deep dive into these conditions: their presentations, workup, and therapies. Is herpes gestationis related to herpes virus? Can pruritic papules and plaques on the abdomen have bullae? Which conditions are linked to adverse maternal-neonatal outcomes? And what is the condition known as, TRIPLE P? …Stay with us and find out. 🧴😳❓😬

It has long been considered that iron deficiency does not exist in Thalassemia syndromes, including Thalassemia major as well as Trait (Thal minor). But that is incorrect. Recent studies have shown the occurrence of iron deficiency in patients with Beta-Thalassemia Trait. Iron deficiency anemia (IDA) during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality and should be treated with iron supplementation in addition to prenatal vitamins. However, patients with Beta-Thalassemias have been considered to be at risk of iron overload due to alterations in function of hepcidin. So, can pregnant women with Beta-Thalassemia Trait, found on hemoglobinopathy screening, take oral iron supplementation for concomitant iron deficiency anemia? That’s a big question, and we’re going to answer it in this episode!

When performing cervical examinations during labor, providers in the United States commonly use sterile gloves, even when there is no rupture of membranes. Is this an evidence-based practice or is it simply tradition? This debate has been going on for decades. In this episode, we will highlight some interesting/intriguing hospital policies and procedures, and walk-down our history timeline of data. We will start in 2010 and end with a recent publication from June 2023 from the AJOG-MFM. Finally, there is some Level I evidence to help settle this debate. 🧤🧤🧤❓❓❓

Here’s a real world clinical conundrum: A patient first presents for prenatal care in the 3rd trimester. As healthcare providers, we play a game of “catch-up” with routine serum tests ordered to make up for time lost. But what about specific pregnancy tests that are restricted to gestational age? Take, for example, GDM screening. Currently, traditional screening for GDM occurs at 24 to 28 weeks based on the original studies by O’Sullivan and Carpenter-Coustan. Or take this parallel, clinical scenario: A patient passes routine screening between 24 and 28 weeks, but in the 3rd trimester has suspected fetal macrosomia or new onset polyhydramnios. Should we rescreen these patients for GDM? As cut off values for the GDM screens are based on a 24 - 28 week pregnancy, we don’t really know what the cut off serum glucose levels should be after 28 weeks. And more importantly, does diagnosing GDM in the 3rd trimester improve maternal or neonatal outcomes? In this episode, we will walk down history’s timeline of data starting in 2001 and ending with a publication in 2022. We’ll discuss the findings of these publications (6 total) and at the end of the episode, I’ll give you my personal perspective on the subject.

We are now 5 years into the publication of the Arrive trial (2018) which opened the door to elective induction of labor at 39 weeks in an otherwise low risk pregnancy. But five years later authors and researchers are still debating whether a 39 week elective induction is helpful or not. Yep, the rebuttals and retorts against the ARRIVE trial began shortly after its publication, and they are still active even now- with a recent publication, from February 2023, having an opposing view. Yep…While some have called for universal adoption of the “39 week IOL rule“, others have put the brakes on the plan. in this episode, we’re going to dive into this persistent on again off again dilemma of elective induction at 39 weeks. This podcast idea comes from one of our podcast family members who sent me this message on May 27: “Hey Dr. Chappa, what are your and your team's thoughts on elective induction at 39 weeks? I've had multiple discussions with my co-fellow about how it may not be the best option for some of our pregnant folks, especially those who have had a successful un-induced vaginal delivery. My attending sent me an interesting article from the Journal of Perinatology which questions the validity of the Would love any input you have on this. Thanks!” What a great topic to discuss. There’s so much to unpack here and we’re going to summarize that article which came out in print in February 2023, and we will also discuss a separate study that followed in March 2023 on this very issue. And…Is 39 week eIOL cost effective? Lots of angles to examine here and we will do all of that in this episode. And- as always- you’ll want to stay with us until the end of the episode because I’ll provide my personal perspective and typical practice regarding eIOL at 39 weeks.

The fetal heart rate is controlled by various integrated physiological mechanisms, most importantly by a balance of parasympathetic and sympathetic nerve impulses. Intrapartum, fetal bradycardia may be in direct response to an evolving or acute hypoxic event, including tachysystole, uterine rupture, or placental abruption. Antepartum, excluding acute events like maternal trauma which could lead to an acute hypoxic episode, most fetal brady arrhythmias will be nonhypoxia related. We recently evaluated and cared for a patient at 23 weeks gestation with the incidental finding during her routine prenatal visit of a fetal HR of 90. This was confirmed by bedside ultrasound, and then noted to be in the 70s on reexamination in L&D. There was no fetal hydrops, no evidence of maternal injury, no maternal connective tissue disease, normal amniotic fluid, and a normal fetal movement seen on ultrasound. What are the possible causes of antepartum fetal bradyarrhythmia? What’s the work-up? What is the fetal Long QT syndrome? And when is delivery recommended? Listen in and find out.

On May 19, 2023, the FDA cleared a novel biomarker serum test for the risk stratification for severe preeclampsia in hypertensive pregnant women. This clearance is the first given to any blood-based biomarker test for assessing preeclampsia risk. The company is Thermo Fisher Scientific (no disclosures). But what does this test actually check for? Who qualifies for this? And what was the clinical investigation that the FDA based its clearance decision on? And most importantly…what do we do with this result?! We will answer all of these questions- the what, why, how, and what now- in this episode.

The 3rd stage of labor is the time from child's birth to delivery of the placenta. Delayed placental separation and expulsion is a potentially life-threatening event because it hinders expected postpartum uterine contraction, which can lead to PPH. The concept of umbilical vein injection of a variety of substances (saline, pitocin, plasma expanders) is nothing new. It was first described in the 1930s! This had found new life in the 1980s and 1990s but soon thereafter again fell into ambiguity. What is the theorized MOA of this intervention? Does oxytocin injection into the umbilical vein help prevent PPH? Is this an effective management option in the 3rd stage? We will walk down history's timelime and find out. We will also summarize the data of 2 Cochrane Reviews that have twice looked at this technique, with the last published report in 2021. Thank you Haley for the podcast topic suggestion!

Although labor epidural remains the gold standard for labor analgesia, some patients may opt for a trial of a less invasive analgesic agent. While IV/IM narcotics are an option, others may prefer a trial of nitrous oxide (N2O). In this episode, we will review the crazy history of this useful inhalational agent, and how it has ties to the manufacturing of the Colt45 handgun, how it transformed dentistry, and review the contribution to medicine by Dr. Horace Wells. We will review N2O's current application in obstetrics, and summarize statements from the ACNM and the ACOG. And…What does this gas have to do with vitamin B12? Are there any safety warnings out there regarding its use? And does it even work? Let’s answer these questions, and more, in this episode.

Just the other day I received a text from one of our wonderful FM attendings in our group concerned about refilling a patient’s Lamictal in early pregnancy. When asked if that was acceptable to do, I quickly answered ABSOLUTELY. We’ve come a long way in understanding bipolar disorder and a long way since lithium was first described for its use. While its use in psychiatry dates to the mid-19th century, the widespread discovery of lithium is usually credited to Australian psychiatrist John Cade who introduced it for mania in 1949. The first randomized trial was published in 1954 showing efficacy for this mental health condition. The drug was not US FDA approved for treatment of bipolar disorder until 21 years later in 1970. Thankfully, now- safer options of medical therapy are available for reproductive age women. In this episode we will summarize the data on medical therapy for bipolar disorder. Which medications are preferred? Are serum drug levels recommended? Does lithium really cause Epstein's Anomaly? And what drastic move did the UK perform to reduce fetal exposure to some medications commonly used for bipolar disorder in reproductive age women? We’ll explain it all in this episode.

The ACOG recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding while complementary foods are introduced during the infant’s first year of life, or longer, as mutually desired by the woman and her infant (ACOG CO 820; 2021). Problems may arise that can keep women from achieving their breastfeeding goals, and only 25.4% of women are breastfeeding exclusively at 6 months. One of the most common reasons women stop breastfeeding is engorgement, which could lead to lactational mastitis due to milk stasis. In this episode we will review the current best practice plans for lactational mastitis and one its complications, breast abscess. Plus, new data regarding the pathogenesis of lactational mastitis is challenging the old traditional model of causation; we’ll explain in this episode.

This is our second episode in the format of “You Asked, We Answered!” In this episode we will clarify and discuss 4 topics currently active: (1) Is the FDA approving OTC Birth Control? What is the progestin in the OPill? Do you know what “Free the Pill” is? We’ll discuss here. (2) Why did the USPSTF change the MMG screening rec to age 40? Has’nt the ACOG already recommended that? And what did the USPSTF comment regarding dense breasts? We’ll discuss here. (3) What is the “10 and 10” association between HbA1c and Birth defects? We’ll discuss this and the “rule of 30”, and lastly (4) We recently summarized a new publication on IPI after stillbirth and commented on the higher risk of PTB overall in the first pregnancy after stillbirths. Was this due to medically indicated inductions or due to spontaneous PTB (Ruthy’s question)? We will discuss in this episode!

Historically, governmental and professional societies referred to gestational "completed" weeks in their definitions of preterm or term deliveries. But this term of "completed weeks" has remained a point of confusion for clinicians and researchers alike. The ACOG favors simply stating the gestational age as clear designations of weeks and days (e.g., 34 weeks 5 days) rather than "completed weeks". Nonetheless, state and national vital statistics reports still rely on documented completed weeks. Does "34 completed weeks" imply the day after 33 weeks and 6 days, or the day after 34 weeks and 6 days"? We'll clear up the confusion regarding "completed" weeks of gestation in this episode.

Obstructive sleep apnea (OSA) affects nearly 30 million people in the United States. OSA isn’t just a disruption to pregnant women’s sleep, it is linked to serious pregnancy complications. In this episode will summarize the latest research on OSA and disorganized sleep patterns and their associated pregnancy outcomes. Should we screen for this in pregnancy? Is CPAP safe in pregnancy? Should these patients be on low dose aspirin? Does treatment for OSA prevent the adverse perinatal outcomes? Screening for OSA in pregnancy is controversial…so you’ll need to stay with us until the end of the episode to find out why. This topic suggestion comes from a second-year resident in Columbus, Ohio, who is part of our podcast family. Dani, thanks for reaching out. Enjoy your residency journey… It goes by fast. Dani, here’s your podcast.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. The optimal interpregnancy interval (IPI) after stillbirth is unclear. Currently, many organizations recommend IPIs greater than 18 months due to findings that, after live birth, a short IPI is associated with increased risk of spontaneous preterm birth, small for gestational age (SGA), and, sometimes, stillbirth. But this was based largely on expert opinion and not peer reviewed data. Recently, data has been published on this very subject that may aid bereaved parents in planning for a next pregnancy. In this episode we will review the first large-scale population study on the subject (from 2019) and summarize a soon-to-be released publication from Obstetrics Gynecology (the Green Journal) examining the effect of IPI after stillbirth.

The ACOG defines FGR as fetuses with an estimated fetal weight or abdominal circumference that is less than the 10th percentile for gestational age (ACOG PB 227). BUT, some argue against this cut off. There may be a subgroup of AGA fetuses with placental insufficiency who display slowing of fetal growth trajectory while in utero, but do not end up with a birthweight <10th centile at term, and so not classed as FGR. Such a cohort that has declined in weight centiles in late pregnancy may be an important under-recognized group with sub-optimal placental function. Growth velocity represents the rate of fetal growth in a specific time interval and may have more clinical utility to distinguish normal from pathological fetal growth and may help to identify fetal growth abnormalities that are abnormal yet still above the crucial 10% cut off. So in this episode we're going to focus on this very question... what do we do with those fetuses that we find have plateaued or have slowed trajectories of fetal growth antepartum but are still above the 10th percentile. It's a common clinical conundrum. This podcast idea comes from one of our podcast family members who reached out for this very reason. Lauren, thank you for your message, here's your podcast.

Can you believe that in 1977, the public health guidelines issued by the National Institutes of Health suggested a two-drink-per-day limit for pregnant women? It's TRUE. Ethanol had even been investigated, and promoted, and an "effective tocolytic agent". We now, of course, understand that there is no safe amount of ethanol use during pregnancy. Our understanding of FASD has evolved over the years, so much so that we now understand that FASD is possible by PATERNAL use of alcohol in the prericonception period. This is due to epigenetic changes in the sperm. In this episode we will review some historical facts regarding the use of alcohol in pregnancy and summarize new data demonstrating the MALE partner's contribution to FASD.

Epidural anesthesia remains the gold standard for relieving labor pain. Currently, there are 3 techniques for providing epidural related analgesia (traditional epidural, combined spinal- epidural, and dural scrape/puncture epidural). A controversial subject dating back to the 1990s, epidural related maternal fever (ERMF) has been extensively studied. In this episode, we will summarize two recent publications on the subject from the AJOG and review historical data. What is the pathophysiology of ERMF? Are antibiotics still indicated in these patients? Listen in and find out.

Medical/Nursing simulations which focus on high-acuity, low-frequency crisis events improve team dynamics, team morale, and most importantly patient outcomes. One such high-acuity, low-frequency event is malignant hyperthermia (MH). On labor and delivery (L&D) units, neuraxial (spinal and epidural) blocks are the safest and most commonly used anesthetics. However, general anesthesia is performed when the case is emergent (stat), when the regional anesthesia level is insufficient, or regional anesthesia is contraindicated (low platelets). Joint Commission accreditation included preparedness for medical reactions/emergent conditions, including malignant hyperthermia. In this episode we will provide a high-yield summary of MH including etiology, pathophysiology, medication rescue, and supportive care for this potentially life threatening emergency.

One of the sources of ideas for our podcast topics is our daily clinical practice. During my recent shift in ultrasound clinic, we encountered 4 clinical scenarios which became wonderful teaching opportunities at that moment. In this episode, we will share these common- at times, daily – clinical dilemmas, and we will provide evidence-based, easy answers!

In June 1999 the FDA approved the first continuous glucose monitor for diabetic intervention. We have come along way since 1999. Continuous glucose monitors (CGMs) come in 2 different varieties: real-time CGM, and intermittent/“flash” monitor devices. The use of these devices in pregnancy has exponentially grown. In this episode, we will summarize the key findings from the landmark study, published in 2017 in patients with Type I diabetes in pregnancy (the CONCEPTT study). Is there evidence supporting the use of these devices for gestational diabetes? Has the FDA cleared any of these devices for use in pregnancy? We will answer these questions and much more in this episode.

You asked… We did! Listen in and find out what this means.

It’s a rather uncommon, but not rare, phenomenon: the incidental hCG finding in a postmenopausal patient. What are we supposed to do with that? Is this automatically cancer? In this episode, we will highlight a real clinical case from one of our podcast listeners, Cynthia. We will review the likely causes of low-level hCG levels in a postmenopausal woman (who is not pregnant). You may be surprised of some possible etiologies. Towards the end of the episode, we will also provide an evidence-based recommendation on the diagnostic evaluation/work up of this type of patient. Lastly, we will give an important reminder of how urine could be a valuable tool in this schema.

The earliest studies of misoprostol’s use in cervical ripening and labor induction were done by South American investigators, who reported their experience using intravaginal misoprostol. This was published in the Lancet in 1992. Despite its widespread incorporation into obstetrical practice, there’s still some lack of uniformity in its administration. Is there a cumulative maximum dose allowed for cervical ripening? What about time… is there a maximal amount of time in which misoprostol can be used? Is that 12 hours, 18 hours, 24 hours? In this episode we will review important misoprostol’s FDA label information, summarize position statement from the ACOG and AWHONN, and discuss issues with “scoring” the 100mcg tablet to give a 25mcg dose. And of course, we will summarize the important peer-reviewed data regarding “maximum vaginal cumulative doses” of this medication for cervical ripening/labor induction.

The concept of measuring intrauterine contractions strength was first proposed in 1949, and eventually published in 1952. The use of an IUPC is well ingrained in modern obstetrical/intrapartum practice. Even though it is so commonly performed, we tend to forget some potential limitations and possible risks of this procedure. In this episode, we will review the history and purpose of the IUPC and remind ourselves of some real (though rare) limitations and risks. We will also touch on an evolving, new alternative to intrapartum uterine monitoring: electrical uterine monitoring (EUM). This is electromyography (EMG) of the uterine muscle activity as a contraction monitoring technique.

Once considered on the fringe of main-stream medicine, “alternative therapies” are becoming more accepted into clinical practice. Such is the case of psilocybin (a mushroom extract) for certain mood disorders. 🍄 And now, another mushroom extract (AHCC) has gained attention in gynecology. Could this extract help eliminate the most common viral STI? Is this evidence-based? The research may surprise you. Let’s review the data on ‘shrooms and HPV. Thank you Leah for the episode suggestion! Keep up the great work up north in Long Island! 😊

We ❤️ our podcast community! Over the last 3 recent episodes, we have received similar “themed“ listener questions. So in this episode, we are going to respond to some recent inquiries regarding three recent episodes: 1. combination birth control and estrogen levels (and Perimenopausal use), 2. vaginal progesterone for patients without a history of preterm birth, and 3. the use of vaginal dilators for vaginismus. This is how we all grow together! Now… Let’s get to your questions. 😊😊😊🤔🤔🤔

I recently had a patient (young reproductive age, without prolapse or urinary incontinence) ask me about using the “Jade Egg” vaginally for better sex. Women’s sexual intimacy is a big dollar commercial industry. What’s the history behind this Jade Egg and/or other vaginal insertion weights? Is there a benefit to using these inside the vagina for pelvic floor training and enhanced sexual intimacy? Are these any better than regular Kegel exercises? In this episode, we’ll do a deep-dive into the data and find out when, if ever, these devices may be used as ancillary tools.

Presence of meconium stained membranes/placental tissue has been used in medico-legal cases by both plaintiffs and the defense alike. Using the presence of meconium stained tissue has been used as a tool to “timeline” fetal hypoxia. Is this evidence-based? In the session, we will review the historical data (1985) that fueled this concept, and give the latest scientific and medical expert opinion regarding the possibility of this theory (highlighting a new Expert Review in the AJOG, April 2023).

Oh, the ever evolving drama of “progesterone in high risk obstetrics”. Today, April 13, 2023, the SMFM released its Special Statement response to the recent change in the progesterone PTB prevention landscape. Where does cerclage fit in? In this episode we will summarize the current recommendation for cerclage for preterm birth prevention and how it fits in to the vaginal progesterone story. Is cervical ultrasound surveillance after vaginal progesterone initiation warranted? We will make it clear in this episode.

We have come a long way in our understanding regarding the safety of intrauterine contraception. Once withheld from adolescents and immediately postpartum patients, the safety in both populations is now well established. Postpartum IUD/IUS placement is a balance between risk of expulsion and patient loss to follow up. In this episode, we will summarize a new RCT from JAMA discussing this very subject. Is it better to place immediately Postpartum, at 2 weeks after delivery, or as an interval procedure at 6 to 8 weeks? We will summarize this Level I evidence and also provide helpful resources for increased accessibility of LARC options, including the new (April 2023) ACOG Committee Statement on this very issue.

This episode is in reply to one of our fantastic podcast family members who had some wonderful clinical questions regarding dosage of combination BC after listening to our past episode. In our immediate past episode, we discussed hypoestrogenemic symptoms on ultra low-dose pills in certain patients (young, thin). Is a 20 µg BC pill less thrombotic than a 30 or 35 µg pill? What does the data say? In this episode will answer this question and also dive deeper into serum estradiol levels not only with combination birth control but also with menopausal hormone therapy. Is there a “target level” of systemic/serum estrogen with combination HRT? Listen in and find out.

In 1972, a publication in which a radioimmunoassay measured serum estradiol levels in participants taking oral combination birth control concluded that levels of serum estrogen were “sufficient to prevent symptoms of estrogen deficiency”. Knowing NOW what we do, and looking back to that article, those authors’ conclusions were completely incorrect! Is it possible for a patient to experience hypoestrogenic symptoms despite taking an estrogen containing birth-control? What are normal, endogenous estradiol levels in a reproductive age female? In this episode, we will review the various degrees of hypothalamic – pituitary – ovarian axis suppression from different categories of hormonal birth-control. Should certain micrograms of ethinylestradiol be preferred in thin and/or adolescent patients? Listen in and find out.

Here’s proof that our catchphrase, “Medicine Moves Fast“ is 100% true! On October 30, 2022, and again on November 1, 2022, we released episodes on “Dense Breasts on MMG? What to do?”. Those episodes were in response to Katie Couric’s public outcry for the need for additional screening at time of mammogram in the setting of dense breasts. On March 9, 2023, the FDA issued a new ruling/guidance on patient notification of breast density at screening mammogram. And now, in April 2023, the ACOG has released its new Practice Advisory (PA) on the subject. In this episode, we will quickly summarize this practice advisory, it’s implications for us as clinicians, and implications to our patients.

A quick update and commentary on the recent (April 6, 2023) FDA decision to withdraw approval of Makena for preterm birth prophylaxis.

Pregnancy causes some well-known and well documented physical changes to the body. While hyperpigmentation, breast enlargement, and increase in vaginal discharge are non-disputed physical changes during pregnancy, other effects on mental capacity (memory and cognition) are more controversial. Does “mommy brain” really exist? Or is it a fulfilled psycho-social expectation? Does pregnancy actually change the brain? In this episode, we’ll present the data and provide some practical tips at the end of the show to help tackle the elusive foe called “momnesia”.

For a patient who presents after an episode of unprotected sexual intercourse, seeking testing for STIs, it’s important to know when to perform the test. The time between infection and a positive test is called the testing window. This testing window can be different for different pathogens. In this episode, we will review the importance of knowing this testing window, and we will also review the differences between pathogen inoculation, incubation/latency, and their overlap with the testing window.

Von Willebrand Disease (VWD) is the most common inherited bleeding disorder among American women, and it may present with a history of mucocutaneous bleeding patterns. Ideally, women should be screened/identified with this condition prior to pregnancy- but that is not always the case. How does VWD affect delivery? Is this a cause of immediate PPH? In this episode we will review the clinical manifestations of VWD in pregnancy. We will: 1. review appropriate labs tests for this evaluation, 2. summarize the recommended management peripartum, and 3. discuss if a C-Section is required in the affected patient. LOTS of material is covered in this episode! (References: ACOG's Clinicals Expert Series, March 2023; ACOG CO 785).

For women’s healthcare, there are 3 ways to screen for genital GC, chlamydia, and trichomoniasis: 1. vaginal swab, 2. endocervical swab, or 3. first-catch urine. The CDC states that, “For female screening, specimens obtained with a vaginal swab are the preferred specimen type. Vaginal swab specimens are as sensitive as cervical swab specimens.” Why does it not favor urine screening? Although acceptable at a POPULATION level, there are several caveats to urine screening for STIs at an INDIVIDUAL level. In this episode, we will review the latest published data (March/April) regarding the sensitivity of urine screening for these 3 common STIs. Additionally, we will summarize important instructions/tips for proper self-swab collection, and proper first-catch urine testing.

We have come a long way in our understanding of the “Stein and Leventhal Syndrome”. First described in 1935, our understanding of the pathogenesis and future health morbidities of PCOS has grown exponentially. We now know that AMH levels may help in the certain PCOS diagnoses. At the center of this clinical condition lies insulin resistance (IR). One of the manifestations of IR is Acanthosis nigricans (AN). (But AN can also be a marker of a much more deadly condition.) It is important to remember that not all PCOS patients are the same. In this episode, we will review the 4 phenotypes of PCOS and discuss a specific variant of the condition which is called the “lean PCOS variant”.

The rate of vegetarianism in the United States is dramatically on the rise. While in 2014, a national survey found that only 1% of the US population considered themselves vegetarian, current estimates put that number up to 6%. But not all vegetarians are the same. Is being a strict vegetarian (a.k.a., vegan) associated with any adverse perinatal outcomes? Does being vegan increase your risk of preterm birth? In this episode, we will cover the latest data on how diet can affect perinatal outcomes, and in-utero metabolic programming of the child. 🥑🥗🍎🍇🍊🌾🌾

Traditionally, fetal growth restriction (FGR) was diagnosed when the Hadlock EFW was < 10th percentile. However, in 2020, SMFM updated its publish guidelines endorsing the use of an isolated abdominal circumference (AC) under the 10th percentile as an additional diagnostic criterion. Is the isolated small AC linked to adverse perinatal outcomes? And what are the delivery recommendations for an isolated small AC? It’s a complicated issue with complicated data. In this episode we will provide the “He said, She said” reported outcomes for this clinical conundrum. At the end of the episode we will provide some real-world practical tips on how to manage the isolated AC growth restricted fetus. 🫄

Our current discipline of obstetrics owes a lot to the practice of Midwifery. In a previous episode, we covered “lessons learned from Midwifery” and that is available on our podcast archive. In this episode, we will discuss the data regarding a practice originally propagated by Midwifery: the Birthing Ball. What is the origin of this, and how did it make its way into obstetrical practice? Is there data for it’s use? Does it really help reduce labor pain? In this episode we will summarize the data of a soon-to-be released publication from the AJOG. In this episode, we will find out if the Birthing Ball is a toy… or a labor tool.

Gerri, thank you for your voice message today! Welcome to our podcast family. Here’s some helpful notes for you. 😊😊

In Oct 2006, the ACOG released Opinion Number 346. This stated that “Based on current literature, routine prophylactic amnioinfusion for the dilution of amnioinfusion for meconium-stained amniotic fluid should be done only in the setting of additional clinical trials”. Back then, some experts criticized the decision to abandon amnioinfusion for meconium based on the limitations of the 2005 study which helped to motivate the ACOG decision. And now, a new systematic review and meta-analysis (published ahead of print March 18, 2023; AJOG) has brought new life into this old debate. Can amnio-infusion, in fact, reduce meconium aspiration syndrome (MAS)? Do current professional guidelines need to be updated? We will explore and dissect this new data in this episode.

Infertility. It’s real. It affects 10-15% of couples in the US. After a thorough investigation, 30% of couples will be left without an identifiable cause for their infertility. This has been termed unexplained infertility. While traditionally this may have been considered a reassuring result, new data is raising the yellow flag of caution in these patients. Research has now established the link between infertility and some potential future negative health outcomes. As “next generation“ genetic tests become more integrated into clinical practice, new data (released ahead of print on March 16, 2023 in the New England Journal of Medicine) has revealed some life-changing realities for couples struggling with unexplained infertility. In this episode, we will highlight the advances in genetic medicine and summarize the key findings of this eye-opening new publication.

Such a small gland… Yet so much confusion, and controversy: the THYROID gland in pregnancy. Let’s start with this foundational question: should we universally screen for thyroid abnormalities in pregnancy? And as a follow-up question, should we be checking for anti-thyroid antibodies? The answer to both of those queries depends on who you ask! In this episode, we will solve the conundrum of whether we should be screening for anti-thyroid antibodies pre-pregnancy and/or during pregnancy itself. Does identification of these antibodies affect management? What is their role in recurrent miscarriage? Listen in, and find out.

The traditional explanation and assumed pathophysiology of HELLP syndrome stated that it was a late manifestation/further progress of preeclampsia with severe features. But can HELLP present clinically without hypertension? What about without proteinuria? If a patient has lab criteria of HELLP alone, without hypertension, does she still require magnesium sulfate? In this episode, we will summarize data from 3 sources (ACOG practice bulletin on thrombocytopenia, ACOG practice bulletin on gestational hypertension and preeeclampsia, CMQCC hypertension bundle), and answer these questions and more.

The pathophysiology of menopausal hot flashes has remained largely a mystery until about a decade ago when KNDy neurons were found to be the key triggers of the hot flash. Since then, research and development has been going fullsteam to develop a non-hormonal, receptor-based therapy for the common hot flash. In April 2023 in the journal, Obstetrics and Gynecology (the Green Journal), new safety data will be published on the revolutionary new medication, Fezolinetant. With Phase 3 study results already in print, the FDA is projected to rule on this new medication’s approval potentially in May 2023. In this episode, we will review the fascinating biochemistry of KNDy activity and how this new medication works.

The fetal NST is a hallmark of antepartum fetal surveillance and a key component of the BioPhysical Profile (BPP). Historically, and still done today, one of the low-risk interventions for rectifying a non-reactive NST has been the maternal administration of glucose/PO challenge. Is this evidence-based? Does maternal hypoglycemia contribute to a nonreactive NST? In this episode, we will review the data spanning a 40-year interval that has sought to answer this question. And what about fetal movement? Does maternal glucose loading increase perception of fetal movement? Let’s go to the data now.

The Liggins and Howie trial demonstrating the benefit of antenatal corticosteroids (ACSs) on fetal lungs was published in 1972 in the journal Pediatrics. First adopted as weekly injections, ACSs were then found to be associated with decreased birth weights and decreased head circumferences. Hence, weekly administration was abandoned in the late 1990s. But the ACOG/SMFM does still recognize a single repeat dose “based on clinical scenario”, called a rescue dose. Is a rescue dose of steroids associated with altered neurodevelopment in the child? In this episode, we will summarize a brand new study just accepted for publication in the AJOG MFM (the Pink Journal) shedding some light on this question.

This is a brief update regarding our recent podcast on “the French C-section”. Having an Israeli member of our podcast family…is priceless! ❤️Listen to the latest development regarding the extraperitoneal C-section in Israel and how this situation bears similarities to the US approval of ADDYI in 2015. Thank you Liel N.!! 😊😊

In 1999, the CDC had a national plan of action to “completely eliminate syphilis” by the year 2005. Although rates of syphilis did dramatically decrease to record lows during that time, we are now experiencing record HIGH rates of congenital syphilis. Some states are having a close to 500% increase in congenital cases. How did we get to this point? In this episode, we will review and summarize 3 key recent publications regarding the rise of congenital syphilis (Journal Women’s Health Issues [Elsevier]– article in press: AJOG Dec 2022; ACOG Clinical Expert Series May 2020) which have resulted in the SCARY STATE of SYPHILIS. We will also review the JH reaction, and provide a clinical pearl regarding the interval restriction between doses of Penicillin G injections, AND we will summarize the time frames permitted to allow a decrease in RPR titers after therapy. Lots of material covered in this episode! 👍

The historic saying is, “there is nothing new under the sun”. So true! Such is the case with the extraperitoneal C-section. First advocated in 1823 by French obstetrician, Louis-Auguste Baudelocque, this complex technique fell to the waste-side with the advent of antibiotic availability. But now, this extra-peritoneal cesarean technique, A.K.A. the "French AmbUlatory Cesarean Section" technique (FAUCS), is trending on social media. Is this safe? Does this have any advantage over a traditional C-section? And why has one country recently BANNED this procedure? In this episode we will present this novel technique and explain why some are calling for caution in its adoption.

The “cure” for preeclampsia is NOT delivery. Preeclampsia is an important signal for future cardiovascular complications once pregnancy is over. While there may not be a true “cure”, we do have options for chemoprophylaxis of preeclampsia. Currently, only low-dose aspirin is ACOG/SMFM endorsed for preeeclampsia prevention. But pravastatin is gaining steam. Pravastatin was previously classified (in the now discontinued FDA label) Category X. However, the FDA recently removed the warning regarding use of statins in pregnancy, resulting from the favorable data on pravastatin as a potential chemoprophylactic agent against preeclampsia. While short term fetal safety has already been documented, there was a gap in data regarding long-term neurodevelopmental outcomes in children exposed to this medication in- utero. But new data has some reassuring findings (with a CAVEAT). In this episode, we will highlight a soon-to-be released publication in the AJOG, which is the first to report on the long-term neuromotor, cognitive, and behavioral outcomes of children exposed to pravastatin in utero.

Some obstetrical publications discuss adverse perinatal outcomes based on a short interpregnancy interval (IPI). A separate, yet related topic, is a short interdelivery interval (IDI). Most obstetrical care providers are aware of the adverse obstetrical outcomes following a short IPI. However, short IPI has also been linked to adverse neurodevelopmental disorders in the child. Are repeat fetal growth ultrasounds indicated in a pregnancy following a short IPI? Is antepartum fetal surveillance indicated? In this episode, we will tackle the short interpregnancy interval, and we will end the podcast with the Level C guidance regarding pregnancy management following a short IPI.

In 2018, the ACOG recommended immediate induction of labor/delivery for patients with PPROM, who had sure gestational dating, and were at 34 weeks and 0 days or more. This was in order to reduce the risk of neonatal sepsis. This changed, however, in 2020 with ACOG Practice Bulletin 217 which discussed expected management for PPROM in the late preterm interval. Nonetheless, as is our tagline for this podcast, “medicine moves fast”. In February 2023, a current commentary was published in BJOG adding a cautionary note to the option of expected management in the late preterm interval. In this episode, we will review the acog guidelines, review GBS culture versus NAAT, and summarize this current commentary from BJOG. What is the one clinical factor that should be considered in planning for expected management with PPROM in the late preterm interval? We will explain it in this episode.

As part of our medical training and education, we often learn diagnoses in isolation. For example, we have learned that Proliferative Endometrium on EMB is a non-pathological finding. That result can be left alone without therapy, correct? But what if that is found in the context of a postmenopausal patient. Is it still considered a nonpathological finding? In this episode, we will summarize the current nomenclature for endometrial pathology and why one classification scheme is favored over the other (EIN over WHO). We will also summarize key points form a February 2023 publication (Obstetrics and Gynecology) released under the section, “Clinical Conundrums: Proliferative Endometrium in Menopause, to Treat or Not to Treat?”.

Marginal cord insertions can be found on antenatal ultrasound. What is the data regarding marginal cord insertion and adverse neonatal outcomes? Is there a relationship, or is this a benign finding? Are serial growth ultrasounds recommended? What about antepartum fetal surveillance for isolated marginal cord insertion? In this episode, we will review the latest data on pregnancies with marginal cord insertion. We will end the episode with a summary of the expert opinions regarding best practice for management of pregnancies found to have a marginal cord insertion.

This is our impromptu podcast session in-between patients in our OB Clinic. In this episode, Dr. Leon-Arango (Senior Resident) highlights the importance of looking “deeper” into a patient’s persistent complaint of depression despite a negative PHQ9 score, based on her encounter from today. This real example of a physician’s perception of need for intervention likely helped to change the trajectory of this patient’s life. Listen in as we go “beyond the PHQ9”.

The first case of placenta accreta listed on PubMed was reported in 1927 by Dr D.S. Forster out of Montreal. That was 1 case in 8000 deliveries! Now, according to the National Accreta Foundation, PAS occurs in 1 in 272 pregnancies. How did we get to this rate? In this episode we will highlight data from ACOG, SMFM, and the National Accreta Foundation. We will highlight key ultrasound markers, patient risk stratification, and review what a PAS Care Center is. This is how we win the battle against PAS.

Delayed cord clamping (DCC) provides vital placental transfusion to newborns and is endorsed by ACOG, SMFM, March of Dimes, and the ACNM. However, DCC in nonvigorous newborns may not be provided owing to a perceived need for immediate resuscitation. Umbilical cord milking, in late-term and full-term neonates, is an alternative in these cases. In December 2020, the ACOG’s Committee Opinion stated a lack of outcomes data for umbilical cord milking in nonvigorous newborns. This Level 1 data has now arrived (February 2023). In this episode, we will summarize the key findings from this soon-to-be released publication from the AJOG on umbilical cord milking in nonvigorous newborns born at >/= 35 weeks.

Historically, IUDs where considered contraindicated in a patient with a prior ectopic pregnancy. This was due to concerns that IUDs may be causative of tubal gestations. Is this true? Are IUDs contraindicated with a past history of ectopic pregnancy? In this episode we will review the data from the CHOICE project, the CDC (US), and the Royal College of OBGYN (UK). We will also summarize key findings from a May 2022 Green Journal publication that investigated this very issue, and we will explain why some IUSs may be MORE protective (52mg vs 13.5mg) against ectopic than others (Thank you Jessica W. for this timely and clinically relevant podcast topic suggestion).

A 2020 publication from JAMA Pediatrics reported that labor epidural analgesia may be associated with an up to 37% increased risk of offspring autism spectrum disorder. The ASA has rejected those results based on methodologic limitations of the study, the lack of biological plausibility. But some remain fearful of labor epidurals because of that publication. In February 2023, a new publication in AJOG will help put this matter to rest with the largest population-based analysis done to date. In this episode, we will highlight and summarize the key findings of this landmark study, and better understand whether or not Labor epidurals are tied to offspring ASD/ADHD.

Platelet Rich Plasma (PRP) therapy is a HOT and TRENDY item right now. PRP use was initiated in sports medicine in the 1970s. It has since expanded into many medical specialty fields, and now it is being heralded as the new hope for diminished ovarian reserve for those desiring pregnancy…even in menopause! Can injecting the ovaries with PRP really rejuvenate the ovary? We’ll examine the evidence as it sits as of January 2023.

Routine, repetitive urine dipsticks (meaning at each prenatal visit) were introduced into prenatal care back in the 1960s and 70s. The idea was to act as an early screen for bacteriuria (ASB), proteinuria as a screen for preeclampsia, and glycosuria as a screen for GDM. That was based more on expert opinion rather than clinical trials. The utility of urine dipstick testing in pregnant women has been debated for years, with studies suggesting minimal use in asymptomatic patients. Urine dips as still integrated into clinical practice mainly out of tradition…But is this evidence-based now? And if it is NOT evidence-based to do this with every visit and with every patient, when SHOULD it be done? What does ACOG have to say? Well, turns out ACOG says a lot- so you’ll want to stay tuned until the end of the episode as we cover that and a lot more.

Paragard, Mirena, and Liletta IUDs are the most effective types of emergency contraception. Data from the 1980s, now seemingly forgotten, showed that IUDs work primarily on inhibition of fertilization rather than implantation effects. Nonetheless, misperceptions regarding the IUDs mechanisms of action persist, with some websites stating IUDs are abortive agents. Do IUDs cause abortion? Let’s examine the evidence.

“Placentophagy” is not a new concept. Most non-human mammals eat their placentas after giving birth but humans, historically, have not. Is there evidence to support this practice? Where did this idea come from? How did Rolling Stone magazine help launch this phenomenon back in the 1970s? Is Kim Kardashian onto something cutting edge by advocating for Placental encapsulation? In this episode we will walk through history and learn some pretty remarkable things about this practice. Grab your favorite placental snack, and start listening! 🍽️🍴🍴

The American College of Obstetricians and Gynecologists supports the use of both low-dose and high-dose oxytocin regimens to induce and augment labor, but does not specify MAXIMUM DOSE RATES. Most hospitals, however, have protocols that impose a maximum dose rate of oxytocin infusion. Is this evidence-based? Is there a danger with going above a certain threshold of infusion, for example, greater than 20 milliunits/minute? A new publication coming out in Obstetrics and Gynecology (the Green Journal) sheds some light on this very issue. Let’s talk about the maximum oxytocin infusion rate and labor.

The ACOG states, “In spite of its unproven value, antepartum fetal surveillance is widely integrated into clinical practice in the developed world”. Antepartum fetal surveillance can be done by a variety of techniques and, despite its unproven value, is a mainstay of obstetrical management. At what BMI should we offer fetal surveillance? Is this current BMI or pre-pregnancy BMI? And what about advanced maternal age? What is recommended for that? Did you know that there was a change in the ACOG wording regarding this AMA issue from June 2021 to August 2022? And what about ultrasound surveillance for cervical length after cerclage placement? Is that evidence based? We are going to dive into these 3 clinical scenarios (obesity, AMA, cervical length after cerclage) in this episode. 👍

Breech presentation at term occurs in approximately 3 to 4% of pregnancies. While the vast majority are simply chance events, breech presentation could be a marker of other fetal comorbid conditions. When should ECV be attempted? Does the ACOG recognize neuraxial analgesia as a tool to increase ECV success rates? What’s better spinal or epidural block? What are relative contraindications to ECV? In this episode, we will summarize the latest data on fetal breech presentations and answer key questions regarding the process of ECV. Jasmine…here’s your podcast! 😊

On some current social media channels, there is a hot debate as to why professional medical societies still recommend prenatal folic acid compared to the more “biologically, active” L-methylfolate. Are they onto something here? Published data has shown that anywhere from 40-60% of the general population may have an MTHFR mutation leading to the inability to process folic acid. Should we be screening for this mutation? What about screening for homocystine levels? Are these medical societies incorrect in still recommending folic acid rather than L-methylfolate? We are going to tackle these questions and provide a very simple take home message at the end of this episode. We’ll set the record straight regarding “Folic acid, folate, or L-methylfolate”.

Currently on social media, there seems to be an interest in prenatal choline supplementation. Choline, a B vitamin, is not typically within standard prenatal vitamins. Is this micronutrient important for prenatal supplementation? What do professional/medical societies have to say regarding prenatal supplementation? What’s the data? In this episode, we will summarize choline’s role in fetal/newborn development, examine the data regarding deficiency, and talk supplementation recommendations. (Shout out to Dr. Cat Jimenez for the subject suggestion.)

Uterine fibroids are benign tumors that arise from a single genetically altered myometrial stem cell under the influence of gonadal hormones. Traditionally, it has been taught that fibroids universally diminish in size after menopause. However, an article published in 2021 showed a possibility of fibroid growth after menopause in overweight/obese women. Do fibroids need surveillance in menopause? Is HRT contraindicated in the fibroid patient? And which HRT is the most fibroid friendly? We will answer these questions in this episode.

I am a fan of the original hit TV show, “ER”. Although mostly melodramatic and outside of bounds of reality Medicine, one episode (season 6, episode 6) has a valuable life lesson for all of us. I originally viewed that episode when it was live and current, and I have never forgotten the message. In this episode, will discuss this important life lesson learned, and I promise you won’t be the same thereafter.

In January 2023, a new publication in Obstetrics and Gynecology- the Green Journal, will highlight the disheartening statements being made on social media (TikTok) regarding IUDs. IUDs are highly effective forms of contraception and the progesterone releasing variety have significant non-contraceptive benefits. Most of the dissatisfaction stated on social media surrounds pain during insertion. Do you offer topical lidocaine for IUD insertion? Ever consider lavender aromatherapy? What about music as a non-pharmacological intervention? Are these options evidence-based? In this episode, we will review the soon to be released January 2023 publication and also summarize a 2020 systematic review analyzing both pharmacological and non-pharmacological strategies to reduce pain and anxiety during IUD insertions.

Pre-operative vaginal preparation before gynecological surgery has unquestionable benefit for the prevention of postop infectious morbidity. Does the same hold true for vaginal prep at C-section? There has been over a decade of data, but a new publication- soon to be released in AJOG- is calling previous results into question. Does iodine work as a vaginal prep? What about chlorhexidine? There’s answers for all of these questions, and we will summarize them in this episode.

Surgical site infection (SSI) is the most common complication resulting from cesarean section. Despite advances in infection control, SSIs remain a significant post-op burden, to the patient first, and to the healthcare system second. Negative pressure wound therapy devices (NPWT) are a potential solution to post C-section. wound infections/complications. Do these devices prevent incisional wound complications after C-section? In this episode, will dive into the data and review the specific CDC criteria for diagnosing surgical site infections.

Traditionally, the CDC has recommended delaying IUD insertion for 3 months in a woman diagnosed with asymptomatic, cervical Gonorrheal or Chlamydial infection. This is to first confirm a negative test of cure. However, this leaves the patient at a greater risk of unplanned pregnancy compared to the risk of PID. Is this really the most evidence-based approach? The CHOICE CONTRACEPTIVE Study data provides an alternative approach. In this episode, we will discuss this dilemma and allow the data to settle the discussion. (With special co-host guest: 3rd year medical student, Ms. Carley Hagar).

In the upcoming (May) 2023 ACOG Annual Clinical Meeting, the College will have a highlighted session to “redesign, prenatal care”. The traditional model of prenatal care includes 12 to 14 in-person visits. However, there is no data that supports the theory that adverse outcomes are reduced by the number of prenatal contact visits. In 2020, at the height of the COVID-19 pandemic, women’s healthcare practitioners became more flexible in how they delivered prenatal care. Now, the ACOG is supporting an alternative prenatal care visit schedule for patients at “average risk”. This is called the PATH Prenatal proposal. Let’s talk about that in this episode, and discuss the ONE BIG Limitation to this proposal.

Did you know that not all cases of a single umbilical artery (SUA) result in a 2-vessel cord? Some umbilical cords with a SUA still have 3 vessels! How is that possible? Although SUA is only found between 0.2 to 1% of all live births, they can have important clinical implications. Although sonographic absence of other congenital anomalies is very reassuring (isolated SUA), some fetal conditions may not be apparent until time of birth. In the session, we will review the etiology of, diagnosis of, and management of the SUA.

The ACOG recommends universal screening for gestational diabetes between 24 and 28 weeks of pregnancy with occasional early screening for those at high risk. Is there an advantage to completing the 1-hour 50 g GTT while fasting? First studied in the 1990s, a new publication further validates the original study results. In this episode we will summarize this new publication soon to be released in Obstetrics & Gynecology (the Green journal) and discuss the paradox/conundrum of GTTs while fasting.

As I’ve said on previous podcasts, “we all need some encouragement every now and again”. Well this morning I received mine, through a small gift…from Germany!

Anti-D immune globulin has been advocated for use in appropriate patients since the 1970s. Historic data showed that 0.1ml of fetal D+ blood was all that was required to potentially sensitize an Rh negative mother. New data is questioning whether this prophylaxis is required in all cases of threatened miscarriage/abortion in early pregnancy, or if a more selective approach is appropriate. In this episode, we will highlight a soon to be released “Questioning Clinical Practice” commentary from Obstet Gynecol (the Green Journal) tackling this issue. Is it time to change our current and standard practice?

Fragile X Syndrome is the most common inherited form of intellectual disability, and the most common single gene cause of Autism Spectrum Disorder. It is also responsible for some cases of premature ovarian insufficiency. Do you recall the difference between a Fragile X “pre-mutation” versus the full mutation? Should we do universal screening for this as part of expanded maternal carrier testing, or should this be a targeted screening approach? Although we covered maternal carrier screening on November 4, 2022, this episode will go into much more detail, focusing specifically on Fragile X Syndrome and who should be screened for this. (For Emma…Great question! Thank you for reaching out to us).

Marijuana is the most commonly used federally illegal drug in the United States; its use among pregnant and lactating women is on the rise. Is breast-feeding contraindicated with marijuana use? It is difficult to separate marijuana use from several confounding variables, leading to conflicting data in print. Is marijuana use and breast-feeding compatible? A patient friendly article on Parents.com, released on November 23, 2022 seems to imply just that. In this episode, we will review the data on marijuana use during lactation and help clear up the seemingly contradictory outcomes data. Also, we will summarize key position statements from a variety of professional organizations, and find out what data gaps still exist.

Several cohort studies and meta-analysis have shown a direct association between poor oral health and adverse pregnancy outcomes. The key driver for this association is systemic inflammation. In this episode, we will review the ADA, ACOG, and CDC data on how maternal oral health can influence pregnancy outcomes. Although this association is pretty strong, remember that association does not necessarily prove causation. We will explain this in this episode.