Dr. Chapa’s Clinical Pearls.
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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.
