Dr. Chapa’s Clinical Pearls.

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.

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.