Obgyno Wino Podcast

I have left the conventional medical model for good in search of brighter pastures! With the amount of painting, dancing, and kissing my baby and wife that I've been doing over the past several days, I encourage you all to try living a life free of the medical industrial complex! I have been liberated, and now I've got the bandwith the shake things up and create the life of my dreams. The new iteration of my podcast will be titled The Holistic OBGYN Find me at: www.BelovedHolistics.com

Important PSA for healthcare professionals... Theme music by Evan Handyside

Practice Bulletin #136 - Published July 2013 (Reaffirmed 2017) 1. Know your reproductive endocrinology like the back of your hand! 2. AUB-O is classically associated with cycles that differ in length by `10 days or more. Patient with AUB-O also generally don't experience the classical cyclical breast tenderness, mucoid cervical discharge, premenstrual cramping, or bloating seen in ovulatory bleeding. 3. Anovulation is the most common etiology of AUB in 13-18-year olds. Transfusion or hospitalization is rare in this age group, but, when it happens, you should investigate coagulopathy. 4. AUB-O in patients >18 years of age should prompt investigation for hyperplasia/malignancy. 5. Hysterectomy or hormonal contraceptives are the mainstays for treating AUB-O, but neither address the underlying endocrine abnormality. 6 .SIS + EMB is a sweet combo: if both are negative, the likelihood of pathology is extremely low and conservative measures are be offered without you losing sleep Show Notes Theme music by Evan Handyside

Practice Bulletin #135, Published June 2013 (Reaffirmed 2017) 1. It's none of your damn business why a woman desires a 2nd trimester abortion. There are also a lot of scenarios in which 2nd trimester abortion skills are necessary but that have nothing to what many perceive to be a seemingly easy decision to terminate a pregnancy. 2. If you don't feel confident in your skills as a provider to perform 2nd trimester abortions, do your patients the service of developing a referral relationship with another provider who does. 3. Inducing fetal demise prior to 2nd-trimester abortion does not improve safety or decrease procedure time in case of D&E, but he it does shorten induction time for medical abortion. 4. Misoprostol + mifepristone = the most effective protocol of medical options 5. All methods of contraception are effective on the day of 2nd-trimester abortion apart from cervical cap, diaphragm, or hysteroscopic sterilization (including IUD) Show Notes Theme music by Evan Handyside

Practice Bulletin #1114, Published July 2010 (Reaffirmed 2018) 1. Pelvic pain and infertility are characteristic. Severe dyspareunia and dyschezia are indicative of deeply infiltrative disease. 2. The etiology is unknown, but currently thought to be due to the implantation of endometrial glands and stromal cells outside the uterus within the peritoneal cavity due to retrograde menstruation 3. Histologic evaluation of a surgical specimen is the gold standard for diagnosis. Visualization of endometriotic lesions has a high false positive rate. The finding of an endometriomas on imaging studies can alone be highly predictive, though. 4. Excision of endometriosis can improve fertility rates, particularly with the excision of an endometrioma. 5. NSAIDs, COCs, GnRH analogues, and progestins are all great alternatives to surgery for managing endometriosis-related pain Show Notes Theme music by Evan Handyside

July 2021 Journal Club I'm joined by Emmie Sturgess, DO, an OBGYN, MFM, and friend of the show to review relevant articles from the major OBGYN journals. I promise it's not as boring as it sounds... Show Notes Theme music by Evan Handyside

Welcome to Beloved Holistics Radio, a podcast for the holistic OBGYN! Expect summaries of ACOG's practice bulletins, important voices with birth keepers and birth warriors, and discussions around the most up-to-date research and publications. www.BelovedHolisticsRadio.com

Practice Bulletin #183, Published October 2017 w/ co-host Sara Rosser, CPM (@sararosser) 1. PPH is defined as 1000 mL for either vaginal or cesarean birth. 2. Go with your gut in diagnosing PPH, and do it fast! You can't rely on vital signs or lab work to make the call to action in the acute setting. 3. Uterine atony is the most common cause of PPH. Manage through uterine massage, uterotonics, tamponade, and UAE. Opening up her abdomen to place compression sutures, ligate the uterine vessels, or perform hysterectomy are last resort! 4. Remember the triad of the amniotic fluid embolism: respiratory decompensation, hemodynamic instability, and DIC. 5. As soon as you feel that she's lost too much blood activate your institution's transfusion protocol. Remember that you can never get pre-screened blood fast enough when you actually need it. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Theme music by Evan Handyside

Practice Bulletin #175 - Published December 2016 (Reaffirmed 2020) w/ co-host Sara Rosser, CPM (@sararosser) 1. US may be harmful if overutilized. 2. Important uses include pregnancy dating/viability, fetal growth, and amniotic fluid assessment. 3. US pregnancy dating is most accurate in the 1st trimester. If significant discordance exists between US dating and LMP dating, it may be appropriate to adjust due date. 4. Fetuses at risk for FGR should be monitoring by serial growth ultrasound. It's not recommended to repeat growth ultrasound more frequently than q2 weeks. 5. Growth-restricted fetuses can be monitored through umbilical artery Doppler velocimetry as a means of avoiding bad perinatal outcomes. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Theme music by Evan Handyside

June 2021 Journal Club I'm joined by Emmie Sturgess, DO, an OBGYN, MFM, and friend of the show to review relevant articles from the major OBGYN journals. I promise it's not as boring as it sounds...because...I mean...come on...WINE. Show Notes Wine pairing: 2016 Primitivo di Manduria from Antico Sigillo Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

"To help you further understand why we did not get the vaccine, what follows is my assessment of the C19 situation so far. Like I said, there is no doubt that many people were getting very sick over the first half of 2020. What is most challenging for me is the narrative that ensued thereafter, which seems at best misleading and at worst nefarious." www.ObgynoWino.com

Practice Bulletin #129 - Published September 2012 (Reaffirmed 2016) 1. In any hypoestrogenic state, resorption begins to overwhelm building, leading to decreased bone density. 2. Treatment is warranted if T-score ≤ 2.5 on DXA scan or if patient has history of vertebral facture or other type of fragility fracture 3. FRAX tool can be helpful in determining usefulness of treating patients in the osteopenic range (T-score < - 1 to ≥ -2.5). It predicts risk of osteoporotic fracture over next 10 years . 4. Bisphosphonates are first-line therapy for all-comers, though raloxifene is also reasonable first-line in younger postmenopausal women. 5. HRT is a great alternative to bisphosphonates in younger women at risk for osteoporotic fracture: ~35% decreased risk of hip fracture (estrogen alone or estrogen + progestin) Show Notes Wine pairing: 2017 Tempranillo from Baron de Ley Varietales Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #132 - Published December 2012 (Reaffirmed 2017) 1. The clinical diagnosis of APS is made through a careful clinical history that takes into account thrombotic events, history of pregnancy loss, and development of preterm preeclampsia. 2. Lab studies to detect specific antibodies can confirm your diagnosis, but these lab studies are not indicated when clinical criteria are not met. 3. The three relevant antibodies on your board exam are: lupus anticoagulant, anti-β₂-glycoprotein, and anticardiolipin 4. The worst consequence of APS is thrombosis. 5. In pregnancy, thrombotic risk is EVEN higher. APS patients with history of thrombosis should be treated with prophylactic heparin throughout pregnancy until 6 weeks postpartum. Show Notes Wine pairing: 2018 Sonoma Zinfandel from Seghesio Family Vineyards Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #128 - Published July 2012 (Reaffirmed 2016) 1. "Normal menstruation" is classified by ACOG as: 5 days of bleeding with cycle length of 21-35 days 2. PALM-COIEN is a classification system for abnormal uterine bleeding. 3. Get good at SIS and hysteroscopy! A meta-analysis found intrauterine cavitary anomalies in roughly 50% of women with AUB 4. Fibroids tend to present as heavy periods. Polyps tend to present as intermenstrual bleeding. Adenomyosis presents with painful and heavy periods. 5. Accuracy of blind endometrial biopsy is great if (a) an adequate sample is collected and (b) the endometrial process is global. A blind EMB can miss cancer if less than 50% of the endometrium is involved. Show Notes Wine pairing: 2018 Cabernet Sauvignon from Los Vascos Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #169 - Published October 2016 (Reaffirmed 2016) w/ co-host Sara Rosser, CPM (@sararosser) 1. Multifetal gestations have overall increased risk of morbidity for both mom and baby. 2. Chorionicity is an important piece of information for managing these pregnancies. Monochorionic pregnancies carry higher risks than dichorionic pregnancies. 3. Outside of dx of cervical insufficiency: available data doesn't support cervical cerclages, bed rest, tocolytics, or pessaries decrease morbidity or mortality associated with preterm birth in setting of multifetal gestation. 4. NIH recommends administration of corticosteroids for any pregnancy, irrespective of GA, at risk of birthing from 24-34 wga within 7 days 5. Unless monoamniotic, twin pregnancy is not a preclusion to vaginal birth Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Red Blend from King Estate Winery Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #156 - Published December 2015 (Reaffirmed 2018) w/ co-host Sara Rosser, CPM (@sararosser) 1. Women with obesity are at increased risk for fetal congenital anomalies, c-section, preeclampsia, fetal macrosomia, childhood behavioral/developmental issues, and other bad outcomes. 2. Pre-conception weight loss to normalize BMI improves maternal and neonatal outcomes. 3. Weight loss while pregnant is not recommended. 4. There are a variety of special considerations intrapartum and postpartum for women with obesity. 5. If your patient undergoes c-section, a thick subcutaneous fat layer should be well-irrigated and approximated with sutures in multiple layers if necessary. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Bourbon Barrel-Aged Cabernet Sauvignon from Ménage à Trois Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #146 - Published August 2014 (Reaffirmed 2019) 1. When pregnancy goes beyond 41 wga, there are increased risks for mom and baby, but absolute risk is overall still very low. these risks are still low in absolute. 2. Pregnancy dating by LMP combined with early ultrasound is far more reliable than LMP alone. 3. "Membrane sweeping" decreases the chance of a pregnancy going beyond 41 wga, but consent your patient first! 4. If fluid checks out, particularly if BPP is otherwise reassuring, it's reasonable to continue pregnancy 5. IOL at or beyond 41 wga does not improve fetal or neonatal outcomes apart from a possibly lower risk of meconium aspiration syndrome. NNT = 410 to prevent one perinatal death. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: Dark Side Red Blend from 7 Moons Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #126, Published March 2012 (Reaffirmed 2016) 1. Rapidly dividing cells - like those in the gonads - are the most susceptible to chemo, so suppressing with GnRH analogues prior to chemo may be protective against ovarian toxicity, but data is mixed. 2. BRCA mutation carriers are at increased risk for both breast and ovarian cancers, therefore prophylactic BSO is recommended at age 40 or after childbearing is complete 3. 5 years of tamoxifen use decreases the annual risk of recurrence by 40% and annual mortality risk by 35% 4. Women treated for breast cancer are at higher risk for bone fracture because chemotherapy, ovarian suppression, and, especially aromatase inhibitors all lead to bone loss and osteoporosis. 5 .HRT has a bad rap historically due to concern that it may predispose women to de novo breast cancer or recurrence, but the findings have been mixed and generally not statistically insignificant. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Perlita Malbec-Syrah from Bodega DiamAndes Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #187, Published May 2017 (Reaffirmed 2016) 1. Neonatal complication risk is overall low (5%), including brachial plexus injuries, clavicle fracture, humerus fracture. HIE/death are also possible, but extremely unlikely. 2. The faster that a shoulder dystocia is resolved, the less likely HIE/death. 3. It's nearly impossible to predict shoulder dystocia, but risk seems to be higher with larger fetuses and diabetic mothers. 4. Insufficient evidence to conclude that early induction of labor when fetal macrosomia is suspected decreases the risk of shoulder dystocia. 5. Steps to resolving shoulder dystocia per ACOG: stop pushing, McRobert's maneuver w/ head traction, suprapubic pressure, rotational maneuvers, then posterior arm delivery. My advice? Get her on all fours way before any of the other maneuvers (Gaskin maneuver). Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Central Coast Red Blend from Smith & Hook Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #101, Published January 2010 (Reaffirmed 2016) 1. Most COCs combine a progestin (i.e. synthetic progesterone) for contraceptive effects with 10-35 mcg of an estrogen (usually ethinyl estradiol) to stabilize the endometrium and reduce unwanted spotting 2. COCs are a safe bet for management of heavy menstrual bleeding. If patient responds to COCs, they are most cost-effective for the first year, then it's more effective to switch to a levonorgestrel intrauterine system 3. The levonorgestrel intrauterine systems work better than progestin-only pills (e.g. norethindrone acetate) to reduce heavy menstrual bleeding and patients report greater satisfaction. 4. DMPA and the progestin IUD can regulate the menstrual cycle over the long haul, but will initially increase the irregularity of bleeding. 5. Before prescribing any hormonal contraception, review the US Medical Eligibility Criteria for Contraceptive Use. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2018 Pinot Noir from Tres Palacios Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

"How can we reimagine our relationship with Mother Nature? This seems like a privileged luxury of the few, but it's far more important than a philosophical suggestion. Based on the preceding examples found through the challenges of monocultural farming and efforts to sterilize the human body, it should be obvious that we are a part of a variety of ecosystems that rely on us reciprocally. As such, in allowing the Earth to deteriorate, we are inadvertently corrupting any possibility for the survival of our own species." www.ObgynoWino.com

SPECIAL EPISODE - Interview w/ Sara Rosser, CPM (and my dear sweet friend!) In episode 66, Sara Rosser, a CPM at the famous Farm in Summertown, TN, is joining the Obgyno Wino team to co-host coverage of future OB-related practice bulletins. She is also anticipating her second surrogacy pregnancy on behalf of a gentleman who is otherwise unable to start a family. Between her choice to offer herself as a surrogate and her family's adoption of their beautiful son, Silas, from Ethiopia, Sara has been forced to navigate a wide range of criticism (amidst an equal amount of support!) for her decisions around pregnancy, surrogacy, and adoption. Fortunately, Sara is a beautiful unicorn of a woman guided by intuition and morality, two principles of which we could use a little more in this world. Show Notes Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #105, Published July 2009 (Reaffirmed 2017) 1. Combined oral contraceptives may be poorly absorbed in patients who have undergone malabsorptive bariatric surgery (e.g. Roux-en-Y) 2. Micronutrient and macronutrient deficiences are common in pregnancy after Roux-en-Y. These include iron, calcium, vitamin B12, protein, folate, and vitamin D. It's reasonable to screen widely for nutrient and micronutrient deficiencies pre-pregnancy or early in pregnancy and supplemental as appropriate. 3. For patients who underwent a banding procedure, early consultation with a bariatric surgeon is recommended in order to actively manage the band 4. Dumping syndrome is caused by ingestion of refined sugars that are rapidly dumped from the stomach into the small intestine; this causes hyperinsulinemia -> hypoglycemia -> tachycardia; otherwise characterized by bloating, nausea, abdominal pain, n/v, and diarrhea. 5. Patient with dumping syndrome can be screened for GDM by regular glucose fingerstick checks at 24-28 wga Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Pinot Noir from Ferrandière Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

SPECIAL EPISODE - Interview w/ Brad Bootstaylor, MD, OB/GYN and MFM (and all-around awesome guy!) Dr. B is back on the show to talk about the unfortunate turn of events that forced him to leave his collaborative OBGYN practice in Atlanta, GA. At the hospital where Dr. B worked for 20 years and even served as chair of the Department of OBGYN, a non-clinical professional committee determined - apparently arbitrarily - not to renew Dr. B's hospital privileges, essentially forcing him out of practice. Perhaps the silver lining of these very unfortunate circumstances is that he has more freedom to explore creative avenues for changing U.S. maternity care from outside of the hospital system. Dr. B is a hero to many of us in the OBGYN community, and in conversation with him, I still have a great deal of hope that his legacy will live on through his book and his engagement directly with birthing people, the true keepers of birth. Show Notes Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #95 - Published July 2008 (Reaffirmed 2017) 1. Normal physiologic changes in pregnancy that are relevant in anemia include increased blood volume, increased red blood cell mass, and increased iron stores. 2. Low serum ferritin is the most sensitive and specific single lab finding in iron deficiency anemia. 3. The CDC recommends universal screening for iron deficiency anemia in pregnancy along with universal supplementation. 4. B12 deficiency and folic acid deficiency are common causes of macrocytic anemia; folic acid deficiency much more likely than B12. 5. Blood transfusions are almost never indicated in pregnancy, apart from the rare case of a large, concealed placental abruption (Hgb non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death) Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2018 Red Blend from Horse Heaven Hills Wine Growers Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

SPECIAL EPISODE - Interview w/ Tracey Vogel, MD, OB anesthesiologist In Episode 62, Tracey Vogel, MD, an OB anesthesiologist, is on the show to talk about her very unique path into trauma-informed birth keeping. Tracey is a practicing anesthesiologist at West Penn Hospital in Pittsburgh who has taken a unique interest in tendering women through their hospital-based birth process. When she's not training medical students and residents in OB anesthesiology, you can find her lecturing at ACOG, writing books, and devoting a portion of her time Pro bono to counseling women who have suffered through past personal trauma, whether birth-related or otherwise, in the context of pregnancy and birth planning. Show Notes Wine pairing: PInot Noir from Nicolas Idiart Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #91 - Published October 2009 (Reaffirmed 2016) 1. E. coli are the most common bug in UTI. 2. Presence at at least 1,000 CFU/mL on culture or presence of leukocyte esterase or nitrite on UA, particularly if bacteria 2+ or greater in a symptomatic patient is pretty much a slam dank for UTI diagnosis 3. 3-day antibiotic course is sufficient for uncomplicated acute cystitis (trimethoprim-sulfamethaxazole is the preferred agent) 4. Treatment of pyelonephritis can be done as outpatient unless patient is very sick, in which hospitalization w/ parenteral antibiotics may be warranted 5. If symptoms persist beyond 7 days of antimicrobial therapy or if clinical condition worsens, further evaluation through repeat cultures and contrast imaging may be warranted. Show Notes Wine pairing: 2018 Cabernet Sauvignon from La Freynelle Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #86 - Published October 2009 (Reaffirmed 2016) 1. Poorly controlled asthma is associated with prematurity, preeclampsia, growth restriction, and maternal morbidity and mortality. 2. Nonselective β-blockers, carboprost, ergonovine, indomethacin, misoprostol, and dinoprostone can trigger bronchospasm, and they are all commonly used agents in pregnancy/postpartum. 3. Short-acting β2-agonists (e.g. albuterol) are the mainstay for acute asthma exacerbations 4. Long-acting inhaled corticosteroids and inhaled long-acting β2-agonists are the mainstays of maintenance asthma therapy. Oral corticosteroids may be required in the most severe cases. 5. For pregnant patients with poorly-controlled asthma or asthma classified as moderate or severe persistent, fetal growth should be monitored by serial ultrasound beginning around 32 wga. Show Notes Wine pairing: 2019 Chardonnay from Sean Minor Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

"The restructuring of my healing practice affords me the opportunity to ask the bigger questions, to challenge dogma, and to truly heal people, communities, and the planet. I have the same skillset as most physicians: laboratory analysis, expertise in interpreting medical literature, medication, antibiotics, imaging studies, and surgery. The difference is in how I use these powerful but limited tools. Healing begins with your story, and it grows outward from there in concentric circles. This approach has been called 'slow medicine' by author Victoria Sweet." www.ObgynoWino.com

SPECIAL EPISODE - Interview w/ Maryn Green, CPM, independent midwife and author Maryn is a midwife, midwifery instructor, and a mom to now 10 children, all of whom were born vaginally, most of which were born at home. The birth of her most recent, Rumi Sol, happened in the hospital as the result of Maryn acting on her intuition while in labor and transferring herself to the hospital when she sensed things weren't right. The most surprising part of her story is that she ultimately had an unassisted birth in the hospital. Maryn is a unicorn is more ways than one, and every OBGYN could learn a great deal from her experiences. Show Notes Wine pairing: 2018 Valpolicella Classico from Ca' La Bionda Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #84 - Published August 2007 (Reaffirmed 2018) 1. Most patients who die from PE do so within 30 minutes of the event, so prevention is key. 2. If a patient is known to have Factor V Leiden mutation or prothrombin gene mutation 20210A, they should be considered high risk and managed appropriately intra- and post-operatively and in pregnancy 3. Compression stockings, pneumatic compression devices, and pharmacologic prophylaxis are all safe and useful in preventing VTE 4. Highest risk patients benefit most from a combined approach of mechanical or stocking prophylaxis combined with pharmacologic prophylaxis 5. Platelet inhibitors should be stopped 14 days before spinal or epidural anesthesia, unfractionated heparin or twice daily low molecular weight heparin 8-12 hours before, and low molecular weight heparin 18 hours before Show Notes Wine pairing: 2019 Les Quatre Cepages from Domaine de Pajot Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #81 - Published May 2007 (Reaffirmed 2018) 1. Both resectoscopic and non-resectoscopic techniques are safe and effective. 2. Size and shape of the uterine cavity and the presence of fibroids may impact efficacy of non-resectoscopic techniques 3. With resectoscopic techniques, careful monitoring of distension medium fluid is important. If too much fluid intravasates, dilutional electrolyte imbalances can have serious consequences. 4. Ablation is not recommended for patients who wish to preserve fertility. 5. Sample the endometrium before performing an ablation to evaluate for hyperplasia or malignancy. Show Notes Wine pairing: 2017 Nero d’Avola Cabernet Sauvignon from Barone Montalto Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #87 - Published October 2007 (Reaffirmed 2018) 1. Sickle cell trait (heterozygous for the mutation) is generally asymptomatic; sickle cell disease can have severe consequence 2. Sickle cell disorders are more common among individuals of African descent, whereas the thalassemias are more common among individuals of Southeast Asian and Mediterranean descent. 3. Alpha thalassemia results from deletion of any number of the four genes that code for the alpha chain. The more deletions, the worse the presentation. 4. Beta thalassemia results from mutation of one or both of the genes that code for the beta chain. Severity of disease is determined by presence and degree of functionality within intact genes. 5. Sickle cell disease is a risk factor for preterm delivery, IUFD, IUGR, etc., therefore, antepartum fetal surveillance is recommended Show Notes Wine pairing: 2018 Sainte Marie Corbieres from Domaine Faillenc Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #225 - Published October 2020 1. Medication abortion is safe and effective (just slightly less effective than uterine evacuation). 2. The standard regimen is mifepristone 200 mg PO followed by misoprostol 800 mcg per vagina 24-48 hrs later 3. Patients who reliably report menstruation within 56 days of presentation for medication abortion do not require ultrasound confirmation 4. Patients at high risk for ectopic pregnancy based your clinical assessment should not be offered medication abortion. 5. Medication abortion has no adverse effect on future fertility or future pregnancy outcomes. Show Notes Wine pairing: 2017 Willamette Valley Pinot Noir from Chemistry Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #226 - Published October 2020 1. Cell-free DNA screening has the best sensitivity and specificity of all screening methods. But before you order it, it's best to get a prenatal ultrasound 2. Best non-cell-free screening modality is the sequential integrated serum screen (1st-tri serum + NT ultrasound + 2nd-tri serum) 3. Formal anatomy survey should be offered at 18 - 22 wga; can identify soft markers for T21 and T18 4. Prenatal genetic screening should be offered to all pregnant women regardless of risk profile 5. Anything that doesn't add up, it's best to just refer to a genetics counselor or even your friendly MFM for clarification. Show Notes Wine pairing: 2017 Garnacha from Las Rocas Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #224 - Published July 2020 1. A systematic approach is required to evaluate and treat vulvar pain and pruritis. 2. In premenopausal women: contact dermatitis is most likely culprit. 3. In postmenopausal women: Genitourinary syndrome of menopause is your most likely culprit, and this relates to the natural increase in pH associated with the hypoestrogenic state. 4. Lichen sclerosus is best diagnosed through biopsy, because if left-untreated it can develop into vulvar squamous cell carcinoma 5. Topical steroids w/ topical anti-histaminic agents are the mainstay of therapy for inflammatory vulvar disorders. Show Notes Wine pairing: 2017 Chardonnay from Eighteen Eighty Three Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #223 - Published June 2020 1. Fetal brain development relies on adequate maternal T4 until the fetal thyroid gland takes over at ~12 wga 2. Fetuses who develop in environments deficient in thyroid hormone may suffer from impaired psychoneurological development of the newborn 3. Hyperthyroidism is most commonly due to Graves' disease, which is caused by antibodies that stimulate the thyroid gland 4. Screening for thyroid disease in pregnancy starts w/ TSH. More sensitive than thyroid hormone. 5. Propylthiouracil is generally used to treat hyperthyroidism in the 1st trimester because methimazole is associated w/ rare embryopathies Show Notes Wine pairing: 2016 Cabernet Sauvignon from Embrazen Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

"If I could live for another twenty years loving, laughing and touching in the ways that I could before this pandemic, would I choose this over fifty years of living in a place of fear, where I'm forced to question the safety even of hugging my own mother?" www.ObgynoWino.com

Practice Bulletins #220 - Published May 2020 1. Herpes simplex virus (HSV) is transmitted directly from lesions to mucosa or open skin: this includes cold sores to mucosa, active lesions on the skin, or ulcers on or inside the genitals. 2. Infection of babies generally occurs during passage of the newborn through mom's GU tract, not in-utero. 3. Neonatal herpes infections carry relatively high mortality and morbidity. 4. Active or recurrent infections in pregnancy should be treated with antiviral therapy. Suppression therapy should be given to all women with history of HSV starting at 36 wga and continued until birth. 5. Women who have active genital HSV infections manifested as active lesions or prodromal vulvar symptoms at the onset of labor should be counseled against vaginal birth. Show Notes **Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!** Wine pairing: 2017 Armando Bonarda from La Posta Vineyards Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #221 - Published May 2020 1. Training physicians in external cephalic version (ECV) and encouraging the practice of this procedure could significantly reduce c-section rate 2. It's best to wait until 37w0d to attempt ECV due to high likelihood of spontaneous version prior to that but likelihood of success decreases with advancing gestational age beyond 37w0d 3. Risks to mom/fetus include: cord prolapse, fetomaternal hemorrhage, terminal deceleration, placental abruption, or demise but these risks are all

Practice Bulletins #219 - Published April 2020 1. Episiotomies should never be performed routinely, even if you were trained to do it routinely to assist in operative vaginal delivery. If you think it's absolutely necessary, counsel the patient so that she can make an informed decision. 2. Overall, operative vaginal delivery carries low absolute risk for baby and mom w/ comparable relative risk compared to c-section 3. Vacuum-assisted delivery carries higher risks to the fetus when compared to forceps and lower risks to mom. 4. Major benefit to operative vaginal birth is decreased risk of hypoxic injury to the newborn in the event of successful expedited vaginal delivery through operative means (assuming there is concern for fetal acidemia) 5. Forceps, even in trained hands, carries significantly higher risk of severe perineal injury compared to vacuum. Show Notes **Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!** Wine pairing: 2018 Willamette Valley Pinot Noir from Inscription Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #218 - Published March 2020 1. Up to 33% of women with chronic pelvic pain will also meet criteria for diagnosis of major depression 2. An interdisciplinary approach is the way go to: gynecologist, physical therapist, and psychologist in the very least. 3. The physical exam should be approached very carefully and systematically 4. Yoga, acupuncture, and other complementary and integrative therapies should absolutely be considered. 5. Don't prescribe opioids for chronic pelvic pain. Go with neuropathic agents, SNRIs, and tricyclic antidepressants. Show Notes **Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!** Wine pairing: 2017 Red Blend from Francis Coppola Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #188 - Published January 2018 1. Management recommendations in PROM/PPROM is dependent on gestational age: >37 0/7 wga => induction/augmentation 34 0/7 - 36 6/7 wga => expectant management or induction/augmentation expectant management 2. Diagnosis of PROM is based on history and physical: pooling of fluid, pH of vaginal fluid, and ferning on microscopy. 3. Indications for induction/augmentation for both PROM and PPROM include abnormal fetal testing, evidence of intra-amniotic infection, and vaginal bleeding suggestive of abruptio placentae. 4. For PPROM (24 0/7 - 33 6/7 wga) --> antibiotics and steroids should be offered, and magnesium sulfate should be offered at

SPECIAL EPISODE - Interview w/ Hermine Hayes-Klein, JD, and Brad Bootstaylor, MD, FACOG In this episode, we'll be discussing the problematic culture of hospital-based birth. We explore the physician-patient relationship, the responsibilities that come with the rights to informed consent and refusal of treatment, and how supercomputers in the hands of our patients have enabled them to view us as the enemy, and vice-versa. Most importantly, we discuss ways in which we may all begin to mend the physician-patient relationship in order to redirect the culture of hospital-based birth. Show Notes Wine pairing: 2017 Sauvignon Blanc from Psyche Wines Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletins #189 - Published January 2018 Five pearls: 1. The decision to treat should be informed by the woman’s perception of the severity of symptoms, her desire for treatment, and the potential effect of treatment on her fetus 2. Use of prenatal vitamins 1 mo before fertilization may reduce incidence and treating nausea and vomiting of pregnancy (NVP) can prevent progression from NVP to hyperemesis gravidarum (HG) 3. After dietary and nonpharmacologic options (e.g. ginger) have been tried, first-line pharmacotherapy entails trying vitamin B6 alone or vitamin B6 plus doxylamine 4. Antithyroid drugs are not recommended for abnormal maternal thyroid tests attributable to gestational transient thyrotoxicosis or HG 5 .Hospitalization for evaluation and treatment of dehydration and electrolyte imbalance is indicated when a woman can’t tolerate liquids without vomiting and hasn’t responded to outpatient management Show Notes Wine pairing: 2018 Pinot Noir from Hedgeline Vineyards Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

SPECIAL EPISODE - Interview w/ Elizabeth Catlin, CPM, Melissa Carman, CPM, and Hermine Hayes-Klein, J.D. In this special episode, I speak with two midwives about their recently being arrested and charged with the "unauthorized practice of a profession" in the state of New York. They have served the Amish and Mennonites communities for years, and these charges are just another piece in the government's and medical profession's efforts to control a woman's right to choice in pregnancy and childbirth. We are joined by an attorney who specializes in human rights in childbirth. Show Notes Wine pairing: 2017 Merlot from Chalkboard Wines Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

"Today is my final shift as an obstetrician. You'll find me breaking bread with the birth educators, doulas, witches, midwives, nurses, and other physicians who guide their patients to safety without failing to appreciate the beauty and majesty displayed by a birthing human." www.ObgynoWino.com

Practice Bulletins #181 and #192 - Reaffirmed in 2019 Five pearls: 1. Risk of alloimmunization is around 15% after 2nd delivery of an Rh positive fetus to an Rh negative mother; this risk is decreased dramatically with administration of postpartum RhoGam 2. RhoGam is never indicated if both mom and dad are Rh negative or in women who are already sensitized (indirect coombs screen) 3. The KB test can used to determine if excessive feto-maternal hemorrhage has occurred in order to guide RhoGam administration in less obvious cases such as abdominal trauma in pregnancy 4. Alloimmunization can present as mild to severe anemia; if concerning antibodies are found, serial titers and/or peak systolic velocity of the middle cerebral artery ma be indicated 5. "Kell kills" Show Notes SIGN UP FOR LOUISVILLE BREECH WORKSHOP! Wine pairing: 2017 Pinot Noir from Longford Estate Wines Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

We need more senseless acts of kindness in our world, in feeding the masses, in home repair needs, and particularly in medicine. www.ObgynoWino.com

SPECIAL EPISODE - Interview w/ Rebecca Dekker, PhD (Instagram, Twitter, and Website). Rebecca also wrote a book called Babies Are Not Pizzas...you may have heard of it. Show Notes SIGN UP FOR LOUISVILLE BREECH WORKSHOP! Wine pairing: 2017 Chardonnay from Montoya Vineyards Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

SPECIAL EPISODE - Interview w/ Lori Forner BScH, MPhtySt, PhD Candidate, APAM, Physiotherapist (Instagram, Twitter, and Website) 5 Pearls: 1. Exercise with intensity in addition to strength training is non-negotiable 2. Exercise needs to be enjoyable in order to be sustainable 3. Pelvic floor health needs to be taken into consideration with exercise, and this goes beyond muscle strength and contraction 4. Risk factors for pelvic floor dysfunction exist (e.g. pelvic floor trauma, POP, family hx, parity, etc), but they shouldn't preclude exercise 5. Abdominal strengthening exercises are not dangerous, though the focus in pregnancy is different. Show Notes Mentioned in this podcast: - ACOG CO#650: Physical Activity and Exercise During Pregnancy and the Postpartum Period Wine pairing: 2018 Malbec from Alamos Wines Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)