Dr. Chapa’s Clinical Pearls.

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/S0002937825004752 2. 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. 1. SMFM CS #53,2021 2. ACOG CO #831, 2021 3. 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. 1. SMFM Special Statement (July 2025): Society for Maternal-Fetal Medicine Special Statement: Checklists for management of pregnancies complicated by stillbirth. 2. ACOG OCC 10; March 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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