Dr. Chapa’s OBGYN Clinical Pearls

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

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

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

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

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

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

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

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

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

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