Dr. Chapa’s OBGYN Clinical Pearls

Stress fractures are common injuries in athletes and military recruits, that’s’ understandable- based on the physical forces placed on the long bones. A stress fracture can be defined as a partial or complete fracture of the bone that is a result from repeated application of stress lower than that required to fracture the bone in a single loading situation. In pregnancy, the body is subjected to various physiological changes that make women more vulnerable. In this pregnancy, we will highlight a REAL patient case which our team cared for on the inpatient service where a simple cough at 34 weeks leads to a painful spontaneous rib fracture! Is there any data published on this? Are serum tests for bone turn-over required as part of this workup? Listen in for clinical pearls!1. 1962: Long A.E.: “Stress fracture of the ribs associated with pregnancy”. Surg. Clin. North Am., 1962, 42, 909.2. 2000: Baitner AC, Bernstein AD, Jazrawi AJ, Della Valle CJ, Jazrawi LM. Spontaneous rib fracture during pregnancy. A case report and review of the literature. Bull Hosp Jt Dis. 2000;59(3):163-5. PMID: 11126720. https://pubmed.ncbi.nlm.nih.gov/11126720/3. 2015: Rib stress fractures in pregnancy: a case report and review of literature. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/file:///C:/Users/hchapa/Downloads/1575956493464-5157163%20(1).pdf4. Zhang Y, Li R, Zhang J, Zhou W, Yu F. Changes in Serum Concentrations of Bone Turnover Markers in Healthy Pregnant Women. International Journal of Clinical Practice. 2023.

We have learned a lot about extended spectrum coverage of prophylactic antibiotics for cesarean section. The landmark C/SOAP trial randomized 2,013 women undergoing nonelective cesarean delivery to azithromycin 500 mg IV plus standard prophylaxis versus placebo, demonstrating a 51% reduction in the composite outcome of endometritis, wound infection, or other infection. Adjuvant Zmax (plus standard first-generation cephalosporin) is now recognized as evidence-based antibiotic coverage for intrapartum cesarean, cesarean with ruptured membranes, and patients with obesity. This last patient characteristic comes from the ERAS latest update. But what is ZMAX is not available? Is there an evidence-based peri-op alternative in these cases? Does Gent and Clinda cover mycoplasma/Ureaplasma? What about postop flagyl? Listen in for details. 1. Tita AT, Szychowski JM, Boggess K, et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. The New England Journal of Medicine. 2016. 2. Yang M, Yuan F, Guo Y, Wang S. Efficacy of Adding Azithromycin to Antibiotic Prophylaxis in Caesarean Delivery: A Meta-Analysis and Systematic Review. International Journal of Antimicrobial Agents. 2022. 2. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstetrics and Gynecology. 2018. Committee on Practice Bulletins-Obstetrics 3. Martingano D, Nguyen A, Nkeih C, Singh S, Mitrofanova A. Clarithromycin Use for Adjunct Surgical Prophylaxis Before Non-Elective Cesarean Deliveries to Adapt to Azithromycin Shortages in COVID-19 Pandemic. PloS One. 2020. 4. Valent AM, DeArmond C, Houston JM, et al. Effect of Post–Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial. The Journal of the American Medical Association. 2017. 5. Wood, G. E., et al. "In Vitro Susceptibility of Mycoplasma genitalium to Nitroimidazoles." Antimicrobial Agents and Chemotherapy 6. https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm

We have covered the subject of whether to include the decidual (innermost) layer when closing the uterine incision during cesarean section (CS) on at least 2 episodes. The most recent was in September 2025, when we focused on a published (September 2025) systematic review and meta-analysis from the Green Journal. Back then, we compared those new findings to our prior episode from 2023 on the same matter. Well, we are back at it again with the same subject as there is a new EXPERT REVIEW from the AJOG on hysterotomy closure technique which just came out January 2026. What did these authors conclude? There are also some controversial suggestions made by the authors. Listen in for details. 1. Antoine C, Meyer JA, Silverstein J, Buldo-Licciardi J, Lyu C, Timor-Tritsch IE. Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders. Obstet Gynecol. 2025 Jun 1;145(6):674-682. doi: 10.1097/AOG.0000000000005813. Epub 2025 Jan 9. PMID: 39787602. 2. Gialdini, Celina et al.Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. eClinicalMedicine- Lancet (June 2024), Volume 72, 102632 3. Dahlke, Joshua D. MD; Mendez-Figueroa, Hector MD; Maggio, Lindsay MD, MPH; Sperling, Jeffrey D. MD, MS; Chauhan, Suneet P. MD, Hon DSc; Rouse, Dwight J. MD. The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees. Obstetrics & Gynecology 136(5):p 972-980, November 2020. | DOI: 10.1097/AOG.0000000000004120 4. Antoine C, Timor-Tritsch IE, Bujold E, Young BK, Reece EA. Endometrium-free closure technique for hysterotomy incision at cesarean delivery. Am J Obstet Gynecol. 2026 Jan;233(6S):S103-S114. doi: 10.1016/j.ajog.2025.07.009. PMID: 41485813.

As OB healthcare providers, we have several pieces of guidance regarding determination of amniotic fluid volume antepartum. The SMFM has Consult Series #46 (2018), which describes the management of polyhydramnios. We'll touch on that in this episode. However, while we have clear understanding of the increased risks of oligohydramnios, where an MVP is preferred for diagnosis over AFI, we have less information about polyhydramnios. But a new study published in BJOG (January 2026) provides more insights on this. While MVP is preferred for oligo diagnosis, can the same be said for polyhydramnios? Is there an increased risk in perinatal morbidity with polyhydramnios, and is that better detected by MVP or AFI? This new study findings left the authors unsatisfied although it CONFIRMED what we have covered in past episodes. Listen in for details.1. Dashe, Jodi S. et al. SMFM Consult Series #46: Evaluation and management of polyhydramnios. American Journal of Obstetrics & Gynecology, Volume 219, Issue 4, B2 - B8 (2018)2. ACOG PB 229: Antepartum Fetal Surveillance (2021)3. Petrecca A, Chauhan SP, Tersigni C, Ghi T, Berghella V. Amniotic Fluid Index Versus Maximum Vertical Pocket Versus Both for Polyhydramnios. BJOG. 2026 Jan 7. doi: 10.1111/1471-0528.70139. Epub ahead of print. PMID: 41502220.

Back in March of 2025, the green journal (obstetrics andgynecology) published A systematic review and meta-analysis on 2 medications (non-hormonal) and their efficacy in menopausal hot flash relief period these medications were Fezolinetant and Elinzanetant. However, the editors have just recently released an “Expression of Concern” about this review. Listen in for details. 1.     Menegaz de Almeida, Artur MS; Oliveira, PalomaMS; 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 MenopausalWomen Experiencing Vasomotor Symptoms: A Systematic Review and Meta-analysis.Obstetrics & Gynecology 145(3):p 253-261, March 2025. | DOI:10.1097/AOG.00000000000058122.     Expression of Concern: Fezolinetant andElinzanetant Therapy for Menopausal Women Experiencing Vasomotor Symptoms: ASystematic Review and Meta-Analysis. Obstetrics & Gynecology():10.1097/AOG.0000000000006180, January 16, 2026. | DOI: 10.1097/AOG.0000000000006180

Implanon (etonogestrel implant) first received FDA approval in 2006, followed by the improved, radiopaque version, Nexplanon, approved by the FDA in 2010, which is now the only contraceptive implant available in the U.S. It was originally FDA approved for a 3-year use duration, although peer reviewed clinical data had demonstrated efficacy through year 5. Now, as of January 2026, the FDA has formally agreed to extend the label for 5-year use. In this episode, we will review the clinical data that prompted the FDA’s decision, based on a multicenter, single-arm, open-label study evaluating contraceptive efficacy and safety during years 4 and 5 of implant use.1. https://www.contemporaryobgyn.net/view/fda-approves-5-year-use-for-etonogestrel-implant-68-mg-contraceptive2. Organon announces US Food and Drug Administration approval of supplemental new drug application extending duration of use of NEXPLANON (etonogestrel implant) 68 mg Radiopaque. Organon. Press release. January 16, 2026. Accessed January 19, 2026. https://www.organon.com/news/organon-announces-us-food-and-drug-administration-approval-of-supplemental-new-drug-application-extending-duration-of-use-of-nexplanon-etonogestrel-implant-68-mg-radiopaque/3. Ali M, Akin A, Bahamondes L, et al. Extended Use Up to 5 Years of the Etonogestrel-Releasing Subdermal Contraceptive Implant: Comparison to Levonorgestrel-Releasing Subdermal Implant. Human Reproduction. 2016. 4. McNicholas C, Swor E, Wan L, Peipert JF. Prolonged Use of the Etonogestrel Implant and Levonorgestrel Intrauterine Device: 2 Years Beyond Food and Drug Administration-Approved Duration. American Journal of Obstetrics and Gynecology. 2017. 5. McNicholas C, Maddipati R, Zhao Q, Swor E, Peipert JF. Use of the Etonogestrel Implant and Levonorgestrel Intrauterine Device Beyond the U.S. Food and Drug Administration-Approved Duration. Obstetrics and Gynecology. 2015.

Ursodiol (ursodeoxycholic acid) is a prescription bile acid medication used to dissolve cholesterol gallstones, prevent gallstones during rapid weight loss, and treat liver diseases like primary biliary cholangitis (PBC) by reducing toxic bile acids and cholesterol production. It works by changing bile composition, making it less saturated with cholesterol, and is available as oral medication. Of course, it is also the foundational medication for treatment of diagnosed Intrahepatic Cholestasis of Pregnancy (ICP). Does this medication reduce adverse perinatal outcomes? In this episode, we will review a new study from the Green Journal, which will be out in February 2026, examining the recurrence risk for ICP using data from NY. In a patient with prior history of ICP, is there any guidance on monitoring of serum bile acids in the subsequent pregnancy before symptoms develop? We will explain. PLUS we will review the data on whether Ursodiol may hold promise in recurrence prevention or in reduction of adverse outcomes once the condition is diagnosed. Listen in for details. 1. 2019: Chappell LC, Bell JL, Smith A, Linsell L, Juszczak E, Dixon PH, Chambers J, Hunter R, Dorling J, Williamson C, Thornton JG; PITCHES study group. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet. 2019 Sep 7;394(10201):849-860. doi: 10.1016/S0140-6736(19)31270-X. Epub 2019 Aug 1. PMID: 31378395; PMCID: PMC6739598. https://pubmed.ncbi.nlm.nih.gov/31378395/2. February 08, 2025: Rahim, Mussarat N et al. Pregnancy and the liver. The Lancet. 2021; Volume 405, Issue 10477, 498 – 513 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02351-1/fulltext3. SMFM CS 53; 20214. Rosenberg, Henri M. MD; Sarker, Minhazur R. MD; Ramos, Gladys A. MD; Bianco, Angela MD; Ferrara, Lauren MD; DeBolt, Chelsea A. MD. Intrahepatic Cholestasis of Pregnancy Recurrence in a Subsequent Pregnancy. Obstetrics & Gynecology 147(2):p 239-241, February 2026. | DOI: 10.1097/AOG.0000000000006033 https://journals.lww.com/greenjournal/fulltext/2026/02000/intrahepatic_cholestasis_of_pregnancy_recurrence.13.aspx5. Ovadia C, Sajous J, Seed PT et al. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterol Hepatol. 2021 Jul;6(7):547-558. doi: 10.1016/S2468-1253(21)00074-1. Epub 2021 Apr 27. PMID: 33915090; PMCID: PMC8192305.6. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. European Association for the Study of the Liver; 2023

HCG is a heterodimeric glycoprotein typically produced by trophoblastic tissue. However, there are occasions where a serum HCG is obtained that remains low level POSITIVE, yet the patient is not pregnant, nor does she have a gynecologic malignancy. Why dose this happen. Not all these instances can be explained by the “PHANTOM” HCG. In this episode, we will review a new Clinical Consensus guideline from the ACOG officially being released in Feb 2026. Like the finding of an aberrant aneuploidy on cell-free DNA testing in pregnancy (NIPT) where the child is found to NOT be affected, where that abnormal result may signal a hidden malignancy, a persistent low level positive HCG that cannot be explained by pregnancy or a gyn cancer may signal a hidden malignancy elsewhere. Listen in for details. 1. ACOG CC #11, February 2026

The ENG implant has data placing it as the most reversible, hormonal contraceptive agent available with a typical use failure rate of 0.05%. Unfavorable bleeding patterns, such as frequent or prolonged bleeding, affect approximately 40% of ENG implant users within the first 3 months but typically improve over time. Nonetheless, it is the main reason for patient discontinuation. In the past, various medications have shown to have at least some short-term reduction in bothersome breakthrough bleeding (BTB). These include doxycycline, ethinyl estradiol (EE), mefenamic acid, combined oral contraceptives (COCs), short term tamoxifen, norethindrone, and ulipristal acetate. In this episode, we will summarize a new RCT (AJOG, released as epub on Jan 7, 2026) which describes the use of TXA for ENG related BTB. Did it work? Listen in for details.1. Andrade, Maíra Cristina Ribeiro et al. Norethisterone for prolonged uterine bleeding associated with etonogestrel implant (IMPLANET): a randomized controlled trialAmerican Journal of Obstetrics & Gynecology, Volume 234, Issue 1, 101 - 1152. Edelman, Alison et al. Treatment of unfavorable bleeding patterns in contraceptive implant users with tranexamic acid: randomized clinical trial. American Journal of Obstetrics & Gynecology, Volume 0, Issue (Articles in Press January 07, 2026)

It’s a controversial topic: the impact of uterine incision (hysterectomy) on the neonate delivery interval (also called the U-D interval). Does it matter? Just to be clear, we’re talking about time from uterine entry to fetal extraction, not skin incision to fetal extraction. Past publications have produced conflicting results, often limited by small sample sizes, heterogeneous indications for delivery, and reliance on surrogate markers (like apgar scores) rather than clinical morbidity. But a new study published in the Gray journal at the end of 2025 (December 30, 2025) gives some new insights. In this episode, we will review this retrospective study and play the “Devil’s advocate” as we summarize the rebuttal data. As the reports are conflicting, we will end the podcast with a real-world interpretation and application of this data. Listen in for details. 1. Bart, Yossi et al. Uterine Incision-to-Delivery Interval and Neonatal Outcomes among Non-urgent, Term, Cesarean Deliveries. American Journal of Obstetrics & Gynecology, Volume 0, Issue 0. https://www.ajog.org/article/S0002-9378(25)00980-9/fulltext?rss=yes2. Maayan-Metzger A, Schushan-Eisen I, Todris L, Etchin A, Kuint J. The effect of time intervals on neonatal outcome in elective cesarean delivery at term under regional anesthesia. Int J Gynaecol Obstet. 2010 Dec;111(3):224-8. doi: 10.1016/j.ijgo.2010.07.022. Epub 2010 Sep 19. PMID: 20855070. https://pubmed.ncbi.nlm.nih.gov/20855070/3. Spain JE, Tuuli M, Stout MJ, Roehl KA, Odibo AO, Macones GA, Cahill AG. Time from uterine incision to delivery and hypoxic neonatal outcomes. Am J Perinatol. 2015 Apr;32(5):497-502. doi: 10.1055/s-0034-1396696. Epub 2014 Dec 24. PMID: 25539409.4. Bader AM, Datta S, Arthur GR, Benvenuti E, Courtney M, Hauch M. Maternal and fetal catecholamines and uterine incision-to-delivery interval during elective cesarean. Obstet Gynecol. 1990 Apr;75(4):600-3. PMID: 2107478.5. Tekin, E., Inal, H.A. & Isenlik, B.S. A Comparison of the Effect of Time from Uterine Incision to Delivery on Neonatal Outcomes in Women with One Previous and Repeat (Two or More) Cesarean Sections. SN Compr. Clin. Med. 5, 80 (2023). https://doi.org/10.1007/s42399-023-01427-x