Dr. Chapa’s OBGYN Clinical Pearls

The ACOG acknowledges that maternal obesity affects labor curves and recommends allowing more time for cervical dilation before diagnosing labor arrest in obese patients. This approach aims to avoid unnecessary interventions, such as premature cesarean delivery, which may occur if standard labor curves are strictly applied to obese women. In this episode, we will review a new study from the AJOG (08 Nov 2025) which describes labor progression and duration according to maternal body mass index, validating the need (possibly) for a BMI -based labor curve. Has there been advocates of a BMI-based labor curve? Listen in for details.1. Edwards, Sara et al. Characterizing Labor Progression and Duration According to Maternal Body Mass Index. American Journal of Obstetrics & Gynecology, Volume 0, Issue 02. Lundborg L, Liu X, Åberg K, et al. Association of Body Mass Index and Maternal Age With First Stage Duration of Labour. Scientific Reports. 2021;11(1):13843. doi:10.1038/s41598-021-93217-5.3. Kominiarek MA, Zhang J, Vanveldhuisen P, et al. Contemporary Labor Patterns: The Impact of Maternal Body Mass Index. American Journal of Obstetrics and Gynecology. 2011;205(3):244.e1-8. doi:10.1016/j.ajog.2011.06.014.4. Norman SM, Tuuli MG, Odibo AO, et al. The Effects of Obesity on the First Stage of Labor.Obstetrics and Gynecology. 2012;120(1):130-5. doi:10.1097/AOG.0b013e318259589c.

The podcast dives into the controversial use of prophylactic antibiotics during second-degree laceration repairs. It evaluates the latest BMJ randomized trial and a meta-analysis revealing mixed evidence on infection rates. Dr. Chapa discusses why recommendations often lag behind emerging data and contrasts protocols for more severe injuries. He also shares insights on practical applications for high-risk patients. Ultimately, a modest benefit for antibiotics is identified, but universal use remains unadvised.

Explore the complexities of polycystic ovary syndrome (PCOS) as experts discuss four distinct phenotypes. Discover how new research largely reconfirms existing classifications and the implications for IVF and pregnancy outcomes. Learn that not all PCOS patients experience insulin resistance and that traditional views may overlook critical differences. Delve into lab-based subtypes and the importance of individualized care in managing this heterogeneous condition.

Discover the latest updates on folic acid recommendations for women on anti-seizure medications. High doses are no longer the standard, shifting from 4-5 mg to a safer range of 400-800 mcg. Dr. Chapa highlights research suggesting that additional folate may not reduce risks for neural tube defects linked to certain epilepsy drugs. International guidelines are changing too, as countries adopt lower dosing. Tune in for crucial insights that impact clinical practices and patient care during pregnancy.

Back on August 9, 2024, we released an episode (link in the show notes) reviewing the renewed interest in transfusing whole blood for PPH rather than component therapy. Now, in O&G open, authors from my Alma Mater (UT Southwestern) have published new data bolstering the use of whole blood for PPH. Listen in for details.1. Clinical Pearls Episode 2024: https://open.spotify.com/episode/0ZhqoIE9wMcAboDlevq9OW?si=rM32uK8ER8uuWmq4mf5dzA2. Ambia, Anne M. MD; Burns, R. Nicholas MD; White, Alesha MD; Warncke, Kristen MD; Gorman, April MS; Duryea, Elaine MD; Nelson, David B. MD. Whole Blood in the Management of Postpartum Hemorrhage. O&G Open 2(5):e130, October 2025. | DOI: 10.1097/og9.00000000000001303. ACPG PB 183STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

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