Dr. Chapa’s Clinical Pearls.

In November 2023, the ACOG will release Clinical Consensus #6, “Compounded Bioidentical Menopausal Hormone Therapy”. We have covered bioidentical hormones in past episodes. However, this ACOG clinical consensus sheds new light on an old topic. Is there ever a role for bioidentical hormone therapy? What about postmenopausal testosterone use? What does the College say about the marketing of these compounded options? And, were you aware that for the first time ever there is now a novel, bioavailable estrogen in a combination oral contraceptive? That same estrogen (E4) is now being considered as another option for bioidentical hormone use. In this episode, we will review this new estrogen, estetrol (E4), answer the questions posed, and provide other high yield facts from the clinical consensus.

On June 27, 2023, researchers published a population based analysis of the prevalence of Iron Deficiency and Iron-Deficiency Anemia in Females in the US who were aged 12-21 Years. This study spanned from 2003 to 2020. What they found was staggering: Almost 40% of American teenage girls and young women had iron deficiency. This was published in JAMA. It's the first research to look at iron deficiency in young women and adolescent girls. Iron deficiency and iron-deficiency anemia are both common, underappreciated conditions with significant morbidity and mortality despite widespread availability of effective treatment. Iron deficiency is the most common micronutrient deficiency worldwide and is the most frequent cause of anaemia. Historically, the focus of screening has been preschool-aged and pregnant females. The CDC-P recommends anemia screening for nonpregnant female adolescents and women every 5 to 10 years, whereas the USPSTF does not address screening for these populations. Ands that’s for anemia, not iron-deficiency alone. Oh, and that CDC recommendation is from 1998! That’s right, no update since 1998. Also, guidelines from the ACOG focus only on anemia during pregnancy. But now, and here’s a clinical pearls: This year, for the first time in its history, the International Federation of Gynecology and Obstetrics issued a recommendation that all women and girls who menstruate should regularly be screened for iron deficiency, not just for anemia and not just during pregnancy. This was recently picked up as a story in the New York Times, being published on October 17, 2023. And here’s another clinical pearl… It is completely possible for someone with normal hemoglobin levels to still have iron deficiency. So in this episode, we’re going to address the new FIGO guidelines and review why a “screening CBC“ just does not have the sensitivity to detect iron deficiency in reproductive age women. We will also review the appropriate screening test for this condition, as well as review basic iron physiology.

In 2009, the ACOG released practice bulletin 106 which introduced the 3- tier fetal heart rate classification system. This was followed up in November 2010 with its sister practice bulletin, number 116, “Management of Intrapartum Fetal Heart Rate Tracings”. Yet now, 13 years later, management of the category II tracing remains a conundrum. How long can you watch/observe a category II tracing? Can category II tracings predict fetal acidemia? And what is a step-by-step, evidence-based algorithm for category II management? In this episode, we will cover all of these questions, and summarize a new systematic review/meta-analysis from the AJOG (October 2023) focused on this very condition.

In April 2023, both the ACOG and SMFM released their clinical updates regarding the use of progesterone for preterm birth prevention. While 17-OHP is gone, vaginal progesterone remains an option in the appropriate patient, with some slight differences between the opinions from ACOG and SMFM. A new expert commentary from October 2023 in the AJOG -MFM is calling for a reappraisal of those opinions. Is vaginal progesterone for PTB prevention coming back to treat ALL patients with a history of PTB, not just those with a short cervix? That depends on how you look at the data. And, where does cerclage fit in? Listen in for all this...and more.

Nuchal cords are found in 25-30% of deliveries and can pose challenges during birth. The podcast delves into the fetal somersault delivery maneuver, a safer alternative to the traditional clamp and cut method. This technique preserves vital placental blood transfusion, improving neonatal outcomes. Listeners learn that nuchal cords are generally benign and that effective management can lead to better health for infants. The discussion emphasizes the importance of evidence-based practices in obstetrics.

Hypertensive Disorders in Pregnancy/Preeclampsia is a persistent problem, world-wide. Over the last decade, studies have highlighted the role of vitamin D in modulating several mechanisms associated with hypertensive disorders of pregnancy, including but not limited to vessel compliance, the maternal immune response, the renin angiotensin response, and placental implantation and angiogenesis. There has also been published concern that maternal vitamin D deficiency may be associated with childhood neurodevelopmental issues including autism. However, the last ACOG CO on UNIVERSAL SCREENING for vitamin D in pregnancy was in 2011…this stated that UNIVERSAL screening is just not recommended (FYI, this was reaffirmed 2021, and is currently being reaffirmed by the OB committee). But this is different than targeted screening. Since the ACOG stance in 2011, despite RCTs of vitamin D supplementation in pregnancy, everything has changed and yet nothing has changed regarding the approach to screening for vitamin D deficiency. Should vitamin D levels be assessed? Are the cutoffs for vitamin D insufficiency and deficiency the same in pregnant patients? Who is the ideal pregnant patient for vitamin D intervention? How can the intervention be optimized? And what’s that link between maternal vit D deficiency and the child’s neurodevelopmental outcomes? There is data to answer these questions, and we will lay it all out in this episode.

The FDA’s approval of the first oral hormonal contraceptive pill, Enovid, in 1960 launched a revolution in women’s reproductive healthcare. From that one initial pill sprang a plethora of oral contraceptive choices, representing estrogen-progestin combinations in standard dose to ultra-low dose options, progesterone only pills, and cyclic or continuous use pre-packaged formulations. According to a survey conducted from 2017 to 2019 by the Centers for Disease Control and Prevention (CDC), around 65% of women aged 15-49 use some form of birth control, with the pill being the most common birth control method used by younger women. Around 20% of women aged 15-29 use oral contraceptives. Similarly, the FDA’s approval of levonorgestrel-based (LNG) emergency contraception (EC) in 1998, and its subsequent approval of the selective progesterone receptor modulator-based option in 2010 (ullipristal acetate or UPA), provided another layer of contraceptive protection during times of unprotected or ill-protected sexual intercourse. More recently, this revolution in medical control over reproductive ability has resulted in the FDA’s approval of the first over-the-counter, norgestrel-only oral contraceptive, the Opill. This move allows the Opill to be available in a variety of venues, from online to local pharmacies and grocery stores. Nonetheless, despite this major success in women's contraception, some suspicions remain. In this episode we will review latest data on Opill and its plan for release in 2024. This has already lead to the potential for a combination OTC pill coming out soon. Have you heard of it? And...does your state already offer OTC hormnal BC? Listen in and find out more.

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There is no controversy regarding the definition of the 2nd stage of labor: it is the phase of labor from 10 cm until complete delivery of the child. However, there has been persistent controversy about what defines a prolonged 2nd stage of labor. In other words, are the hour limits stated by the ACOG “active pushing” or “total duration” in 2nd stage? 🤔 Historically, this has been a very gray area. Even though we have guidance on this going back to 2014 with the ACOG Obstetric Care Consensus 1, “Safe Prevention of the Primary C-Section”, certain phrases within that document caused confusion. Does the ACOG make a distinction between active vs passive 2nd stage of labor? Listen in and find out. 🎙️🎙️🎙️

Mirror Syndrome also known as “triple edema” or Ballantyne syndrome, is a rare disorder affecting pregnant women. Mirror Syndrome is often underdiagnosed or misdiagnosed due to a general unawareness of the condition, and sometimes its preeclampsia-like manifestations. However, until now, the characteristics of Mirror Syndrome have not been fully elucidated. But medicine moves fast, and we now have a better understanding of its presentation, likely contributing factors, and outcomes. Still, some knowledge gaps remain. In this episode we will summarize the data on this terrible, potentially life threatening, obstetrical emergency. Our centerpiece for discussion will be a recent systematic review published in September 2023 in the AJOG with authors from my home state of Texas.