Dr. Chapa’s Clinical Pearls.

First published in 1952, the Apgar Score has remained unchanged over 70 years and is entrenched in current OB/Pediatric/Neonatal care. The ACOG highlighted the Apgar Score in 2015 in CO 644. In that release, the ACOG reminds us that although it provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed, it has important limitations: A. The healthy preterm infant with no evidence of asphyxia may receive a low score only because of immaturity, B. The incidence of low Apgar scores is inversely related to birth weight, and C. a low score cannot predict morbidity or mortality for any individual infant. Most importantly, it is inappropriate to use an Apgar score alone to diagnose asphyxia. It has been previously shown that not all items of the conventional Apgar score are of equal importance. However, Virginia Apgar did not differentially weigh or remove individual items since it was her intention to have a score that can be “determined easily and without interfering with the care of the infant”. Accordingly, use of the score has been found to have important use limitations across babies whose skin color has more pigmentation, leading to more NICU admissions in some despite other more objective measures of neonatal status. As the United States and many other countries have become more racially and ethnically diverse, embedding skin color scoring into basic data and decisions of health care may propagate unintentional race-based medicine. In this episode we will discuss the data leading some to call the traditional Apgar score “antiquated” and are calling for a change.

Listen to this! According to recent US statistics from both consumer reports and statista.org: 26% of Americans used CBD in 2022, 24% of people owning pets use CBD for their animals and themselves, 33% of Americans have used CBD products at least once, 64% of Americans have used CBD for pain, 49% of Americans use it for anxiety and stress, and 42% of Americans have used it for sleep and insomnia. CBD is super common, and it is super unregulated. CBD, or cannabidiol, is one of the numerous cannabinoids found in cannabis plants. After THC, CBD is the second most active substance found in the plant. THC produces the euphoria that users feel when consuming it through various methods. CBD differs in that it doesn't produce a high, is non-psychoactive, and like THC, isn't physically addictive. Although CBD has shown promise in migraine care, chronic pelvic pain, fibromyalgia, and cancer associated pain, it is NOT benign. CBD contains several terpenes that are all oil-based. These are known to cause some disturbances in the body's immune system. Other things like lethargy, sedation, and increases in liver enzymes are possible when used regularly. Things like malaise, weakness, heavy fatigue, diarrhea, and a skin rash may occur. Nonetheless, as CBD is viewed as “natural”, many pregnant women look to this as an alternative medication for pregnancy aches and pains. Is this safe? We know that THC is problematic, but what about CBD? We have learned much more about CBD in pregnancy since the ACOG’s CO 722, first released in 2017 and reaffirmed in 2021…and even the term has changed! In this episode we will review the data on CBD use in pregnancy from 2018 (since the last ACOG CO) onward and let you know why one word in particular is no longer favored.

This episode subject was requested by Emily, one of our podcast family members. She has noticed the reporting of “large placental, venous lakes” on antepartum ultrasound. Placental lakes are enlarged spaces in the placenta filled with maternal blood. These spaces are also called intervillous spaces because they are found between the placental villi the finger-like projections of the placenta that contain fetal blood vessels . The placental villi float in the intervillous spaces and absorb oxygen and nutrients from the maternal blood. The blood-filled placental lakes appear nearly black on ultrasound because they do not reflect soundwaves back to the ultrasound machine. Placental lakes can be seen within the placenta or on the fetal surface of the placenta bulging into the amniotic cavity. Slow swirling blood flow may be seen within the spaces, and the shape of the spaces tends to change with uterine contractions. These features may help to distinguish a placental lake from a thrombus. Well, why is this even supposed to be an issue? How can venous lakes affect the fetus, after all…maternal blood is normally found in the intervilluous spaces between the chorionic villi which house the placental vessels for gas exchange. Well, the theory is that these large placental lakes may affect blood redistribution in the chorionic fetal vessels, leading to increased incidence of placental growth abnormalities or fetal distress in labor. Are these placental sono findings a harbinger of bad things to come or are they simply benign findings? Let’s look at the data!

We recently had a patient in our OB high-risk community clinic whose maternal carrier screen result was either late or lost. Thinking the test may be lost, another resident ordered hemoglobin electrophoresis. The electrophoresis was NEGATIVE (that is, no abnormal hemoglobin was found at detectable levels)…by the way, good for that resident! After calling the lab for the genetic screen and not getting a clear answer from that location, they had the self- initiative in ordering a back-up test. AND TURNS OUT: this was a GREAT educational opportunity as the results from these two tests were discordant: the maternal carrier screening panel returned the day after and was POSITIVE for alpha thalassemia trait. So, which is better? Hgb electrophoresis (once considered the clinical gold standard over CBC with indices) or molecular testing? Let’s explore the data in this episode.

Desquamative inflammatory vaginitis (DIV) made its debut in the medical literature in 1965, by the hands of Gray and Barnes. In that paper, they presented their findings on 478 women complaining of vaginal discharge. Then, in 2002, Donders et al. described a new entity, referred to as aerobic vaginitis (AV). This term emphasized the clear contrast with the far more common and acknowledged form of dysbiosis: bacterial vaginosis (BV). These 2 clinical conditions are now thought to exist on a clinical continuum of presentations with AV being the "milder form" and "DIV" manifesting as a more severe condition. Recently, I received three separate questions regarding aerobic vaginitis (AV) and the potential role of GBS in its etiology...which lead to the research for this episode. Can GBS cause vaginitis (AV)? Or is it simply a "colonizer", and not a pathogen? This topic and the role of GBS in it has been a hot debate for 40 years PLUS! However, new data published in March 2023 by the ISSVD has contributed to: the credibility of AV as a cause of vaginitis, the pathogenesis of this DIAGNOSIS OF EXCLUSION, and resulted in a guideline for therapy. We will cover all this- and more- in this episode.

The word placenta, first used in a 1638 anatomy textbook, was borrowed from the New Latin phrase placenta uterina, meaning "uterine cake", because the circular, flat shape of the organ was thought to resemble a traditional Roman flat cake. Circumvallate is another Latin derived term meaning the "encircled placenta, by a rampart". Circumvallate placentas are a form of extrachorial placenta where the basal plate extends past the margins of the chorion plate resulting in the chorion and amnion folding over one another onto the fetal surface. Is a circumvallate placenta an incidental finding or is it a harbinger of adverse outcomes? The answer to that question depended, until recently, on who you asked and WHEN you asked. In this episode, we will summarize and highlight a new publication from the American Journal of Perinatology from May 2023 which serves to offer a more definitive answer to this question. So, is the circumvallate placenta Maleficent or Meh? Listen in and find out!

Over the past decade, there’s been about a 700% increase in the cases of congenital syphilis in the United States. That’s 700%! Rates of congenital syphilis, meaning the number of cases for every 100,000 live births, are highest in the South and Southwest, in states such as Arizona, New Mexico, Louisiana, Mississippi and Texas. Individual states have seen increases that are even more astounding. From 2016 to 2021, cases shot up 3,300% in Mississippi, nearly 3,000% in Oklahoma, more than 2,200% in Hawaii, more than 1,800% in Washington, more than 1,600% in New Mexico, according to CDC data . "Clinical Pearls" has covered screening and diagnosis of maternal syphilis in past episodes; one past episode focused on the traditional and the now-favored reverse sequence algorithms. You can find that episode in our archives from July 03, 2022. Do you know what the CDC calls “inadequate treatment” for congenital syphilis prevention? Having recently had concern for a child born at high risk of congenital syphilis, in this episode we will focus on the vertical transmission of syphilis and congenital syphilis (CS) and provide several clinical pearls related to this subject.

LARCS provide remarkable contraception. The IUD and the IUS are both HIGHLY effective, although they do not have the same typical-use failure rates. While it is common knowledge that active mucopurulent cervicitis is a contraindication for IUD/IUS placement, what about the presence of bacterial vaginosis (BV)? BV has been identified for years as an independent risk factor for Pelvic Inflammatory Disease. Is placement of an IUD/IUS in a patient with current BV contraindicated? What do the guidelines say? Listen in and find out.

Endometriosis is caused by endometrial-like tissue containing endometrial glands and extensive fibrotic tissue growing outside the endometrial cavity, most often in the pelvic peritoneum or ovaries, resulting in chronic pelvic pain and infertility. It is reported to affect 10 to 15% of women of reproductive age, with an unknown percentage of women who go on undiagnosed or misdiagnosed. For decades, Sampson's Theory has survived as the most "likely" to explain the pathogenesis of endometriosis. But why do some women with retrograde menstruation go on to develop endometriosis while others do not? That has been the big UNKNOWN for decades....until NOW. Could the answer be because of the uterine microbiome? Its highly possible! If so, certain combination of antibiotics may reduce and/or reverse some of the pathology of endometriosis. In this episode, we will summarize a brand new study (from 06/14/23) that is SHAKING UP gynecology! Listen in...and find out what this data is about, its clinical applications, and the gaps that still remain in this story.

The world of "Hypertension (HTN) in Pregnancy" is an ever-evolving environment! Many clinicians have adopted patients' home monitoring of blood pressure (BP) in their management of hypertensive disorders in pregnancy. Do you recommend home BP monitoring in your OB patients? On May 4, 2022 we summarized the results of 2 RCTs examining whether home BP monitoring during antepartum care prevents HTN morbidity and mortality. These were BUMP1 and BUMP2 (JAMA). We will again summarize the key findings from those 2 RCTs in this episode. PLUS, we will highlight a brand new publication from Obstet Gynecology (the Green Journal) which was just released on June 13, 2023 (Steele et al) which examines the effectiveness of POSTPARTUM home BP monitoring in patients with hypertensive disorders of pregnancy. Does that reduce postpartum HTN morbidity? Its completely acceptable to be "medically conservative" and have patients self-monitor their BPs at home...but is that also data-driven? And which antihypertensive seems to work the best in the immediate postpartum interval: labetalol, nifedipine, or is it furosemide? Listen in and find out!