Dr. Chapa’s Clinical Pearls.

Just a quick clarification regarding a previous statement, on an earlier episode, regarding MSAFP….thank you Maggie Rey! ❤️❤️❤️this community.

Does the combination birth control pill cause depression? This has been a controversial subject for over 2 decades. While some observational studies have described a possible association, randomized clinical trials have shown little to no connection. On June 12, 2023, a new population-based cohort study from the UK sought to evaluate this possible association. This resulted in some interesting claims! These results, just within 24 hours, have now made their way to major news outlets and social media circles. In this episode, we will summarize the key findings as well as the key limitations to this “hot-off the press" publication.

I recently received a message from one of our podcast family members requesting more gynecological topics...that was perfect timing, since the NAMS just released its 2023 Position Statement on "NonHormonal Therapies" for vasomotor symptoms on June 1st. In this episode we will summarize this 18 page monograph. The NAMS expert working work critically evaluated the published literature on all nonhormonal therapies for hot-flashes and grouped them into 5 categories: lifestyle modifications; mind-body techniques; prescription therapies; dietary supplements; and acupuncture-other treatments-and technologies. In this episode we will cover each of these categories to keep you informed, up to date, and evidence-based. Is yoga recommended for hot-flash relief? What about cannabinoids? Can chiropractic adjustments help with hot-flashes? Listen in and find out!

Welcome back to part 2. In this episode we will wrap up our discussions on dermatoses of pregnancy, focusing on atopic eruptions of pregnancy and ICP. Do you know what the 3 comorbidities are which may follow a diagnosis of ICP? We’ll cover that here. AND we’ll throw in a weird one as our final discussion point, one that is considered by some to be the 5th dermatosis of pregnancy. This is the Triple P: Pustular Psoriasis of Pregnancy.

I’ve said this many times before: I ❤️ our podcast community. This podcast topic idea comes from Jerry, an OBGYN Resident in Virginia. 👏👏 Jerry writes, “I wanted to know if you could do a topic on the Dermatoses of Pregnancy. My program has had some interesting cases recently and most of what I could find was in UpToDate. I couldn’t find a specific PB or CO on the topic, so I wanted to reach out.” Honestly, I hadn’t even thought of this topic…and it is a good one! We do see patients with these complaints very frequently. So, in this episode we are going to not just scratch the surface—see my dad joke there? “Scratch the surface”, as we talk about dermatoses—anyway…we will be taking a deep dive into these conditions: their presentations, workup, and therapies. Is herpes gestationis related to herpes virus? Can pruritic papules and plaques on the abdomen have bullae? Which conditions are linked to adverse maternal-neonatal outcomes? And what is the condition known as, TRIPLE P? …Stay with us and find out. 🧴😳❓😬

It has long been considered that iron deficiency does not exist in Thalassemia syndromes, including Thalassemia major as well as Trait (Thal minor). But that is incorrect. Recent studies have shown the occurrence of iron deficiency in patients with Beta-Thalassemia Trait. Iron deficiency anemia (IDA) during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality and should be treated with iron supplementation in addition to prenatal vitamins. However, patients with Beta-Thalassemias have been considered to be at risk of iron overload due to alterations in function of hepcidin. So, can pregnant women with Beta-Thalassemia Trait, found on hemoglobinopathy screening, take oral iron supplementation for concomitant iron deficiency anemia? That’s a big question, and we’re going to answer it in this episode!

When performing cervical examinations during labor, providers in the United States commonly use sterile gloves, even when there is no rupture of membranes. Is this an evidence-based practice or is it simply tradition? This debate has been going on for decades. In this episode, we will highlight some interesting/intriguing hospital policies and procedures, and walk-down our history timeline of data. We will start in 2010 and end with a recent publication from June 2023 from the AJOG-MFM. Finally, there is some Level I evidence to help settle this debate. 🧤🧤🧤❓❓❓

Here’s a real world clinical conundrum: A patient first presents for prenatal care in the 3rd trimester. As healthcare providers, we play a game of “catch-up” with routine serum tests ordered to make up for time lost. But what about specific pregnancy tests that are restricted to gestational age? Take, for example, GDM screening. Currently, traditional screening for GDM occurs at 24 to 28 weeks based on the original studies by O’Sullivan and Carpenter-Coustan. Or take this parallel, clinical scenario: A patient passes routine screening between 24 and 28 weeks, but in the 3rd trimester has suspected fetal macrosomia or new onset polyhydramnios. Should we rescreen these patients for GDM? As cut off values for the GDM screens are based on a 24 - 28 week pregnancy, we don’t really know what the cut off serum glucose levels should be after 28 weeks. And more importantly, does diagnosing GDM in the 3rd trimester improve maternal or neonatal outcomes? In this episode, we will walk down history’s timeline of data starting in 2001 and ending with a publication in 2022. We’ll discuss the findings of these publications (6 total) and at the end of the episode, I’ll give you my personal perspective on the subject.

We are now 5 years into the publication of the Arrive trial (2018) which opened the door to elective induction of labor at 39 weeks in an otherwise low risk pregnancy. But five years later authors and researchers are still debating whether a 39 week elective induction is helpful or not. Yep, the rebuttals and retorts against the ARRIVE trial began shortly after its publication, and they are still active even now- with a recent publication, from February 2023, having an opposing view. Yep…While some have called for universal adoption of the “39 week IOL rule“, others have put the brakes on the plan. in this episode, we’re going to dive into this persistent on again off again dilemma of elective induction at 39 weeks. This podcast idea comes from one of our podcast family members who sent me this message on May 27: “Hey Dr. Chappa, what are your and your team's thoughts on elective induction at 39 weeks? I've had multiple discussions with my co-fellow about how it may not be the best option for some of our pregnant folks, especially those who have had a successful un-induced vaginal delivery. My attending sent me an interesting article from the Journal of Perinatology which questions the validity of the Would love any input you have on this. Thanks!” What a great topic to discuss. There’s so much to unpack here and we’re going to summarize that article which came out in print in February 2023, and we will also discuss a separate study that followed in March 2023 on this very issue. And…Is 39 week eIOL cost effective? Lots of angles to examine here and we will do all of that in this episode. And- as always- you’ll want to stay with us until the end of the episode because I’ll provide my personal perspective and typical practice regarding eIOL at 39 weeks.

The fetal heart rate is controlled by various integrated physiological mechanisms, most importantly by a balance of parasympathetic and sympathetic nerve impulses. Intrapartum, fetal bradycardia may be in direct response to an evolving or acute hypoxic event, including tachysystole, uterine rupture, or placental abruption. Antepartum, excluding acute events like maternal trauma which could lead to an acute hypoxic episode, most fetal brady arrhythmias will be nonhypoxia related. We recently evaluated and cared for a patient at 23 weeks gestation with the incidental finding during her routine prenatal visit of a fetal HR of 90. This was confirmed by bedside ultrasound, and then noted to be in the 70s on reexamination in L&D. There was no fetal hydrops, no evidence of maternal injury, no maternal connective tissue disease, normal amniotic fluid, and a normal fetal movement seen on ultrasound. What are the possible causes of antepartum fetal bradyarrhythmia? What’s the work-up? What is the fetal Long QT syndrome? And when is delivery recommended? Listen in and find out.