Dr. Chapa’s Clinical Pearls.

The ACOG defines FGR as fetuses with an estimated fetal weight or abdominal circumference that is less than the 10th percentile for gestational age (ACOG PB 227). BUT, some argue against this cut off. There may be a subgroup of AGA fetuses with placental insufficiency who display slowing of fetal growth trajectory while in utero, but do not end up with a birthweight <10th centile at term, and so not classed as FGR. Such a cohort that has declined in weight centiles in late pregnancy may be an important under-recognized group with sub-optimal placental function. Growth velocity represents the rate of fetal growth in a specific time interval and may have more clinical utility to distinguish normal from pathological fetal growth and may help to identify fetal growth abnormalities that are abnormal yet still above the crucial 10% cut off. So in this episode we're going to focus on this very question... what do we do with those fetuses that we find have plateaued or have slowed trajectories of fetal growth antepartum but are still above the 10th percentile. It's a common clinical conundrum. This podcast idea comes from one of our podcast family members who reached out for this very reason. Lauren, thank you for your message, here's your podcast.

Can you believe that in 1977, the public health guidelines issued by the National Institutes of Health suggested a two-drink-per-day limit for pregnant women? It's TRUE. Ethanol had even been investigated, and promoted, and an "effective tocolytic agent". We now, of course, understand that there is no safe amount of ethanol use during pregnancy. Our understanding of FASD has evolved over the years, so much so that we now understand that FASD is possible by PATERNAL use of alcohol in the prericonception period. This is due to epigenetic changes in the sperm. In this episode we will review some historical facts regarding the use of alcohol in pregnancy and summarize new data demonstrating the MALE partner's contribution to FASD.

Epidural anesthesia remains the gold standard for relieving labor pain. Currently, there are 3 techniques for providing epidural related analgesia (traditional epidural, combined spinal- epidural, and dural scrape/puncture epidural). A controversial subject dating back to the 1990s, epidural related maternal fever (ERMF) has been extensively studied. In this episode, we will summarize two recent publications on the subject from the AJOG and review historical data. What is the pathophysiology of ERMF? Are antibiotics still indicated in these patients? Listen in and find out.

Medical/Nursing simulations which focus on high-acuity, low-frequency crisis events improve team dynamics, team morale, and most importantly patient outcomes. One such high-acuity, low-frequency event is malignant hyperthermia (MH). On labor and delivery (L&D) units, neuraxial (spinal and epidural) blocks are the safest and most commonly used anesthetics. However, general anesthesia is performed when the case is emergent (stat), when the regional anesthesia level is insufficient, or regional anesthesia is contraindicated (low platelets). Joint Commission accreditation included preparedness for medical reactions/emergent conditions, including malignant hyperthermia. In this episode we will provide a high-yield summary of MH including etiology, pathophysiology, medication rescue, and supportive care for this potentially life threatening emergency.

One of the sources of ideas for our podcast topics is our daily clinical practice. During my recent shift in ultrasound clinic, we encountered 4 clinical scenarios which became wonderful teaching opportunities at that moment. In this episode, we will share these common- at times, daily – clinical dilemmas, and we will provide evidence-based, easy answers!

In June 1999 the FDA approved the first continuous glucose monitor for diabetic intervention. We have come along way since 1999. Continuous glucose monitors (CGMs) come in 2 different varieties: real-time CGM, and intermittent/“flash” monitor devices. The use of these devices in pregnancy has exponentially grown. In this episode, we will summarize the key findings from the landmark study, published in 2017 in patients with Type I diabetes in pregnancy (the CONCEPTT study). Is there evidence supporting the use of these devices for gestational diabetes? Has the FDA cleared any of these devices for use in pregnancy? We will answer these questions and much more in this episode.

You asked… We did! Listen in and find out what this means.

It’s a rather uncommon, but not rare, phenomenon: the incidental hCG finding in a postmenopausal patient. What are we supposed to do with that? Is this automatically cancer? In this episode, we will highlight a real clinical case from one of our podcast listeners, Cynthia. We will review the likely causes of low-level hCG levels in a postmenopausal woman (who is not pregnant). You may be surprised of some possible etiologies. Towards the end of the episode, we will also provide an evidence-based recommendation on the diagnostic evaluation/work up of this type of patient. Lastly, we will give an important reminder of how urine could be a valuable tool in this schema.

The earliest studies of misoprostol’s use in cervical ripening and labor induction were done by South American investigators, who reported their experience using intravaginal misoprostol. This was published in the Lancet in 1992. Despite its widespread incorporation into obstetrical practice, there’s still some lack of uniformity in its administration. Is there a cumulative maximum dose allowed for cervical ripening? What about time… is there a maximal amount of time in which misoprostol can be used? Is that 12 hours, 18 hours, 24 hours? In this episode we will review important misoprostol’s FDA label information, summarize position statement from the ACOG and AWHONN, and discuss issues with “scoring” the 100mcg tablet to give a 25mcg dose. And of course, we will summarize the important peer-reviewed data regarding “maximum vaginal cumulative doses” of this medication for cervical ripening/labor induction.

The concept of measuring intrauterine contractions strength was first proposed in 1949, and eventually published in 1952. The use of an IUPC is well ingrained in modern obstetrical/intrapartum practice. Even though it is so commonly performed, we tend to forget some potential limitations and possible risks of this procedure. In this episode, we will review the history and purpose of the IUPC and remind ourselves of some real (though rare) limitations and risks. We will also touch on an evolving, new alternative to intrapartum uterine monitoring: electrical uterine monitoring (EUM). This is electromyography (EMG) of the uterine muscle activity as a contraction monitoring technique.