Dr. Chapa’s OBGYN Clinical Pearls

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.

On May 19, 2023, the FDA cleared a novel biomarker serum test for the risk stratification for severe preeclampsia in hypertensive pregnant women. This clearance is the first given to any blood-based biomarker test for assessing preeclampsia risk. The company is Thermo Fisher Scientific (no disclosures). But what does this test actually check for? Who qualifies for this? And what was the clinical investigation that the FDA based its clearance decision on? And most importantly…what do we do with this result?! We will answer all of these questions- the what, why, how, and what now- in this episode.

The 3rd stage of labor is the time from child's birth to delivery of the placenta. Delayed placental separation and expulsion is a potentially life-threatening event because it hinders expected postpartum uterine contraction, which can lead to PPH. The concept of umbilical vein injection of a variety of substances (saline, pitocin, plasma expanders) is nothing new. It was first described in the 1930s! This had found new life in the 1980s and 1990s but soon thereafter again fell into ambiguity. What is the theorized MOA of this intervention? Does oxytocin injection into the umbilical vein help prevent PPH? Is this an effective management option in the 3rd stage? We will walk down history's timelime and find out. We will also summarize the data of 2 Cochrane Reviews that have twice looked at this technique, with the last published report in 2021. Thank you Haley for the podcast topic suggestion!

Although labor epidural remains the gold standard for labor analgesia, some patients may opt for a trial of a less invasive analgesic agent. While IV/IM narcotics are an option, others may prefer a trial of nitrous oxide (N2O). In this episode, we will review the crazy history of this useful inhalational agent, and how it has ties to the manufacturing of the Colt45 handgun, how it transformed dentistry, and review the contribution to medicine by Dr. Horace Wells. We will review N2O's current application in obstetrics, and summarize statements from the ACNM and the ACOG. And…What does this gas have to do with vitamin B12? Are there any safety warnings out there regarding its use? And does it even work? Let’s answer these questions, and more, in this episode.

Just the other day I received a text from one of our wonderful FM attendings in our group concerned about refilling a patient’s Lamictal in early pregnancy. When asked if that was acceptable to do, I quickly answered ABSOLUTELY. We’ve come a long way in understanding bipolar disorder and a long way since lithium was first described for its use. While its use in psychiatry dates to the mid-19th century, the widespread discovery of lithium is usually credited to Australian psychiatrist John Cade who introduced it for mania in 1949. The first randomized trial was published in 1954 showing efficacy for this mental health condition. The drug was not US FDA approved for treatment of bipolar disorder until 21 years later in 1970. Thankfully, now- safer options of medical therapy are available for reproductive age women. In this episode we will summarize the data on medical therapy for bipolar disorder. Which medications are preferred? Are serum drug levels recommended? Does lithium really cause Epstein's Anomaly? And what drastic move did the UK perform to reduce fetal exposure to some medications commonly used for bipolar disorder in reproductive age women? We’ll explain it all in this episode.

The ACOG recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding while complementary foods are introduced during the infant’s first year of life, or longer, as mutually desired by the woman and her infant (ACOG CO 820; 2021). Problems may arise that can keep women from achieving their breastfeeding goals, and only 25.4% of women are breastfeeding exclusively at 6 months. One of the most common reasons women stop breastfeeding is engorgement, which could lead to lactational mastitis due to milk stasis. In this episode we will review the current best practice plans for lactational mastitis and one its complications, breast abscess. Plus, new data regarding the pathogenesis of lactational mastitis is challenging the old traditional model of causation; we’ll explain in this episode.

This is our second episode in the format of “You Asked, We Answered!” In this episode we will clarify and discuss 4 topics currently active: (1) Is the FDA approving OTC Birth Control? What is the progestin in the OPill? Do you know what “Free the Pill” is? We’ll discuss here. (2) Why did the USPSTF change the MMG screening rec to age 40? Has’nt the ACOG already recommended that? And what did the USPSTF comment regarding dense breasts? We’ll discuss here. (3) What is the “10 and 10” association between HbA1c and Birth defects? We’ll discuss this and the “rule of 30”, and lastly (4) We recently summarized a new publication on IPI after stillbirth and commented on the higher risk of PTB overall in the first pregnancy after stillbirths. Was this due to medically indicated inductions or due to spontaneous PTB (Ruthy’s question)? We will discuss in this episode!

Historically, governmental and professional societies referred to gestational "completed" weeks in their definitions of preterm or term deliveries. But this term of "completed weeks" has remained a point of confusion for clinicians and researchers alike. The ACOG favors simply stating the gestational age as clear designations of weeks and days (e.g., 34 weeks 5 days) rather than "completed weeks". Nonetheless, state and national vital statistics reports still rely on documented completed weeks. Does "34 completed weeks" imply the day after 33 weeks and 6 days, or the day after 34 weeks and 6 days"? We'll clear up the confusion regarding "completed" weeks of gestation in this episode.

Obstructive sleep apnea (OSA) affects nearly 30 million people in the United States. OSA isn’t just a disruption to pregnant women’s sleep, it is linked to serious pregnancy complications. In this episode will summarize the latest research on OSA and disorganized sleep patterns and their associated pregnancy outcomes. Should we screen for this in pregnancy? Is CPAP safe in pregnancy? Should these patients be on low dose aspirin? Does treatment for OSA prevent the adverse perinatal outcomes? Screening for OSA in pregnancy is controversial…so you’ll need to stay with us until the end of the episode to find out why. This topic suggestion comes from a second-year resident in Columbus, Ohio, who is part of our podcast family. Dani, thanks for reaching out. Enjoy your residency journey… It goes by fast. Dani, here’s your podcast.