Candida in women is being right? Afterall, vulvovaginal candidiasis during pregnancy is common. Candida species may be isolated from the vagina of 15 %-21% of nonpregnant women; this rate increases to 30% during pregnancy. While it is generally benign and isolated to the vagina clinically, some Candida species have the capacity to be troublemakers. C. Glabrata has the potential to be a bad player, with the possibility of invasive disease. Candida IAI is rare but can lead to neonatal infection, high mortality, preterm prelabor rupture of membranes, and childhood neurodevelopmental impairment. The most prevalent predisposing condition is preterm prelabor rupture of membranes, followed by intrauterine pregnancy with a retained intrauterine contraceptive device, cervical cerclage, diabetes in pregnancy, and pregnancy after in vitro fertilization. Preterm labor is the most common symptom with Candida IAI, and only 13% of cases involved fever. Case reports have also associated C. Glabrata with third trimester stillbirth. Although case reports have documented this since the 1980s, this is still an evolving diagnosis as awareness of the condition increases. Nonetheless, the clinical features of Candida IAI are not well understood, and best management of the condition is unclear. In June 2024, Candida Glabrata was called a “global priority pathogens”. In this episode, we will review this rare but very real clinical conundrum. One of our podcast family members actually managed a patient, s/p IVF, with periviable PPROM found to have Candida Glabrata fungemia. How is this possible? Shall we treat Candida in the urine? We will discuss this in this episode.

Biomarker testing has arrived in Obstetrics. Of course, we have been using some biomarkers for years, like PAMG1 (Amnisure) and AFP+ILGFBP1 (ROM Plus) for ROM evaluation. In May 2023, the FDA cleared Thermo Fisher Scientific's maternal serum biomarker test for prediction of preeclampsia with severe features in hospitalized patients (and we have a prior episode on that). Now, as of July 9, 2024, published data has arrived for a new maternal serum biomarker ratio for the prediction of preterm birth in low-risk patients. This is the PreTRM biomarker test. This is on the path for FDA clearance. In this episode, we will review the AVERT Preterm Trial which utilizes a novel biomarker ratio using IGFBP4/SHBG. What did this study find? There some promising aspects to this, and also some striking limitations. Listen in for details!

Published studies, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PG E1) when used for cervical ripening and labor induction. Based on cumulative data, misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Prostaglandin E2 also has proven efficacy. Plus, we are all aware of the safety and efficacy of mechanical methods of cervical ripening; yes…we know that these options may be used either individually or concomitantly. But what about sequential use? Can cervical balloon be used after misoprostol? Or should it be the other way around? Is there a “best way” to do sequential cervical ripening? This episode topic comes from one of our podcast family members. It's a really good clinical question, and we will dive into the data in this episode. And STAY TUNED IN UNTIL THE END for the real-world clinical implications of the data.

Tuberculosis (TB) was historically called "consumption" due to the dramatic weight loss and wasting away experienced by patients. The modern name "tuberculosis" was first published by J. L. Schönlein in 1832. Today, between 3% and 5% of the U.S. population are estimated to be living with latent TB infection. Contrast that with the worldwide statistics which state that nearly one fourth of the world population has TB infection. In some countries in sub-Saharan Africa and Asia, the annual incidence is several hundred per 100,000 population. In the US, the annual incidence is <3 per 100,000 population, but immigrants from countries with a high TB burden and long-term residents of high-burden countries have a 10× greater incidence of TB than the US national average. Thankfully, only 5–10% of individuals with latent TB infection will progress to active TB disease over their lifetimes. But it is difficult to predict who will progress from latent TB infection to active TB disease. The perinatal period is a good opportunity to screen, diagnose, and treat those at high risk for TB. The ACOG the American Academy of Pediatrics, and the Centers for Disease Control and Prevention (CDC) recommend screening all women who are at high risk for TB at the initiation of antenatal care. In this episode, we will review the epidemiology of tuberculosis, who should be screened, and focus on latent TB infection management in pregnancy. What does the “4R” preferred regimen mean? Listen in and find out.

Approximately 0.5% of all births occur before the 3rd trimester of pregnancy, and very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. Preterm prelabor rupture of membranes (PPROM) is a known risk factor for preterm birth and is responsible for 30–40% of preterm deliveries. While PROM occurs around 8% of all (term) pregnancies, PPROM occurs around 1% of the time. Periviable birth is delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. Women who experience PPROM before 27 weeks have a 10% risk of early PPROM and a 35% risk of preterm delivery in a subsequent pregnancy. Despite improvements in perinatal and neonatal care, infants born at <26 weeks of gestation contribute disproportionately to neonatal mortality and morbidity. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. In this episode, we will review the latest data on previable and periviable PPROM based on a new SMFM Consult Series (#71), released July 15, 2024. Is amnioinstillation of fluid into the uterus an option? What about home outpatient management? Listen in for the data.

Researchers estimate that more than 100 million women in over 120 countries use tampons during their menstrual cycle. Tampons are generally considered safe and healthy menstrual products. However, a new study conducted by researchers at the UC Berkeley School of Public Health has identified the presence of 16 different heavy metals in tampons from 14 different brands purchased in the U.S. and the U.K. This is causing a flurry of on-line commentaries, controversies, and conundrums. Are tampons toxic? In this episode, we will summarize this new publication (set to be officially released Aug 2024) and relate it to some real-world, daily exposures.

It's Summer…and its getting HOT in here! Although the effect of heatwaves in pregnancy has been studied various times, the data remains limited because these studies are observational, with very heterogenous populations, so its hard to prove causation between heat exposure and adverse outcomes. Nonetheless, these associations are indeed concerning. YES…just to be clear, there are past studies that have observed associations between heatwaves and PTB, low birthweight, and in some studies…stillbirth. The most recent review on this was published just last year (June 2023) in the J Mother Child, and the title was “A Comprehensive Review on Hot Ambient Temperature and its Impacts on Adverse Pregnancy Outcomes”. This review of 23 articles did again find an association between heat stress and adverse pregnancy outcomes. PLUS, a new publication released July 3, 2024, now raises new concerns about ambient heat and in-utero childhood cancer programming! That article, from Lancet Planetary Health, is the focus of this episode. BUT WAIT there’s more! We will also look at the relationship between ambient heat and PTB and oligohydramnios. So, grab your ice cooled glass of water and Let’s look at the evidence.

Up to 1 in 10 reproductive-aged women are impacted by endometriosis. Dysmenorrhea is the most common pelvic complaint of adolescents. While most cases of primary dysmenorrhea in adolescents will be primary dysmenorrhea, Endo remains a possibility especially after 2-3 years of progressive symptoms. Although the true prevalence of endometriosis in adolescents is unknown, at least two thirds of adolescent girls with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at the time of diagnostic laparoscopy. Now, as of July 2, 2024, a new diagnostic tool for Endo has received FDA Fast Track designation for development. This is different than FDA APPROVAL, but still represents a novel new option (if/when approved) to make ENDO diagnosis possible by using a molecular/protein ligand tracer. Listen in for details!

Well, sometimes when the "traditional", evidence-based recommendations don't have the desired result they are supposed to. When the "usual and standard" ways of doing things fail, its time for "shared-decision making"! In this episode, we will highlight, and give KUDDOS, to an OB care team who exampled thinking outside-the-box in order to care for an acutely ill patient s/p second trimester loss. This is soon to be released in the AJOG, and was released as a journal "pre-proof" July 9, 2024. This is a difficult case of a 19 week septic AB, retained placenta, an overtly abnormal uterus, and the surgical robot! Listen in for details.

RSV season is just around the corner (Fall and Winter months). Newborns are 16x more likely to be hospitalized with serious RSV lung infection than the flu. On August 21, 2023, the FDA approved the first RSV vaccine, Abrysvo, for use in pregnant individuals to protect newborns and infants against severe RSV disease in the first 6 months after birth. The FDA approved the vaccine to be administered between 32 and 36 weeks and 6 days of gestation. Then, on September 22, 2023, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to recommend a single dose of maternal RSV vaccination for pregnant people at 32 through 36 weeks of gestation, using seasonal administration, to prevent RSV lower respiratory tract infection (LRTI) in infants.This resulted in the ACOG’s endorsement, also in September 2023, of Abrysvo in pregnancy. However, the clinical trial resulting in the vaccine’s FDA approval noted “a numerical imbalance” for preterm birth occurrence (1% more) in vaccine recipients. Because of this, there was a call for additional “real world outcomes“ to see if this finding would be replicated outside of the trial. In this episode, we will summarize a brand new (July 8, 2024) publication from JAMA Network Open which provides this data, although some noteworthy study limitations must be acknowledged. Listen in for details!

A substantial collection of evidence indicates that the fallopian tube serves as the primary site of origin for a large portion of high-grade serous ovarian cancers. As a result, clinical practice guidelines (including from the ACOG) recommend salpingectomy for permanent contraception- when necessary- rather than simple tubal ligation. But an August 2023 publication, in JAMA Network Open, stated that women who undergo a salpingectomy are no more or less at risk of ovarian cancer compared to traditional tubal ligation. Why? In this episode, we will summarize this controversial publication and contrast that to a systematic review the following month, in September 2023 in JAMA Surgery, which provides an alternative conclusion. Should we still perform opportunistic salpingectomies (OS) rather than tubal ligations in the average-risk patient? We’ll explain the data and provide clinical pearls for practice at the end of the episode. Thank you, Bret, for this clinical conundrum as a podcast episode recommendation! You ask…we do!

Approximately 20% to 25% of pregnancies end in miscarriage, and there are many medical reasons why it may occur. About half are caused by chromosome aneuploidy. However, less than 5% of women will experience a second first trimester loss, and less than 1% will experience three early losses. The incidence of early spontaneous pregnancy loss increases by maternal age. In this episode, we will highlight an ACOG Clinical Expert Series from May 2024, which discussed the evaluation of recurrent pregnancy loss. Is genetic testing of the POC recommended after the first occurrence, 1st trimester spontaneous loss? If so, which test is the best? What genetic testing applies to parents, and when? Listen in for details.

Happy Independence Day, America! We hope you are enjoying this wonderful, national holiday. Yep...Its a PARTY in the USA! In light of the festivities, here's a clinical question for us: Do fireworks affect the fetus? Even broader than that, do loud sounds in general affect the developing child? The answer is both YES and NO. Listen in to this short- yet fun- episode as we prepare to light the night up in celebration of our nation's independence.

(Here’s a WONDERFUL QI Project for this New Residency Academic Year) With 70.8% of pregnancies among adolescents being unintended, there is a clear need for increased access to contraceptive services. Many adolescents use the emergency department (ED) as their primary healthcare source, highlighting the importance of providing comprehensive sexual health services in this setting. The risk of pregnancy is high among adolescents seeking ED care, indicating an opportunity to expand pregnancy prevention services in this setting. ED clinicians are in a unique position to address pregnancy prevention among adolescents. Novel ED staff training tools kits do exist for brief contraceptive counseling interventions during the ED visit for interested adolescents who present for any chief complaint. Talking to teens about contraceptives in the ED is feasible, acceptable, and allows ED staff to reach youth that may not have access or choose not to access medical care in any other setting. In this episode, we will summarize striking data from a recent publication (June 28, 2024), in JAMA Network Open, which revealed gaps in addressing contraceptive needs among vulnerable adolescent females and gaps in provisions of EC when needed. Additionally, we will propose an easy to adopt strategy to better equip Emergency Department staff for having these conversations.

PROM occurs in approximately 10% of pregnancies and leads to a risk of IAI in women that is 3 times higher than that in non-PROM women. The risk of early-onset sepsis of neonates born to mothers exposed to PROM is 20 times higher than in non-PROM mothers. An increasing time period with PROM increases the risk of infection for both mothers and newborns accordingly. Nonetheless, the ACOG states that there is insufficient evidence to justify the routine use of prophylactic antibiotics with PROM at term in the absence of an indication for GBS prophylaxis (ACOG PB217). HOWEVER, now that the ACOG has provided a clinical practice update on IAI (JULY 2027), emphasizing that the traditional “requirement” of maternal temperature of 38 °C (100.4F) need NOT be present for IAI diagnosis, new data suggests that febrile and infectious morbidity may be increased with PROM after 12 hrs with “low grade” maternal temps. In this episode, we will review the ACOG clinical practice update (briefly, as we covered that previously) in light of a June 11, 2024 AJOG publication analyzing the relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes.

Podcast Family, I hope this episode gives you pause and brightens your day 🌞. Just a quick work and acknowledgement to likley our YOUNGEST podcast family member and his mother, a Co-OBGYN preparing for oral Boards. 👏👏 Let this speak to you as the message spoke to me! (and introducing ​callmestevieray & Connor Price, whose words/song- “GRATEFUL”- always lightens my load). 🎶👏🎶👏🎶

Oral Hormonal contraception gets the blame for a lot of things, including the development of hypothyroidism. Hypothyroidism is one of the most common endocrine disorders affecting 5 to 10 times more women than men, and its prevalence increases with age. This association of OCPs with hypothyroidism comes from a controversial article in BMJ published in 2021, but is still very active in current social media posts. Does combination oral birth control cause hypothyroidism with prolonged use? Are birth control pills responsible for “micronutrient depletion” which negatively affects the thyroid? In this episode, we will explore and dissect this study and look at a January 2024 case-control study that provides an alternative conclusion. Listen in for details.

Podcast Fam, on March 27, 2024 our episode was called "Balloon for PROM: Yea or Nay". Although mechanical cervical balloons for induction were the focus, we also discussed which medication is better (based on published data) for labor induction after PROM. Well, in this episode, we pick up from March with ANOTHER NEW STUDY released today (June 25, 2024) in AJOG MFM. This RCT builds on the evidence that going straight to Pitocin (despite an unfavorable cervix) is the way to go after PROM. Although there are study design limitations, this is reassuring- and validating- information. Listen in for the "I TOLD YOU SO DANCE", and for details.

Anxiety disorders are the most common mental health issue in the United States, affecting nearly 1 in 5 adults, or 40 million people. Another 19 million adults – 8% of the population – has depression. Prenatal mood disturbances are known to affect the fetal brain, and endocrine system. Left amygdalar volumes were smaller in newborns whose mothers had high psychological distress during the COVID-19 pandemic, a small cross-sectional study suggested. Infants of mothers with elevated maternal distress during the pandemic had median reductions in white matter, right hippocampal, and left amygdala volumes compared with neonates whose mothers had low distress levels, this is according to research from the Children's National Hospital in Washington, D.C. This was published in JAMA Network Open on June 20, 2024 and is making the medical headlines. This is fascinating data. BUT, this is NOT new news. In this episode, we will review the concerning effect that maternal mood and stress has on the developing fetal brain, and how maternal stress may even be leading to changes in the child’s puberty! Listen in for details.

Respect for patient autonomy is a fundamental part of the clinician-patient relationship and discussion of healthcare interventions. Some patients decline transfusion of blood products, either for religious or non-religious reasons, but most frequently as part of the Jehovah’s Witness faith. Acceptance of, and decision-making, surrounding blood products and human blood derived medications is complex, however, and some patients who decline certain blood products may still accept other interventions. Because childbirth can be associated with excess blood loss and need for resuscitation, it is important before delivery to clearly delineate which blood products will be accepted or declined, realizing that the patient can change her preferences at any time. One way proposed to address blood loss at cesarean section is the use is intraoperative cell saver (IOCS) for autologous infusion (re-infusion of blood). Is it appropriate to use cell savers to collect and re-infuse blood during a C-section? Does ACOG mention this as an option? And what about the use of erythropoietin antepartum to increase RBC capacity? These questions are the focus of this episode.

"HSDD" as a diagnosis has been gone for some time. According to the ACOG, the DSM-V defines the combined entity of female sexual interest/arousal disorder as a complete lack of or a substantial decrease in at least three of the following symptoms for at least six months: interest in sexual activity and sexual or erotic thoughts or fantasies. This is the most common sexual dysfunction in women, affecting an estimated 5.4–13.6% of women, based on who you read. It is most prevalent in women between the ages of 40–60 and in women who have undergone surgical menopause. Now, a new publication from the Green Journal (June 18, 2024) provides a potential “new”therapeutic option for women, although the data for this actually first came out June of 2023. Can topical sildenafil help with Female Sexual Arousal Disorder? There is already an over the counter cream like this!Let’s take a look at this June 2024 RCT. PLUS, we will also briefly discuss the EROS device for female sexual arousal.

Hypertensive disorders of pregnancy (HDP), including chronic hypertension, gestational hypertension, and pre-eclampsia, are increasingly common in the United States, complicating close to 15% of births, and the incidence is continuing to rise! On this show we have addressed medical management of urgent hypertension in pregnancy and in the immediate postpartum interval. This topic continues to EVOLVE, with a brand new study which has gained a lot of medical news attention. This new study was published in JAMA CARDIOLOGY on June 12, 2024 and is helping redefine the "BP cut off" for medication use in the pp interval. AND...this is evolving within the ACOG as well! We have LOTS of late breaking news to cover here....so listen in!

At time of post cesarean discharge, most providers prescribe a fixed number of opioid tablets. However, past data has shown that most patients don't use all the opioids they are prescribed. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion. In this episode, we will highlight a new publication from the Green Journal (Obstet Gynecol) exemplifying an adoptable strategy using a individualized opioid prescribing protocol (IOPP). While this was published ahead of print on June 10, 2024, the concept of IOPP is not "new" at all. Listen in for details.

Podcast Family, this episode has 2 parts: 1. First, a "non-medical" little life lesson that I heard recently which I will share with you...I hope it ENCOURAGES you, and 2. The MEDICAL part, which comes from Paul- one of our podcast family members. Paul had a GREAT question regarding the data covered in our immediate PAST episode on TOLAC....listen in for details!

After a primary CS, the decision to undergo trial of labor after cesarean (TOLAC) or schedule a repeat cesarean birth is one in which a patient’s values and preferences should be prioritized in a process of shared decision making. Some clinicians elect to utilize a TOLAC calculator as part of the shared decision-making process, while others use a more generalized counseling approach. Once TOLAC is decided upon, which is better: elective induction at 39 weeks, or expected management? Does elective induction at 39 weeks increase the rate of uterine rupture compared to expected management? Older observation data has suggested that very thing. In this episode, we will review a brand new publication from the AJOG (released on June 7, 2024) that provides valuable information in counseling patients on either IOL or expectant care at 39+ weeks for TOLAC.

Hemorrhagic disease of the newborn (HDNB) was first identified over a century ago, and presents as unexpected bleeding, often with gastrointestinal hemorrhage, ecchymosis and, in many cases, intracranial hemorrhage. In newborns, HDNB is typically caused by vitamin K deficiency as neonates are innately deficient in vitamin K secondary to very little vitamin K transferred through the placenta to fetuses in utero, limited liver storage of vitamin K, and low amounts of vitamin K in breast milk. IM administration of vitamin K for prevention of vitamin K deficiency bleeding (VKDB) has been a standard of care since the American Academy of Pediatrics recommended it in 1961. Despite the success of prevention of VKDB with vitamin K administration, the incidence of VKDB appears to be on the rise. This increase in incidence of VKDB is attributable to parental refusal as well as lowered efficacy of alternate methods of administration. Can parents decline this injection for their babies? In this episode, we will review IM Vit K neonatal administration and discuss the controversial data regarding Vit K oral supplementation.

Proving that our podcast tagline, “Medicine Moves Fast” is true… this episode highlights something that is, once again, 🔥🔥🔥 Off the Press! on June 4, 2024, the ACOG released a new Practice Update regarding the determination of paternal and fetal RBC genotyping in pregnancies affected by alloimmunization. This builds upon and updates PB #192 from 2018. There are 3 big areas of change here… And we will highlight each one!

June is CMV awareness month. And that’s the keyword there… Awareness! The way we prevent CMV transmission is by awareness. It would be great to have a vaccine against this virus, but we just don’t…yet. Until a safe and effective CMV vaccine is clinically available, primary prevention of cCMV relies on patient education and hygiene measures. In this episode, will take a look at this strategy and see what the data has to say about it. Will also discuss the very controversial (and non-ACOG recommended) use of antiviral medication’s for primary, perinatal CMV.

In 2011, Congress passed a resolution naming June "National CMV Awareness Month," to raise awareness about the most common congenital infection in the US, affecting 1 of 200 live births. It is the leading VIRAL cause of IUFD & miscarriage & the leading cause of neonatal hearing loss, second only to genetic causes. Furthermore, cCMV is more common than many other neonatal conditions, such as spina bifida and fetal alcohol syndrome. Neonates affected by the virus can experience a wide array of symptoms, from none to severe neurodevelopmental disability, & even death. However, public and healthcare provider awareness remains low. In this episode, which is part 1, we will cover the presentation, transmission, and work up of CMV in pregnancy.

(VACAY EDITION) Recently in our high-risk OB clinic, I saw a patient who was disappointed that she “had to stop breastfeeding” as she entered her 3rd trimester with her 2nd child. Her first pregnancy was via vaginal birth, at term, with no complications. This situation is not frequently addressed and is a clinical dilemma. First, when nursing coincides with pregnancy, there is frequently a significant cultural taboo leading many women to wean their infants when they become pregnant again. Secondly, there is the concern for potential maternal “nutritional depletion” and thirdly, there is a fear of triggering preterm birth due to oxytocin release with breastfeeding. Nonetheless, there are mothers who wish to breastfeed throughout their subsequent pregnancy. This practice is known as breastfeeding during pregnancy (BDP). Is there data that shows that BDP increase miscarriage risk? What about FGR? Does it increase the risk of PTB? In this episode, we will review the latest data on this not too frequent- but real world- occurrence.

In our podcast archive, we have an episode titled, “TikToc’s #IUD is Killing a Good LARC”. In that episode, I discussed our protocol of using viscous lidocaine applied topically to the cervix, cervical canal, and coating the IUD device for placement. This works! In this episode, we will build on that concept by reviewing a publication released on May 23, 2024 in the AJOG. Could this be the remedy for painful IUD insertion? Plus, have you heard of the CAREVIX device? Listen in for details.

It definitely is interesting how published data tends to have sporadic “groupings” in print. For example, last week 2 publications were released which could be placed under one “group”: prediction/prevention of spontaneous preterm birth. One publication (AJOG MFM) presented a systematic review and meta-analysis on universal cervical length screening. The second publication, SMFM’s consult series # 70, pertains to the management of a short cervix in individuals without a history of spontaneous preterm birth. In this episode, we will review these 2 similar, yet different, publications and make sense of all! 👍👍👍

It’s exciting to know that we are practicing a type of medicine that is alive and ever-evolving! Such is the case regarding our clinical practice/management of gestational diabetes. In this episode, we will review brand new (as of May 21, 2024) clinical guidance from the ACOG regarding gestational diabetes. Should we be screening for diabetes before 24 weeks? Is there one diagnostic threshold which is suggested for use over the other (CC versus NDDG)? And is it possible to screen for postpartum DM as early as 2 days after delivery?😳 Listen in and find out.

The United States began adding fluoride to community water supplies in 1945. At that time, Grand Rapids, Michigan became the first community in the world to add fluoride to tapwater. Over the last several years, with an increase in reporting and media stories over the last 3 months, fluorinated drinking water has come under scrutiny and controversy. Does fluoride in drinking water affect children in the womb? Is this a cause of altered neurocognitive development? Does this lower IQ scores? This is a very HOT topic and there’s more fuel towards this fire with a publication which was released on May 20, 2024 in JAMA Network Open. In this episode, we will lay out the facts of this study, and why this must be interpreted with more than just face value. So grab your favorite fluorinated water beverage, and listen in!

Podcast family, this episode is recorded on the last day of the ACOG ACSM. Wanted to share with you some encouragement that I received from our podcast family members over these last 2 to 3 days. AND of course, in typical style, I’ll share with you a brand new publication which was released on May 17, 2024 in the AJOG (GRAY Journal) regarding “optimal dose of antenatal corticosteroids”. And lastly, I’ll share 3 Special Announcements, as an FYI.

We all can agree that we need a new ally against the foe of pre-term birth. With the disappointing results regarding the (lack of) efficacy of progesterone in reducing preterm birth, the search is out for a new, effective tool to reduce pre-term birth rates. Enter: the Lioness(tm) device. In this episode, we will review a new “safety and efficacy” study published today (May 16, 2024) in the AJOG. Is this ready for prime time? And how does this device work? Listen in for details.

Unbelievable timing! In our immediate past episode, we discussed the controversy surrounding pharmacoprophylaxis for antepartum inpatients. Just 3 days from that episode, a new RCT has been published in the Green Journal (Obstet Gynecol) discussing this very subject! This new RCT (published May 14, 2024) investigates the “best dose” of unfractionated heparin (UFH) during antepartum admissions? is there an advantage to “gestational – age based” dosing? Or should standard UFH dosing be used?

All of us can agree that the rates of obesity are progressively climbing, not just in the US, but globally. Obesity is a known independent risk factor in pregnancy for VTE. Several professional societies (ACOG, CMQCC, RCOG, SMFM) have clear recommendations for VTE pharmacoprophylaxis in patients considered at high risk. These include having a high risk thrombophilia, having a personal history of VTE, or having multiple risk factors. But these recommendations address POSTPARTUM prophylaxis. The ACOG does not specifically address inpatient prophylaxis during the antepartum interval. However, in cases of prolonged antepartum admission, where ambulation may be slightly limited, there is concern that the hypercoagulable state of pregnancy, together with obesity, may raise the risk of VTE in these antepartum patients. To be clear, no professional organization or guidelines recommend strict bedrest for pregnancy complications. Is VTE pharmacoprophylaxis endorsed in these admitted antepartum patients? The answer is both YES and NO. The use of heparin based agents in this group is controversial, with published expert opinions having a dichotomy of thought. Plus, recent data (2023) has raised questions regarding pharmacoprophylaxis’ efficacy in the postpartum interval. nonetheless, at the end of the episode, will provide some common sense approaches to VTE prevention in the admitted antepartum, obese patient. (With a special shout-out to our podcast family in Australia.).

Bacterial vaginosis (BV) is known as a normal vaginal microbiota resulting in low lactobacilli; it affects one-quarter to one-third of reproductive-age women. The BV treatment landscape has not appreciably changed in decades: in the US, metronidazole and clindamycin are recommended as first-line treatments for symptomatic BV, and secnidazole and tinidazole are used as alternatives. Although these treatments are effective in the short term, up to 60% of women experience BV recurrence within 1 year of treatment. Some have more frequent recurrences. Suppressive vaginal metronidazole fails for 25% of patients and leads to secondary vulvovaginal candidiasis (VVC) in up to 40%, and many patients have BV recurrence after stopping suppressive therapy. But now a “new” therapeutic option has been in print and is attracting a lot of attention. DQC has been available in other parts of the world for decades, and recently published results from a new European clinical investigation (May 2024) adds more reassuring date. This has led many in the United States to call for trials in this country to begin FDA approval. Listen in for details.

Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety. Plus, more than 90% of the data regarding tocolytic use comes from patients with threatened preterm labor with intact membranes, with (according to the WHO) only 9% of available data is regarding patients with ruptured membranes. But in May 2024, a new publication adds further information to this subset of patients. In this episode, we will review this ongoing controversy regarding the benefits of tocolytic therapy, and when they may provide the most efficacy. And yes, of course, we will provide the ACOG guidance as well.

Haemorrhage, hypertensive disorders, and sepsis are responsible for more than half of maternal deaths worldwide. Further, it is estimated that for every death, there are 50 pregnant people with life-threatening morbidity from sepsis. Heartbreakingly, the incidence of puerperal sepsis has risen over the last decade, in some cases doubling, with increasing rates of severe sepsis contributing to mortality. Underlying this trend is increasing virulence of group A streptococcal (GAS) infection. This is suspected to be due to the predominance of emm1 and emm28 genotypes, which have higher associations with mortality, as well as increasing maternal risk factors for infection such as obesity and DM. PLUS, certain GAS antibiotic resistance is on the rise. Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are Important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome. In this episode, we will highlight this alarming rise of Group A strep in the peripartum period including the most recent 2021 International Society for Infectious Disease in Obstetrics and Gynecology (ISIDOG) guidelines regarding GAS in pregnancy. Listen in for details.

Menopausal HRT is getting a big, big facelift! Get ready for new research trials, physician education programs, and patient awareness campaigns on menopause! Since the WHI study was released in 2002, the world of menopausal HRT has gone through some major changes. WHI initially led to confusion and fear regarding the use of menopausal HRT. But now, 30 years later, where do we stand? In this episode, we will highlight 2 brand new publications released on May 1, 2024, which prove that we are finally digging out of the hole of WHI. Plus, there’s a Hollywood actress behind the new menopause awareness campaign… and we’ll tell you who that is, and more, in this episode. 😊😊😊

Just the other day in my University clinic, in one single morning, I had 3 separate patients with three very interesting histories; these became the basis of this episode. It’s amazing what’s out there in daily practice! So, we will dive into these 3 main questions which arose from these 3 patient encounters: 1. What single test is recommended before initiation of combination birth control pills? And if this is recommended, how do online pharmacies prescribe prescription birth control? 2. Does PCOS cause other hormone (Prolactin? HCG?) disturbances? And 3., Is treatment of acne within the wheelhouse of women’s healthcare providers? We’ve got lots to cover in this episode…so let’s get started, NOW.

Well, once again… Late breaking news! Today, April 30, 2024, the USPSTF released its updated recommendations for breast cancer screening (mammography) in average risk patients. This follows a firestorm of controversy and backlash over the last 1 to 2 years as the USPSTF continued to recommend initiation of mammogram at age 50, despite the increased incidence of breast cancer in women in their 40s. In this episode, we will review this brand new recommendation and summarize the ACOG response from ACOG President, Dr. Hicks.

Traditionally, clinical guidance has incorporated maternal fever as a required criterion for suspected intraamniotic infection. That is exactly what is stated in the ACOG committee opinion #712 from 2017. However, not all patients with clinical IAI have fever! Having fever as a required part of the diagnostic criterion may result in delayed administration of appropriate antibiotics intrapartum. This has now been addressed by the ACOG! Today, on April 29, 2024, the ACOG released a practice update regarding the criteria for the diagnosis of suspected intra-amniotic infection. This is hot of the press, and we will break it down for us all in this episode. 🔥🔥🔥🎙️🎙️🎙️👍👍🙏

Regenerative Medicine is definitively a HOT and marketable offering across a variety of medical disciplines. But it is equally as controversial. The most well known type of regenerative medicine is the use of Platelet Rich Plasma (PRP). This has been proposed as a novel care therapy for musculoskeletal pain disorders, and a variety of GYNECOLOGICAL applications- including POI, pelvic floor dysfunction, uterine infertility treatment, and even some forms of vaginal fistulas. AND YES... RPR is even being used as a type of cosmetic fascial (with a new CDC health investigation underway!). In this episode, we will review the concept of Regenerative Medicine in gynecology, summarizing some key points from a brand new narrative review of the subject published in the Green Journal (Obstetrics Gynecology).

WOW. There has been a lot of new developments in the ObGyn world within the last 48 hours. In this episode, we will highlight 3 big developments/alerts regarding women’s healthcare: 1. the FDA’s approval of a new oral antibiotic for UTIs in females; 2. The updated ACOG practice advisory regarding maternal cell-free fetal RHD testing; and 3. The FDA’s recent (within last 24 hours) clearance of a new digital app for postpartum depression (MAMMALIFT). Special shout out to Dr. Colton for bringing MAMMALIFT to my attention.

(With Resident Co-Host Dr Taylor Apley) Menstrual synchrony is often reported by all-female living groups and by mothers, daughters and sisters who are living together. Is this real? Is this a pheromone issue? Is there biological signaling occurring here? The answer may surprise you! How does this work? Or does it work at all? And…what is the “MALE Effect”?? Where did this concept come from? This topic of menstrual synchronization is still getting its share of publications, like from November 2023- which we will review. Yep, we’re going to get into this fun topic in this episode. PLUS…DON’T say the “Q” word when all is still in L&D, or the ER. Or the OR! Saying the word QUIET is a sure-fire way to increase hospital admissions and patient pass through, right?! Can you believe there is an RCT that actually studied this? YEP…we’ll check out this issue as well: Fact or FICTION? Listen in, and find out.

Our regular podcast family members know that we have been following the antenatal corticosteroid story (especially in the late pre-term/early term interval) for several years now. A variety of countries have now pulled back from recommending corticosteroids in the late pre-term/early term interval due to concerns of adverse child neurodevelopment, especially when the children deliver at term. But today, April 24, 2024, a new publication from JAMA has provided some reassuring information. Is this data truly reassuring? Or is there more to the story? In this episode, we will dive into this brand new publication, released today, which provides follow-up from the original ALPS Study. This issue of steroids in the late pre-term/early term interval is hot hot hot 🔥🔥🔥. Listen in to get the latest information!

Breast cancer is the second most common cancer among women in the United States (with skin cancer are the most common). About 9% of all new cases of breast cancer in the United States are found in women younger than 45 years of age. Unfortunately, breast cancer is being diagnosed in women under 40 at an increased rate. This was recently published in a Jan 2024 JAMA population-based, cross-sectional study using data from Surveillance, Epidemiology, and End Results database. Every year, more than 1,000 women under age 40 die from breast cancer. Nearly 80% of young women diagnosed with breast cancer find their breast abnormality themselves. Breast cancer is the most common form of cancer in women who are pregnant or have recently given birth. According to US statistics, Breast cancer occurs about once in every 3,000 pregnancies, with some reports stating it may be as high as 1 in 1,000. For those under the age of 40, most are diagnosed between the ages 32 to 38 years. Because many women are choosing to delay having children, it is likely that the number of new cases of breast cancer during pregnancy will increase. In this episode, we’re going to look at breast cancer in reproductive age women with a focus on gestational breast cancer. Is MMG contraindicated in pregnancy? Can chemotherapy be used during pregnancy? What about radiation therapy? And is it better to have a complete mastectomy or breast conservation, during pregnancy? Listen in for details.

Historically, colostrum was expressed by women mid- to late-pregnancy with the intent to avoid engorgement and breast trauma in the postnatal period, but it was not stored for use after birth. But storing colostrum antepartum for newborn feeding has gained attention in social media channels. Is antenatal milk expression, also called colostrum harvesting, evidence-based? Are there benefits to this? Does this run the risk of initiating labor? Are there published studies? In this episode, we will “milk” the data- including a RCT from 2023 – and present some key points to consider about what it is and what it isn’t.

From 2012 to 2021, congenital syphilis cases in the United States increased by 755%. According to the CDC, 88% of congenital syphilis cases in 2022 could have been prevented with timely screening and treatment. Despite repetitive messaging about the need to identify syphilis early in pregnancy, with appropriate treatment, gaps remain. A new publication in the Green Journal (4/17/24) provides shocking information about gaps in diagnosis and treatment. In this episode, we will review that original research as well as summarize the new ACOG Practice Advisory (April 2024) regarding screening for syphilis in pregnancy.

There is a STRONG debate within the medical community as to whether testosterone should be prescribed to women during menopause and the time before and after it. Social media influencers and other media personalities are touting testosterone as a cure-all for mood, sex drive, cognitive changes, fatigue, reduced muscle strength, and other symptoms associated with menopause. In fact, the number of testosterone prescriptions for women has risen within the last five years in the United States and internationally. But is that evidence-based. The answer is both YES and NO. In this episode, we will focus on testosterone replacement for female low sexual interest. We will highlight the position statements from a large international coalition in 2019, a separate 2021 position statement, and the opinion of the ACOG. We have LOTS to cover here, so go lather up with your testosterone cream (JK) and listen in!

While the importance of optimizing a woman's hemoglobin level during the peripartum period has been emphasized in recent guidelines by the Society for Obstetric Anesthesia and Perinatology, the ACOG, and the Enhanced Recovery After Surgery Society, postpartum anemia remains a real issue in both the developed and developing world. Postpartum anemia has been associated with depression, fatigue, impaired lactation, and impaired cognition. This may lead to impaired maternal-child bonding. Additionally, severe anemia during the antepartum interval is an important predictive factor of PPH! This relationship was shown in a published meta-analysis in 2021. Postpartum, IV Fe has been proven to be of value for asymptomatic anemia. Packed RBC transfusion may be recommended for women with postpartum hemoglobin levels

Amnioinfusion was first described in 1976 using a rhesus monkey model. In that landmark study, the authors reported that variable decelerations occurred when amniotic fluid was removed from the uterine cavity and resolved when it was replaced. Although this experiment established that variable decelerations related to oligohydramnios and cord compression could be corrected by amnioinfusion, the technique did not achieve clinical application until 1983, when a novel approach to the relief of variable or prolonged decelerations was described. Amnioinfusion is mainly utilized in the rescue of recurrent fetal variable decelerations intrapartum. But what if the patient has suspected IAI? Is that a relative contraindication for amnioinfusion? Is that safe? In this episode we will examine the data and provide some clinical insights.

In 2014, a publication out of JAMA Pediatrics raised questions regarding the safety of acetaminophen in pregnancy describing a possible “association” with later neurodevelopmental and cognitive delays in children. What followed was a string of controversial publications (observational) with mounds of conflicting data. This led to a controversial international consensus opinion in 2021 calling for “caution for use” regarding acetaminophen in pregnancy. The ACOG had a strong rebuttal to that statement at that time. But now, as of April 9, 2024, we have new data on acetaminophen/paracetamol use in pregnancy and possible neurodevelopmental affects in children. This new study was published out of JAMA network and followed 2.4 million children with sibling pairs out of Sweden. This is making a lot of news within the last 24 hours and it is hot off the press 🔥🔥🔥. Listen in, and find out more.

It has been stated that “Trauma is in the eye of the beholder”. Healthcare providers must be aware that a woman makes experience a birth as traumatic, even if she and her infant are healthy. The ACOG has highlighted perinatal PTSD in several publications, which we will review in this episode. Perinatal PTSD has definitely been in the OB/GYN and psychology literature with an increased frequency just over the last 3 months. In this episode, we will review the very real and devastating condition of perinatal PTSD, its diagnosis, and discuss interventions to reduce its development. We will also review new data on “service dogs“ detecting PTSD in people with trauma histories? NOTE: We will also highlight a real world account of a traumatic birth event from one of our podcast listeners (Deidentified, and shared with permission).

In July 2023 and again in November 2023, we discussed the “Rule of 55“ and its role in the management of hypertensive disorders of pregnancy. The Rule of 55 has been mainly applied in the selection of appropriate antipretensive medications when urgent/emergent hypertension is present. Does the Rule of 55 also work for antihypertensive management of gestational hypertension or preeclampsia without severe features? A new publication (April 1, 2024) from the AJOG MFM gives us that answer! In this episode, we will cover the newly released PYTT study from Italy.

On April 8, 2024, parts of the United States will be within the Path of Totality for the total solar eclipse. The state of Texas has already declared a state of emergency as visitors flock to the state to witness the event. This is a fascinating celestial occurrence that is not scheduled to happen again until August 2044. Does the eclipse have a negative effect on pregnancy? Do lunar cycles affect birth rates? What does the data say? Does NASA have a statement on this? And what are neutrinos?! Listen in… And find out. 🌖🌗🌑

Today, April 3, 2024, the ACOG released a clinical practice update to practice bulletin# 222 (gestational hypertension eclampsia). This is in direct response to a recent FDA approved biomarker test for risk stratification for preeclampsia. 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). This new clinical practice update puts this test into proper perspective and gives clinicians some valuable insights of what it can, and what it cannot, do. Listen in for this “off the press” clinical practice update. 🔥🔥🔥🔥

According to the CDC, as well as worldwide data, the percentage of individuals categorized as overweight or obese is rising. First released in 1990 by the IOM, the guidelines for expected weight gain in pregnancy-based on pre-pregnancy weight (BMI)- have been controversial. These guidelines were revised in 2009. Now, a new publication from the Lancet (28 March 2024), is questioning the validity of the “minimal weight gain” recommended for patients with obesity. In this episode, we will review this controversy. Additionally, we will highlight a separate publication from the AJOG MFM (systematic review and meta-analysis) discussing NPWT use at C-section for patients with obesity.

The current dose and schedule for antenatal corticosteroids (ACS) follows the original publication by Liggins and Howie in 1972. That dose and schedule was based on sheep models from the 1960s. The dose in current use had never been evaluated to minimize exposures while assuring efficacy. New pharmacokinetic and pharmacodynamic data is calling into question whether the current dose and schedule is necessary. Translational research in animal models indicate that a constant, low concentration fetal exposure to ACS is sufficient for lung maturation, resulting in lower fetal exposures. In this episode, we will summarize a new clinical commentary published in AJOG in March 2024 highlighting the current state and controversies regarding ACS for threatened preterm labor.

Meningiomas are common intracranial tumors with a female predominance. The vast majority of these tumors are benign (World Health Organization [WHO] grade 1) while 15% to 20% of these tumors can behave atypically (WHO grade 2) and rarely, in 1% to 2% of cases, these tumors can be malignant (WHO grade 3) Their etiology is still poorly documented. The role of sexual hormones has long been proposed, but data have been conflicting across studies. However, a dose-dependent relationship between the incidence and growth of meningiomas and hormonal treatment with the synthetic progestin cyproterone acetate (CPA) has been recently established (2021). Now, a new observational study from France (BMJ) has raised the warning flag for a similar association with a common birth control option, depo medroxyprogesterone acetate. Does Depo-Provera cause brain tumors? It's very important to put this study into proper context. We’ll explain all of this, and more, in this episode.

According to the ACOG, pre-labor rupture of membranes (PROM) complicates 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality. What is the best course of action when patients present with PROM with a “unfavorable cervix”? Should it be a pharmacological method of ripening, or a mechanical? What does the data say? In this episode, we will do a deep dive into published data from the 1980s up to 2023. We will also explain why the Bishop score “is irrelevant“(SOGC) in patients at term with PROM. 😳. The literature does favor one pharmacological agent in cases of PROM. Curious? Listen in and find out more.

Obstetrical vacuum and forceps are incredible tools, when used correctly, to assist vaginal delivery. Appropriately selected and used, they can be pivotal in reducing the number of unnecessary cesareans and potentially decreasing certain fetal and maternal complications. However, there are several pearls of wisdom to remember when using them. In this episode, we will focus on a rare – but potentially fatal – complication of vacuum use: subgaleal hemorrhage. Although subgaleal hemorrhage can occur following normal birth processes, and even cesarean section, vacuum use is the strongest independent factor for its occurrence. In this, we will review these pearls of wisdom and the importance of detecting neonatal subgaleal hemorrhage quickly.

Ovarian preservation by autologous transplantation has given hope to patients desiring future fertility after certain gonadotoxic therapies for malignant conditions. But now, the same procedure is being promoted as a “natural cure” for menopause. Can ovarian tissue-based therapies really be the female, endocrine “fountain of youth”? In this episode, we will highlight a recent publication from the AJOG describing the potential of this procedure. We will also discuss the history of ovarian autotransplantation and why this procedure for menopause prevention has more questions than answers.

Since the late 1990s, the standard practice for GDM care has been to measure postprandial glucose values. For patients with pre-gestational diabetes, whether type I or type II, the ACOG recommends multi-level glucose checks (fasting, pre-meal , postprandial, and nighttime). But what about in the immediate postpartum interval? In patient’s with pre-existing diabetes, should blood sugars be checked pre-meal (qAC) or postprandial while still in the hospital, and after discharge? The topic for this episode comes from one of our podcast family members who had this clinical dilemma? In this episode, we will review the data and recommendations from the American Diabetes Association, the ACOG, and CDC. So grab your sugar-free drink of choice, and listen in!

Is breastfeeding with Hepatitis C safe? The answer: Yes! But confusion persists today mainly surrounding the serum hepatitis C viral load. That’s the topic and focus of the new publication released March 2024 in the Green journal, Obstetrics and Gynecology. We will highlight this new study in this episode. Yep, we have learned a lot about hepatitis C, and HIV, and breast-feeding. In this episode, we will review: the different hepatitis C genotypes and their implications, current breast-feeding guidelines for women with hepatitis C, the updated guidelines for breast-feeding with HIV, how some may be spontaneously “cured” of hep C postpartum, and why viral load matters for one of these conditions – but not the other!

It has been estimated that up to 4.4% of the US adult population has been diagnosed with ADHD. Use of ADHD medication is increasing among pregnant women. In the last several years, there’s been a litany of publications looking at the effects of pregnancy on ADHD, as well as the effects of medication on the pregnancy. In this episode, we will highlight a new publication released March 2024 (Archives Women’s Mental Health) examining prenatal outcomes in women who continued dexamphetamine in pregnancy. We will also summarize the data regarding the effect of ADHD medication on congenital anomalies and neurodevelopmental outcomes in the children.

Four years, the US National Vital Statistics System has reported an abnormally high maternal mortality rate in the United States, showing it to be nearly doubled from 17.4 in 2018 to 32.9 per 100,000 live births in 2021. The United States’s maternal mortality rate has been on the media radar for many years because of this. But that rate is completely WRONG. How is it that maternal mortality rates are more than 2 to 3 times higher than other developed countries despite our vast progress in obstetrical care? The answer? It is a statistical error! In this episode, we will review a brand new publication from the AJOG published on March 12, 2024 that is making media headlines. We have known that this reporting system is greatly flawed for several years, and now it is getting the attention it deserves. Although this is reassuring news for the country overall, there is still ONE patient demographic where we need to dramatically reduce the maternal mortality rate. Curious? Listen in and find out more.

The ACOG, CDC, and WHO currently do not recommend universal screening for thrombophilia in the general population before starting oral contraceptive pills. However, a new publication in AJOG (March 2024) is challenging that stance. In this episode, we will review this new prospective population-based study to see if it makes the case for universal screening for thrombophilia variants before starting OCPs. In this episode, we’ll also discuss high-risk versus low-risk thrombophilia, discuss relative risk versus absolute risk of VTE on the combination pill, and give clear clinical implications for patient management.

Gestational Diabetes (GDM) is vastly more prevalent in pregnancy compared to pre-existing diabetes. In 2009, the ACOG states that 7% of all pregnancies were complicated by a diabetes diagnosis, with 86% being GDM. The prevalence of GDM keeps rising in the US and globally. Metformin is increasingly prescribed in pregnancy, yet its long-term effect on the neurocognitive development of the offspring remains incompletely described. However, newly published data (March 6, 2024; AJOG) has changed that! In this episode, we will summarize and review a systematic review and meta-analysis of childhood neurodevelopmental outcomes after in utero exposure to metformin. Additionally, does some evidence suggest that metformin may be superior to insulin in pregnancy for perinatal outcomes? We will discuss all this and more, in this episode. This information will be helpful as we counsel and educate our patients on metformin use in pregnancy.

On this podcast, we have been following this story of the OPill for several months. Previous episodes on the subject can be found in our podcast library. As expected, this first ever daily use progestin only pill is now available over-the-counter in the US. 👏👏. On Wednesday, March 6, 2024, the ACOG released its Practice Advisory presenting some key reminders for clinicians regarding this new over-the-counter contraceptive option. In this episode, we will summarize this practice advisory and answer some real-world questions patients may have regarding this: does the OPill help with acne? Is this approved for endometriosis pain? What happens if a patient misses the next dose at the scheduled time? Listen in for these answers and more.

Use of second-line noninsulin diabetic medications, like Glucagon-like peptide 1 (GLP-1) agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors, is rapidly increasing for treatment of T2D and other indications. As these drugs are being used by an increasing group of fertile women, it is expected that a few of them will get pregnant and data on their safety when used in the first trimester is needed. Is periconceptional use of glucagon-like peptide 1 (GLP-1) receptor agonists associated with increased risk of major congenital malformations? In this episode, we will look at the available data (although limited) regarding these medications, focusing on specific GLP1 options.

Using mechanical options as a way to prime/ripen the cervix for labor is nothing new. Balloon catheters have been used for labor induction as far back as the 1890s. Embrey and Mollison reinvigorated the method in 1967 using it in combination with extraamniotic prostaglandins. Since then numerous studies have been performed worldwide, mostly using the Foley catheter. Then, in 1990, the double balloon catheter was introduced by Atad; this paved the way for the Cook Balloon. But what is the best way to use a balloon for cervical ripening? Should be a single balloon or a double balloon? If single balloon, does volume of the balloon matter? Should it be used alone or with combination with a second agent? Can it be used safely as an outpatient procedure? In this episode, we will present new data regarding traction vs no-traction for single balloon cervical ripening therapy. This new study was published on March 1, 2024 in Obstetrics and Gynecology (the Green Journal).

It’s very important to stay up-to-date and current with new data. But sometimes you read something that is hot-off-the press and it makes you just stop and say, “hmmm”. In this episode, we will discuss the new USPSTF position statement on screening/treating iron deficiency anemia in pregnancy. We will also review the ACOG August 2023 clinical consensus #4 regarding UTI in pregnancy. In doing so, we present 2 things that “make you go hmmm”.

The “traditional“ Parkland management protocol for GDM included the immediate initiation of medical therapy for those with abnormal fasting blood sugar, in addition to another additional value, on the 3 hour GTT. These patients were automatically labeled as A2 GDM at time of diagnosis, rather than waiting the 1 to 2 weeks of nutritional/diet therapy. Does fasting hyperglycemia on the 100g GTT truly predict the need for subsequent medical therapy? In this episode, we will summarize new data on this subject from AJOG MFM published on February 17, 2024. Does immediate medical therapy after GDM diagnosis improve overall maternal/neonatal outcome? It’s a complicated answer, and we will review it in this episode.

Yes, the subject of RhoGAM/RHIG administration to RH negative patients under 12 weeks gestational age is a continuously controversial issue. We have covered this issue in past episodes, most recently- last month- on January 4, 2024. Today, February 26, 2024, the SMFM released their position statement on the subject. As you would guess, the controversy continues! In this episode, we will review this brand new, hot off the press, position statement regarding RHIG administration, or avoidance, under 12 weeks gestation.

February 2024 has seen its share of medical and mainstream media stories highlighting hypertensive disorders in pregnancy. While some of this can be considered “old news”, there is “new news” and new developments on the horizon. We have covered hypertensive disorders in pregnancy on several past episodes; however, in this episode, we are going to pick up where we left off and review what the current state of understanding is for AHA/ACC Stage 1 hypertension in pregnancy. Does stage I hypertension in pregnancy require medication? What about antepartum fetal surveillance? What are these patients at risk for? Listen in as we simplify the latest data and summarize the latest evidence regarding serum biomarkers for hypertensive disorders in pregnancy.

Hyperemesis Gravidarum (HG) has a reported incidence of approximately 0.3–3% of pregnancies. Without prompt recognition and treatment, severe maternal dehydration, electrolyte abnormalities, cardiac arrhythmias, and potentially altered fetal neurodevelopment may result. Recently, HG made medical and general media news as new data has pinpointed 2 likely culprits of its origin- and neither one is estrogen. In this episode, we will discuss these 2 protein markers, and how researchers are looking to develop a genetic test for patients to predict HG. We will also summarize a new publication from Obstetrics & Gynecology (which was published on February 1, 2024) as an ACOG Clinical Expert Series on the inpatient management of HG.

Women whose fetuses are in the occiput posterior head position at the time of delivery are known to have longer second stages of labor and more complicated deliveries, including more operative assisted births, more 3rd and 4th degree lacerations, PPH, and in some studies lower Apgar scores and lower umbilical cord arterial pH. At what point in labor should the healthcare provider attempt to rotate the fetal head: first stage or second stage of labor? Recent intrapartum studies using ultrasound to verify fetal head position has provided new insights regarding the cardinal phases of labor. In this episode, we will tackle the fetal occiput posterior position and manual rotation. Should this be a 1st or 2nd stage of labor practice?

The ACOG has long-held that shoulder dystocia is “unpreventable and unpredictable”. Nonetheless, as it is a devastating obstetrical occurrence, researchers have attempted to identify a reproducible mathematical formula using ultrasonographic, anthropometric factors to better predict it. What is the data behind these math models? Does the ACOG recognize their use? What is their positive predictive value? In this episode, we will examine the data – going back 40 years – and we will end the episode with the current stance from the ACOG regarding these mathematical calculations for shoulders dystocia prediction.

The ACOG has consistently recommended universal screening for gestational diabetes between 24 and 28 gestational weeks. Although controversial, the ACOG does endorse earlier screening for GDM in patients with additional risk factors. But what about patients who present for prenatal care after the 28th or 29th week? Should screening for GDM be done in the 3rd trimester? And if we do screen in the then, what is the reference range for “normal “or “abnormal”? Is it the same interpretation as when it is done between 24 and 28 weeks? Does 3rd trimester screening impact parental outcome? In this episode, we will examine the data and provide a recommendation of when testing for gestational diabetes in the 3rd trimester may have the most impact.

On February 6, 2024, a new publication in the Lancet Planetary Health received national and international headlines. This study, funded through the NIH, revealed a striking association between certain chemicals in our environment and preterm birth. But is this data really new? We have known that certain chemical components, called phthalates, have a strong association with preterm birth for over 10 years now. Nonetheless, it is always a good reminder to reduce or avoid exposures to potentially dangerous substances which are ubiquitous in today’s culture. What exactly are phthalates? What did this new data reveal? In this episode, we will dive into the data and put things into proper perspective. PLUS, at the end of the episode, I’ll review 10 common-sense things that we can all do daily to try to reduce our exposure to these“forever chemicals”.

YES, it’s true… Not even Super Bowl Sunday 🏈🏈can stop us from getting our podcast episode up and out! In this episode, we will summarize the key findings of a newly released RCT (ahead of print, Obstetrics and Gynecology) that is yet another “nail in the coffin” for late pre-term/early term steroids. This is perfect timing, as we just covered this topic on a separate episode last week. So listen in as we summarize this newly released, triple-blind RCT with eye-opening results.

We are still in an opioid crisis. The number of women with opioid-related diagnoses at delivery has increased by 131% over the last several years (CDC, Data and Statistics, 2023). The ACOG has recommended the use of opioid agonist pharmacotherapy for MOUD during pregnancy. Traditionally, medically supervised withdrawal has not been endorsed for pregnancy. However, some patients may elect to discontinue opioid therapy in favor of an opioid antagonist like naltrexone. In this episode, we will review a new systematic review just released ahead-of-print in Obstetrics and Gynecology. This systematic review evaluates OB and neonatal outcomes following naltrexone use during pregnancy. And listen in until the END of the episode for one of the “issues” with naltrexone as a MOUD option.

It is completely natural, and part of the human experience, to have some anticipatory concern about an upcoming delivery/childbirth. However, when that concern becomes overwhelming, it can develop into a debilitating phobia called Tokophobia. First coined as a term in 2000, there’s been growing awareness of this specific type of anxiety disorder/phobia. Even though it was first described in 2000, this extreme fear of pregnancy and childbirth has, of course, been part of the human experience For centuries. This is now considered a sub-type of PTSD when it happens after a traumatic childbirth experience. The idea for this episode originated from a real patient encounter that one of our residents had just yesterday. Have you heard of Toca phobia? How prevalent is it? And what are the “4 Rs” of trauma informed care? Will cover this, and more, in this episode.

In 1972, Liggins and Howie published their landmark study on the benefits of antenatal corticosteroids (ACS) regarding their reduction of prematurity’s morbidity and mortality. This led to the weekly administration of ACS until 34 weeks. Weekly courses of steroids are no longer given, but the steroid story keeps evolving. In 2016, the ALPS trial demonstrated reduction in short-term respiratory morbidity when steroids were given in the late pre-term interval. Many professional societies and organizations endorsed this intervention shortly thereafter. But since then, there have been renewed commentaries and debates regarding steroids in the late pre-term interval, and steroid exposure in-utero for babies born late pre-term/term. several professional organizations, no longer endorse steroids in the late pre-term interval. In this episode, we will review this complicated and ever evolving debate, highlighting a recent systematic review and meta-analysis from August 2023.

On January 28, 2021, a non-inferiority RCT was published in the NEJM, “Levonorgestrelvs Copper T Device for Emergency Contraception”. This study concluded that the LNG 52mg IUD was “noninferior” to the CopperT IUD for emergency BC up to 120 hours after ill-protected intercourse. Since that time, use of the LNG 52mg IUS has remained controversial with some organizations endorsing its use as EC while others take a more cautionary stance. Now, as a February 1, 2024, a new commentary in the Green Journal (Obstet Gynecol) is raising eyebrows regarding this. What’s the controversy surrounding this? Is the LNG 52 mg IUS a reasonable option for emergency contraception? What does non-inferiority mean? In this episode, we will go through all of the data and put things in proper perspective. While gaps in evidence remain… There is plenty to draw an evidence-based opinion on. Curious? Listen in and find out more.

On January 18, 2024, the FDA cleared a novel new device for osteopenia treatment. This is a vibrating belt (wearable device) that transmits low-amplitude, high-frequency (20 to 40 Hz) vibration to the spine and hips. This belt is called Osteoboost. Osteoboost previously received a breakthrough designation from the FDA in Dec 2020. This FDA clearance has already generated a lot of commentaries regarding the single RCT results. In this episode, we will review the results critically and explain why there is a difference in “per protocol” RCT results and “intend to treat” RCT results. Is Osteoboost a game changer? Listen in and find out.

Bacterial vaginosis (BV) is the most common vaginal aberrant condition in women, in the general population. Even still, the majority of women with BV are asymptomatic. If BV is found at time of elective IUD/S placement, can the device still be inserted? Or is it an independent risk factor for upper tract infection? What category in the CDC MEC is vaginitis/vaginosis for IUD placement? There definitely is some confusion about this in clinical practice, highlighted by the 3 different clinicians which were interviewed in this episode! So…. IUD placement with BV: test and place, or test and differ placement? Listen and find out.

Hypertensive Disorders of Pregnancy (HDP) affect 5 to 15% of women worldwide, and their increasing incidence is likely related to the growing levels of obesity, metabolic syndrome and advancing maternal age. It is widely accepted that women who have preeclampsia are at increased risk of future hypertension, cardiovascular disease, stroke, chronic kidney disease, and even diabetes in later life. But what is the association between HDP and dementia? In this episode, we will review the latest data from a systematic review and meta-analysis published on January 24, 2024 in the AJOG.

Uterine wall perforation at time of IUD placement has been published to occur, in general, about 1-2/1,000 cases. It happens! While there are some risk factors for uterine perforation (very antiflexed, retroflexed, recent postpartum state, lactating), sometimes uterine perforation can happen even with the best of technique and no risk factors. While most providers are concerned about immediate short-term gynecological complications like infection and bleeding, we don’t really consider the possibility of any potential future OB complications. Is a patient at higher risk of future adverse OB issues after perforation during IUD placement? It’s an interesting question, with an even more fascinating answer! In this episode we will dive into the data, and make sense of published case reports and clinical opinions which help us arrive at the answer to that question.

Yep, Medicine moves fast! On Friday, January 5, 2024, I participated in a medical news report published in “The Guardian”. In that news commentary I stated that “Bicillin-LA is the only medication approved for syphilis during pregnancy”. We’ve all heard that statement, and it is a true statement. However, 5 days later on January 10, 2024, the FDA announced the importation allowance of “Extencillin” to combat the Bicillin-LA shortage. Yep, Medicine moves fast. Now we have this medication available as an option until Bicillin-LA increases its availability. But what about Linezolid? In this episode, we will also discuss a recent non-inferiority trial of Linezolid for early syphilis, which was published in “The Lancet”. Although that study had disappointing results, there are some caveats which need explaining. Listen in to find out more.

If you had 5 reproductive age women, all late on their menstrual cycle, who were having unprotected sex, and all have a positive pregnancy test… What would be your diagnosis? The most likely diagnosis would be that there are five pregnancies! Right?! But what if 1 of those patients had end stage renal disease (ESRD), on hemodialysis. Is there anything else to consider? While ruling out pregnancy is priority #1, it is possible that this HCG is a phantom result. This is a slippery slope discussion and one that could easily lead down the rabbit hole. In this podcast, we will highlight this clinical conundrum, based on a real case from our practice, and summarize some fascinating reports from the literature.

Periodically, we respond to podcast family members’ questions as data is available. In this episode, we will cover 3 very clinically relevant questions from our podcast listeners. The first question is regarding our immediate past podcast topic, which was propranolol as a labor stimulant. The question is, “Does the ACOG have a statement on adjuvent propranolol use during labor?“. We’ll answer that question in this episode. The second question is whether the placebo/pill-free interval of combination birth control pills is linked to anxiety/depression. This is a COMPLICATED issue but there is brand new data that helps answer that exact question, and we will cover that in this episode. The final question is whether or not “HPV booster vaccination“ is indicated after CIN2+ treatment in patient who had previous vaccination. Lots of data to help answer these questions… and we will summarize it here.

It has been well reported that rates of elective induction have risen nationally and internationally since the adoption of the ARRIVE trial. But as medicine is at times controversial, some studies have suggested an increase in cesarean section rates with elective induction of labor at 39 weeks. While we will briefly discuss those studies, they are not the focus of this episode. However, as induction of labor becomes more common place, there has been renewed interest in use of adjuvant medications to augment induction success. One of those medication is propranolol. Can giving a beta-blocker help with uterine contractility? The data is conflicting with recent evidence saying “No!“. In this episode, we’re going to put the evidence on trial and present both arguments: one as plaintiff, and one argument as the defense for our shared client, which is propranolol. Is propranolol guilty of its charges of being a labor stimulant? Or is it innocent of all charges? Let’s let the data decide.

On New Year’s Eve 2023 we released “LUST for TOLAC”. LUST stands for lower uterine segment thickness. This is a very enticing, and controversial, approach to TOLAC counseling and direction. I encourage you to go back and listen to that episode, if you have not yet, before listening to this one as this is more data to support those conclusions. In this episode, we will highlight a multi-center, cluster-randomized trial out of Canada, the PRISMA study. This fantastic investigation sheds more light on the application of LUST for prediction of TOLAC uterine rupture.

The gestational age boundary termed viability has shifted dramatically during the past 50 years, and more so in the last 15 years. In 1971, a widely used neonatology textbook stated that, “The lower limit of viability is probably around 28 weeks, at which time most infants weigh two pounds, four ounces (1000 g).” Today, the most immature infants routinely cared for by neonatologists in some parts of the world are born at 22 weeks of gestation, with many weighing around 500 grams. While most studies reporting on neonatal resuscitation at 22 weeks give a main outcome as “alive at discharge”, there are other potential long-term morbid conditions which cannot be ignored. The ability to perform neonatal resuscitation at 22 weeks and 0 days has led to many powerful ethical debates and published commentaries. In this episode we will take a look at the complexities of neonatal resuscitation at 22 weeks focusing on the potential long morbidity after hospital discharge.

This is NOT our regularly scheduled episode. Based on an incredible comment from Rachel – one of our podcast family members, which I received just moments ago, this was too good to not put out. A brief clarification on NIPTS and “46XX or 46XY”. (This is a supplement to our immediate past episode.) 😊😊🧐🧐

NIPT is a prenatal SCREENING method that involves analysis of cell-free fetal DNA (cfDNA) in maternal blood. Prenatal screening for sex chromosome aneuploidies (SCAs) has become readily available through expanded non-invasive prenatal testing (NIPT). NIPTs became commercially available in 2011 and has since been introduced in more than 60 countries around the world and is now part of mainstream obstetrical practice. Initially offered as a secondary screen for pregnancies with a high probability of a fetal chromosomal anomaly, NIPT is now often offered and recommended as a first-line screening test for the main chromosomal aneuploidies. Initially, NIPT was available to screen for fetal trisomies 21 (Down syndrome), 18 (Edwards syndrome) and 13 (Patau syndrome). This has expanded of course to include (separately) fetal sex chromosome aneuploidy (SCA) screening. However, there are some VERY important points we must remember when seeing an “atypical sex chromosome” NIPT result. What is the PPV of a SCA found on NIPT? In this episode we will highlight a recent NIPT atypical sex chromosome result from our practice and review what this may and may not actually mean, and review why NIPT screening for SCA is actually VERY controversial with some potential ETHICAL concerns, with some countries recommending AGAINST ordering it. Lots to cover here….so listen in.

We take pride as healthcare providers in being “evidence based“. But sometimes things that we do, even in 2024, sound, reasonable and sound practical, but actually are NOT evidence-based. But lacking evidence means 2 things: 1. Studies have proven something does not work, or 2. Studies have not been done to confirm or refute the intervention. In this episode, we will discuss 2 common interventions that are recommended in pregnancy that actually don’t have the evidence behind them. First is the “test of cure” urine culture after treatment of ASB or cystitis, and the second is certain physical activities like specific yoga positions/Miles circuit as preparation for labor. I believe in both of these interventions- although we don’t have STRONG data for either. I will explain in this episode. That’s why I am calling this, “No data, No problem!”.

Before the 1960s, there was no method available to prevent Rh sensitization during Rh-incompatible pregnancies. Then, in 1968, the FDA approved the use of RhoGAM to help prevent Rh immunization. This was a landmark move in the field of Obstetrics. More recently, ever evolving data and medical genomic technology has brought new insights to RHD alloimmunization care. Can maternal RH typing be avoided with early pregnancy loss (under 12 weeks)? Why about in cases of pregnancy termination? Is that safe? And what is the UNITY non-invasive prenatal test? How can it be used to decrease unnecessary Rhogam administration? Well cover all this new data in this episode (NOTE: UNITY is not a sponsor of this podcast nor of this episode).

Historically a range of psychiatric and medical conditions have been erroneously attributed to 2 gynecological organs/function. During the time of Hippocrates, the “wandering womb” theory blamed emotional disturbances in women on this condition. Not only was that erroneous, it was nonsensical. However, certain gynecological conditions can indeed manifest with neuro-behavioral disturbances. One of these syndromes can be triggered by the presence of an ovarian dermoid. Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis is a paraneoplastic limbic syndrome which may be caused by ovarian teratomas containing neural components. Neural tissue in a teratoma can trigger the production of anti-NMDA-R antibodies, which causes neuronal dysfunction and loss by altering the neuronal cell-surface NMDA receptors in the limbic system. This syndrome presents with a range of psychiatric, neurological and autonomic features and if not promptly recognized and treated may be associated with long-term morbidity and mortality. Rare…yes. But it is out there in the community and patients are at HIGH risk of misdiagnosis. In this episode we will discuss this “Brain on Fire” syndrome and highlight a real case contributed by one of our podcast family members (HIPPA protected).  

This is our last episode for 2023! A podcast family member reached out to me notifying me of a thread on social media discussing ultrasound measurements of “lower uterine segment thickness” (LUST) for TOLAC candidates. I consider myself pretty social media friendly, but was unaware of this comment thread. Should we be measuring lower uterine segment thickness in the late 3rd trimester as a discriminatory tool for TOLAC approval/denial? Is this evidence-based? Where did this concept originate? Is this supported by the ACOG? The answer to all of this is both YES and NO. We will explain in this episode.

It’s no surprise and understatement to say that the US maternal/neonatal morbidity and mortality rates have to improve. As a way to increase maternal supportive care, an increasing number of states are turning to cover Doula services. Despite this forward thinking, there are still misperceptions, misunderstandings, and “boundary” issues regarding Doulas which must be addressed. Are Doula interventions evidence based? Are Doula services related to improved maternal and neonatal outcomes? What is the position from the ACOG? Does the March of Dimes have a position statement? We will answer all of these questions and explain why 2024 may be the “Year of the Doula” in this episode.

On May 8, 2023, we released an episode called “Slowed Fetal Growth Trajectory and Neonatal Outcome”. That episode highlighted data that slowed fetal growth was an independent risk factor for stillbirth. This is true even though the composite EFW remained above 10 percentile. Now, there is new data which validates this concept and provides a working model which may help predict fetuses with slowed fetal growth who are at risk of stillbirth. PLUS, we will describe a free online fetal growth trajectory calculator (UK) that helps with patient education and prognostication.

On August 26, 2023, we summarized the ACOG update on viral hepatitis in pregnancy and discussed new concepts regarding Hep B viral infection. To follow that up, the SMFM has now released its Consult Series #69 (Hepatitis B in Pregnancy: Updated Guidelines) which was published on December 21, 2023. In this episode, we will reinforce some topics originally discussed back in August 2023 and emphasize key management issues regarding Hep B in pregnancy based on this Consult Series… both for the infected, and the non-infected/non-immune patient. Is antepartum fetal surveillance indicated in these patients? Is C-section a way to prevent perinatal transmission? What’s the viral load cut-off to begin antiviral medication? Is it safe to administer hepatitis B vaccine during pregnancy for those who need it? Listen in for details.

The average height for men in the U.S. is about 5 feet 9 inches. For women, it’s about 5 feet 4 inches. Height stature has been correlated with some interesting health conditions at a population level: Some research shows that a below-average height may mean you have lower odds of getting some types of cancer. For example, a study of more than 100,000 women in Europe and North America showed that shorter women are less likely to get ovarian cancer. Also, although researchers can’t explain why, studies show that the shorter you are, the less likely you are to have a VTE. People who are 5 feet or shorter have the lowest chances of getting one. Those are good correlations to being short! BUT, short stature has also been linked to higher stroke risk, coronary heart disease, and diabetes. It is theorized that individuals at/around the 5 foot mark- outside of simple race/genetics- may have been imprinted for smaller growth trajectories either in utero or in early childhood which metabolically predisposes them to these future issues. What about short stature and pregnancy? Are there any correlations there? Is maternal short stature an independent OB risk factor for negative outcomes? And why do we only have ONE main EFW chart (Hadlock) in pregnancy vs population specific ones? We’ll get to the tall and short of it…in this episode.

Sex has always had its share of misinformation, even as it relates to some medical conditions- like epilepsy. "Coitus brevis epilepsia est" ("Sex is a brief seizure") is an ancient proverb attributed to Galen, the influential Greek physician and philosopher in the Roman Empire. Then, in the 18th and 19th centuries, some physicians, including Samuel-Auguste Tissot and Edward Sieveking, argued that excessive masturbation could cause epilepsy! At the time, castration and clitoridectomy (removal of the clitoris) were reportedly performed on people with severe epilepsy. Terrible! Thankfully we now are all SURE that sex does not CAUSE epilepsy, but sexual release (orgasm) and seizure like activity are indeed similar. Can orgasm trigger epilepsy? And is the reverse possible: can seizures give orgasm like effect? How is PNES related to this? We will review this fascinating clinical conundrum in this episode.

BIG. BIG. BIG Update. In March 2014, the ACOG/SMFM released OCC #1 (Safe Prevention of the Primary C-section) which redefined the labor curve. That document has now been WITHDRAWN. It is being replaced with Obstetrical Care Consensus #8 coming out January 2024. In this episode, we will highlight key points from this updated guidance including: 1. ACOG’s new language surrounding the length of latent phase, 2. the role of “early” amniotomy in labor induction, and 3. clarification on 2nd stage of labor management.

It’s really amazing how fast medical information and discovery happens. For decades, we blamed nausea and vomiting of pregnancy/hyperemesis gravidarum on either estrogen or high levels of HCG. While these 2 hormones definitely have some association with that condition, new evidence has pointed to a separate compound as the likely offender. In this episode, we will review data just published on December 13, 2023 from an international research think tank. This group has likely pinpointed the origin of nausea and vomiting of pregnancy. This discovery opens up a new area of therapeutics aimed at targeting this chemical messenger, rather than simply treating the symptom of nausea. Are you familiar with GDF-15? In this episode, will review this incredible little molecule, and summarize key findings from this recent publication.

According to ACOG’s CO 773 from 2019, “Currently, serum antimüllerian hormone levels are not part of the accepted diagnostic criteria for polycystic ovary syndrome (PCOS)”. But medicine moves fast, and that statement is no longer valid, at least it isn’t valid from the ASRM July 2023 Standpoint. Yep, once considered experimental, AMH has now entered the PCOS diagnostic algorithm. Nonetheless, some important limitations and facts must be understood for its use in this way. In this episode, we will highlight the recommendations from the 2023 international, evidence-based guideline for the assessment and management of polycystic ovary syndrome, focusing on the role of AMH. We will also discuss the condition in adolescents and why this diagnosis is DIFFERENT in this group, and the update to the number of follicles per ovary (FNPO) recommended for the diagnosis. This guideline has been co-published in Fertility and Sterility, Human Reproduction, European Journal of Endocrinology, and The Journal of Clinical Endocrinology and Metabolism.

We thought we had endometriosis all figured out. After all, we know it’s a chronic pain syndrome that’s hormone responsive. But there’s more to it than that. Within the last few years, including this year 2023, we have grown even more in our understanding of this pelvic pain condition. We now have new data explaining the link between endometriosis and migraine attacks. Are you familiar with CGRP? While most attention has focused on this biochemical messenger’s role in migraines, CGRP is also related to endometrial implants. In this episode, we will do a deep dive into the shared pathophysiology of endometriosis and migraine headaches. We will look at the role that CGRP and TRPV1 play in both of these pain conditions.

Advances in obstetrical and neonatal care have allowed for increased survival rates in babies born at extremely premature gestational ages. However, extreme prematurity brings its own set of issues and problems. One of these issues is intraventricular hemorrhage (IVH). Intraventricular hemorrhage is not simply a neonatology issue, but is something that all obstetrical providers should be familiar with. Does the mode of delivery impact the rates of intraventricular hemorrhage for extremely preterm vertex babies? Do corticosteroids help reduce the rate of IVH? And at what gestational age is umbilical cord milking not associated with the risk of intraventricular hemorrhage (Nov 2023 Data)? In this episode, we will do a deep dive into the pathogenesis and behavior of IVH and discuss common obstetrical interventions that may mitigate its occurrence. We will also discuss how magnesium sulfate works for fetal neuroprotection and discuss the importance of neonatal vitamin K administration in extremely pre-term neonates.

We are definitely a “DIY“ society. And now, consumers can add DIY Insemination to that list! On December 6, 2023 the FDA cleared the first device for at home insemination. This over-the-counter option will be available in 2024. In this episode, we will review this landmark and historic device clearance. We will also clarify the distinction between FDA “approval” and FDA “clearance”. Who is best suited to use this device? Is this considered first-line for unexplained infertility? Lots of interesting questions, but we have the answers. Listen in and find out more.

Amniotic fluid embolism remains one of the most devastating conditions in obstetric practice with an incidence of approximately 1 in 40,000 deliveries. The associated mortality for this condition has been reported to be 20% at the low-end, to 80% at the high-end. The use of atropine (1 mg intravenously [IV]), ondansetron (8 mg IV), and ketorolac (30 mg IV) (AOK) as an adjunctive treatment has been widely discussed by obstetric providers as a treatment option which should be considered to supplement other treatment modalities. In this episode, we will review the pathophysiology of AFE and discuss its first-line treatment regimens, as well as the AOK/AOK – T protocol.

Management of CINI is straightforward, as is management of CIN3. CIN1 allows for observation, and CIN3 requires treatment regardless of the patient’s age as it is a true pre-cancerous lesion. But some “gray zone“ exits for CIN2 management. Population-based data has confirmed a high rate of spontaneous resolution within 2 years after CIN2 diagnosis. Is the rate of cervical cancer higher in this surveillance group compared to immediate LEEP? In this episode, we will highlight 2 separate publications, each originating from the same patient database (Danish population-based cohort). These 2 publications are from the same group of authors with one publication coming from the AJOG (December 2023), and the other one published last month in BMJ (November 2023).

A recent analysis of NHANES data from 2021 found that 40% of US adults aged 18 to 44 are insulin-resistant (IR) based on HOMA-IR measurements. While obesity rates have increased considerably over the past 2 decades, this rapid increase in prevalence was not only associated with increased adiposity. Hypertension, dyslipidemia, and limited physical activity also increased insulin resistance. PCOS and IR are intimately tied, although not all PCOS patients will have clinical or biochemical evidence of IR. And remember this clinical pearl: IR is NOT included in the diagnostic criteria for PCOS. According to published estimates, insulin resistance may be found in 44% to 90% of people with PCOS (the widespread percentage is due to various testing modalities and PCOS phenotypes). Screening for IR is an important aspect of preventative health maintenance in PCOS patients, and all patients deemed high risk. In this episode, we will provide an evidence-based review of the various modalities for IR screening and diagnosis.

On July 30, 2023 we released an episode describing the hypertensive “rule of 55” otherwise known as the physiologic approach to hypertension management. The rule of 55 breaks down hypertension into either hyperdynamic/high cardiac output in origin, or systemic vascular resistance in origin. There is plenty of evidence to support this management approach. Late this evening, on November 30, 2023, Obstetrics and Gynecology released a new research letter ahead of print, providing more insights on the physiologic approach to hypertension management. In this episode, we will briefly cover this brand new publication, released just 2 hours ago, and provide clinical application perspectives.

Population based data tells us that 15 to 20% of women will develop an ovarian cyst during their lifetime. Although most ovarian cyst have a low potential for malignancy, their presence causes anxiety for both the patient and the provider. Our typical mental-exercise is balancing the risks of expected management vs choosing surgery prematurely. Which ovarian masses are likely to resolve if given enough time? Do septated ovarian cysts resolve the same as simple cysts? In this episode, we will highlight and summarize a new publication coming out in Obstet Gynecol (Green Journal) in December 2023. We will also review a uniform, standardized approach to reporting and interpreting ovarian masses, originally published in 2020 by the American College of Radiology. This scale is called the O-RADS classification and provides extremely helpful tools for ovarian cyst prognostication and follow up.

The word clitoris comes from the Greek word, “kleitoris” which means “little hill”. In 1559, the clitoris was “discovered” by an anatomist Renaldus Columbus who called it the “love of venus” and concluded that its primary function was strictly for pleasure. It is quite shocking 2 believe, although true, that the first anatomical paper on the clitoris was published only in 1998 and its anatomy, using MRI, fully described in full in 2005. This lack of scientific attention, until recently, to both the anatomical structure and true functioning of the clitoris is equally shameful as it is shocking. It is no wonder that vast misunderstandings of such a vital structure for female sexual well-being persist even today. In this episode, we will review an eye opening, and sad, recent publication released on October 15, 2023 in the Australian and New Zealand Journal of Obstetrics and Gynecology. How well do we truly understand clitoral anatomy? Apparently, not well at all! As Women's Health care providers, we must realize that the results of that study are not only disappointing but that we must also advocate for more information and education pertaining to the mysterious little bean. How is our understanding of the clitoris related to Napolean Bonapart, and to Sigmund Freud? How is the Clitoris-Vaginal Distance related to orgasm? And what is the actual wishbone anatomy of the clitoris? Listen in and find out.

A ruptured uterus is a potentially catastrophic event in which the integrity of the myometrial wall is breached. We all have memorized the usual red flags and contraindications to labor as prior classical cesarean, multiple (more than 2) low transverse cesarean, prior transmural gyn surgery, or grand multiparity. In the absence of previous surgery or multiparity, uterine rupture may go unnoticed, resulting in late diagnosis and considerable mortality and morbidity. Uterine rupture intrapartum has also been reported in primiparous patients, without a history of uterine surgery. Although more likely to go unrecognized and/or underreported, the proposed incidence of rupture in the unscarred uterus has been recently published at less than 0.01% deliveries! Rare right? Well, it’s rare until it happens to you. In contrast, uterine rupture has been reported to occur in 0.2–1% in those with one previous low-transverse scar. Diagnosing this condition in the absence of uterine scar requires a high degree of suspicion and fetal heart tracing abnormalities remain the most common symptom. In this episode, we will look at published data- including a recent review from the Green Journal from April 2023- regarding this terrifying event and review risk factors that may raise the risk of uterine rupture in a patient without the classic historical red flags. And, we will review how 2 GYN diagnoses influence the risk of uterine rupture in labor. Plus, we will review what the published data says regarding characteristic uterine and fetal heart rate patterns in those found to have uterine rupture.

On Tuesday, November 21, we released an episode titled “Optimizing Postpartum HTN Care”. On Wednesday, November 22, I received notification that a new clinical opinion piece will be released in AJOG in December 2023 which also discusses whether or not mag sulfate, should be used in the late postpartum interval in these patients. Amazing timing! Our podcast, and this soon-to-be released clinical opinion, match 100% in the data and recommendations! 🎉🎉🎉 So in this episode, we will highlight the main take-home points from that soon-to-be released clinical opinion regarding whether or not magnesium sulfate should be used in the late postpartum interval for hypertension. This is a perfect and timely supplement to our immediate past podcast. 👏👏👏

Data has shown that more than half of maternal deaths occur past the traditional 6 week postpartum mark. This is why the ACOG recognized the “fourth trimester” in 2018 (ACOG CO 736), reflecting the fact that the patient is still at risk beyond the first 6 weeks after delivery. One of the main areas of focus postpartum is on hypertension care. Growing understanding of the long-term implications of HDP and other medical complications of pregnancy have led to an increasing focus on building transitions from postpartum care to primary care, which will be essential for the long-term wellbeing of women with postpartum hypertension. How many women will develop new onset hypertension more than 6 weeks from delivery? At what blood pressure cut off should anti-hypertensive medication be considered postpartum? Should it be at 150/100 or 140/90? Which medication is preferred for postpartum use? Is magnesium sulfate for severe range blood pressures effective as seizure prevention beyond 7 days postpartum? We will tackle these questions, and more, in this episode.

ACOG’s last practice bulletin on asthma in pregnancy (ACOG PB 90) was back in February 2008. Yep, 2008. Sooo… No advances since then? There’s been big shifts in the management of asthma, of course. That’s why we’re doing this podcast- things move so fast, and it’s often hard for guidelines to keep pace at times. That’s why we’re here. And that’s why it’s important to always stay ahead of the data. are you aware of the new recommendations from the GINA? It has changed the way we view Short Acting B Agonist therapy (SABA) as solo medication. And what about antepartum fetal surveillance? Is that indicated in moderate to severe asthma? Maternal asthma is not listed on the “indications for outpatient fetal surveillance“ from the ACOG‘s 2021 Committee Opinion. Should it be there? Can biologics be used? We’ve got lots to cover in this episode. So take a deep breath in and out… and listen in.

It’s a universal nomenclature… The TPAL system. Despite its traditional and long-standing integration into obstetrical vernacular, there are significant gaps in this system. And, although we use these terms daily, there is controversy about what one of those elements actually means. What is the “L“ actually for? We’ve all learned it as “living children”. But what does that actually mean? Is that live births? Is it number of living children at time of the report? Or does it mean something entirely different? In this episode, Dr. Katie Light joins me as we have a fun time looking into the data. Hang out with us until the end of the episode, because I will give us some practical insights for using the TPAL nomenclature.

This episode is our NEWS BRIEF. Yesterday, on November 15, 2023, the FDA approved the first, patient self-collected, home test kits for GC and Chlamydia. This is a BIG advancement for women's health. But, this is actually not the first at home STI test to be approved. In this episode, we will review this new FDA approved test, the specifics of the product, and why this is not just a "direct to consumer" purchase item.

Recently, we released an episode regarding the limited utility of by BMEs; now, I mean, limited utility as a routine, annual exercise in the low-risk asymptomatic, and non-pregnant patient. And there’s plenty of evidence that has shown that just doing a bimanual exam because “that’s what we’ve always done” -without a real indication- is just not helpful. All to say, we received numerous comments regarding that episode with 99% saying, “this is great”, “thank you for sticking with the evidence”, and “yes, we stopped doing bimanual exams without indication, when the ACOG first put that out several years back”. But of course there’s always that 1% who state something like, “I can’t believe you’re not recommending this exam, this is how we find ovarian cancer, etc”. This is very interesting because the whole episode was how it exactly did NOT help in the early detection of ovarian cancer, but simply increased the ordering of tests and patient anxiety! (Which makes me think, maybe they didn’t even listen to the episode). One of the comments that came in was worth noting. This provider said, “Isn’t the same debate applicable to clinical breast examinations (CBEs)?” What’s the data on that? And how do various medical groups and professional societies agree or disagree with CBEs? Well, that’s exactly why we’re doing this episode! In this episode, we’re going to cover the various guidelines and opinions regarding the utility of clinical breast examinations. Plus, you’ll want to hang out with us until the end of the episode, when we will provide some real, practical applications for daily practice. Yep, let’s “feel the data out” (see what I did there?). 🧐🙂🙂

Trichomoniasis is the most prevalent nonviral sexually transmitted infection (STI) in the United States and is more prevalent than chlamydia and gonorrhea combined. In the US, the southern states share a disproportionate burden of infection, with rates up to 14%. Infection with Trichomonas vaginalis increases risk of human immunodeficiency virus (HIV) acquisition and is associated with adverse perinatal outcomes, including preterm birth, low birth weight, and preterm premature rupture of membranes. Although 80% of infections are asymptomatic, there are no national recommendations for trichomoniasis screening in women who are HIV-negative (including pregnant women who are HIV-negative), except for incarcerated women, where screening is recommended. Plus, there is also perpetual controversy surrounding whether asymptomatic trich should be treated in pregnancy or not. Why is that? Shouldn’t we always treat STIs in pregnancy? The data is a bit confusing for asymptomatic trichomoniasis. We’ll review the data in this episode and we will end with some practical advice for treatment of trich in pregnancy.

The pelvic examination is a standard component of the annual gynecologic visit despite limited evidence supporting its utility. Pelvic examinations can be a source of discomfort and anxiety for some patients seeking routine health care, whereas, for others, they can offer reassurance. In 2018, the ACOG released CO 754 on "The Utility of and Indications for Routine Pelvic Examination". What does the AAFP, ACP, and ACOG say about "routine" pelvic examinations in low-risk, nonpregnant, and asymptomatic women? Why do they say what they do? In this episode, we will summarize a new publication from Obstetrics & Gynecology which was just released yesterday (November 9, 2023) which validates these professional societies' guidelines/stances.

What do think about when I mention to you, Placenta Accreta Spectrum (PAS)? You would probably think placenta previa and prior C-section, right? You should! Those are the two most well-known risk factors. But placenta accrete can happen without either of those 2 factors, although less commonly. I was recently asked to provide insights on a real case of suspected PAS in a primiparous patient who was suspected of having placenta accrete at attempted placenta extraction at time of her primary C-Section performed for failure to progress. Her placenta was fundal. Can a fundal placenta be an accreta? What is the frequency of that? And what is the expected patient morbidity? We’ll examine the data and highlight a recently published case report from September 2023 describing a similar presentation.

I received a very personal and impactful Facebook message today from one of our podcast family members. It was enough to stop me in my tracks, and issue this heartfelt response. For F. L.

The Centers for Disease Control and Prevention, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the World Health Organization all recommend universal topical ocular prophylaxis to prevent gonococcal ophthalmia neonatorum. In the United States, ophthalmia neonatorum caused by N. gonorrhoeae has an incidence of 0.3 per 1000 live births, while Chlamydia trachomatis represents 8.2 of 1000 cases. However, this prophylaxis is not a uniform GLOBAL stance. The Canadian Pediatric Society recommends against universal prophylaxis. Several European countries, including Denmark, Norway, Sweden, and the United Kingdom, no longer require universal prophylaxis, instead opting for a prevention strategy of increased screening and treatment of pregnant women and/or selective use in those delivered without pregnancy screening. But WAIT… it gets even slightly more confusing. According to a 2022 publication from the FROM THE AMERICAN ACADEMY OF PEDIATRICS, the AAP has taken the position that the need for legal mandates for ocular prophylaxis should be reexamined and instead advocates for states to adopt strategies to prevent ophthalmia neonatorum by focusing on maternal treatment, such as compliance with CDC recommendations for prenatal screening and treatment of N gonorrheae and Chlamydia trachomatis. This was also the subject of a recent review published May 2023 in an article titled, “Neonatal ocular prophylaxis in the United States: is it still necessary?”. Confused...don't be. We’ll cover all this information in this episode. So, can erythromycin ophthalmic application be avoided in some cases? Is that safe? And if so, doesn’t that conflict with current US neonatal care expectations? Listen in and find out.

On September 26, 2023 we released an episode titled “LDA in Preg: the SAGA Continues”. Well, it continues still. In this episode, we will review a brand new publication (a Narrative Review) released ahead-of-print yesterday on November 2, 2023 covering “Aspirin in Pregnancy” (Obstet Gynecol). We will focus on 2 main areas: 1. Dose of aspirin best suited for preeclampsia prevention, and 2. support for universal adoption. PLUS, we will throw in one other clinical pearl regarding continuation until delivery. As a reminder, the ACOG is still in the draft stages of revising its “low-dose aspirin for preeclampsia prevention” consensus guideline. Listen in to see which way the data is leaning regarding this common prophylactic treatment plan.

Recurrent vulvovaginal candidiasis (RVCC) is a highly burdensome, long-lasting medical condition that heavily compromises the activities of women and their quality of life. Recently, the prevalence of RVVC has increased, partly due to a rise in VVC caused by non-albicans species. Here's a real-world clinical dilemma (from a real case): What would you offer a patient who is allergic to fluconazole and terconazole, has taken 3 doses of Brexafemme, has used boric acid, and even tried vaginal probiotics? Oh- and vaginal Gent Violet is not available (in this case). In this episode, we are going to review 3 alternative vaginal therapies that could be very helpful in cases where that darn yeast will not go away.

In 2017, the ACOG released committee opinion (CO) 712 which described the 3 categories of intrapartum fever. One of those categories was “isolated intrapartum fever”. In that CO, the ACOG stated that practitioners “should consider” the use of antibiotics in patients with isolated intrapartum fever. However, there was no evidence to support or refute that. But that evidence has now arrived. In this episode, we will discuss an upcoming publication from the AJOG (November 2023) providing important insights into the treatment of “isolated, intrapartum fever”.

DiGeorge syndrome… what a complicated condition for such a little area of a single chromosome being affected. The condition’s descriptive and preferred name is 22q11.2. This is called a microdeletion. Along with microduplications, microdeletions are collectively known as copy number variants. Copy number variants can lead to disease when the change in copy number of a dose-sensitive gene or genes disrupts the ability of the gene(s) to function and affects the amount of protein produced. Other examples of microdeletion syndromes include Prader- Willi, (which is a deletion on 15q), and Cri du chat syndrome which results from a microdeletion on 5p. In this episode, we will review the varied penetrance of DiGeorge syndrome and review its genetic basis. What are some suggestive features found on prenatal ultrasound? What are the associated abnormalities/phenotypes? And how is this condition managed after birth? And why is this also known as CATCH22. We will answer all of these questions, and more, in this episode.

For years, herbalists have touted bee pollen as an exceptionally nutritious food. They've even claimed it is a cure for certain health problems. Bee pollen does contains vitamins, minerals, carbohydrates, lipids, and protein. It comes from the pollen that collects on the bodies of bees as they fly from one flower to another. Bee pollen may also include bee saliva. This is NOT the same as natural honey, honeycomb, bee venom, propolis, or royal jelly. These other products do not contain bee pollen although there are combination products that contain one or more of these substances. A recent Social Media trend has propagated the idea that bee pollen can help breasts grow. Can it? Can it really boost your immunity and longevity? And what is the recommendation for use during pregnancy or breastfeeding? And speaking of pregnancy, can pregnant women eat RAW honey? We’ll get to the “sweet spot” of the data!

Although there were some early reports of sickle cell disease (SCD) in the late 19th century, the 1st time that the disease was referenced in literature was in 1910. Then in 1957, a doctor studying protein chemistry in England discovers that a single genetic mutation causes the abnormal hemoglobin found in patients who inherit SCD. And our knowledge of SCD continues to grow. In this episode, we will review a soon-to-be released new SMFM Consult Series # 68 highlighting the data on management of SCD and pregnancy. Are routine, prophylactic blood transfusions in pregnancy recommended? What about hydroxyurea? What is the dose of folic acid recommended for these patients? Is antepartum fetal surveillance recommended? We will answer all of these questions, and more, in this episode.

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. 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.

Finding a nuchal cord (NC) at delivery is not rare. NCs occur anywhere from 25-30% of all deliveries. When encountered at time of vaginal delivery, the first line maneuver should be an attempt to "reduce" the loop of cord around the fetal head by gently pulling the cord up and around the presenting part. However, if the NC is tight, an attempt at reduction may not be successful- or may risk inadvertent cord rupture withs subsequent fetal blood loss. Historically, the next move described was the +clamp and cut" maneuver. However, this interrupts the vital communication of oxygenated blood to the child from the placenta prior to the fetal body delivery. This prevents the beneficial and physiologic placental blood transfusion to the child immediately after the body delivers. That's why the fetal somersault maneuver has benefits when encountering a tight fetal NC. First described in 1991, this maneuver often gets overlooked as a viable option. In this episode, we will summarize the basis for and technique (the 4 Fs) of the fetal Somersault Maneuver.

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.

Incorrect delivery technique can lead to fetal birth trauma. However, sometimes – despite proper technique and care – fetal birth injuries occur. As I was taught as an intern, “Mal-occurrences don’t always mean Mal-practice“. Does that rule hold true for fetal clavicular fracture? What about Erb’s palsy found at birth? Can these issues occur as part of normal labor and delivery? And at time of cesarean section, does meticulous surgical technique always prevent immediate postop bleeding complications? In this episode, we’re going to review the data on 3 perinatal adverse events that may occur despite proper care: clavicular fracture, Erb’s palsy, and post-operative, rectus sheath bleeding/hematoma.

The ACOG released Clinical Consensus #4 in August 2023, covering Urinary Track Infections in Pregnancy. Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies. These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. In this episode we will summarize some the key points from this monograph, and we will tackle 3 common myths/misperceptions related to OB Pyelonephritis. Are most people who claim a PCN allergy truly allergic? Can an anaphylactic PCN response decrease over time? What antibiotic is recommended for OB Pyelo if patients do have a real anaphylactic PCN history? Can OB Pyelo present without fever? Listen in and find out.

The age at which couples have children in the United States continues to increase. While it is well documented and known that maternal age directly impacts fetal and child outcomes, less attention has been given to advanced paternal age (APA). Medical and Genetic commentaries have stated that limited APA principles have been advocated for or disseminated into the medical communities and the general population. There may be considerations for the development and application of a couple-centered strategy counseling on age-related genetic risks. Is APA a real issue? What age defines that? And what has APA been associated with? Listen in and find out!

A quick clarification about Beyfortus neonatal protection against RSV. Thank you Katie for bringing this to my attention! What a wonderful podcast community we have. ❤️❤️❤️

We have been following this developing story on the Maternal RSV vaccine, Abrysvo. In the recent podcast, we stated that we would let you know when the ACOG releases its “Practice Advisory”, which is its clinical guidance update. This is now out! In this episode will provide the summary, high-yield points regarding this vaccine’s use in pregnancy. Can this be co-administered with other vaccines? What did ACOG say about the preterm birth “numerical imbalance” among study trial participants who received this vaccine? And which option provides a stronger and longer lasting immune response in the child: maternal vaccination, or newborn vaccination? Listen in and find out.

Low Dose Aspirin has been a routine aspect of preeclampsia prevention since first mentioned by the ACOG’s Hypertension in Pregnancy Task Force report, back in November 2013. Since that time, there has been several revisions of the criteria of who qualifies for low-dose aspirin in pregnancy. Nonetheless, there are calls and expert opinions challenging this “risk factor based” approach, favoring a more universal adoption. Additionally, the DOSE of low-dose aspirin has also come under recent critique. Is 81 mg the correct dose to use? Does aspirin have the potential to reduce preterm birth? In this episode, we will review a soon-to-be released clinical commentary from the AJOG (October 2023) which addresses these matters.

According to the CDC’s press release from September 2022, the leading underlying causes of pregnancy-related death include mental health conditions (including deaths to suicide and overdose/poisoning related to substance use disorder), accounting for 23% of cases. The top 2 perinatal, mental health conditions are anxiety and depression. And, although much more rare with an incidence of 1–2/1,000, postpartum psychosis is a major cause of self-harm an infant harm. In this episode, we will review “The College’s” recent clinical practice guidelines on mental health therapies in the perinatal interval. Do you know which 2 classes of medications are most preferred for treating anxiety/depression in the perinatal period? Are SSRIs a leading cause of PPHN? Is Lithium allowed in pregnancy? And what is “neonatal adaptation syndrome”? We will cover all these questions, and more, in this episode.

It’s pretty standard of an evaluation… TVUS for postmenopausal bleeding. It’s well accepted that an endometrial thickness of 4 mm (5 mm in some studies) should trigger further endometrial tissue analysis in women with postmenopausal bleeding. But is there a cut-off endometrial thickness at which endometrial tissue should be evaluated in a postmenopausal patient WITHOUT bleeding, where this was found incidentally? There is definitely an evidence-based recommendation, and we will cover that in this episode.(With a special guest host 😊…. “Anything for SELENAs”)

Welcome to our “OB Smorgasburg” episode, where we have a CORNUCOPIA of topics. Well, maybe not a full cornucopia… But a mini-cornucopia. In this episode, we will address 2 recent publications that really are my “pet peeves“ about medical data! One is from the US Preventive Service Task Force, and the other has to do with “timed intercourse”. You have to listen to this! Then we will get into new data regarding the association of 1 abnormal glucose value on the 3 hour GTT with adverse neonatal outcomes. And lastly, is there such a thing as “organic” 50 g glucose challenge? Let’s get into all this information…Now!

Universal, weekly (surveillance) laboratory screening for expectant management of Hypertensive Disorders in Pregnancy has been routine practice since the release of the ACOG’s Hypertension in Pregnancy executive summary in November of 2013. This plan of care was also recommended in the ACOG Practice Bulletin 222 focused on Gestational Hypertension and Preeclmapsia. But does this actually help prevent maternal morbidity? Does routine weekly lab surveillance, detect worsening disease over clinical presentation alone? In this episode, we will summarize a new study soon to be released in the Green Journal (Obstetrics & Gynecology) which seeks to determine the clinical utility of this outpatient, antepartum management option.

Trichomoniasis has been found in every continent and climate without showing any significant seasonal variability. According to the CDC, trichomoniasis is estimated to be the most prevalent nonviral STI worldwide, affecting approximately 2.6 million persons in the United States. Conditions shown to be associated with T vaginalis infection include: Increased risk of HIV acquisition and transmission, increased prevalence of other sexually transmitted infections, adverse outcomes of pregnancy (eg, preterm delivery, preterm prelabor ROM), pelvic inflammatory disease, and infertility. Nonetheless, despite this potential morbidity, T. Vaginalis remains a non-reportable communicable illness. Why is that? In this episode we will summarize the data and look into the CDC's rationale for that decision.

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women, with a prevalence between 10 to 13%. PCOS has a large component of Insulin Resistance at its core. This is not only a metabolic complication in gynecology, but also has adverse implications for pregnancy. Since metformin is a staple of PCOS care, not only for infertility but also for the metabolic syndrome in adults, a common question is what to do with that medication once conception occurs. Should metformin continue past conception, and if so...should it be stopped at a certain gestational age or continued until delivery. There is data to help with this clinical conundrum. In this episode we will review the data from 2001 up to the most recent ASRM PCOS management guideline for PCOS, which just came out-ahead of print- last month August 2023.

NSAIDs have been shown to be associated with development of VTEs. This data is not new, but is more than 10 years old. Of course, hormonal contraception is also known to potentially increase the risk of VTE depending on the amount of estrogen in the combination product as well as the type of progestin used. So, a reasonable question to ask is whether the use of these two medications TOGETHER synergistically increase the risk of VTE. A recent publication in BMJ (06 Sept 2023) provided some controversial results in this very topic. Could those study results be the result of "indication bias" or protopathic bias? In this episode we will look at the data, summarize the key results, review the study limitations, and provide some real world clinical insights as to what to do with this new info.

Optimal uterine closure remains one of the most studied and controversial aspects of cesarean delivery. Traditionally, a single-layer locking hysterotomy closure has been taught and passes down. Is this evidence based? Is there any advantage to doing a double-layer myometrial closure? We’ll get down to the data in this episode.

A uterine niche is a reservoir-like pouch in the anterior uterine isthmus located at the site of a previous CS scar. First published and describe din 1961, there have been a variety of publications looking at "best practice" at cesarean hysterotomy closure to try to minimize its occurrence. This defect has been linked to abnormal placentation in subsequent pregnancies, CS scar ectopic pregnancies, abnormal uterine bleeding, and dysmenorrhea. While the complete pathogenesis of the niche defect is not completely understood, hysterotomy closure techniques have been implicated in its formation. Should we include the endometrial decidual layer at hysterotomy closure or should we exclude it. Its a debated subject but the data does favor one approach over the other. In this episode, we will examine that data.

SLE can affect people of all ages, including children. However, women of childbearing ages—15 to 44 years—are at greatest risk of developing SLE. Women of all ages are affected far more than men (estimates range from 4 to 12 women for every 1 man). Are you familiar with the 2019 updated diagnostic criteria for SLE? What are some specific concerns regarding this condition in pregnancy? Do patients with anti-SSA/SSB antibodies need serial fetal echocardiograms? And do these patients need early induction of labor? We will cover all this information, and more, in this episode (summary of SMFM, Consult Series # 64; 2023)

Celiac disease is an autoimmune disorder of the small intestine. Celiac disease is the only autoimmune disorder with a single clearly identified environmental trigger...DIET. Although the exact mechanism of the disease development is unknown, celiac disease appears to form after gluten intake from a complex interplay of environmental, immune, and genetic factors. What is Tropical Sprue and hoe is this different than Tropical Sprue? Does this lead to infertility? How is this linked to a specific dermatologic condition? And what about pregnancy outcomes in Celiac Disease. In this episode, we will cover all this data and more! (For Ana!)

Probiotics may be good for your gut, but does your vagina need them too? Probiotics are in everything from fermented drinks to pills and powders, and in many cases, are being advertised as a way of improving your vaginal health. Is that evidence based? Do oral probiotics help support a healthy vaginal microbiome? What about vaginal probiotics? Can vaginal probiotics augment BV therapy? The answer may surprise you. So…Grab your kombucha and take a seat… We’re going to cover this and much more, in this episode. 😊

We recently provided some additional information regarding the recently approved medication for postpartum depression, Zoranalone. One of the benefits of this medication is it’s rapid mechanism of action. Although not yet approved for major depressive disorder outside of the perinatal interval, there is a separate medication, which was FDA approved last year, which is ultra-fast acting for depression. Oddly enough, one of its main ingredients is a traditional cough suppressant. Have you heard of this medication? In this episode we will review this incredible development AND highlight some cautionary ⚠️ details.

As a true testament that we read each one of our Podcast Facebook messages, this is a “You asked, We answered” episode regarding 3 main recent topics: 1. dose of oral MI for PCOS, 2. Zoranalone for Major Depressive Disorder, and 3. the “shoulder shrug” maneuver for shoulder dystocia. 👍👍👍👍

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder and one of the most frequent causes of infertility in women. It affects 5–20% of women of childbearing age. The pathogenesis of PCOS is still not fully understood; however, insulin resistance (IR) is known to have a central role in its pathogenesis. According to a cross-sectional study, IR is present in 75% of lean and 95% of overweight women with PCOS. This IR seems to have something else behind it: an imbalance in the ratio of 2 vital inositols! In the treatment of PCOS, metformin is the gold standard metabolic treatment. However, metformin may induce mild to severe gastrointestinal side effects such as nausea, diarrhea, and vomiting. So, an evidence-based and data driven alternative is highly welcome…especially one that could be seen as “natural”. Can inositol, specifically myo—inositol, “reverse” some PCOS metabolic derangements? Can it help normalize cycles? The data may surprise you.

In 1990, the ACOG released the “Perinatal Hepatitis B Prevention Program“. OB healthcare workers have doing universal screening for Hepatitis B using HBsAg in each pregnancy, ever since. However, there is a new guidance being released in September 2023 from the ACOG. This new guidance aligns with the national Hep B screening and testing recommendations from the CDC released March 2023. Are you familiar with the “Hep B triple screen”? Is antiviral therapy recommended for Hep B in pregnancy? When should it be used? And is breast-feeding still allowed in mothers with Hep B viral infection? We will cover all of this- and more- in this episode. 🎙️🎙️🎙️

OK, OK…we all get that past history of DVT related to hormonal exposure is a true and persistent contraindication for estrogen birth control. We get that. But what about the incidental presence of lower extremity varicose veins? Are varicose veins a contraindication to estrogen containing birth control? After all, some data has linked superficial varicose veins to the development of DVT. That must mean that estrogen containing BC is contraindicated due to the additional risk of clot formation, right? Is that true? There is some STRANGE information on the internet regarding the association of oral birth control pills and varicose veins. Do combo OCPs cause varicose veins? Do they increase the risk of DVT in those with varicose veins? In this episode we will explore the science, data, and published guidelines related to the prescribing of estrogen containing birth control in patients with varicose veins. PLUS, we will cover which patients- who do by chance develop a superficial venous thrombus in a varicose vein- need anticoagulation.

On August 21, 2023, the FDA approved a new RSV vaccine for maternal use, ideally in the late third trimester. However, there are some nuances and some cautionary notes here! In this episode, we will review the phase 3 data, which fostered the FDA approval and review the nuances to this study. Are we ready for mass incorporation of the maternal RSV vaccine into clinical practice? The answer quite simply is… “No”. We will explain why in this episode.

In 2015, the ACOG released its Committee Opinion on "Endometrial Intraepithelial Hyperplasia", or EIN (CO 631). EIN is of clinical significance because it is often a precursor lesion to adenocarcinoma of the endometrium. Making the distinction between hyperplasia and true precancerous lesions or true neoplasia is super important because their differing cancer risks must be matched with an appropriate intervention to avoid under/overtreatment. As is our podcast tagline, "medicine moves fast"; coming out in September 2023, the ACOG will release a new Clinical Consensus guideline on "EIN-AEH". What are the new changes? Why are we moving from a EIN designation to EIN-AEH? Is a progestin IUS a reasonable therapeutic option for those wishing to preserve fertility after this diagnosis? In his episode, we will answer all these questions and more, focusing on this new Clinical Consensus guideline.

Recently, a horrific and unimaginable birth event made national (USA) news. A case of shoulder dystocia resulted in an extremely morbid and rarely witnessed complication. On August 16, 2023, an extremely important review article was released (ahead of print) in the American Journal of ObGyn. This article summarizes important key aspects and tips for the proper performance of rescue maneuvers for shoulder dystocia, with the aim of keeping both the mother and the baby safe. In this episode, we will review these critical and vital tips for safe resolution of shoulder dystocia. Should the buttocks rotate upwards with McRoberts maneuver? What is the Ruben I procedure? We’ll get to all of this, and more, in this episode.

Access to effective oral emergency contraception is vital, now more than ever. While use of either levonorgestrel or ulipristal is endorsed by the ACOG, pharmacodynamic and clinical data does show that ulipristal has the efficacy advantage. Although the process of ovulation is directed by the LH surge, it is also put into action by prostaglandin resulting from COX2 activity. So, can the addition of a COX2 inhibitor increase the efficacy of Plan B when taken as a combo? A new study published 24 hrs ago in the Lancet provides some exciting data. We will cover this new RCT, and more, in this episode.

Persistent genital arousal disorder (PGAD), now called Genito-Pelvic Dysesthesia, was first described by Leiblum and Nathan in 2001 in a five-patient case series. This is now a well-recognized pelvic floor/genital abnormality with a consensus statement being released in 2019 by the International Society for the Study of Women's Sexual Health. Are you familiar with this condition? It is a source of severe emotional and mental hardship for those affected. In this episode, we will summarize the data on this strange but very REAL condition that is NOT related to sexual desire or sexual arousal.

The definition of recurrent pregnancy loss (RPL) in the US is 2 or more consecutive failed clinical pregnancies documented by ultrasound or histopathology, while, in the United Kingdom, the definition is as having 3 or more consecutive early pregnancy losses. Up to 50 percent of cases of recurrent pregnancy loss lack a clear etiology. Where do we stand, in 2023, in regards to our understanding of the effects of inherited thrombophilias on recurrent pregnancy losses? Do they cause recurrent ABs? Does LMWH help? In this episode, we will summarize a June 2023 publication in the Lancet that provides a clear answer.

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%! Obstetrical lacerations of all degrees can lead to significant physical and even psychological morbidity, and have been identified as an independent risk factor for sexual dysfunction- which could last up to 18 months after delivery. Can perineal massage help reduce the rate of obstetrical trauma at time of vaginal birth? In this episode, we will summarize a new publication from the AJOG which was released on Aug 10, 2023 (first released as an ePub at the end of 2022) and compare the results covered in that publication with a separate systematic review and meta-analysis published in Feb 2023 in a separate journal. Does antepartum perineal massage help? What about intrapartum perineal massage? The answer depends on who you ask/read? Listen in, and find out why.

In 2019, brexanolone, better known as Zulresso, became the first postpartum depression (PPD) drug to receive FDA approval. While we have previously discussed this IV medication for PPD in other episodes, there is now a novel oral version of this antidepressant which has made the news as of last week (ie, early august 2023). That medication was known as SAGE 217 during the clinical trials, but it is now known as zuranolone (ZURZUVAE™). YEP.. in the first week of August 2023, the US Food and Drug Administration approved the medication zuranolone for the treatment of postpartum depression – making it the first FDA-approved oral pill in the United States specifically for postpartum depression. Do you know how this medication works? What’s the data on it? Does ACOG have an opinion on this? And what’s the special FDA warning that ended up as a BLACK BOX on the approval? In this episode, we will learn the ins and outs of Zurzuvae.

In our most recent episode on vaginal prep at C-section, we referenced a parallel topic where individual data pieces seem to be contradictory: prophylactic TXA at time of cesarean section. In that past episode, we referenced a systematic review and meta-analysis that showed prophylactic TXA was indeed beneficial. Well… we are going to build on that data regarding prophylactic TXA in this quick/targeted episode that we call our NEW DATA BLURB. In this episode, we will highlight a fantastic, brand new, systematic review and meta-analysis published by one of our very own podcast family members out of Arizona. Dr. “KC”… Great job and congratulations to you and your co-authors on a wonderful publication. 👏👏👏👏

With improvements in the screening & treatment of Breast Ca, the number of female survivors continues to rise, with a reported 5-year survival rate of up to 90%. However, several of the systemic treatments for breast cancer, including endocrine therapy, chemotherapy, and radiotherapy, can result in a new or worsened hypoestrogenic state. Up to 70% of postmenopausal women will develop symptoms of genitourinary syndrome of menopause (GSM). With an estimated 3.8 million breast cancer survivors in the US, women’s healthcare providers are on the front lines of addressing survivorship issues, including these hypoestrogenic-related adverse effects of cancer therapies or early menopause. This isn’t simply bothersome vaginal dryness, but this also affects sexual intimacy, and may even be linked to recurrent UTIs. Although nonhormonal vaginal agents are traditionally considered first-line for patients with a history of breast cancer, there’s been evolving data on the efficacy and safety of vaginal, low-dose estrogen therapy for genitourinary syndrome of menopause in breast cancer survivors. In this episode, we will highlight pivotal pieces of data starting from 2021 and ending with a new publication just released on August 3, 2023 revealing very impactful and clinically applicable insights reffing vaginal E2 in breast cancer patients.

CS is the most important risk factor for postpartum infection with a 20-fold increase compared to the vaginal delivery route. For post-cesarean section metritis, infection is considered to be primary due to ascending bacteria from the vagina. Although antibiotic prophylaxis is thought to reduce postoperative infections, it has little effect on bacterial colonization of the vagina. Over the past 20 years, multiple randomized clinical trials have investigated the effect of preoperative vaginal preparation/disinfection (including povidone-iodine, chlorhexidine, metronidazole gel, etc.) on postoperative infection, but the conclusions have not been consistent. Actually, a publication from June 2023, which we summarized in a prior episode back in Dec 2022 when it was released ahead of print, concluded that vaginal pre- CS prep with povidone-iodine did NOT prevent infectious morbidity over standard infectious precaution use (abdominal prep and standard IV antibiotics). But as of August 2023, there is new data that seeks to provide a more definitive recommendation. In this episode, we will summarize this new systematic review and meta-analysis (AJOG MFM) examining the effectiveness of vaginal cleaning with either povidone-iodine or chlorhexidine acetate in the prevention of post CS infectious morbidity.

Venous thromboembolic events (VTE) are among the top three causes of maternal death in developed countries and prevention with thromboprophylaxis has been identified as the most readily implementable means of reducing maternal mortality from VTE. Most guidelines address VTE prophylaxis after cesarean section, and/or in those with thrombophilias- not after vaginal delivery alone. The ACOG does not directly address inpatient pharmacologic thromboprophylaxis during antepartum admission nor after vaginal deliveries for patients without a known thrombophilia or without a personal history of a VTE event. Guideline recommendations regarding thromboprophylaxis strategies for women with more commonly occurring risk factors- such as Preeclampsia with severe features- vary widely, leading to uncertainty regarding the optimal strategy for prevention. Do you order pharmacoprophylaxis for postpartum (SVD) patients with “minor risk factors”? What about the patient whose BMI is 40? Have you heard of the recommendations from the NPMS and the CMQCC regarding VTE prevention after vaginal birth? In this episode we're going to review VTE prophylaxis after vaginal delivery and take a look at the data.

We are still in an opioid crisis state in the US. Have you heard of Kratom? It is likely at your neighborhood health food store or even on the counter at your local gas station. A derivative of the coffee plant, Kratom is making national headlines. Whether Kratom, a legal, widely available herbal supplement, should be classified as an opioid is contentious. Although the US Food and Drug Administration has recently addressed this controversy, Kratom continues to be marketed as an over the counter, nonopioid, "natural" remedy for a variety of conditions- including pain, anxiety, mood, and opioid withdrawal. YES.. its use is increasing in the United States. and it is now getting new attention from both medical as well as governmental authorities for its possible adverse effects during pregnancy and its association with NAS. In this episode, we will discuss this novel OTC herbal supplement which has now earned the watchful eye of the FDA. Kratom: wonder supplement or dangerous herb? Let’s discuss.

In 2019, the ACOG released CO 767 discussing “Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period”. currently, 3 meds are recommended for the treatment of emergent hypertension in pregnancy: oral nifedipine, IV, labetalol, and IV hydralazine. But which one is “better” at normalizing blood pressure? A new meta-analysis, published on July 24, 2023, provides one answer. However, this meta-analysis did not take into account the most crucial factor determining success of antihypertensive medication: “The Rule of 55”. In this episode, we will review this new meta-analysis from the journal of Mat-Fetal Neonatal Medicine, and review the petition by hypertension experts to tailor antihypertensive treatments based on the “hemodynamic expression” of the hypertensive disorder in pregnancy.

We have learned so much about the natural progression of HPV induced cervical abnormalities. In 2019/2020, the ASCCP published its updated guidance using a “risk-based” algorithm for management of cervical intraepithelial neoplasia. Traditionally, HPV vaccination was considered ineffective once cervical dysplasia already was present. But recent data has proven this concept incorrect! In this episode, we’re going to summarize a brand new ACOG practice advisory released today, on July 28, 2023, related to this “adjuvant HPV vaccination” for patients undergoing treatment for CIN2 or more.

There are, indeed, FDA indicated applications for purified, amniotic membrane (wound healing). Is there also a role for the use of purified amniotic fluid as a “regenerative medicine” treatment option? Can amniotic fluid injections help repair osteoarthritis and aching joints? Can it be used as EYE DROPS for dry eyes? The subject is trendy on certain social media channels and on certain websites. But this concept of injecting amniotic fluid into various body locations has landed one Texas healthcare professional in hot water. Specifically, the US Department of Justice, has pressed charges. 😳 In this episode we will discuss this whole issue of “regenerative medicine” and the legitimate an illegitimate use of amniotic products, AND we also review the inherent qualities of amniotic membranes and fluid which makes them attractive for "regenerative" uses. 💉💉💉

Skin conditions can't affect pregnancy outcomes, right? After all, the skin is just the skin. WRONG! As a chronic inflammatory disease, hidradenitis suppurativa (HS) exemplifies the link between integumentary and comorbid systemic disease through shared inflammatory pathways. Patients have double the comorbidity burden compared with the general population, and hidradenitis suppurativa has independent associations with several individual comorbid diseases. During pregnancy, HS also is associated with some specific pregnancy related morbidities. Successful management of hidradenitis suppurativa is challenging and at times requires comprehensive care from a coordinated team of health care professionals, including dermatologists, general or plastic surgeons, experts in pain management and wound care. In this episode, we ill summarize the pathogenesis of HS, its treatment, and its affect on pregnancy and vice-versa.

In Feb 2023, the USPSTF recommended that clinicians “screen for hypertensive disorders of pregnancy”. Specifically, they stated that “measuring blood pressure at each prenatal visit is the best approach”. Mind blowing I know. 😳😊 But sarcasm aside, a new publication- set to be released next month in AJOG (Slade LJ et al; Aug 2023)- validates this recommendation…not that it needed validation of frequent BP monitoring during pregnancy. This has to do with the “sensitivity” of BP results in pregnancy compared to the “specificity”. Ahhh…intrigued? In this episode, we will review this upcoming publication aimed at evaluate whether the definition of gestational HTN should be revised according to the 2017 ACC and AHA criteria, and whether or not there is an association between adverse maternal and perinatal outcomes based on those lower BP levels. And as always, you’ll want to stay with us until the end of the episode as we pass on real world clinical implications of these findings.

On April 5,2023 the U.S. FDA withdrew its approval of Makena and generic forms of 17-a hydroxyprogesterone caproate for the prevention of recurrent preterm birth. Having the only medication which had been FDA approved for the prevention of preterm birth taken away, has left clinicians investigating other possible strategies that can cause a dent in preterm birth rate. As Bacterial vaginosis (BV) is the most common vaginal abnormality in reproductive age women, naturally the spotlight would fall on the treatment of BV for preterm birth prevention. After all, BV is a well-known risk factor for preterm birth. There’s been new advances in the diagnostic tools for vaginal infections, so BV is back in the hot seat as a possible intervention for PTB prevention. Yes, this has been investigated in the past. But in this episode, we’re going to highlight 2 recent publications- one from March 2023, and one from July 17th 2023- which help to solidify the answer to this question: “can treatment of BV help prevent preterm birth?” Let’s talk about that… now.

FYI. We just released our episode for today, July 14, 2023, and will be out until July 23!

Its hard to be pregnancy in the late third trimester, especially in a HOT state like TEXAS in the summer. Pregnant individuals will try just about anything "to just get this baby to come out already!" Historically, walking, spicy foods, and SEX have been "employed" to get the labor process going. Does it work? In this episode we will look at the data examining whether labor can induce spontaneous labor. Is this a myth or a real thing? What about CURB WALKING?! That works, right? Lots to cover and explain in this one...so let's get our walking shoes on and get to it.

There’s no such thing as a “false positive syphilis confirmation test”, is there? After all… It’s right there in the name, CONFIRMATION test! Well, not all positive confirmation tests are true positives, especially when that test is the FTA-ABS. Yes, it’s true, the specificity for this is very good between 95 to 98%. But there are cases of BFPs (Biologic False Positives), which have been reported and published in the literature. This is why putting the test results in clinical context is very important. In this episode, we will highlight a real clinical scenario where a “low level“ confirmation test did not fit the clinical picture (asymptomatic, monogamous, low risk patient). Is there something else going on here? What about autoimmune conditions? Can pregnancy itself cause a false positive FTA-ABS? And more importantly… What are the options for management in this case? We’ll discuss all of this, and also review the “reverse syphilis algorithm” in this episode.

The Bandl Constriction Ring. It is real. It exists. Its true incidence is unclear as it lacks uniform reporting when found at time of cesarean. As labor guideline are more permissive of slowed labor progress, some fear that the incidence of Bandl's Band may rise. What is this ring? What is the pathophysiology of this abnormal uterine response? Can ultrasound detect this labor abnormality? In this episode we will cover the fascinating and controversial history of the Bandl Band and review some key publications describing its potential morbidity.

Just a little description of what happens “behind the scenes“! Enjoy. 😊😊❤️❤️😩😩

Gestational diabetes (GDM) is a risk factor for adverse perinatal outcomes. Currently, the ACOG recommends early screening for GDM for women “at risk”. However, other experts disagree with this approach. On October 6, 2022 we released a podcast episode called “Early GDM Screening: Evidence-based?”. In that episode we covered the controversy regarding early GDM screening, in other words- screening under 24 weeks. We have been following this story and debate for over 2 years now; we first released the episode investigating the utility of early screening back on May 7, 2021 with an episode called “early GDM screening: Does it matter?”. The controversy surrounds maternal and neonatal outcomes… does it improve with early screening? Well… we have more data now! YEP.. looks like we were vindicated in our prior messages covering this! In this episode, we will summarize key findings from a recent June 2023 publication in the NEJM titled, “Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy”. The lead author is Simmons. So…should we be doing early screening for GDM? We’ll highlight the data.

Well, Well, Well, this is very interesting. Back in May 10, 2023, we released an episode on "OSA (Obstructive Sleep Apnea) in Pregnancy: Time to Screen?". In that episode, we summarized the impressive data on OSA in pregnancy and its association with some adverse perinatal sequelae. Spring forward to July 6, 2023, the ACOG has now released a brand new Consensus Statement on OSA in pregnancy. This statement is a joint guideline from the Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology. Seems that we were ahead of the curve on this one. So, should we screen for OSA in pregnancy? The answer is YES and NO. Is CPAP really safe in pregnancy? We'll explain in this episode.

The headline from CNN Health form June 28, 2023 reads, "HRT use by younger women linked to dementia, study says". That is FRIGHTENING to any patient using hormone therapy for menopausal symptoms. Does HT cause dementia? Or is HT a "easy suspect"? The question of HT and cognitive function has been a subject of controversy for many years. In this episode we will summarize the NAMS position statement on HT for cognitive issues (2022) as well as summarize this new June 2023 publication from BMJ causing quite a stir among menopauses' medical experts. PLUS, we will provide a likely reason, which is the proverbial "elephant in the room", for this new study's conclusions.

First published in 1952, the Apgar Score has remained unchanged over 70 years and is intrenched 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!

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.

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 is 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.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. The optimal interpregnancy interval (IPI) after stillbirth is unclear. Currently, many organizations recommend IPIs greater than 18 months due to findings that, after live birth, a short IPI is associated with increased risk of spontaneous preterm birth, small for gestational age (SGA), and, sometimes, stillbirth. But this was based largely on expert opinion and not peer reviewed data. Recently, data has been published on this very subject that may aid bereaved parents in planning for a next pregnancy. In this episode we will review the first large-scale population study on the subject (from 2019) and summarize a soon-to-be released publication from Obstetrics Gynecology (the Green Journal) examining the effect of IPI after stillbirth.

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.

Once considered on the fringe of main-stream medicine, “alternative therapies” are becoming more accepted into clinical practice. Such is the case of psilocybin (a mushroom extract) for certain mood disorders. 🍄 And now, another mushroom extract (AHCC) has gained attention in gynecology. Could this extract help eliminate the most common viral STI? Is this evidence-based? The research may surprise you. Let’s review the data on ‘shrooms and HPV. Thank you Leah for the episode suggestion! Keep up the great work up north in Long Island! 😊

We ❤️ our podcast community! Over the last 3 recent episodes, we have received similar “themed“ listener questions. So in this episode, we are going to respond to some recent inquiries regarding three recent episodes: 1. combination birth control and estrogen levels (and Perimenopausal use), 2. vaginal progesterone for patients without a history of preterm birth, and 3. the use of vaginal dilators for vaginismus. This is how we all grow together! Now… Let’s get to your questions. 😊😊😊🤔🤔🤔

I recently had a patient (young reproductive age, without prolapse or urinary incontinence) ask me about using the “Jade Egg” vaginally for better sex. Women’s sexual intimacy is a big dollar commercial industry. What’s the history behind this Jade Egg and/or other vaginal insertion weights? Is there a benefit to using these inside the vagina for pelvic floor training and enhanced sexual intimacy? Are these any better than regular Kegel exercises? In this episode, we’ll do a deep-dive into the data and find out when, if ever, these devices may be used as ancillary tools.

Presence of meconium stained membranes/placental tissue has been used in medico-legal cases by both plaintiffs and the defense alike. Using the presence of meconium stained tissue has been used as a tool to “timeline” fetal hypoxia. Is this evidence-based? In the session, we will review the historical data (1985) that fueled this concept, and give the latest scientific and medical expert opinion regarding the possibility of this theory (highlighting a new Expert Review in the AJOG, April 2023).

Oh, the ever evolving drama of “progesterone in high risk obstetrics”. Today, April 13, 2023, the SMFM released its Special Statement response to the recent change in the progesterone PTB prevention landscape. Where does cerclage fit in? In this episode we will summarize the current recommendation for cerclage for preterm birth prevention and how it fits in to the vaginal progesterone story. Is cervical ultrasound surveillance after vaginal progesterone initiation warranted? We will make it clear in this episode.

We have come a long way in our understanding regarding the safety of intrauterine contraception. Once withheld from adolescents and immediately postpartum patients, the safety in both populations is now well established. Postpartum IUD/IUS placement is a balance between risk of expulsion and patient loss to follow up. In this episode, we will summarize a new RCT from JAMA discussing this very subject. Is it better to place immediately Postpartum, at 2 weeks after delivery, or as an interval procedure at 6 to 8 weeks? We will summarize this Level I evidence and also provide helpful resources for increased accessibility of LARC options, including the new (April 2023) ACOG Committee Statement on this very issue.

This episode is in reply to one of our fantastic podcast family members who had some wonderful clinical questions regarding dosage of combination BC after listening to our past episode. In our immediate past episode, we discussed hypoestrogenemic symptoms on ultra low-dose pills in certain patients (young, thin). Is a 20 µg BC pill less thrombotic than a 30 or 35 µg pill? What does the data say? In this episode will answer this question and also dive deeper into serum estradiol levels not only with combination birth control but also with menopausal hormone therapy. Is there a “target level” of systemic/serum estrogen with combination HRT? Listen in and find out.

In 1972, a publication in which a radioimmunoassay measured serum estradiol levels in participants taking oral combination birth control concluded that levels of serum estrogen were “sufficient to prevent symptoms of estrogen deficiency”. Knowing NOW what we do, and looking back to that article, those authors’ conclusions were completely incorrect! Is it possible for a patient to experience hypoestrogenic symptoms despite taking an estrogen containing birth-control? What are normal, endogenous estradiol levels in a reproductive age female? In this episode, we will review the various degrees of hypothalamic – pituitary – ovarian axis suppression from different categories of hormonal birth-control. Should certain micrograms of ethinylestradiol be preferred in thin and/or adolescent patients? Listen in and find out.

Here’s proof that our catchphrase, “Medicine Moves Fast“ is 100% true! On October 30, 2022, and again on November 1, 2022, we released episodes on “Dense Breasts on MMG? What to do?”. Those episodes were in response to Katie Couric’s public outcry for the need for additional screening at time of mammogram in the setting of dense breasts. On March 9, 2023, the FDA issued a new ruling/guidance on patient notification of breast density at screening mammogram. And now, in April 2023, the ACOG has released its new Practice Advisory (PA) on the subject. In this episode, we will quickly summarize this practice advisory, it’s implications for us as clinicians, and implications to our patients.

A quick update and commentary on the recent (April 6, 2023) FDA decision to withdraw approval of Makena for preterm birth prophylaxis.

Pregnancy causes some well-known and well documented physical changes to the body. While hyperpigmentation, breast enlargement, and increase in vaginal discharge are non-disputed physical changes during pregnancy, other effects on mental capacity (memory and cognition) are more controversial. Does “mommy brain” really exist? Or is it a fulfilled psycho-social expectation? Does pregnancy actually change the brain? In this episode, we’ll present the data and provide some practical tips at the end of the show to help tackle the elusive foe called “momnesia”.

For a patient who presents after an episode of unprotected sexual intercourse, seeking testing for STIs, it’s important to know when to perform the test. The time between infection and a positive test is called the testing window. This testing window can be different for different pathogens. In this episode, we will review the importance of knowing this testing window, and we will also review the differences between pathogen inoculation, incubation/latency, and their overlap with the testing window.

Von Willebrand Disease (VWD) is the most common inherited bleeding disorder among American women, and it may present with a history of mucocutaneous bleeding patterns. Ideally, women should be screened/identified with this condition prior to pregnancy- but that is not always the case. How does VWD affect delivery? Is this a cause of immediate PPH? In this episode we will review the clinical manifestations of VWD in pregnancy. We will: 1. review appropriate labs tests for this evaluation, 2. summarize the recommended management peripartum, and 3. discuss if a C-Section is required in the affected patient. LOTS of material is covered in this episode! (References: ACOG's Clinicals Expert Series, March 2023; ACOG CO 785).

For women’s healthcare, there are 3 ways to screen for genital GC, chlamydia, and trichomoniasis: 1. vaginal swab, 2. endocervical swab, or 3. first-catch urine. The CDC states that, “For female screening, specimens obtained with a vaginal swab are the preferred specimen type. Vaginal swab specimens are as sensitive as cervical swab specimens.” Why does it not favor urine screening? Although acceptable at a POPULATION level, there are several caveats to urine screening for STIs at an INDIVIDUAL level. In this episode, we will review the latest published data (March/April) regarding the sensitivity of urine screening for these 3 common STIs. Additionally, we will summarize important instructions/tips for proper self-swab collection, and proper first-catch urine testing.

We have come a long way in our understanding of the “Stein and Leventhal Syndrome”. First described in 1935, our understanding of the pathogenesis and future health morbidities of PCOS has grown exponentially. We now know that AMH levels may help in the certain PCOS diagnoses. At the center of this clinical condition lies insulin resistance (IR). One of the manifestations of IR is Acanthosis nigricans (AN). (But AN can also be a marker of a much more deadly condition.) It is important to remember that not all PCOS patients are the same. In this episode, we will review the 4 phenotypes of PCOS and discuss a specific variant of the condition which is called the “lean PCOS variant”.

The rate of vegetarianism in the United States is dramatically on the rise. While in 2014, a national survey found that only 1% of the US population considered themselves vegetarian, current estimates put that number up to 6%. But not all vegetarians are the same. Is being a strict vegetarian (a.k.a., vegan) associated with any adverse perinatal outcomes? Does being vegan increase your risk of preterm birth? In this episode, we will cover the latest data on how diet can affect perinatal outcomes, and in-utero metabolic programming of the child. 🥑🥗🍎🍇🍊🌾🌾

Traditionally, fetal growth restriction (FGR) was diagnosed when the Hadlock EFW was < 10th percentile. However, in 2020, SMFM updated its publish guidelines endorsing the use of an isolated abdominal circumference (AC) under the 10th percentile as an additional diagnostic criterion. Is the isolated small AC linked to adverse perinatal outcomes? And what are the delivery recommendations for an isolated small AC? It’s a complicated issue with complicated data. In this episode we will provide the “He said, She said” reported outcomes for this clinical conundrum. At the end of the episode we will provide some real-world practical tips on how to manage the isolated AC growth restricted fetus. 🫄

Our current discipline of obstetrics owes a lot to the practice of Midwifery. In a previous episode, we covered “lessons learned from Midwifery” and that is available on our podcast archive. In this episode, we will discuss the data regarding a practice originally propagated by Midwifery: the Birthing Ball. What is the origin of this, and how did it make its way into obstetrical practice? Is there data for it’s use? Does it really help reduce labor pain? In this episode we will summarize the data of a soon-to-be released publication from the AJOG. In this episode, we will find out if the Birthing Ball is a toy… or a labor tool.

Gerri, thank you for your voice message today! Welcome to our podcast family. Here’s some helpful notes for you. 😊😊

In Oct 2006, the ACOG released Opinion Number 346. This stated that “Based on current literature, routine prophylactic amnioinfusion for the dilution of amnioinfusion for meconium-stained amniotic fluid should be done only in the setting of additional clinical trials”. Back then, some experts criticized the decision to abandon amnioinfusion for meconium based on the limitations of the 2005 study which helped to motivate the ACOG decision. And now, a new systematic review and meta-analysis (published ahead of print March 18, 2023; AJOG) has brought new life into this old debate. Can amnio-infusion, in fact, reduce meconium aspiration syndrome (MAS)? Do current professional guidelines need to be updated? We will explore and dissect this new data in this episode.

Infertility. It’s real. It affects 10-15% of couples in the US. After a thorough investigation, 30% of couples will be left without an identifiable cause for their infertility. This has been termed unexplained infertility. While traditionally this may have been considered a reassuring result, new data is raising the yellow flag of caution in these patients. Research has now established the link between infertility and some potential future negative health outcomes. As “next generation“ genetic tests become more integrated into clinical practice, new data (released ahead of print on March 16, 2023 in the New England Journal of Medicine) has revealed some life-changing realities for couples struggling with unexplained infertility. In this episode, we will highlight the advances in genetic medicine and summarize the key findings of this eye-opening new publication.

Such a small gland… Yet so much confusion, and controversy: the THYROID gland in pregnancy. Let’s start with this foundational question: should we universally screen for thyroid abnormalities in pregnancy? And as a follow-up question, should we be checking for anti-thyroid antibodies? The answer to both of those queries depends on who you ask! In this episode, we will solve the conundrum of whether we should be screening for anti-thyroid antibodies pre-pregnancy and/or during pregnancy itself. Does identification of these antibodies affect management? What is their role in recurrent miscarriage? Listen in, and find out.

The traditional explanation and assumed pathophysiology of HELLP syndrome stated that it was a late manifestation/further progress of preeclampsia with severe features. But can HELLP present clinically without hypertension? What about without proteinuria? If a patient has lab criteria of HELLP alone, without hypertension, does she still require magnesium sulfate? In this episode, we will summarize data from 3 sources (ACOG practice bulletin on thrombocytopenia, ACOG practice bulletin on gestational hypertension and preeeclampsia, CMQCC hypertension bundle), and answer these questions and more.

The pathophysiology of menopausal hot flashes has remained largely a mystery until about a decade ago when KNDy neurons were found to be the key triggers of the hot flash. Since then, research and development has been going fullsteam to develop a non-hormonal, receptor-based therapy for the common hot flash. In April 2023 in the journal, Obstetrics and Gynecology (the Green Journal), new safety data will be published on the revolutionary new medication, Fezolinetant. With Phase 3 study results already in print, the FDA is projected to rule on this new medication’s approval potentially in May 2023. In this episode, we will review the fascinating biochemistry of KNDy activity and how this new medication works.

The fetal NST is a hallmark of antepartum fetal surveillance and a key component of the BioPhysical Profile (BPP). Historically, and still done today, one of the low-risk interventions for rectifying a non-reactive NST has been the maternal administration of glucose/PO challenge. Is this evidence-based? Does maternal hypoglycemia contribute to a nonreactive NST? In this episode, we will review the data spanning a 40-year interval that has sought to answer this question. And what about fetal movement? Does maternal glucose loading increase perception of fetal movement? Let’s go to the data now.

The Liggins and Howie trial demonstrating the benefit of antenatal corticosteroids (ACSs) on fetal lungs was published in 1972 in the journal Pediatrics. First adopted as weekly injections, ACSs were then found to be associated with decreased birth weights and decreased head circumferences. Hence, weekly administration was abandoned in the late 1990s. But the ACOG/SMFM does still recognize a single repeat dose “based on clinical scenario”, called a rescue dose. Is a rescue dose of steroids associated with altered neurodevelopment in the child? In this episode, we will summarize a brand new study just accepted for publication in the AJOG MFM (the Pink Journal) shedding some light on this question.

This is a brief update regarding our recent podcast on “the French C-section”. Having an Israeli member of our podcast family…is priceless! ❤️Listen to the latest development regarding the extraperitoneal C-section in Israel and how this situation bears similarities to the US approval of ADDYI in 2015. Thank you Liel N.!! 😊😊

In 1999, the CDC had a national plan of action to “completely eliminate syphilis” by the year 2005. Although rates of syphilis did dramatically decrease to record lows during that time, we are now experiencing record HIGH rates of congenital syphilis. Some states are having a close to 500% increase in congenital cases. How did we get to this point? In this episode, we will review and summarize 3 key recent publications regarding the rise of congenital syphilis (Journal Women’s Health Issues [Elsevier]– article in press: AJOG Dec 2022; ACOG Clinical Expert Series May 2020) which have resulted in the SCARY STATE of SYPHILIS. We will also review the JH reaction, and provide a clinical pearl regarding the interval restriction between doses of Penicillin G injections, AND we will summarize the time frames permitted to allow a decrease in RPR titers after therapy. Lots of material covered in this episode! 👍

The historic saying is, “there is nothing new under the sun”. So true! Such is the case with the extraperitoneal C-section. First advocated in 1823 by French obstetrician, Louis-Auguste Baudelocque, this complex technique fell to the waste-side with the advent of antibiotic availability. But now, this extra-peritoneal cesarean technique, A.K.A. the "French AmbUlatory Cesarean Section" technique (FAUCS), is trending on social media. Is this safe? Does this have any advantage over a traditional C-section? And why has one country recently BANNED this procedure? In this episode we will present this novel technique and explain why some are calling for caution in its adoption.

The “cure” for preeclampsia is NOT delivery. Preeclampsia is an important signal for future cardiovascular complications once pregnancy is over. While there may not be a true “cure”, we do have options for chemoprophylaxis of preeclampsia. Currently, only low-dose aspirin is ACOG/SMFM endorsed for preeeclampsia prevention. But pravastatin is gaining steam. Pravastatin was previously classified (in the now discontinued FDA label) Category X. However, the FDA recently removed the warning regarding use of statins in pregnancy, resulting from the favorable data on pravastatin as a potential chemoprophylactic agent against preeclampsia. While short term fetal safety has already been documented, there was a gap in data regarding long-term neurodevelopmental outcomes in children exposed to this medication in- utero. But new data has some reassuring findings (with a CAVEAT). In this episode, we will highlight a soon-to-be released publication in the AJOG, which is the first to report on the long-term neuromotor, cognitive, and behavioral outcomes of children exposed to pravastatin in utero.

Some obstetrical publications discuss adverse perinatal outcomes based on a short interpregnancy interval (IPI). A separate, yet related topic, is a short interdelivery interval (IDI). Most obstetrical care providers are aware of the adverse obstetrical outcomes following a short IPI. However, short IPI has also been linked to adverse neurodevelopmental disorders in the child. Are repeat fetal growth ultrasounds indicated in a pregnancy following a short IPI? Is antepartum fetal surveillance indicated? In this episode, we will tackle the short interpregnancy interval, and we will end the podcast with the Level C guidance regarding pregnancy management following a short IPI.

In 2018, the ACOG recommended immediate induction of labor/delivery for patients with PPROM, who had sure gestational dating, and were at 34 weeks and 0 days or more. This was in order to reduce the risk of neonatal sepsis. This changed, however, in 2020 with ACOG Practice Bulletin 217 which discussed expected management for PPROM in the late preterm interval. Nonetheless, as is our tagline for this podcast, “medicine moves fast”. In February 2023, a current commentary was published in BJOG adding a cautionary note to the option of expected management in the late preterm interval. In this episode, we will review the acog guidelines, review GBS culture versus NAAT, and summarize this current commentary from BJOG. What is the one clinical factor that should be considered in planning for expected management with PPROM in the late preterm interval? We will explain it in this episode.

As part of our medical training and education, we often learn diagnoses in isolation. For example, we have learned that Proliferative Endometrium on EMB is a non-pathological finding. That result can be left alone without therapy, correct? But what if that is found in the context of a postmenopausal patient. Is it still considered a nonpathological finding? In this episode, we will summarize the current nomenclature for endometrial pathology and why one classification scheme is favored over the other (EIN over WHO). We will also summarize key points form a February 2023 publication (Obstetrics and Gynecology) released under the section, “Clinical Conundrums: Proliferative Endometrium in Menopause, to Treat or Not to Treat?”.

Marginal cord insertions can be found on antenatal ultrasound. What is the data regarding marginal cord insertion and adverse neonatal outcomes? Is there a relationship, or is this a benign finding? Are serial growth ultrasounds recommended? What about antepartum fetal surveillance for isolated marginal cord insertion? In this episode, we will review the latest data on pregnancies with marginal cord insertion. We will end the episode with a summary of the expert opinions regarding best practice for management of pregnancies found to have a marginal cord insertion.

This is our impromptu podcast session in-between patients in our OB Clinic. In this episode, Dr. Leon-Arango (Senior Resident) highlights the importance of looking “deeper” into a patient’s persistent complaint of depression despite a negative PHQ9 score, based on her encounter from today. This real example of a physician’s perception of need for intervention likely helped to change the trajectory of this patient’s life. Listen in as we go “beyond the PHQ9”.

The first case of placenta accreta listed on PubMed was reported in 1927 by Dr D.S. Forster out of Montreal. That was 1 case in 8000 deliveries! Now, according to the National Accreta Foundation, PAS occurs in 1 in 272 pregnancies. How did we get to this rate? In this episode we will highlight data from ACOG, SMFM, and the National Accreta Foundation. We will highlight key ultrasound markers, patient risk stratification, and review what a PAS Care Center is. This is how we win the battle against PAS.

Delayed cord clamping (DCC) provides vital placental transfusion to newborns and is endorsed by ACOG, SMFM, March of Dimes, and the ACNM. However, DCC in nonvigorous newborns may not be provided owing to a perceived need for immediate resuscitation. Umbilical cord milking, in late-term and full-term neonates, is an alternative in these cases. In December 2020, the ACOG’s Committee Opinion stated a lack of outcomes data for umbilical cord milking in nonvigorous newborns. This Level 1 data has now arrived (February 2023). In this episode, we will summarize the key findings from this soon-to-be released publication from the AJOG on umbilical cord milking in nonvigorous newborns born at >/= 35 weeks.

Historically, IUDs where considered contraindicated in a patient with a prior ectopic pregnancy. This was due to concerns that IUDs may be causative of tubal gestations. Is this true? Are IUDs contraindicated with a past history of ectopic pregnancy? In this episode we will review the data from the CHOICE project, the CDC (US), and the Royal College of OBGYN (UK). We will also summarize key findings from a May 2022 Green Journal publication that investigated this very issue, and we will explain why some IUSs may be MORE protective (52mg vs 13.5mg) against ectopic than others (Thank you Jessica W. for this timely and clinically relevant podcast topic suggestion). 

A 2020 publication from JAMA Pediatrics reported that labor epidural analgesia may be associated with an up to 37% increased risk of offspring autism spectrum disorder. The ASA has rejected those results based on methodologic limitations of the study, the lack of biological plausibility. But some remain fearful of labor epidurals because of that publication. In February 2023, a new publication in AJOG will help put this matter to rest with the largest population-based analysis done to date. In this episode, we will highlight and summarize the key findings of this landmark study, and better understand whether or not Labor epidurals are tied to offspring ASD/ADHD.

Platelet Rich Plasma (PRP) therapy is a HOT and TRENDY item right now. PRP use was initiated in sports medicine in the 1970s. It has since expanded into many medical specialty fields, and now it is being heralded as the new hope for diminished ovarian reserve for those desiring pregnancy…even in menopause! Can injecting the ovaries with PRP really rejuvenate the ovary? We’ll examine the evidence as it sits as of January 2023.

Routine, repetitive urine dipsticks (meaning at each prenatal visit) were introduced into prenatal care back in the 1960s and 70s. The idea was to act as an early screen for bacteriuria (ASB), proteinuria as a screen for preeclampsia, and glycosuria as a screen for GDM. That was based more on expert opinion rather than clinical trials. The utility of urine dipstick testing in pregnant women has been debated for years, with studies suggesting minimal use in asymptomatic patients. Urine dips as still integrated into clinical practice mainly out of tradition…But is this evidence-based now? And if it is NOT evidence-based to do this with every visit and with every patient, when SHOULD it be done? What does ACOG have to say? Well, turns out ACOG says a lot- so you’ll want to stay tuned until the end of the episode as we cover that and a lot more.

Paragard, Mirena, and Liletta IUDs are the most effective types of emergency contraception. Data from the 1980s, now seemingly forgotten, showed that IUDs work primarily on inhibition of fertilization rather than implantation effects. Nonetheless, misperceptions regarding the IUDs mechanisms of action persist, with some websites stating IUDs are abortive agents. Do IUDs cause abortion? Let’s examine the evidence.

“Placentophagy” is not a new concept. Most non-human mammals eat their placentas after giving birth but humans, historically, have not. Is there evidence to support this practice? Where did this idea come from? How did Rolling Stone magazine help launch this phenomenon back in the 1970s? Is Kim Kardashian onto something cutting edge by advocating for Placental encapsulation? In this episode we will walk through history and learn some pretty remarkable things about this practice. Grab your favorite placental snack, and start listening! 🍽️🍴🍴

The American College of Obstetricians and Gynecologists supports the use of both low-dose and high-dose oxytocin regimens to induce and augment labor, but does not specify MAXIMUM DOSE RATES. Most hospitals, however, have protocols that impose a maximum dose rate of oxytocin infusion. Is this evidence-based? Is there a danger with going above a certain threshold of infusion, for example, greater than 20 milliunits/minute? A new publication coming out in Obstetrics and Gynecology (the Green Journal) sheds some light on this very issue. Let’s talk about the maximum oxytocin infusion rate and labor.

The ACOG states, “In spite of its unproven value, antepartum fetal surveillance is widely integrated into clinical practice in the developed world”. Antepartum fetal surveillance can be done by a variety of techniques and, despite its unproven value, is a mainstay of obstetrical management. At what BMI should we offer fetal surveillance? Is this current BMI or pre-pregnancy BMI? And what about advanced maternal age? What is recommended for that? Did you know that there was a change in the ACOG wording regarding this AMA issue from June 2021 to August 2022? And what about ultrasound surveillance for cervical length after cerclage placement? Is that evidence based? We are going to dive into these 3 clinical scenarios (obesity, AMA, cervical length after cerclage) in this episode. 👍

Breech presentation at term occurs in approximately 3 to 4% of pregnancies. While the vast majority are simply chance events, breech presentation could be a marker of other fetal comorbid conditions. When should ECV be attempted? Does the ACOG recognize neuraxial analgesia as a tool to increase ECV success rates? What’s better spinal or epidural block? What are relative contraindications to ECV? In this episode, we will summarize the latest data on fetal breech presentations and answer key questions regarding the process of ECV. Jasmine…here’s your podcast! 😊

On some current social media channels, there is a hot debate as to why professional medical societies still recommend prenatal folic acid compared to the more “biologically, active” L-methylfolate. Are they onto something here? Published data has shown that anywhere from 40-60% of the general population may have an MTHFR mutation leading to the inability to process folic acid. Should we be screening for this mutation? What about screening for homocystine levels? Are these medical societies incorrect in still recommending folic acid rather than L-methylfolate? We are going to tackle these questions and provide a very simple take home message at the end of this episode. We’ll set the record straight regarding “Folic acid, folate, or L-methylfolate”.

Currently on social media, there seems to be an interest in prenatal choline supplementation. Choline, a B vitamin, is not typically within standard prenatal vitamins. Is this micronutrient important for prenatal supplementation? What do professional/medical societies have to say regarding prenatal supplementation? What’s the data? In this episode, we will summarize choline’s role in fetal/newborn development, examine the data regarding deficiency, and talk supplementation recommendations. (Shout out to Dr. Cat Jimenez for the subject suggestion.)

Uterine fibroids are benign tumors that arise from a single genetically altered myometrial stem cell under the influence of gonadal hormones. Traditionally, it has been taught that fibroids universally diminish in size after menopause. However, an article published in 2021 showed a possibility of fibroid growth after menopause in overweight/obese women. Do fibroids need surveillance in menopause? Is HRT contraindicated in the fibroid patient? And which HRT is the most fibroid friendly? We will answer these questions in this episode.

I am a fan of the original hit TV show, “ER”. Although mostly melodramatic and outside of bounds of reality Medicine, one episode (season 6, episode 6) has a valuable life lesson for all of us. I originally viewed that episode when it was live and current, and I have never forgotten the message. In this episode, will discuss this important life lesson learned, and I promise you won’t be the same thereafter.

In January 2023, a new publication in Obstetrics and Gynecology- the Green Journal, will highlight the disheartening statements being made on social media (TikTok) regarding IUDs. IUDs are highly effective forms of contraception and the progesterone releasing variety have significant non-contraceptive benefits. Most of the dissatisfaction stated on social media surrounds pain during insertion. Do you offer topical lidocaine for IUD insertion? Ever consider lavender aromatherapy? What about music as a non-pharmacological intervention? Are these options evidence-based? In this episode, we will review the soon to be released January 2023 publication and also summarize a 2020 systematic review analyzing both pharmacological and non-pharmacological strategies to reduce pain and anxiety during IUD insertions.

Pre-operative vaginal preparation before gynecological surgery has unquestionable benefit for the prevention of postop infectious morbidity. Does the same hold true for vaginal prep at C-section? There has been over a decade of data, but a new publication- soon to be released in AJOG- is calling previous results into question. Does iodine work as a vaginal prep? What about chlorhexidine? There’s answers for all of these questions, and we will summarize them in this episode.

Surgical site infection (SSI) is the most common complication resulting from cesarean section. Despite advances in infection control, SSIs remain a significant post-op burden, to the patient first, and to the healthcare system second. Negative pressure wound therapy devices (NPWT) are a potential solution to post C-section. wound infections/complications. Do these devices prevent incisional wound complications after C-section? In this episode, will dive into the data and review the specific CDC criteria for diagnosing surgical site infections.

Traditionally, the CDC has recommended delaying IUD insertion for 3 months in a woman diagnosed with asymptomatic, cervical Gonorrheal or Chlamydial infection. This is to first confirm a negative test of cure. However, this leaves the patient at a greater risk of unplanned pregnancy compared to the risk of PID. Is this really the most evidence-based approach? The CHOICE CONTRACEPTIVE Study data provides an alternative approach. In this episode, we will discuss this dilemma and allow the data to settle the discussion. (With special co-host guest: 3rd year medical student, Ms. Carley Hagar).

In the upcoming (May) 2023 ACOG Annual Clinical Meeting, the College will have a highlighted session to “redesign, prenatal care”. The traditional model of prenatal care includes 12 to 14 in-person visits. However, there is no data that supports the theory that adverse outcomes are reduced by the number of prenatal contact visits. In 2020, at the height of the COVID-19 pandemic, women’s healthcare practitioners became more flexible in how they delivered prenatal care. Now, the ACOG is supporting an alternative prenatal care visit schedule for patients at “average risk”. This is called the PATH Prenatal proposal. Let’s talk about that in this episode, and discuss the ONE BIG Limitation to this proposal.

Did you know that not all cases of a single umbilical artery (SUA) result in a 2-vessel cord? Some umbilical cords with a SUA still have 3 vessels! How is that possible? Although SUA is only found between 0.2 to 1% of all live births, they can have important clinical implications. Although sonographic absence of other congenital anomalies is very reassuring (isolated SUA), some fetal conditions may not be apparent until time of birth. In the session, we will review the etiology of, diagnosis of, and management of the SUA.

The ACOG recommends universal screening for gestational diabetes between 24 and 28 weeks of pregnancy with occasional early screening for those at high risk. Is there an advantage to completing the 1-hour 50 g GTT while fasting? First studied in the 1990s, a new publication further validates the original study results. In this episode we will summarize this new publication soon to be released in Obstetrics & Gynecology (the Green journal) and discuss the paradox/conundrum of GTTs while fasting.

As I’ve said on previous podcasts, “we all need some encouragement every now and again”. Well this morning I received mine, through a small gift…from Germany!

Anti-D immune globulin has been advocated for use in appropriate patients since the 1970s. Historic data showed that 0.1ml of fetal D+ blood was all that was required to potentially sensitize an Rh negative mother. New data is questioning whether this prophylaxis is required in all cases of threatened miscarriage/abortion in early pregnancy, or if a more selective approach is appropriate. In this episode, we will highlight a soon to be released “Questioning Clinical Practice” commentary from Obstet Gynecol (the Green Journal) tackling this issue. Is it time to change our current and standard practice?

Fragile X Syndrome is the most common inherited form of intellectual disability, and the most common single gene cause of Autism Spectrum Disorder. It is also responsible for some cases of premature ovarian insufficiency. Do you recall the difference between a Fragile X “pre-mutation” versus the full mutation? Should we do universal screening for this as part of expanded maternal carrier testing, or should this be a targeted screening approach? Although we covered maternal carrier screening on November 4, 2022, this episode will go into much more detail, focusing specifically on Fragile X Syndrome and who should be screened for this. (For Emma…Great question! Thank you for reaching out to us).

Marijuana is the most commonly used federally illegal drug in the United States; its use among pregnant and lactating women is on the rise. Is breast-feeding contraindicated with marijuana use? It is difficult to separate marijuana use from several confounding variables, leading to conflicting data in print. Is marijuana use and breast-feeding compatible? A patient friendly article on Parents.com, released on November 23, 2022 seems to imply just that. In this episode, we will review the data on marijuana use during lactation and help clear up the seemingly contradictory outcomes data. Also, we will summarize key position statements from a variety of professional organizations, and find out what data gaps still exist.

Several cohort studies and meta-analysis have shown a direct association between poor oral health and adverse pregnancy outcomes. The key driver for this association is systemic inflammation. In this episode, we will review the ADA, ACOG, and CDC data on how maternal oral health can influence pregnancy outcomes. Although this association is pretty strong, remember that association does not necessarily prove causation. We will explain this in this episode.

Happy Thanksgiving, Podcast family! As we gather with family, friends, and loved ones… Let’s make the practice of gratitude a daily habit, not some thing that we do just once a year. There is real science on the art and practice of gratitude! In this brief episode, we will remind ourselves that gratitude is not just “something we do” on Thanksgiving, but really should be our way of life. We will cover gratitude’s effect on neurochemistry and it’s activation of critical brain centers. ❤️🦃❤️🦃❤️🦃

On November 17, 2022 Wimbledon showed a major head nod to women’s health. Do you know what that was? Nonetheless, this recognition of menstruation is just one small move forward, noting that Period Poverty is still widespread right here in the US. In this episode, we will review “Wimbledon, the period, and lack”.

“The Lotus Birth”… Although first described back in the 1970s, this birthing trend is gaining popularity today mainly because of social media. Is this practice evidence-based? Is it safe? There are real concerns here which have spurred several professional organizations and societies to issue HARSH warnings about this practice. In this episode, we will review the origins and current state of “the Lotus Birth”. We will also review the tragic case of Baby Harlow Eden. We will wrap up this episode with some practical peer advice as to how to handle this unconventional birth experience. 🪷

Systemic Lupus Erythematosis is several-fold more common in women than in men. As it primarily targets reproductive age women, identification of and proper management of patients with associated antiphospholipid antibodies is crucial to improve maternal and neonatal outcomes. In this episode, we will review the 2019 ACR diagnostic criteria for SLE and review the management of SLE patients with/without antiphospholipid antibodies and with/without antiphospholipid antibody syndrome.

The idea of keeping women “Nil per os” (NPO) during labor traces back to the 1940s with the pivotal work of Dr. Curtis Mendelson. His work on “aspiration pneumonitis” has kept women NPO during labor up to present day. But is this still evidence-based? Is it risky to allow women to have PO intake during an otherwise uncomplicated labor course? In this episode we will walk through history and provide an updated view on the risks and benefits of this historic practice.

TXA was first found to reduce maternal morbidity at time of established postpartum hemorrhage in the WOMAN trial (2017). Since then, evidence has grown to include TXA as a prophylactic agent to prevent postpartum hemorrhage. Despite its known effectiveness in BOTH the prevention and treatment of postpartum hemorrhage, there is a renewed global warning regarding this medication. In this episode, we will review the WHO and FDA warning regarding the misapplication/inadvertent intrathecal use of TXA at time of cesarean section.

Maternal carrier screening (either pan-ethnic or expanded carrier panel) is recommended by the ACOG and SMFM. Ideally, this is done pre-conception or with the first pregnancy. Did you know that in August 2022 the ACOG added an additional test for universal maternal carrier screening? Does this maternal carrier screen include BRCA? In this episode we will cover what maternal carrier screening is, and what it is not.

Katie Couric recently described her path to her diagnosis of breast cancer, urging women with “dense breast tissue” to get supplemental breast imaging. Do these supplemental imaging tests improve overall survival? In this session, we will review the statements of 4 professional societies/organizations regarding the use of supplemental breast imaging for women with dense breasts who have no additional breast cancer risk factors and are asymptomatic.

Dense breasts can decrease the sensitivity of screening mammogram (MMG). Some US states have mandated reporting of breast density on MMG, while the rest of the states report on dense breasts voluntarily as a standardized reporting system. What supplemental breast imaging tools are advised as a follow up in these patients? Does the ACOG support supplemental breast imaging in average risk patients? What about the USPSTF? In this session we will do a deep dive into this common MMG description of “dense breast noted”.

The Enhanced Recovery After Surgery guidelines were birthed (no pun intended) as a way to curb post-op morbidity from colorectal surgery. In 2019, CSection ERAS guidelines were published in the AJOG. Despite widespread agreement that ERAS is valuable, one aspect of the guideline is controversial: timing of Foley removal. Should the Foley be removed immediately after C-section? Should an indwelling bladder catheter be used at all? Let’s dive into this topic now.

The United States is currently facing an oxytocin shortage. How long this medication shortage is projected to continue is not clear. In an attempt to curb unnecessary use of oxytocin, is it safe to consider stopping oxytocin after induction, once the active phase of labor is reached? Is there data to support the practice? And what about using oxytocin for first trimester D&C? Is that evidence-based? In this session, we will review the data regarding discontinuation of oxytocin once the active phase of labor is reached. Is it safe? Is this effective? Let’s find out!

In 1964, John O’Sullivan published his original research describing abnormal cut off values following an oral glucose challenge in pregnancy. O’Sullivan laid the foundation for screening and diagnosis of gestational diabetes. We have learned a lot since that 1964 publication. In this session, we will review a new meta-analysis coming to print in November 2022 comparing the 1-step with the 2-step oral glucose tolerance test. We will also summarize data on point of care glucometers (capillary blood glucose) for diagnosing gestational diabetes. Is the use of POC testing devices for GDM diagnosis evidence-based? There’s an answer for that… And we will cover it.

Hattie… with these kind of insights, you are going to ROCK your oral boards in the next 72 hours! We are cheering you on! 👏👏👏👏

Recently, we reviewed the 3 vaccines generally recommended for every woman, in each pregnancy. But as they often say on late night commercials, “but wait… There’s more!” In this session, we will review 3 separate vaccinations which are applicable in special populations. Do you know which 3 they are? In this session our special guest, Carley Hager (3rd year medical student), will help us review the ACOG recommendations.

Fetal fibronectin was first reported as a possible biomarker for identifying those at risk of preterm birth back in 1991. Despite over 3 decades of ever evolving published data on FFN, underuse, misuse, and misunderstandings regarding what fetal fibronectin is and is not still persist. In the session we will review the SMFM recognized transvaginal ultrasound/FFN algorithm for preterm labor triage assessment. What is traditionally accepted as a “short cervix” on TVUS? Is it really safe to send patients home after a negative FFN result? Let’s review the data now. (Thank you Matt S. for the podcast suggestion.)

In 2015, the ACOG included immediate release nifedipine as an intervention for acute, emergent hypertension in pregnancy. But what about extended release nifedipine? Is there a role for this medication in patients with preeclampsia with severe features intrapartum? Does this calcium channel blocker prevent uterine contractility? In this session we will review a new study from the American Heart Association reviewing the effectiveness of oral extended release nifedipine during labor induction for preeeclampsia with severe features.

Gestational diabetes (GDM) is a risk factor for adverse perinatal outcomes. Currently, the ACOG recommends early screening for GDM for women “at risk”. However, other experts disagree with this approach. In this session, we will review the latest controversies regarding early screening for gestational diabetes. Is hemoglobin A1c an option for early testing? What about impaired glucose tolerance? We will cover all this and do a deep dive into the data in this episode. (For Dr. Kim! 😊)

Anticoagulation sure has come along way from warfarin. Although largely replaced by direct oral anticoagulants (DOACs), warfarin is still in use- mainly for patients with mechanical heart valves. For those on anticoagulation chronically, who require gynecological surgery, how/when is bridge therapy performed? In this episode, we will cover the ins and outs of anticoagulation bridge therapy. We will also review why bridge therapy is 100% not needed for a patient on DOACs.

Up to 70% of women who are anticoagulated will experience episodes of heavy menstrual bleeding. Traditionally, progestin only hormonal agents have been used in these cases. Can combination birth control pills be used in the anticoagulated patient? Is there data regarding their safety? In this episode, we will walk down the data timeline starting in 2009 and ending in 2021 regarding the use of combination birth control for menstrual/ovulation suppression in women who are anticoagulated. (For Elise 😊)

A great podcast topic recommendation/suggestion: anticoagulation bridge therapy, and patients undergoing gynecological surgery. More to come…

In January 2022, the American Heart Association conducted a study and concluded that labetalol may be the best antihypertensive medication antepartum. However, the ACOG has not endorsed one antihypertensive medication over the other. But what about Postpartum? Is labetalol the best to prevent postpartum hypertensive readmissions? In this episode we will review a new publication being released October 2022 from Obstetrics and Gynecology (Green Journal). Which medication is best to prevent postpartum hypertensive readmissions? Listen and find out.

This message is for Dr. Rob in Northern California preparing for his OBGYN oral boards. Rob, thank you for your voice memo on the app! Great question and absolutely fantastic clinical insights. With that kind of clinical inquiry and drive, I am sure you will ACE your upcoming OB/GYN oral boards. Dr. Rob’s question is which progesterone would be best for treatment of abnormal uterine bleeding: a progestational agent or one that is more androgenic. Listen and find out.

Current ACOG/SMFM/CDC guidelines for the prevention of Group B Strep neonatal infection are aimed at prevention of early onset GBS neonatal disease. But late onset infections still occur worldwide and are devastating for the newborn. This is why there is a new Group B Strep (GBS6) vaccine in the pipeline! On September 22, 2022 the FDA granted this vaccine “Breakthrough Therapy designation”. In this session, we will review what that designation means, why this vaccine is needed, and where we are in the process.

Acetaminophen (Paracetamol) is the most common medication used in pregnancy. For several years now, observational studies have raised concern for use of this common OTC medication in pregnancy and autism spectrum disorder/attention deficit disorder in children. Does acetaminophen cause these neurodevelopmental disorders? In this session we will highlight 3 recent publications that have gained national and international attention. We will also summarize the statements from the FDA, ACOG, SMFM, and the SOGC.

There is a current trend advocating for women to do complete “hormone panels” for wellness. There is also persistent confusion surrounding the use of “bioidentical hormones” stemming mainly from the vast options of OTC and compounded “natural” hormone supplements. For women, compounded bioidentical hormones (cBHT) mainly takes the form of testosterone supplements/pellets. With decades of use of these products, what is the current state of opinion on them? In this episode we will review updated position statements for bioidentical hormone use from the National Academy of Science & Medicine, the NAMS, the ASRM, and the International Society of Sexual Health. We will discuss the use of “pan- hormone testing” and will also review when serum testosterone levels may be indicated and summarize key concepts for testosterone use in women.

Maternal mortality in the United States is among the highest of all industrialized nations. Shockingly, the top cause of obstetric death no longer belongs to pregnancy related factors; homicide is the most common cause of pregnancy associated death. And suicide is not far behind. In this episode we will review a new publication from the ACOG reviewing staggering statistics on pregnancy associated deaths. We will distinguish between “pregnancy related deaths” and “pregnancy associated deaths”, and discuss how “the big 4” are risk factors for both homicide and suicide.

Neonatal herpes infection can be devastating to the newborn. For patients with a history of known genital herpes, daily suppression beginning at 36 weeks until delivery has been the standard for over 2 decades. For the HSV2 negative pregnant patient with a HSV2 positive partner, is PREP an option? In this session, we were review management of the HSV2 discordant couple during pregnancy.

Gentian Violet has been used for over a century for a variety of conditions including vaginal candidiasis. Does it work? More importantly… is it safe? In this session we will review the medical history, current use of, and safety profile of Gentian Violet. We will discuss ACOG’s stance on ordering vaginal medications WITHOUT an examination and we will also cover the most recent antifungal medication which has been FDA approved, Brexafemme.

Progesterone has long been hoped to be a remedy for 1st trimester pregnancy loss. Does progesterone help reduce miscarriage risk? The data is ever evolving. In this session we will review 2 landmark studies that helped answer this question (PROMISE, PRISM). We will also cover a 2020 Cochran systematic review that helped change the 2021 NICE practice guidelines on the subject. Lastly, we will also cover the latest data on this from May 2022 (ACOG ACM).

Oh, the twisted love story of progesterone and pre-term birth! Ever since the Meis trial in 2003, we have been fascinated with the use of progesterone as a possible cure-all of all things preterm birth. But the data keeps piling in, with results just contrary to that. In this episode we will review the publication history of progesterone and it’s fight against PTB. We will also highlight a new publication from the AJOG coming out September 1, 2022 analyzing vaginal progesterone’s effectiveness against PTB. Does it work? Let’s find out.

In 1949, Priscilla White published her landmark study on diabetes in pregnancy, launching the “White Classification”. This has been a staple of pre-pregnancy diabetes nomenclature since that time. However, despite its historical role in obstetrics, is this scale still relevant? In this episode we will review the history, definitions of, and proposed alternative nomenclature to the traditional White Classification.

Epilepsy/seizure disorders disproportionately affects women of reproductive age over men. The influence of sex hormones on seizure prevalence is well documented. As women’s healthcare providers, it’s vital for us to understand the influence of seizure disorders on women’s overall care. In this session, we will review important aspects regarding contraception and review the data on pregnancy outcomes in women with epilepsy.

There are so many things to go over with our pregnant patients especially at their initial intake visit. However, one thing that should not be left off that discussion list includes food items to avoid! Listeriosis during pregnancy can be devastating for the fetus. Are you familiar with the work up and CDC recommended treatment for this condition? In this episode we will present an easy to remember protocol for managing patients with a possible exposure to listeria monocytogenes.

I’ll let this episode title speak for itself… LOL. Hope this makes you smile.

Endometriosis is a devastating condition. Once thought to have its impact only during reproductive age, endometriosis has been linked to an increased risk of stroke later in life. Any new medication which shows safety and efficacy in menstrual pain reduction is welcome in this space. In this session we will review a new FDA approval of an existing medication in the battle against endometriosis. (Special guest co-host, Kacie Mitchell, 3rd medical student)

Yesterday, 08/01/2022, we released a podcast on “The 22 Week Birth”. As a follow-up to this, and in response to 5 separate questions (all related to the use of magnesium sulfate for fetal neuroprotection) from podcast members, we decided to get this episode out! While we all understand the upper limit for magnesium sulfate for CNS protection to be 32 weeks and 0 days, is magnesium sulfate a consideration at 22 weeks? We will lay out the timeline of data from 2017 to current day in this session.

Over the last several years, the “limit of viability” for neonates has decreased dramatically. The new “lower limit” of neonatal viability can now be considered to be as early as 22 gestational weeks. But there’s a lot more to that statement! In this session, we will review the latest data on neonatal survival in the Periviable interval. We will highlight and summarize a new publication from the Lancet published on July 25, 2022. Should we be performing “universal resuscitation” at 22 weeks? Or should we take a more “selective” approach? Let’s summarize the latest data.

Polyhydramnios affects from 0.2 to 2% of all pregnancies. Which is preferred for diagnosis, MVP or AFI? Is amnioreduction an effective intervention? When is indomethacin indicated? In the session we will dive into the issue of polyhydramnios, its workup, and delivery implications.

One of the most common techniques to assess fetal status intrapartum is the fetal scalp stimulation test. First proposed in 1936, its incorporation in modern obstetric practice is still evident. However, there are some common misapplications and misunderstandings of this intervention. Does fetal scalp stimulation help resolve a fetal deceleration? Or could it be potentially harmful? In this podcast we will set the record straight to prevent misuse of the fetal scalp stimulation test. Thank you Abby for the podcast topic and bringing this to my attention.

In this session, we will continue our brief summary of the NAMS 2022 clinical update on hormone therapy. Is hormone therapy allowed in patients with known BRCA genetic mutations? Is Bazedoxifene safe? What about vaginal estrogen therapy? We will answer these questions and more in this session.

Medical information moves fast. We know a lot more about risks and benefits of hormone therapy since the impactful WHI study was first released. In this session we will review important new concepts from the NAMS Hormone Therapy update just released Summer of 2022. Is it safe to continue hormone therapy beyond the age of 65? Is “lowest dose for shortest duration” still a valid concept? We will tackle this question and more in this session!

For several years, data has validated the value of water immersion during labor (1st stage). However, when it comes to the 2nd stage of labor, the AAP and the ACOG are unified in their positions which is at odds with the ACNM. But what does the new data support? In this session we will cover a new systematic review and meta-analysis from BMJ Open which was published July 2022. Let’s set the record straight on water immersion during the first and second stages of labor.

Sleep disruption and poor sleep quality are not unusual during pregnancy. That’s obvious! What’s not so obvious is whether a common over-the-counter sleep agent, melatonin, is safe to use during pregnancy or not. While traditionally, options like diphenhydramine and doxylamine have been used as sleep aids during pregnancy, up to 4% of women (reportedly) use this over-the-counter supplement during gestation. What does the data say? Let’s address this common supplement use…now.

Lots of practical clinical pearls in this episode! “Reverse sequence testing” for syphilis has largely taken over the traditional testing algorithm. Traditionally, non-Treponemal tests (RPR, VDRL) were done first with a reflex to a Treponema specific test if that was positive (MHATP). But this is now considered the antiquated technique. Reverse sequence testing has the advantage of potentially identifying infected patients very early on. In this session, we will give easy to use/practical tools for reverse sequence test interpretation, and how to best manage “discordant“ results.

Over the last several days I have received numerous Facebook messages, podcast voice memos, and personal texts regarding the potential for misapplication of Ulipristal’s mechanism of action as emergency contraception. Will Ella be banned? Does it affect implantation? It’s time to clear the dust and set the record straight.

On June 16, 2022, the ACOG released a new practice advisory regarding PreP in the ObGyn patient population. This has important implications on how we counsel patients especially after recent STI diagnosis. In this podcast we will cover important aspects of PreP to get you comfortable with this preventative option. What are the 3 currently approved options? Are they safe? What about monitoring? Do adolescent patients qualify? We will answer all of these questions and more in this session.

We have come a long way from the first report from Stein and Leventhal describing “polycystic ovaries“ on ultrasound in infertile women back in the 1950s. We already well understand that PCOS raises the risk of certain antepartum complications including gestational diabetes, possible macrosomia, and the development of gestational hypertension or preeclampsia. But there actually is scant data on the risk of acute peripartum complications. In this podcast we will summarize a large study just published June 16, 2022 out of the Journal of AHA. We will also cover the importance of distinguishing between “Odds Ratios” and “absolute numbers” for clinical implications. Ready? Let’s dive into acute PeriPartum risks for women with PCOS.

Well…so there’s this. 😳😳😳

This is your crash course into all things “Monkeypox”. Data for this podcast comes from the CDC, WHO, and the Royal College of Obstetricians and Gynecologists. Information is moving fast and we’re here to keep you evidence-based. How does Monkeypox affect pregnancy? When is a C-Section indicated? What are the treatments available? And what about the 2 vaccines available in the USA… Why is one more problematic than the other? Listen in and find out.

Which is better for determining amniotic fluid volume: the AFI or MVP? There’s data to support one or the other. In cases of isolated oligohydramnios in the late preterm interval, is there a role for maternal oral hydration? Does that actually work? We are going to dive into the amniotic fluid (no pun intended) dilemmas now.

According to the ACOG, by natural menopause it is estimated that up to 70% of women will have developed a uterine leiomyoma. 70%! Most of course are asymptomatic. For those with symptoms, heavy menstrual bleeding and pain are the most common afflictions. In May 2021, the FDA approved a new triple combination pill for heavy menstrual bleeding associated with fibroids. Can this medication also be used as hormonal birth control? We will review the ACOG, FDA, and manufacture’s information for MyFimbree in this clinical update.

Meet Hilda! In this quick episode, I’ll share a very unique story of one of our coworkers (our featured guest on the podcast). I know this will encourage, inspire, and just make your day! Listen in, and find out why.

There are currently (in the USA) 4 generations of available progestins in combination birth control pills. Are these differences clinically relevant, or is it all manufacturer marketing? In this session we will review the chemical nature, biology of, and clinical manifestations of the different progestins. We will set the record straight. (This topic was suggested by an OB/GYN senior resident at Lincoln Hospital, South Bronx… Thank you for listening to our podcast and for the wonderful podcast topic suggestion).

Fetal microcephaly is a devastating diagnosis. Prognosis is dependent on whether fetal microcephaly is isolated or part of other congenital anomalies. Prognosis is also directly related to the degree of fetal microcephaly. In this session, we will review the diagnostic criteria, workup, and prognosis of this devastating fetal condition.

Here’s what’s going on… As of May 26, 2022.

Pregnancy can definitely work some changes on the body. Melasma is a common pregnancy reaction, and can be a cosmetic concern to many affected. Are treatments safe to use during pregnancy? Are cutaneous lasers allowed? In this session we will review the available literature and cover the first, second, and third-line options for treatment of the mask of pregnancy.

The etonogestrel implant is the most effective LARC available. Well, how many years AFTER the FDA approval of 3 years does the implant remain effective? Also, currently, the usual and customary standard is for the provider and patient to palpate the implant area after insertion. But what happens when the insert is non-palpable? In the session, we will review the evidence-based protocol to find this nonpalpable implant. Can you order a serum etonogestrel level? Do these things “migrate”? Can a patient still use it for birth control after 3 years? Listen in, and find out.

Historically, obstetrical providers cautioned patients about decreased fetal movement. But what about maternal perception of INCREASED fetal movement? Is increased fetal movement a harbinger of adverse neonatal outcome? In this session we will highlight and summarize a new publication from the AJOG (April 26, 2022) that helps shed light on this clinical conundrum.

Since the 1960s, metronidazole has carried a label warning stating that alcohol use while taking the medication can lead to significant side-effects. This was termed a “Disulfurim-like reaction”. However, that’s 100% not true! Where did this metronadazole myth come from? Why has it survived for over 50 years? In this podcast… We’ll set the record straight! Yes, you can have your cake and eat it too… I mean, your beer and drink it too! 🍻🍺🍻🍺🍷🍷🍷

On May 3, 2022, JAMA published 2 separate randomized clinical trials (RCTs) regarding patient’s self-monitoring of blood pressures at home. Historically, clinicians instructed patients either at risk of developing hypertension in pregnancy or those with existing chronic hypertension/hypertensive disorders in pregnancy to self-monitor their blood pressure in-between clinician visits. Is that recommendation clinically useful? Does the data support that? Once again, the world of “hypertension in pregnancy” is being shaken up! In this podcast we will review these 2 recent RCT studies which may the change the way we practice obstetrics.

In May 2022, the ACOG Will release a new Clinical Practice Guidance (#3). This will cover “Headaches in Pregnancy and Postpartum”. Do you know which classes of medication are considered first line for primary headache prevention during pregnancy? And for acute treatment of migraine, which medications are recommended? Are Ergot alkaloids safe for use? What about Triptans? In this session, we will summarize and highlight Clinical Pearls for the prevention and treatment of primary headache in pregnancy and during lactation.

Addressing severe maternal morbidity is a public health priority in the US. Postpartum hemorrhage is one of the driving contributors to severe maternal morbidity/mortality peri-partum. A recent study published in JAMA open network in February 2022 is showing an unusual benefit of labor epidural analgesia which may help close the gap in severe maternal morbidity-related healthcare disparities. In this episode, we will highlight the key findings of this publication and review “epidural’s secret benefit”.

It could not have been timed any better: Coming off the heels of the recent FDA warning on the use of noninvasive prenatal test (NIPTS), a new study soon to be released in May 2022 is calling its use into further question. Is this a return of the Maternal Serum QUAD screen? Listen in and find out.

On April 19, 2022 the FDA released a warning regarding the inappropriate use of cell free DNA genetic screening tests. Within 24 hours, the ACOG (April 20, 2022) issued a statement response. In this podcast we will highlight these two key documents. We will also review what cell free DNA is and is not. What is the role of Ultrasound in genetic screening? Can cell free DNA be repeated after a “no call” result? Lots of important information… Covered here!

Without doubt, the most common reason for requested progestin-intrauterine system (IUS) removal is abnormal bleeding patterns. But do you know what the second most common reason is? It’s acne! In this episode, we will summarize a soon to be released article accepted for print in Obstetrics and Gynecology (the Green Journal). This episode will provide practical clinical pearls to truly obtain informed consent from our patients seeking long acting reversible contraceptives (LARCS).

On Friday, April 15, 2022, I received a Facebook question regarding a recent episode on ROM test. We stated that ROM Plus, as a test, has accuracy between 23 to 37 weeks. Where does that come from? In this brief episode, will explain the facts.

Today, April 11, 2022, the ACOG updated its practice advisory regarding chronic hypertension in pregnancy. This follows the statement from the Society of Maternal Fetal Medicine recognizing the change in practice based on the CHAP trial. In this session we will summary ACOG’s response.

Since 2005, experts have advocated for ovarian conservation, until the age of 65, at time of hysterectomy for benign indication. However, a soon to be released publication is calling for a retraction of that opinion! Based on brand new data, do you know the age NOW at which ovarian removal is recommended? In this session, we will review this brand new information that will greatly impact how we perform hysterectomy for benign indications.

A study published on April 2, 2022 in The New England Journal of Medicine, "Treatment for Mild Chronic Hypertension during Pregnancy” (CHAP Trial) has resulted in ACOG calling to order its Practice Advisory Committee to prepare a “practice update” regarding the management of mild to moderate hypertension in pregnancy. This recent publication is practice changing! While we await the revised guidelines and official statement from the ACOG, this podcast will review the current state of affairs regarding management of mild to moderate chronic hypertension in pregnancy.

This is Part 2 where we will wrap up our review of commercially available screening tests for ROM. Do you know what each test specifically checks for? Which test seems to outperform the others? And what about ferning and pH testing? Are those still done? Let’s wrap up our 2-part series with these answers and more.

PROM is a common diagnosis in Labor and Delivery. However, making a false positive diagnosis OR a false negative one may place the pregnancy at risk of either unnecessary interventions or adverse perinatal outcomes- or both. In this session, we will review best practices for exam based diagnosis. Are you aware of the FDA “Dear Doctor” letter regarding ROM biomarker testing (2018)? This session is Part 1. In Part 2, we will dive deep into the 3 main biomarker tests for ROM- how they differ, how they perform, their strengths and their weaknesses.

Some things in medical practice stem more out of tradition than true clinical evidence. Such is the case for histological examination of the placenta. When is pathological examination of the placenta actually helpful? Should we send of the placenta in cases of multifetal birth? What about meconium or chorioamnionitis? In the session, we will review a soon to be released clinical brief from Obstetrics and Gynecology (ACOG) coming out April 2022. This new evidence review questions our current clinical practice of routine placental histological evaluation.

There is a recommendation for universal screening of Hepatitis B surface antigen in pregnancy. Which antiviral medication is recommended for prevention of Hep B vertical transmission in pregnancy? Is there a antiviral medication approved for Hepatitis C in pregnancy? In this session, we will review new data which is soon-to-be released in the American Journal of OB/GYN (Gray Journal) reviewing antepartum (maternal) antiviral medication used to prevent mother to child transmission of Hepatitis B. We will also review the SMFM guidelines for hepatitis B viral infection during pregnancy.

Why is Magnesium Sulfate the first-line medication for preeclampsia/eclampsia? How did that arise into the current, international, standard-of-care regiment for that condition? Is 24 hours of Postpartum Mag evidence-based? In this episode we will review the evolution of magnesium sulfate for eclampsia prevention/treatment. We will also summarize a soon to be released systematic review and meta-analysis publication from Obstetrics & Gynecology examining the duration of postpartum MagSulfate use.

Pregnancies that arise after assisted reproductive technologies (ART) are at higher risk of maternal, fetal, and even placental complications. In this session we will summarize and highlight key prenatal management pearls for pregnancies that arise after ART. This is a summary of the SMFM consult series # 60, from March 2022.

Preeclampsia occurs in 3 to 5% of the general OB population. It has even higher prevalence among those with high-risk conditions. Currently, aspirin stands alone as the most evidence-based pharmacological option for preeclampsia prevention (risk reduction). But over the last decade new interest has arisen for the use of statins for preeclampsia prevention. Well, do statins work? What is the state of statin therapy as of 2022? In this session we will review the latest data and review the key pathogenesis in preeclampsia formation.

Couples trying to conceive often ask questions like these: When is the best time to have sex to get pregnant? Is there a better sexual position to have sex in order to conceive? Is one type of over the counter lubrication better than the other? Well despite weird myths and misperceptions about these subjects, there are firm answers we can give. In this podcast we will cover the January 2022 ASRM Bulletin on ways to “optimize natural fertility”.

Hydrotherapy (water immersion) has a proven safety record and proven benefits in the first stage of labor. But what about actually delivering with water immersion? In January 2022, the AAP released a Committee Opinion regarding water immersion delivery. The AAP echoes the words from the ACOG regarding water immersion births. However, the ACNM does not agree. In this session, we will review the established and conflicting viewpoints from these organizations regarding water immersion in labor and delivery.

The old adage, “Too much of anything is a bad thing”, is traditionally credited to Mark Twain. Was he right? Does the same apply to medical information?What about finding incidental genetic carrier states from online companies like “23AndMe”? In a patient with no personal or family history of any medical complication or malignancy, is this information helpful or more psychologically harmful? In this episode we will review a recent real-world case of how gynecological care was impacted by a patient’s curiosity regarding her genetic makeup.

Semen allergy is a real (although rare) immune reaction. Do you know what the presenting signs/symptoms are?The ISSM has established diagnostic criteria for this. In this session, we will review the diagnostic algorithm for a patient presenting with possible semen allergy.

Postpartum hemorrhage continues to be a worldwide leaning cause of maternal morbidity and mortality. In May 2021, the WHO updated it’s global recommendations for the use of “uterine balloon tamponade” in the management of PPH. Did the WHO ban the Bakri? In the session we will review the May 2021 WHO updated guidance and summarize a soon to be released guideline commentary from the ACOG (proposed release date March 2022).

Globally, more than 200 million infants have been born since the onset of the COVID-19 pandemic. It has been unclear whether fetal exposure to maternal SARS-CoV2 infection can adversely affect the child’s neurodevelopmental progress. Does having Covid during pregnancy affect the child’s neurodevelopment? The answer is intriguing! This is a tale of a pandemic, psychosocial stress response, and epigenetic changes. (Data summary from JAMA Pediatrics; Jan 2022).

In the ACOG Practice Bulletin #106, which was released in 2009, the use of maternal supplemental oxygen for fetal heart rate tracing correction is mentioned. In that original bulletin, it states “despite inadequate data to support its use” consideration can be given to supplemental maternal oxygen for category II or III fetal heart rate tracings. However, within the last 7 years, an ever-growing body of evidence has proven that supplemental oxygen for fetal heart rate pattern abnormalities is not only ineffective but may actually be harmful to the premature fetus. Now, as of January 2022, we now have new guidance on this. Find out how and why the ACOG has now changed its original opinion.

Hypertensive disorders in pregnancy are a large contributor to maternal mortality. Maternal mortality rates for chronic hypertension in pregnancy have increased 15-fold over the last 4 decades! The California Maternal Quality Care Collaborative (CMQCC) has been a leading authority in the Pregnancy Hypertensive space. In the session, we will review BIG updates from the CMQCC. Should we aggressively treat chronic hypertension in pregnancy? What about treating nonsevere gestational hypertension? Are you familiar with the new Cardiology subspecialty of “Cardio- Obstetrics“? Let’s cover all this information… NOW!

Concerns about a possible association between COVID-19 vaccination and abnormal menstrual cycles may lead to vaccine hesitancy. Social media sites have claimed that cycles are affected, although temporarily, after vaccination. Is this true? In the session, we will summarize a soon to be released publication out of Obstetrics and Gynecology which helps clarify this issue. We will also highlight a press release from January 6, 2022 from a major news outlet which seemingly appears to distort those results.

Women with multiple prior low-transverse CSs show a trend toward increased risk of rupture compared with a single prior CS. While some have advocated planned repeat CS at 39 weeks as in patients with a SINGLE previous cesarean, planned repeat CD at 38 weeks is likely to be associated with a lower risk of uterine rupture. Yet, there is no consensus on best practice. In this session, we will summarize a new AJOG publication (Jan 2022) that raises some interesting and clinically meaningful data regarding the timing of repeat CS in women with 2+ prior cesareans (Shinar et al. Timing of cesarean delivery in women with 2+ previous cesarean deliveries. AJOG; Jan 2022).

In 1997, Mercer et al first published their data on antibiotic use for PPROM latency. With IV Erythromycin shortages, Zmax is a known substitute. New data (EPUB December 2021) now points to Zithromax’s validated clinical advantage over Erythromycin in this protocol. In this session, we will review this soon to be released publication in AJOG.

Traditionally, physicians have informed patients that long acting reversible contraceptives are “just as effective“ as female sterilization. While as a Class that statement is correct, not all individual LARCS have the same efficacy; one in particular beats all other birth control methods, hands-down. Do you know which one? In this session we will review key facts regarding female sterilization and review the individual efficacies of long acting reversible contraceptives. We will also review the historic “math model” for female sterilization.

As of December 23, 2021 the FDA has granted Emergency Use Authorization to 2 different oral medications (Pfizer; Merck) in the fight against Covid-19. Do you know the differences between PAXLOVID and molnupiravir (LAGEVRIO)? What are their indications for use? Are both allowable in pregnancy? This information is “hot off the press” and will update you on these 2 new, novel therapies.

In our previous podcast, we stated that – due to lack of data – early cord clamping may be considered with nonvigorous neonates. However, the babies that may benefit the most (preterm or extremely pre-term) are often “nonvigorous” at birth. So how do we reconcile this issue? This podcast will answer this dilemma, summarizing points from the January 2022 CME publication on “Placental Transfusion of the Neonate“.

There are 3 umbilical cord management strategies at time of delivery: (1) Early cord clamping, (2) Delayed clamping, and (3) Cord milking. How long should umbilical cord clamping be delayed? Is cord milking beneficial or potentially harmful? Are you familiar with the contraindications to delayed umbilical cord clamping? In this session, we will review this soon to be released CME article from Obstetrics & Gynecology (The Green Journal) covering “placental transfusion of the neonate”.

The clinical gold standard for the diagnosis of ruptured membranes is the sterile speculum examination (SSE). Tests like Amnisure or ROM+ are considered ancillary and supplemental. What is best clinical practice for performing a SSE? In the session we will review this procedure, discuss ancillary testing, and answer the age-old-question… “To lube or not to lube”.

Postpartum neuropathies are an infrequent occurrence but can significantly impact a patient’s quality of life. Are you familiar with “strawberry picker’s” neuropathy? It is the most common type of nerve injury during vaginal delivery. In the session, we will review safe maternal positioning during vaginal delivery.

New onset hypertension in the postpartum period should be assumed to be preeclampsia until proven otherwise. Up to 26% of eclamptic seizures occur beyond 48 hours and as late as 4-6 weeks after delivery. However, most of eclamptic seizures occur within the first 7 days after birth. In this session, we will review the recently updated CMQCC healthcare provider toolkit focusing on delayed postpartum hypertension/eclampsia. We will also point out a frequently forgotten fact about a potential risk of methyldopa use in the postpartum interval.

Thanksgiving 2021 is upon us! However, did you know that mental health experts make the very important distinction between gratefulness, thankfulness, and gratitude? While being thankful is important, it is much more vital to live in a state of Gratitude. In this session, I am joined by Lisa Chapa (LCSW). We will explore this concept and the Science of Gratitude.

(Introducing Dr. Garrett Dunn as guest resident on today’s episode!) The CDC estimates that more than 1.1 million people in the US are living with HIV infection, and 1 of 7 individuals is unaware of their infection. HIV care has come a long way over the years. In this episode, we will review QUICK FACTS from the SMFM on HIV care during pregnancy. Data summarized is from the last SMFM update on HIV care in pregnancy (Checklist data).

How do you diagnose vaginitis? Do you treat BV/yeast/trichomoniasis found on Pap smear? Do you use the Wet Prep, or molecular/DNA test? An ePub recently released in Obstetrics and Gynecology (the Green Journal), revealed some disappointing results for the Wet Prep. In the session, we will summarize key points from this article, as well as remind all of us of some key information released by the ACOG in January 2020 regarding vaginitis in the non-pregnant patient.

This session is a follow-up to our immediate pest episode. Are there any evidence-based true alternatives to the 50 g screening test for GDM? What about hemoglobin A-1 C? What about home blood glucose monitoring? Let’s dive into the data and see. We will also introduce you to… “Chapa chocolates”. 😳😊😆

It’s true, patients do NOT enjoy the 50 gram oral glucola test for gestational diabetes screening. And, the 100 gram test is even worse! Online sources claim that consuming a certain number of jellybeans is comparable to the standard screening/diagnostic test. Is that valid information? In this session we will review this jellybean theory and review what the data actually says.

The prevalence of Hepatitis C viral infection in pregnancy has doubled over the past 10 years. Active hepatitis C viral infection in pregnancy increases the risk for both maternal and neonatal morbidity. In the session, we will review this alarming trend along with key screening and management recommendations from the ACOG/CDC/SMFM.

In this episode, a simple to follow algorithm for management of APS in pregnancy will be presented. We will cover both antepartum and postpartum care.

Antiphospholipid syndrome has well established diagnostic criteria. Nonetheless, healthcare providers still find the condition- and it’s management-somewhat confusing. In this session, we will cover the diagnostic criteria for APS and who qualifies for investigation. In Part 2, we will cover specific management algorithms in pregnancy.

Fetal renal pelvic dilation occurs in 1% to 5% of all pregnancies. Although most are benign, it can be associated with genetic and structural disorders. Are you familiar with the CAKUT syndrome? When should Chromosomal MicroArray Analysis (CMA) be offered? What about prognosis? In the session, we will summarize and highlight the main points of the SMFM consult series #4 covering fetal renal pelvis dilation.

Just a quick message response for one of our listeners, Liane. Great points Liane… I take your message to heart! Here’s is our response. Thank you for being a contributing part of our listening family.

October is Domestic Violence Awareness month. This is such an important issue to discuss, and we will give into it here! Making her podcast debut is one of our residents, Dr. Katie Light. AND… as you will learn at the end of the podcast, she’s also a very proud Texas A&M Aggie! WHOOP.

Molnupiravir is now on the scene as a potential new therapy for mild to moderate COVID-19. As an oral administered medication, this could revolutionize care of the condition. In this session, we will review the early origins of this medication, its MOA, and what the data in the phase 3 study showed.

There continues to be a lot of faulty assumptions regarding testosterone therapy in women. In 2014 the Endocrine Society joined an international panel and provided an evidence-based review of testosterone use in women. This was reaffirmed in 2017 and 2019. Most recently, in October 2021, the ACOG released a “clinical commentary” ahead of print, “Testosterone Therapy in Women”. In the session, we will review this soon to be released current commentary and provide key clinical pearls regarding the use of testosterone replacement in women.

Sexual climax has been defined not only as a bodily/physiological reaction but as a mental process as well. First termed “the little death” historically, the phrase focused on the altered state of awareness following sexual release. But there’s many reasons/benefits why sexual release may be voluntarily delayed (by mutual agreement) during intimacy. In the session, we will approach the once taboo subject which has now gone mainstream. So let’s talk about “the edging experience” and what medical evidence there is to support it.

Thank you to Dr. Leslie Clark (Senior Resident) for your great work in wrapping up our discussion on antepartum fetal surveillance. In this session, we cover one of the most misunderstood tests in fetal surveillance, the biophysical profile. Is the NPV for the modified version the same as the full? Which test is the “most reassuring”? We will answer this question and more in the session!

In this session I am joined by one of our upper level (Senior) wonderful residents, Dr. Catherine Jimenez. Dr. Jimenez and I recorded this as an impromptu podcast covering antepartum fetal surveillance. Does maternal eating actually affect fetal movement? Do kick counts really work to prevent fetal morbidity? We will cover these questions, and more, in this episode (Part 1).

Here’s a question for you: would you rather have motivation, or inspiration? Used interchangeably in common dialogue, the two can actually be polar opposites. This is a brief review of the power of inspiration, not just in our daily work, but in living life overall. Taken from psychological studies and CBT, this session will hopefully INSPIRE you in your daily life. Choose inspiration over motivation!

PTSD has come a long way from its original designation as “shellshock”relating to veterans of war. PTSD is also possible following childbirth, even in otherwise “uncomplicated” Labor And Delivery events. Childbirth-related PTSD has been historically overlooked. In this session we will summarize the DSM5 criteria for this condition in order to better recognize and diagnose the condition.

In this session we wrap up our discussion of emergency contraception. Is there a preferred option for those with larger BMIs? What if the patient has emesis after a dose of oral EC? We will summarize the evidence/data here.

Despite its use for decades, misinformation and misperceptions about emergency contraception still persist. Are all options the same? What is their efficacy? Does bodyweight affect EC’s ability to prevent pregnancy? And what about medical contraindications to birth control use? In the session, which is Part 1, we will dive into the facts regarding emergency contraception.

The US is ranked 65th among industrialized nations for maternal morbidity and mortality outcomes. That is unacceptable! Maternal levels of care initially began in Texas. Now, there is a plan to make this nationwide. With the goal of reducing maternal mortality and morbidity in the United States, ACOG has partnered with The Joint Commission on the development of a new Maternal Levels of Care (MLC) Verification program, effective January 1, 2022. This session, we will review what this program will look like as well as its primary goal.

Available mAbs are directed against a large number of antigens and used for the treatment of immunologic diseases, reversal of drug effects, and cancer therapy. Now of course they are also being used against COVID-19. As these are IgG based, is the use of monoclonal antibodies allowed in pregnancy? What is the ACOG/SMFM position statement? In this session, we will review the latest data regarding monoclonal antibody use in the OB patient.

Tranexamic Acid’s use in obstetrics skyrocketed in 2017 after the release of the WOMEN trial. At that time, the ACOG endorsed TXA for use with diagnosed PPH, not for its prevention. Does TXA prophylaxis reduce postpartum hemorrhage? Does it matter whether it is used at vaginal birth or cesarean? Data moves fast and we will highlight those new answers here.

(Part 2) In this session, we will wrap up our summary review of the ACOG September 2021 Clinical Consensus bulletin on postpartum pain management. What are “ultra rapid metabolizers” of opioid medication? How does that affect our prescriptions for postpartum pain control? In this session we will answer these questions and more! ⚕️⚕️⚕️⚕️

Uncontrolled postpartum pain can lead to postpartum depression, impaired maternal-child bonding, and even chronic pain syndromes. Uncontrolled postpartum pain can also lead, in some individuals, to a form of PTSD. In this session, we will review the September 2021 Clinical Consensus statement from the ACOG on using a “MultiModal Stepwise Approach” to Postpartum pain management. Do NSAIDS increase blood pressure? When are TAP blocks recommended? We will answer these questions and more in this session. (This is Part 1)

The diagnostic algorithm for primary amenorrhea is extremely logical once one understands this pathophysiology. While some patients presenting with primary amenorrhea are indeed genetic females, some are actually 46XY. Do you remember the difference between Swyer syndrome and androgen insensitivity (AIS)? In this session, we will present an easy to follow diagnostic algorithm for primary amenorrhea based on ASRM guidelines. We will also provide high-yield facts contrasting Swyer syndrome with AIS.

At the end of July 2021, the CDC updated its treatment guidelines for sexually transmitted infections. Changes were made to recommended treatments for chlamydia, gonorrhea, trichomoniasis, and PID. There’s also new updated information regarding mycoplasma genitalium. In this session, we will provide a summary review of the key take-home changes made by the CDC.

In 2003, the ACOG/SMFM endorsed IM progesterone for PTB prevention. But new data has called this into question (PROLONG trial). In this session, we will review the PROLONG data and compare it to the newly released EPPPIC study. What does the ACOG now recommend? We will answer these questions and more in this session.

The last time ACOG released a practice bulletin on the prevention of preterm birth was in 2012. In August 2021, the ACOG will release a new practice bulletin addressing prediction and prevention of preterm birth. In this session, we will summarize transvaginal ultrasound for cervical length screening. Is there a “reassuring“ cervical length using TRANSABDOMINAL ultrasound? When should these be done? And what about all the new progesterone data? Listen to find out.

Non-sexually acquired genital ulceration (NSGU) is painful ulceration of the external genitalia, usually in adolescents, unrelated to sexual activity. In this session, we will review the likely ideology, the clinical presentation, its diagnostic criteria, and the management approach for this condition.

There is a whirlwind of false/misleading information on social media regarding the COVID-19 vaccines. Some social media posts state that breast-feeding should be STOPPED after this vaccine. Is that evidence-based? What does the Academy of Breast-Feeding Medicine recommend? In this session, we will review a recent report from JAMA Pediatrics (July 2021) which provides some much needed clarification on breast-feeding after COVID-19 (mRNA) vaccination.

Our understanding of Intrahepatic Cholestasis of Pregnancy has changed just over the last 5 years. What is the best laboratory test to help diagnose this condition? At what level of total serum bile acids is the risk of fetal death greatest? What does the SMFM say about induction of labor for these patients? In this episode, we will highlight and summarize the latest clinical brief on ICP from the SMFM (2021). This is SMFM consult series # 53.

Thank you for sharing your message! And, most importantly, congratulations on your board certification! Hope this makes someone else smile, as it did for me.

Atypical Breast Hyperplasia may present either as Atypical Ductal Hyperplasia or Atypical Lobular Hyperplasia. Which of these two is considered the more “pre-malignant”? Is surgical excision necessary for all atypical breast hyperplasia? Who qualifies for tamoxifen? And, how does breast tomosynthesis fit into the management scheme? We will dive into these questions and more in this session.

Correction of iron deficiency anemia in pregnancy is not just about fixing a low “H & H”. Iron deficiency during pregnancy is associated with real adverse maternal and neonatal outcomes. What is the best way to take oral iron supplementation? What about IV iron? Does “intramuscular” iron injection have a place in practice? Let’s cover these questions and more in this session.

Nifedipine is one of the most common medications used for tocolysis. However, does it actually improve neonatal outcomes? What about tocolysis in general? In this session we will review a new randomized trial from Parkland, published in July 2021 in Obstetrics Gynecology (Green Journal).

According to the latest US Census Bureau report analyzing the use of languages in the United States, over 20% of Americans speak a language other than English at home. Of this population, greater than 24% report that they do not speak English well or do not speak English at all. With a US population of more than 300 million, this makes over 70 million people with limited English proficiency. In this session, we will review best practices for using medical translation with our patients and why using family members as “ad hoc translators“ can land us in hot water (aqua caliente!)

Our understanding of gestational diabetes has changed over the last two decades, and more changes are sure to come! The traditional screen between 24 to 28 weeks may actually be too late. Enter the “GO MOMs” study. This NIH study, starting now, aims to answer the persistent unknowns regarding maternal blood levels during gestation. Listen to how this remarkable study may impact our screening, diagnosis, and management of gestational diabetes in the very near future.

Welcome back! In this session, we will review the contraindications for LEEP and the specific indications for CKC.

In 2019, the ASCCP made some impactful changes to the management algorithm for cervical dysplasia. Why was the treatment algorithm divided between those under the age of 25 years and those over 25 years of age? When is observation without excision preferred? And, what’s the best way to perform surveillance after an excision procedure? In this session, which is Part 1, we will review the guidelines related to surgical excision of high-grade dysplasia.

Cesarean section is the most common laparotomy performed worldwide. So, you would think we would have a standardized way of closing the uterine incision. But we don’t! What does the data say about single layer hysterotomy closure compared to two layer closure? Is one really better for TOLAC? Is one associated with more complications than the other? The answer is a little bit more complicated than you think. In this session, we will review the aggregate data on this persistent debate.

I love how our medical community can come together to discuss and brainstorm on better ways to care for our patients. Last night I received a message from Allison, from Chicago. Thanks Allison! She had a question regarding our recent RLS podcast and the potential role for magnesium supplementation for the condition. Is magnesium an effective treatment choice for RLS? Let’s review that data now.

Welcome to Part 2! In this session we will complete our discussion of RLS in Pregnancy and review its workup and management strategies.

Restless Leg Syndrome (RLS), now often referred to as Willis–Ekbom Disease (WED), is a common sensorimotor disturbance much more prevalent in women and during pregnancy. Do you know the potential pathophysiological tie between pregnancy and this condition? What are RLS symptoms? What about treatment? Let’s dive into this very common, yet largely overlooked, issue in the session.

The FDA has approved Brexafemme, an antifungal drug, for treating vaginal yeast infections. The drug represents the first new antifungal drug class in 20 years. How does this new medication work? and What's the dose? Does this work for recurrent vaginal cases? Please note that there are also some cautionary items that WE MUST address here... Lets cover that now!

PROM complicates 8% of term pregnancies, approximately 270,000 births in the US annually. In this session, we summarize and review a June 2021 Systematic Review/Meta-Analysis (of RCTs) where an intracervical balloon catheter was compared with a pharmacologic agent for the induction of labor after PROM,including preterm PROM.

Hepatitis C is the most commonly reported bloodborne infection in the United States. The ACOG is updating its Hepatitis C screening guidance regrading pregnancy. In this session, we will review the May 2021 ACOG Practice Advisory regarding hepatitis see screening in pregnancy.

The ACOG will release a new Practice Bulletin in June 2021 discussing obesity in pregnancy. The prevalence of obesity in reproductive age women in the United States is 39.7% In this session we will review some key practical issues regarding cesarean sections in the obese patient. Is one type of skin closure better than the other? What is the optimal VTE pharmacological protocol? Tune in and see!

The information in this section will shake your foundation regarding what you had previously been told about the origins of preeclampsia. Is the placenta the villain or the victim? This is Part 2 of our Myth-Busting Preeclampsia Episode. We will review the maternal cardiovascular changes that actually PRE-EXIST the development of preeclampsia.

The pathophysiology of preeclampsia continues to be discovered. For decades, the placenta has been portrayed as the “villain“ in the preeclampsia saga. But is it? Evolving data is putting that into question and is eliminating previously held concepts previously thought to be true. In this episode we will myth-bust some long-standing beliefs regarding preeclampsia.

Is the high dose Pitocin protocol (6 mU/min) associated with increased C-sections for fetal distress? What about perinatal outcomes? There are a variety of Pitocin protocols in L&D units across the country. In this episode, we will review a soon to be released publication out of Obstetrics and Gynecology. We will summarize an RCT comparing high-dose versus low-dose Oxytocin for labor augmentation in nulliparous women.

Given the known benefits to BMZ for preterm infants and the difficulty in predicting which women will actually deliver preterm, it is common for providers to administer antenatal corticosteroids in an effort not to miss the opportunity to give them before delivery and to try and get the maximal time benefit. However, many of these babies will be born at term. Do these term born babies benefit or experience adverse outcomes after steroid exposure? In this session, we will review an article that is published ahead of print from the AJOG. The results may surprise you. (Reference: McKinzie, A., et al. Are Newborn Outcomes Different for Term Babies Who Were Exposed to Antenatal Corticosteroids? AJOG 2021)

Sex can fulfill the human psychological needs of connectedness as well as the physical needs of intimacy. Being alone and lonely can cause major health and psychological problems for many. Is there data that sexual frustration impairs well-being? This session will review this often controversial subject as well as summarize an eye-opening study previously published from Carnegie Mellon describing state of happiness based on frequent of sex.

In this session we wrap up our review of Adenomyosis. Are you familiar with the MUSA ultrasound criteria? What is the role of MRI in the diagnosis of Adenomyosis? And is there a role for hysteroscopic diagnosis? Let’s wrap up our discussion on Adenomyosis now.

Historically, Adenomyosis was a pathological diagnosis only. However, new imaging standards/techniques have moved Adeno into a clinical diagnosis. Is there a patient risk profile for this condition? Is this strictly a gynecological issue or is there adverse perinatal outcomes as well? Welcome to Part 1 of Adenomyosis where we will answer these questions and more.

OB Patients admitted with medical or obstetrical complications to an antepartum hospital unit face separation from loved ones, stress from their diagnosis, face isolation, and are prone to develop perinatal mood disorders. In this episode, we will review a soon to be released publication from the Green Journal (May 2021) addressing this under diagnosed and under recognized issue.

On April 12, 2021, Illinois agreed to provide Medicaid benefits to eligible mothers for up to 12 months postpartum, a major extension from the previous 60-day limit. Follow up of postpartum women for 12 months after delivery is gaining favor as data is evolving which shows that “the 4th trimester” (the first 12 weeks postpartum) is just not long enough to detect postpartum complications. In this episode we will review a new editorial which states that “the 4th trimester” is not long enough.

We often encounter the acutely agitated patient. Acute agitation may be from and uncontrolled medical condition, psychiatric condition, or illicit substance induced. The acutely agitated patient is also at increased risk of some prenatal complications. In this session we will review the evidence-based protocols for management of the acutely agitated OB patient.

The ACOG has stated that caffeine consumption in pregnancy should be limited to 200 mg/day. However, a new study published on March 25, 2021 in JAMA Network Open is questioning that recommendation. In this study, we will review this longitudinal cohort publication stating that “there may be no safe limit to caffeine consumption”.

The CDC released a health alert through its Health Alert Network on April 13, 2021, notifying physicians and other health care practitioners that the CDC and FDA are reviewing data involving six U.S. cases of a rare type of blood clot in individuals after receiving the Johnson & Johnson COVID-19 vaccine. In this session, we will review what CVST is, how it can present, the work-up, and potential treatment options. Do you give heparin for this? What is a correlation with thrombocytopenia? This is a vital summary of data that all healthcare practitioners should know.

The field of obstetrics was “birthed“ out of midwifery. The concept of second stage of labor in the lithotomy position was not how it was “always done”. In this episode we will review the evidence behind the “flexible sacral positions” and learn how maternal positional changes can assist with the labor process.

The prevalence of trauma is quite sobering. General population surveys have found extremely high rates of traumatic experiences encountered which span all races, ages, and socioeconomic status is. Nonetheless, some groups are disproportionately affected by trauma compared to others. This is why all healthcare providers should be aware of “trauma informed care” practices. In this episode, we will summarize the ACOG committee opinion from April 2021 on the subject. Do you know what the “4 Rs“ of trauma informed care are? How do we screen for this? Are traumatic events linked to chronic physical diseases as well? Let’s cover this very important topic now.

Hysteroscopy, and especially office-based hysteroscopy, is a fantastic tool in the evaluation of suspected endometrial abnormalities and/or heavy menstrual bleeding. In this session, we will review the ACOG committee opinion on hysteroscopy. At what fluid deficit should you stop the procedure if using normal saline? What about glycine? What is the significance of a “mill-wheel” murmur. Do you know what the Durant maneuver is? We answer all of these questions and more in this session!

Algorithms and opinions on cervical cancer screening change quickly. In this session, we will review the uses for HPV testing as a primary screening tool as well as post treatment surveillance. Are you familiar with which HPV tests can be used as primary screening? What is the frequency of tests? Let’s cover this now.

In this session, we will pick up where we left off with our immediate past podcast covering the SMFM “Choosing Wisely” recommendations. When should we screen for MTHFR for adverse pregnancy outcomes? When should we start screening for FGR with Umbilical Dopplers? We’ll answer these questions and much more in this session as we wrap up the SMFM “don’t do” list.

Sometimes what sounds good in clinical practice actually is not evidence-based. In March 2021, the SMFM updated the “Choosing Wisely”list of practices/recommendations for OB care. Should routine screening for microdeletions be done? What about serum screening for preterm labor? In this session we will cover the most recent 5 “don’t do“ items released by SMFM.

In the era of social media and easy to spread public opinion platforms, misinformation can grow rampant. Is the Covid vaccine associated with infertility in the general population? Where did this idea come from? What is “Syncytin-1” and how is this related to this controversy? Here we will review the origin of this story, any theoretical basis for the claims, and the conclusions from the CDC, FDA, and multiple professional societies regarding this.

What are the delivery recommendations for pregnant Covid patients? When is expectant management favored compared with elective delivery? Is mechanical ventilation alone an indication for delivery? This is our second session in which we will wrap up our summary of the SMFM updated treatment guidelines for pregnant Covid patients (February 2021).

COVID-19 management guidelines change quickly. In this session we will review the February 2021 SMFM update regarding when to consider inpatient care for COVID-19 in pregnancy. Do you know which 02 saturation categorizes severe compared to moderate disease? What dose of dexamethasone is recommended for pregnant Covid patients that require oxygen? Is outpatient anticoagulation recommended? We will cover these and more in this session! (Source: SMFM COVID-19 in pregnancy guidance February 2021).

In February 2021, the ACOG will release a new committee opinion (818) updating guidelines on “medically indicated late preterm and early term deliveries”. Are steroids still recommended in this preterm interval? How has new data on fetal morbidity with intrauterine growth restriction and intrahepatic cholestasis affected these guidelines? Listen… And find out!

Historically, brachial plexus palsy was considered proof of shoulder dystocia or traumatic birth. Can brachial plexus injuries occur with normal, uneventful deliveries? Do brachial plexus palsies happen even at C-section? The answer may surprise you. In this episode, we will review the different types of brachial plexus injuries and review the most recent data on the pathophysiology of these nerve conditions. Reference: Johnson et al. Obstetrics and Gynecology, October 2020,

There have been a variety of published and accepted clinical presentations of COVID-19: from lack of taste, GI disturbances, muscle aches, to the usual fever and shortness of breath. But this COVID-19 affect a woman’s menstrual cycle? There is increased chatter on the ever accurate Internet regarding this. But is there data? In this session we will go over the possible association between COVID-19 and irregular cycles.

Are you still treating urogenital gonorrhea with ceftriaxone and azithromycin? That was a standard for over a decade. But things have now changed. In December 2020, the CDC updated the treatment regimen for urogenital infections with neisseria gonorrhea. Is “dual-agent” still a therapy? Does cefixime still have a treatment role? What about test of cure? We will cover these questions and more in the session.

We all know there is a national opioid epidemic. This, like the current viral pandemic, is robbing people of their lives. Pregnant women are not immune to opioid use disorder. Is methadone endorsed for use in pregnancy? What about buprenorphine? Is naltrexone safe as an alternative treatment during pregnancy? In this session, we will review the updated literature regarding opioid use disorder and medical assisted treatment options (MATs).

Historically, CS prophylactic antibiotics were given after umbilical cord clamp and cut to prevent exposure of the neonate to antimicrobials. The recommendation then changed, in line with typical surgical practice, to give prophylactic antibiotics before skin incision. However, new data published in December 2020 is calling this practice into question. In this session we will review this new publication, co-authored from Rutgers university, which has some surprising results.

It’s the holiday season, but the holidays can exacerbate depression/anxiety and even increase suicidal ideation in some individuals. Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. Oddly, the CDC data excludes deaths from "accidental or incidental causes," such as suicide, overdose, or homicide in their maternal mortality reporting. In this session, we will review US maternal mortality rates and review new data regarding perinatal suicidal ideation and acts.

A brief explanation regarding our podcast just released, “Ovaries In or Out”!

Historically, prophylactic oophorectomy was performed at time of benign hysterectomy in patients at/over 45 years of age. Is this still evidence based? Is the reduction in ovarian cancer development a net win or net loss compared to ovarian conservation? In this podcast we will review the data regarding risks/benefits of ovarian conservation at time of benign hysterectomy in the general population.

Considered controversial, traditionally steroids for fetal lung maturation were not given in patients with clinical chorioamnionitis. But is this really evidence-based? And since most patients will be delivered quickly after this diagnosis, how fast can steroids be expected to have a benefit on the child? In this session we will summarize a December 2020 Expert Review from the AGOG on that subject.

In the very near future, possibly just days away, the FDA is anticipated to approve at least 1 new COVID-19 vaccine. Were pregnant and/or lactating women included in the phase III vaccine clinical trials? What is the safety data for the vaccine in pregnancy? Are pregnant and/or lactating women part of the vaccine distribution framework? These are tough, and even controversial, aspects that must be considered. In this session, we will review the current state of the vaccine and how it applies to pregnant/lactating women.

A woman dies every 12 hours in this country from pregnancy-related complications. 2/3rds of these deaths are preventable! Let that sink in. On December 3, 2020, the US Surgeon General released a CALL TO ACTION to rectify this reality. In particular, ONE race is carrying this burden more than others. In this podcast we will summarize the main points of this 71 page monograph, and tie in potential solutions.

Once considered TABOO, women having receptive “Backdoor” sexual attention has gained a lot of press in both medical as well as non-medical publications. Does ACOG have a committee opinion on this? YES. And in this podcast we will discuss data on prevalence of, orgasmic response to, and possible STI implications of “backdoor activities” in women.

The two most common types of headaches in pregnancy are tension type and migraine. Is Imitrex safe to use in pregnancy? A common alternative medication regimen includes the use of Benadryl and Reglan for acute headache. Is there data for this? And what about Botox in pregnancy? In this podcast we will review the data on the medical management of migraine headaches in pregnancy.

In December 2020, ACOG will release an updated committee opinion on delayed umbilical cord clamping with 3 additional areas addressed: 1. multiple gestations, 2. cord milking in extreme premature infants, and 3. the effect of delayed cord clamping on umbilical cord blood collection. We will summarize these key points in this session!

In 2017, the American College of Cardiology and the American Heart Association revised the definition of normal BP, elevated BPs, and Stage 1 & 2 Hypertension. ACOG has not adopted these new classifications for pregnancy care. Are women with elevated blood pressures or Stage I hypertension at risk of adverse pregnancy outcomes? In this podcast, we will review a soon to be released publication from the AJOG which helps answer these questions. (Data from: “Perinatal outcomes in women with elevated blood pressure and stage 1 hypertension”, GREENBERG et al)

The birth control pill remains one of the most common medications used in reproductive aged women. As all birth control pills have a net antiandrogenic affect, does this result in less libido? What does the data say? Do you inform women of this potential side effect when they start combination birth control? We will tackle these questions in this session!

Ever since the first progestin was isolated and reproduced out of Mexican Yams in the early 1950s, the race was on to formulate a low-risk, highly effective, oral birth control agent. Birth control pills remain one of the most common medications used by reproductive age women. We are now in the 4th generation of synthetic progestins in the pill. But do these matter? Is anti-androgenic activity real or just something found in the lab? In this podcast, we will review not just the history of the pill but we will also review how to “choose the right one“. Thank you, Lindsey and Jeanna, for the recommendation.

Modafinil and armodafinil are stimulant meds called “smart meds”. Their use is on the rise, but there are important drug interactions with these meds and certain birth control (BC) options. Additionally, new data has revived attention to the association of the stimulants to congenital birth defects. In this session, we will review the MOA of these meds and discuss BC options with their use. We will also summarize the newly released data showing the association with congenital birth defects.

It has been a debate for many years: should we be doing routine screening for BV before hysterectomy/gynecology procedures? What about at C-section? It’s a good question especially acknowledging that there is a high rate of asymptomatic BV. In this episode, we will review an “expert review“ from the AJOG from March 2020 and a recently released rebuttal to that review. What does the ACOG say? Let’s take a look now.

Bacterial vaginosis (BV) is one of the most common vaginal diagnoses in women’s health practices. Over the years there has been increasing evidence that BV is not just an annoying vaginal condition but has true risks of heightened STI acquisition, PID, post-op vaginal complications, and even infertility. In this session, we will review a new soon to be released publication from the AJ0G. This article makes a strong case for the link between BV and infertility. We will summarize this new data here ( Ravel J et al; AJOG EPub Oct 19,2020).

In this continuation, we will cover the reported potential, adverse reproductive outcomes with CUAs. Which surgical corrective procedures should be attempted, and when? Let’s cover that now.

The evaluation of congenital uterine anomalies can be traced back to the mid 19th-century. In this session, we will review the ASRM and the ESHRE classification schemes for these anomalies. What is the gold standard for diagnosis? When is an MRI necessary? We will answer these questions and more in the session. We will address reproductive outcomes in part 2.

On September 25, 2020, a new cervical cancer screening working group revised the algorithm (as a proposal) for management of minimally abnormal cervical cancer screening tests. This was released in JAMA. The new focus is on the presence/persistence of high risk HPV in the pathogenesis of cytology abnormalities. Let’s cover that in this session.

In October 2020, JAMA Pediatrics released a publication that is drawing MAJOR criticism from 5 major professional societies. This study highlighted a potential association between labor epidurals and child autism risk. However, there is a lot more to the story that needs to be told. In this session, we will break down the study and offer reassurance that “association“ does not prove “causation“. Also summarize the key rebuttals from these professional societies, which are pretty much ON FIRE.

In May 2020, the FDA approved a new novel, non-hormonal vaginal contraceptive that can be used “on demand“. Although this functions as a “pH regulator“ of the vagina with spermicidal properties, it is not nonoxynol-9-based. In this session, we will review the information in the instructions for use of Phexxi, and summarize key points from some published commentary on the subject.

There are calls to remove 17 OHP from the market based on the results of the PROMISE trial. This leaves us with a gap in tools for prevention of preterm birth. This is where CERCLAGE comes in. Cerclage is not only indicated in patients with previous history of incompetent cervix, as there is emerging data that cerclage plays a role in preterm birth prevention based on cervical length. In this podcast, we will give an in-depth summary of the data on how cerclage may be used as an intervention to prevent preterm birth. At what cervical length can cerclage be used? How does previous history come into play? Is this valid in twins? Let’s cover that… Now.

Over the past several years there’s been some alarming publications “linking“ endometriosis to certain ovarian epithelial malignancies. Is this a valid cause for concern? What is the absolute risk? In this podcast we will put the data into perspective and highlight information from the Lancet as well as MD Anderson‘s Gynecology Oncology data.

Antenatal corticosteroids help reduce a number of morbidities in the preterm infant. However, chorioamnionitis is generally considered a contraindication. The scientific basis for this is actually unclear. On September 28, 2020, the AJOG released a new publication ahead of print that helped shed some light on the subject. Are steroids harmful or beneficial to the preterm infant in the setting of Chorio? Let’s check it out.

Endometriosis, a chronic disease that afflicts millions of women worldwide, has traditionally been diagnosed by laparoscopic surgery. This diagnostic barrier delays identification and treatment by years, resulting in prolonged pain and disease progression. Development of a noninvasive diagnostic test could significantly improve timely disease detection. Recently, 2 innovative/non-invasive tools have gained attention for the diagnosis of Endo: MicroRNAs (Oct 2010; AJOG) and MRI (Sept 2020; Acad Rad). In the session, we will highlight these 2 interesting publications.

One theory behind elevated post-partum blood pressure is that there is a large volume of sodium mobilized into the intravascular compartment in the post-partum period. Loop diuretics have been suggested as methods to accelerate post-partum blood pressure recovery due to their ability to mobilize sodium and fluid excretions. Is there level I data on the use of furosemide for postpartum preeclampsia/hypertension management? Does the use of Lasix affect serum magnesium levels? In this session, we will review 2 recent RCTs on the use of furosemide for Postpartum hypertension management and briefly review the pharmacology of furosemide.

Stillbirths occur in approximately 6/1000 pregnancies in the US. Currently, the ACOG recommends placental histological analysis and fetal chromosomal study in these cases. However, as up to 50% (or more) of cases are left “unexplained“, more investigation/options are needed. On September 17, 2020, a new publication in the NEJM adds valuable insights as to how whole exon sequencing may help provide a genetic cause in an otherwise unexplained stillbirth. In this podcast, we will review this publication by Stanley et al.

Advanced Maternal Age (AMA) has long been associated with adverse obstetrical outcomes. However, is the same true for Advanced Paternal Age (APA)? What is the specific characteristic mutation associated with APA? What does paternal age have to do with chromosomal telomere length and how is that related to cancer in the child? In this podcast, we will review Data from the American College of Medical Genetics regarding APA. This information will be helpful in giving prenatal counseling to couples who present with fathers with age equal to/greater than 40.

Postpartum hemorrhage is a leading cause of maternal mortality even in the United States. In September 2020, a new device to help treat postpartum hemorrhage was FDA cleared (The Jada System). This is a novel device that uses vacuum pressure for uterine cavity collapse/myometrial compression. In the session, we will review this new data which was published ahead of print September 10, 2020 in Obstetrics Gynecology (Green Journal).

A prolonged second stage of labor, or failed vaginal vacuum extraction, can lead to a deeply impacted fetal head. Is the “push“ technique better than the “pull“ technique? Have you heard of the Patwardhan method? What is a C-section SPOON? And is the “Fetal pillow” actually helpful? In this podcast we will review each of these techniques in detail.

An EIF is a small echogenic area appearing within the fetal cardiac ventricle that has a sonographic brightness equivalent to that of bone. What are the clinical implications of an isolated EIF? Are structural malformations of the heart more common with EIF? What specific workup is required? In this session, we will review the SMFM management of this ultrasound finding.

A woman in her 20s with preeclampsia has a worse cardiovascular prognosis at 10 years compared to a woman in her 40s without previous preeclampsia. Additionally, preeclampsia is linked to other future maladaptive conditions (even dementia and renal disease) which have severe life impact. In this session, we will review the data on preeclampsia as a risk factor for future morbidity.

Intraventricular hemorrhage (IVH) is the most common type of intracranial hemorrhage in the neonate and is the most serious. Which antepartum therapy is proven to reduce IVH severity? Does Mag Sulfate reduce IVH? How is umbilical cord “milking” related to IVH? In this session we will cover this in detail and highlight professional societal guidelines.

Recurrent pregnancy loss affects between 3 and 5% of reproductive age couples. Traditionally, the category of “unexplained“ pregnancy loss made up 25% of cases. However, use of Chromosomal MicroArray analysis (CMA) has dropped the category of unexplained to approximately 10%. In this session, we will review the traditional and updated algorithm for recurrent pregnancy loss using CMA for the products of conception (source: Clinical Opinions in ObGyn, published ahead of print)

There is biological plausibility for vitamin D to play a role in pregnancy outcomes, given the presence of receptors in gestational tissues. Data has progressed since the ACOG committee opinion regarding vitamin D supplementation in pregnancy released in 2011. Does low maternal vitamin D actually affect maternal outcomes? In the session we will review the latest data from “Current Opinions in OB/GYN” regarding vitamin D supplementation in pregnancy, focusing on preeclampsia risk and GDM.

On August 12, 2020, the ACOG released a revised practice bulletin (226) on screening for fetal aneuploidy. In this session we will focus on cell free DNA genetic screening. How should we counsel younger women on this screening tool? Can cell free DNA be used after an abnormal QUAD screen? How is cell free DNA related to maternal malignancy? We will answer these questions and more in this session.

TOAs are typically considered the end result of severe PID. However, not all cases are PID related. TOAs may also be a harbinger of genital tract malignancy in a subgroup of patients. In this session, we will review the presentation, work-up, and management of TOAs and we will end with who may be at greater risk of genital tract cancer with them.

Fantastic! As healthcare professionals, we have to remember to use “patient centered“ terms when possible. This is a brief commentary describing a very important issue as a follow up to today’s educational podcast released just hours ago.

It is the age old question at Gyn Surgery… Candy Cane leg holders or Boot support? Is it just physician preference? In August 2020, a new RCT published in the journal Obstetrics & Gynecology addresses this issue. However, as we will discuss, the study raises more questions than answers.

VTE is a major cause of maternal morbidity and mortality in pregnancy, particularly in postpartum after a cesarean birth. In August 2020, the SMFM released consult series No. 51 on the prevention of VTE. What is the first-line pharmacological agent desired? Should prophylaxis be for 10 days, 2 weeks, or 6 weeks? What about risks of use? We will cover these questions and more, here..

Maternal genetic carrier screening is endorsed by the ACOG. Should this be ethnicity-based or should this be “pan-ethnic” screening of disorders? What are the 2 main genetic disorders that should be universally screened for? In this episode, we will cover the ACOG Committee Opinions 690 and 691.

On July 26, 2020, the AAP updated its guidance regarding infant separation from a COVID19 positive mother in the immediate postpartum interval. In this session, we will review this updated recommendation.

Your patient is a 22 yo female who has tested positive for SARS-CoV2. Will you keep her on her estrogen containing birth control? In this podcast, we will cover the ACOG response to this clinical dilemma as well as provide updated information from a soon to be released commentary in ENDOCRINOLOGY.

Yes, information keeps changing! That is why medical education is so important. In this session, we will review the ACOG updated recommendations for both healthcare providers and patients regarding COVID-19 management. These guidelines were released July 27, 2020.

⭐️Feb 11, 1990. ⭐️ It was a worldwide sports event. It has been called one of the greatest upsets in sports history. This brief recap of the Douglas-Tyson match has a powerful lesson applicable to today’s stressful times. Let this brief episode encourage you and motivate you on your life’s adventure. 🙂

Given the perceived safety of aspirin during pregnancy, there have even been increasing calls to administer aspirin universally to all pregnant women. However, there are no population-based studies addressing whether there is a bleeding risk with aspirin administration during pregnancy. In this session, we will review a recently accepted manuscript (July 2020) in AJOG which will soon be in print which is a population based study from Sweden. Are there risks with aspirin use in pregnancy? Lets analyze the data.

In August 2020, the ACOG will release a new Committee Opinion (809) reviewing the HPV vaccination. How many doses are required by age? Can the vaccine be given during pregnancy? What about breast-feeding? We will answer these questions and more in this episode.

CS deliveries are the most frequently performed inpatient surgeries in the US. The ERAS pathway for planned cesarean deliveries does not include preadmission CHG cloths because of the lack of evidence from randomized, controlled trials. In July 2020, the AJOG published the STRIPES RCT to see whether use of these cloths resulted in decreased SSI. We will cover this in this episode.

Pregnancy is a co-adaptive, quasi-symbiotic state. There are a variety of maternal physiological and anatomical adaptations which must not be interpreted as pathological. In this session we will review these vital changes as well as the fetal circulatory system and provide a quick review of fetal acid base status.

On January 1, 2021, the Joint Commission will release new standards for maternal safety at discharge from the hospital. Discharge teaching and postpartum follow up planning will be part of this mandate with a focus on patients with hypertensive disorders. To prepare everyone for this, the SMFM is releasing a new statement and checklist for postpartum discharge of hypertensive patients. In this session, we will review and summarize this new (July 2020) special statement which is scheduled to be in print in the American Journal of Obstetrics and Gynecology.

COVID19 can have varied clinical manifestations. In pregnancy, new data has highlighted its potential to cause a “preeclampsia like syndrome“. This, together with the increased thrombotic state of COVID-19, elevates the risk for VTE above that of pregnancy alone. Can TXA be used for PPH in these cases? In this podcast we will review these 2 high risk clinical manifestations of COVID-19 in pregnancy.

LARCS are endorsed by the ACOG due to the high efficacy. However, unpredictable bleeding can affect continuation rates. A new RCT has evaluated the use of tamoxifen to control and prevent future abnormal bleeding with etonogestrel implant use. Does this work? What is the MOA? In this session, we will summarize this new publication (published ahead of print) in Obstetrics and Gynecology.

Did you know that silver wire helped to dramatically reduce maternal mortality at cesarean section? And what does the Goodyear Rubber Company have to do with surgical techniques? In this episode we will wrap up our walk through history reviewing CS’s AMAZING History.

What does a pig gelder, a woman dressed as a man, and the Queen of England all have in common? The answer: ALL CONTRIBUTED TO CS’s history! The history of C-section has been called the combination of “death, deceit, and germs“. In this historical review (Part 1), we will take a look at the origin of this all too frequent abdominal surgery.

Prone positioning during invasive mechanical ventilation improves oxygenation, as shown in large randomized clinical trials of patients with ARDS. In an RCT that included 466 patients with moderate and severe ARDS, prone positioning for at least 16 hours per day with protective mechanical ventilation reduced 90-day mortality. Is prone positioning for respiratory support possible in pregnancy? In this session we will cover the beneficial effect of probe positioning and summarize an article (EPUB) soon to be in print in Obstetrics & Gynecology regarding prone therapy in pregnancy (Tolcher et al).

Gastroschisis occurs in about 1 in 1800 births in the US. Does this abdominal wall herniation usually occur to the right or left of the umbilical cord? Is this condition tied to chromosomal/genetic syndrome? What about antepartum fetal surveillance? Is a cesarean birth required? In this episode, we will review the SMFM and CDC data regarding management of gastroschisis.

Female genital mutilation (FGM) is also known as female circumcision. The ACOG and the World Health Organization have issued public statements condemning the practice. What is this procedure? What are the 4 different types of female genital cutting? In this session we will review these answers as well as the immediate and long-term complications of FGM. We will also review the WHO international response to this unnecessary medical practice.

Is labor affected by polyhydramnios? What is the suggested manner of performing artificial rupture of membranes in this setting? In this session, we will wrap up our discussion of polyhydramnios with a quick summary on intrapartum care.

Polyhydramnios can be mild, moderate, or severe. Is deepest vertical pocket (DVP) or AFI preferred for amniotic fluid assessment? Is antepartum Indocin a valid treatment option? What about antepartum fetal surveillance? In this session, which is Part 1, we will review the SMFM guidance regarding polyhydramnios.

Placenta accreta spectrum, formally known as morbidly adherent placenta, refers to a range of pathologic adherence of the placenta (accreta, increta, and percreta). There is significant risk of maternal morbidity and mortality including risk of blood transfusion, life-threatening hemorrhage, and hysterectomy. In this session, we will review the obstetric care consensus by the ACOG and SMFM regarding this condition (obstetric care consensus # 7).

On May 29, 2020, the U.S. FDA approved an novel oral drug, Oriahnn, for HMB use to fibroids. This medication (elagolix, estradiol, and norethindrone acetate) is the first oral medication designed specifically for Fibroid HMB. In this session, we will review this new medication. (No financial disclosures to report).

In this session, we will conclude our summary of the new ACOG clinical expert series, “Female Sexual Dysfunction“. This episode will focus on specific treatments of each of the 4 different DSM5 categories of female sexual dysfunction.

Human sexual response is a highly individual and emotional process. Sexual dysfunction is common among women and leads to personal distress. The ACOG has released a new “clinical expert series“ which currently is published ahead of print. In this session (Part 1), we will review the prevalence, risk factors, and DSM5 categories of female sexual dysfunction.

Unlike fetal thrombocytopenia resulting from maternal ITP, fetal- neonatal alloimmune thrombocytopenia may occur earlier in gestation and can lead to in-utero fetal intracranial hemorrhage. The condition can be severe. In this podcast, we will review the presentation, diagnosis, and management of this potentially lethal fetal acquired condition. (ACOG Data 2019).

On June 1, 2020, the American Journal of Obstetrics and Gynecology released a new publication with surprising results related to maternal oxygen use in labor for Category II fetal heart rate tracings. Although we have covered this in some form in previous episodes, we will provide new up-to-date information on this subject.

Medical information moves fast. Although the increased morbidity with fetal macrosomia has long been known, the ACOG has revised his practice bulletin on the subject (January 2020). In this session, we will review this updated practice bulletin. What’s the new data on exercise and fetal birthweight? Is operative vaginal delivery contraindicated in macrosomic infants? What about TOLAC with a suspected macrosomic infant? Let’s cover these topics, and more, in this session.

Multiple societies and experts have weighed in on whether 2nd stage of labor warrants universal use of respirators (e.g., N95 masks) vs surgical masks. The ACOG/SMFM has petitioned the CDC for clarity on this issue. In May 2020, the AJOG published a new “clinical perspective“ in MFM which is pushing for use of 1 mask over the other. We will highlight this new development in this session.

Some experts have called for universal screening of all patients admitted to labor and delivery. The foundation of this opinion is to decrease exposure to healthcare workers and identification of asymptomatic women for the prevention of horizontal newborn transmission. However, there are some potential negative implications of this proposal. In this podcast, we will review a soon to be released editorial (Torri Metz, MD) from Obstetrics & Gynecology (the Green Journal) on the pros/cons of universal testing in Labor & Delivery.

Examination (macroscopic and microscopic) of the placenta can give valuable insights into the intrauterine environment. The College of American Pathologists has issued guidelines about when to submit a placenta for histological examination. In this session, we will review the “what, when, and whys“ of histological placental referral. We will also review abnormal umbilical cord insertion and it’s link to adverse obstetrical/neonatal outcomes. SHOUTOUT TO LAUREN (our podcast listener) for the podcast topic!

Does the ACOG endorse universal screening for thyroid disease in pregnancy? What about treating subclinical hyperthyroidism or subclinical hypothyroidism? And what about those pesky anti-thyroid autoantibodies? In this podcast, we will highlight the June 2020 ACOG Practice Bulletin (223) covering thyroid disease in pregnancy.

The benefit of antenatal corticosteroids in preterm infants was first reported in 1972, but it took 20 years for widespread adoption. Now, antenatal steroids are recommended by the ACOG up to 36 weeks and 6 days. However, a new study (JAMA May 2020) has raised concerns about steroid exposure in utero and possible behavioral and mental diagnoses in children up to age 5. These outcomes were significant for infants who were born full term. In this podcast, we will highlight this new study and summarize the editorial perspective in JAMA regarding this study.

Information can be confusing regarding COVID-19. The WHO, CDC, ACOG, AAP all have slightly different recommendations based upon what topic you’re looking at. Is a patient with COVID-19 allowed to breast-feed? In this episode, we will review the CDC/AAP recommendations for breast-feeding regarding a patient under investigation or confirmed positive case.

Sexual assault/rape is a devastating occurrence for all victims. Post exposure infectious disease prophylaxis has been expanded to include hepatitis B and HPV vaccinations. In this session, we will review the medical/vaccine regimens as post exposure prophylaxis after assault. We will also cover HIV prophylaxis. Are 3 anti-retroviral medications more effective than 2 for HIV prevention? The answer is in this podcast!

The ACOG/SMFM does not recommend bedrest in pregnancy for the prevention of preterm birth for women at risk, nor in multiple gestation, or management of hypertensive disorders. Does bedrest actually RAISE PTB risk? In this session, we will summarize updated information about the real physiological, psychological, and possibly OB adverse effects of bedrest in pregnancy. (NEW SMFM Consult Series #50).

Advances in 1st trimester aneuploidy screening have increased the need for early prenatal diagnostic testing. There are only 2 prenatal diagnostic tests : CVS and amniocentesis. In this podcast, we will review these procedures and rates of potential complications. We will also summarize the difference between microarray chromosomal analysis and conventional karyotype.

On May 1, 2020, the FDA authorized the emergency use of Remdesivir for COVID-19. This was based on a preliminary analysis of an NIH clinical trial. However, information is still lacking on safety and efficacy in a larger study population. In this session, we will review the known mechanism of action of this novel antiviral medication and limitations of data.

In May 2020, the ACOG will release a new committee opinion regarding tobacco/nicotine use during pregnancy. What are the risks of nicotine use during pregnancy? Are medications to assist smoking cessation in pregnancy endorsed by the ACOG? In this session, we will highlight and summarize this new committee opinion.

In 2018, the ACOG stated that screening for bacterial vaginosis before gynecological procedures “can be considered“ as a way to reduce infection. However, in March 2020, a new expert review was published in the AJOG making a much stronger recommendation. In this session, we will review the publication from March 2020 from the American Journal of ObGyn highlighting this stronger recommendation to screen for bacterial vaginosis before gynecological procedures.

Women with seizure disorders often have altered menstrual function, with or without anti-seizure medications. One anti-seizure medication has even been linked to the development of PCOS. Seizure disorders in reproductive age women can also influence contraceptive choice. Do you know what makes Lamotrigine unique? In this session, we will summarize the upcoming May 2020 ACOG committee opinion (806) focusing on gynecological care of reproductive age women with seizure disorders.

Data on exercise during pregnancy and the postpartum period has evolved. For example, once considered relatively contraindicated, jogging during pregnancy is not prohibited. Does exercise cause preterm birth? What about exercise in women with pre-existing diabetes or hypertension? In this session we will cover the April 2020 committee opinion clarifying myths/misperceptions regarding exercise in the pregnant and postpartum patient.

Maternal oxygen administration in labor has been used as a traditional tool for intrauterine fetal resuscitation. However, excluding times of maternal hypoxemia, the practice could actually be detrimental to fetal well-being. In this session, we will review data from the SMFM annual meeting from February 2020.

Being deaf and blind in the late 1800s (and a female!) was a prime recipe for failure and poverty. However, one young woman beat incredible odds to change American history. During these uncertain times of COVID19, we can still learn from Ms. Helen Keller, and her proven formula for overcoming life’s challenges: self-motivation, and personal encouragement.

Elmiron (pentosan polysulfate sodium) is the only oral FDA approved medication for interstitial cystitis/painful bladder syndrome. Initially approved in the late 1990s, recent evidence (within two years) has described a new medication associated ocular pathology: retinal maculopathy. In the journal Obstetrics and Gynecology, a new commentary will soon be released on this topic. In this podcast, we will review the data to date regarding this newfound medication concern.

The AAGL and the RCOG have released position statements regarding the use of laparoscopy during this viral pandemic. Can surgical plume from energy devices transmit infection? Is laparotomy safer for the OR team? In this podcast we will highlight and summarize the position statements of these professional societies regarding non-elective surgical procedures during this viral pandemic.

ARDS in pregnancy carries an increased rate of maternal and perinatal mortality. Specific respiratory physiological changes make care of the pregnant ARDS patient more complex than in the non-pregnant individual. Is temporary hypocapnia or hypercapnia more favorable? What about ventilation pressures? We will review maternal respiratory changes and ARDS care in this session (Source: SMFM Critical Care in Obstetrics).

The SMFM has just released new labor guidelines for SARS-CoV2 patients under investigation/confirmed COVID-19. This new practice guideline addresses oxygen use for fetal decelerations, amniotomy, labor epidural, HCW protection during 2nd stage of labor, as well as antenatal corticosteroids and magnesium sulfate. We will review these points in this session.

COVID-19 MEMEs are plentiful across social media platforms. Cynical medical humor has been around for decades. This phenomenon was made public in the late 1970s with a book called, “The House of God“. What does the literature say about the pros/cons of dark medical humor? Is this helpful or detrimental? And, what does dark humor have to do with “mind medicine”? We will dive into these questions in this session!

Phenylketonuria is better known as Phenylalanine Hydroxylase Deficiency (PAH-D). This genetic condition can have significant implications for the reproductive age woman including adverse pregnancy outcomes and congenital fetal malformations. In April 2020, the ACOG will release a new committee opinion (802) on the management of women with PAH-D. What Maternal serum levels are optimal to prevent adverse obstetrical outcomes? Do these pregnancies require specific fetal evaluation? What are the other health implications of elevated phenylalanine levels? We will answer these questions more in this session.

In April 2020, the ACOG will release a new committee opinion (803) on adolescent confidentiality and ObGyn. What is the difference between a “mature minor” and an “emancipated” minor? Can minors receive contraception without parental consent? What about emergency care? In this podcast we will highlight (and expand upon) very important points made in this new committee opinion. We will also address potential breaches of adolescent confidentiality due to the use of electronic health records.

It doesn’t matter who you are, what your title/position is, or how physically strong you are, times of social distancing and quarantine can take a mental toll on everyone. Nonetheless, we have a non-prescription, powerful anti-depressant at our disposable. Medical science has proven that the act of gratitude can physically affect not only our mindset, but can physically alter our brain, and impact our overall health as well. In this podcast, will take a look at the data.

The AHA has just released interim guidance for healthcare providers performing CPR on suspected or known COVID-19 patients. This guidance include the restriction on procedures that can generate aerosols (bag-valve masks, nebulizers, non-invasive positive pressure ventilation). This guidance is divided into pre-hospital/transport care, and hospital care. In this podcast we will summarize the AHA guidance adopted from the CDC.

This current global viral pandemic has shed light on the value of telemedicine. The ACOG endorses the use of telemedicine for pregnancy care as a way to “enhance“ prenatal/antepartum services. In this podcast we will review an effective model for prenatal telemedicine services, review its implementation, and discuss barriers to use.

March 20, 2020: Currently, we are in desperate need of some encouraging news. Social distancing, times of quarantine, and a viral pandemic can easily overwhelm the strongest of individuals. So, this is our inaugural podcast for MIND MEDICINE. In this episode we will cover 2 incredible stories of 2 physicians who overcame incredible odds by the power of their will to survive: Dr. Leo Rogozov and Dr. Viktor Frankl. Let the true accounts of these two remarkable individuals inspire you, encourage you, and prove to you that uncertain times can still be an opportunity for extraordinary survival.

Stay encouraged, focused, and passionate.

Even though we have covered this topic in a prior podcast, the urgent need for Hepatitis C screening in pregnant women still leads the medical literature. In the journal Obstetrics and Gynecology, a new current commentary will soon be released titled, “A call to action: the urgent need for hepatitis C screening in pregnant women“. In this podcast, we will summarize the key aspects of this current commentary, proving that despite the ACOG recommendation of using a risk-based model, that ACOG recommendation is now outdated.

Welcome back! In this session, we will cover the echogenic cardiac focus, short humerus and femur length, fetal pyelectasis, and single umbilical artery!

In this session, Part 1, we will review soft markers of aneuploidy and their management. Soft markers of aneuploidy can be isolated or multiple. They can be associated with chromosomal, genetic, infectious causes, or they can be normal variants. In this session we will cover: ventriculomegaly, choroid plexus cysts, absent/hypoplastic nasal bone, nuchal folds, and echogenic bowel. Data for this podcast comes from SMFM and AIUM.

In the ACOG committee opinion (743) on low-dose aspirin in pregnancy, the College states that more data is necessary before low-dose aspirin can be recommended for the prevention of spontaneous preterm birth. However, that was in 2018. Data since then (including data from January 2020 from the NIH) is supportive of aspirin use for the prevention of preterm birth. What does this data look like? In this episode we will review the possible indication of low-dose aspirin for the prevention of spontaneous preterm birth.

Virtual reality is well-established in the gaming community, but data is expanding regarding its utility and effectiveness for a variety of medical conditions. In February 2020, at the annual meeting of SMFM, researchers released their findings on a randomized controlled trial using VR headsets for labor pain. In this podcast we will briefly review VR technology and its application for medical pain conditions including labor. (NOTE: No financial disclosures or other commercial interests in any VR device exist or were implied in the generation of this podcast).

Worried about airline travel amid global health concerns? Well, you’re not alone. What does the CDC say about airline infectious disease precautions? And what about air travel during pregnancy in general? In this podcast, we will review the CDC recommendations regarding viral precautions and highlight some key points from the ACOG committee opinion, 746, regarding air travel in pregnancy.

Vulvar pain (vulvodynia) is subdivided into generalized or local. The symptoms can either be spontaneous or provoked. Vulvodynia can result in painful intercourse, and affect other quality-of-life measures. In this session we will review the diagnosis, subcategories, and management of vulvodynia.

Pre-labor rupture of membranes should be diagnosed based on clinical assessment. In March 2020, the ACOG will release a new practice bulletin (217) on PROM. This bulletin highlights the potential hazards of over reliance on lab tests for the diagnosis, and offers a new management option for PROM in the late preterm interval. Are steroids contraindicated in the presence of suspected intraamniotic infection? We will take a look at the data in this session.

Chronic pelvic pain has been redefined by the ACOG and includes a broader range of etiologies. There are 3 main categories of potential etiologies for chronic pelvic pain. In this episode, we will review the March 2020 practice bulletin ( 218) on the subject. What is the Carnett test? Do trigger point injections work? What is the role of SNRI medications in treating chronic pelvic pain? What about lysis of adhesions? We will address these questions and more in this episode!

Cannabinoid Hyperemesis Syndrome: Although widely recognized in the gastroenterology and psychiatry literature, its occurrence in pregnancy is well known. The pathophysiology of this condition is not well known but potential MOAs have been published. How does this present? And what do “hot baths“/“hot showers“ have to do with his condition? In this podcast we will review this interesting and intriguing condition specifically as it relates to pregnancy.

In 2013, actor Michael Douglas blamed frequent oral sex with his wife as a cause of his throat cancer. In the 17 years from 1999 through 2015, the mouth and throat replaced the cervix as the most common site of cancer associated with human papillomavirus (HPV) infection in the United States. What is a data show about vaginal to oral HPV transmission, and even oral to oral transmission? Does Gardasil have a role in prevention here as well? In this podcast, we were review published data on oral HPV transmission and trends of acquisition.

Malignant GTD includes choriocarcinoma, invasive mole, and placental site trophoblastic tumor. When is single agent chemotherapy indicated? What about multiagent care? What is the classification system for malignant GTD? In this episode we will review the diagnosis, work up, and management of this condition.

Gestational Trophoblastic Neoplasia is a complex condition with various histological and clinical distinct entities. In this episode, we will review the benign variants of GTN, hydatidiform moles (complete and partial). We will review their clinical presentations, diagnosis, management, and follow up. Data for this podcast comes from the ACOG practice bulletin 53 as well as the SGO.

Currently, the CDC does not recommend “routine screening” for extragenital gonorrhea or chlamydia in women, although it does make that recommendation for MSM or bisexual males. However, as most extragenital infections are asymptomatic, this is potentially missing a large reservoir of infection. In this episode, we will review the USPSTF and CDC screening guidelines and compared that to evolving prevalence data of extragenital STIs.

Opioid use disorder (OUD) Is a national crisis. Pregnancy is not immune to OUD. Traditionally, methadone and buprenorphine have been used as medical treatments for this condition in pregnancy, with concerns about naltrexone (an opioid antagonist) use. In January 2020, a new prospective cohort study (AJOH) adds reassuring data on the safety and effectiveness of this medication option.

Up to 30% of initial BV diagnoses will have a recurrence. Does partner therapy (male or female) help reduce recurrence? Most of the original data which stated “No”, is now outdated. Additionally, what is the data on vaginal Vit C for recurrence prevention? Does that actually work? Let’s examine both of these questions...now.

Vaginismus is the involuntary tightening of pelvic floor muscles that surround the vagina; this can make penetration very painful, if not impossible. The DSM5 reclassified female sexual dysfunction into 4 main categories, with vaginismus fitting in the “penetration disorder“ group. What role does medical therapy play with this condition? Does physical therapy have a role? In this session, we will review the July 2019 practice bulletin from the ACOG (213) focusing specifically on vaginismus.

In 2018, the Lancet released the AFFIRM trial. They reported a NONsignificant decrease in the stillbirth rate from 4.40/1,000 births in the control group to 4.06/1,000 births in the fetal movement counting intervention group. In February 2020, a new systematic review and meta-analysis reveals additional information on the clinical utility of maternal perception of fetal movement. Let’s review that data now.

Currently, the ACOG and SMFM recommend a “risk-based” approach to HCV screening in pregnancy. HOWEVER, a soon to be published original article (February 2020) in Obstet Gynecol confirms that “The reported prevalence of maternal HCV infection has increased 161% from 2009 to 2017”. The IDSA has called for UNIVERSAL screening of HCV. In the session, we will review the Nov 2019 IDSA HCV screening recommendations and provide key points from the Rossi et al Feb 2020 Green Journal publication.

Most studies on the risks of post menopausal hormone therapy have focused on the oral route of administration. Does the transdermal route of estrogen delivery reduce the risk of VTE? In this episode, we will review the ACOG committee opinion (556) and ASRM guidelines on the use of transdermal estrogen vs oral estrogen therapy.

Is vaginal E2 therapy safe in women with a history of breast cancer? What is the data regarding systemic absorption levels? Are you familiar with the recently FDA approved medication IMVEXXY? In the session, we will review the data behind the use of vaginal estrogen and vaginal, non-estrogen therapy for persistent genital atrophy symptoms in women with a current or past history of breast cancer.

In North America, the median age of menopause is 51 years. Among women reporting menopausal symptoms, vasomotor and vaginal symptoms are the most closely associated with these hormonal changes. Can progesterone use alone relieve vasomotor symptoms? What about the use of testosterone? What is Intrarosa vaginal therapy? Does ospemifene increase endometrial a risk? In this session, we will answer these questions and review the medical management of menopause according to the ACOG practice bulletin 141.

Up to 30% to 50% of infertile women have endometriosis, based on laparoscopic diagnosis. Endometriosis affects fertility through a variety of mechanisms. In this session, we will review the ASRM position statement on endometriosis related infertility: work-up and patient management.

Infertility can affect up to 15% of all couples. Male factor infertility can account for up to 40 to 50% of cases, while in 30% of couples there may no identifiable etiology (unexplained infertility). This session, we will review the ASR M guidelines for the infertility evaluation. Is postcoital testing still recommended? What role does laparoscopy play in the infertility evaluation? We will answer these questions and more in this session.(ACOG CO 781).

BRCA1 & BRCA2 are tumor suppressor genes; mutations in either are transmitted in an autosomal dominant pattern. Loss of both copies of either BRCA1 or BRCA2 is just the 1st step in the process of potential carcinogenesis. In this session, we will review the pathophysiology of BRCA mutations and review the NCCN guidelines for breast and ovarian cancer screening. We will also review the surgical & chemoprophylactic management of the BRCA positive patient.

Once considered pathognomonic for gonorrhea or chlamydia, Bartholin’s gland abscesses are now recognized to be polymicrobial. Is I&D alone 1st line therapy for a Bartholin’s abscess? What about Word Catheter use? Are there any alternatives to Marsupialization for recurrent cases? In this session, we will review the data behind diagnosis and management of this common gynecological condition.

There are 4 types of single umbilical artery (SUA), based on pathogenesis. The incidence of SUA is up to 1% of all singleton fetuses, and up to 4.6% of twins. SUA can occur either as an isolated finding or as part of a congenital anomaly syndrome. In this session we will review the pathogenesis, identification of, fetal work-up, and patient management of SUA. Data from the SMFM, and ACOG.

Methamphetamine and amphetamine use has greatly increased all throughout the United States. While similar to cocaine, it’s mechanism of action is quite unique and dangerous. In this session we will cover the pharmacology of amphetamines/meth and its affects on pregnancy. We will also cover some common every day medications which can actually test false positive for meth/amphetamines on toxicology screening. Data for this podcast come from the ACOG, SMFM, and the CDC.

Interest in, and performance of, female cosmetic genital surgery increased 50% from 2014 to 2018. As close to 80% of US females have some degree of pubic hair removal, self awareness of vulvar variation is increasing. Although labial hypertrophy can be a true functional/medical concern requiring labial reduction, what about elective cosmetic genital procedures? In January 2020, the ACOG will release its updated committee opinion on this topic. These are important points to review as patients often seek “designer labioplasty“ or “vaginal rejuvenation“ from their gynecologist.

Pregnancy-related venous thromboembolism is the most common cause of maternal death and a significant cause of maternal morbidity. The factor V Leiden (FVL) mutation is the most common known genetic factor that predisposes to thrombosis. How does obstetric management differ regarding a heterozygous or homozygous carrier? When should anticoagulation be used, and at what dose? In this session we will review data from the SMFM, RCOG, and the ACOG practice bulletin 197.

The initial gynecological visit for an early teen/adolescent is crucial in establishing patient trust, education of gynecological health, and establishment of healthy personal and sexual behaviors. At what years should the first visit occur? What about patient confidentiality when dealing with minors? Is a clinical breast exam part of the adolescent screening exam? In this session, we will review the ACOG committee opinion (598) on the first gynecological visit.

Commercial laboratories offering cell free DNA for fetal prenatal screening are offering microdeletion testing. Is this valid? Microdeletions are varied and include 22q and 15q syndromes. In this session, we will review the pathophysiology of microdeletions and review 22q and 15q conditions. What does the SMFM have to say about cell free DNA screening for these conditions? How is Angelman syndrome related to Prader –Willi condition? Let’s cover this now.

The “ideal“ interpregnancy interval depends on the outcome of the immediate, prior pregnancy. For example, the recommended interpregnancy interval following a 1st trimester miscarriage is different compared to a live, term birth. But what about the interpregnancy interval after a stillbirth? Are the recommendations the same? In this podcast will review updated data from 2019 regarding interpregnancy interval following stillbirth. The reference for this podcast summary is Regan AK, et al; Lancet, April 2019.

You find that there is a medical indication for a cesarean birth- yet the patient refuses! What are your next steps? Should you seek a court order to intervene? “Informed refusal” encompasses a complex, multifaceted, ethical dilemma. In this session, we will review some clear guidelines from the American Academy of Pediatrics, the ACOG, and the AMA regarding the management of this difficult situation.

No! Julius Caesar was not born by cesarean birth. What does a pig-gelder in 1500 have to do with CS History? From Jacob Nufer to Munroe Kerr, we will walk down the path of the cesarean’s incredible history.

Medicine: it’s an incredibly rewarding profession. The opportunity and ability to comfort and heal the sick is an absolute privilege. BUT...if you are not careful, that wonderful of all professions can consume you, and may devour you. Two theories have been proposed to explain this: Burnout, and Moral Injury. But are these 2 separate conditions? How does the issue of mindset (fixed or growth) apply? In the session, we will review the latest (as of December 2019) on this ever evolving issue.

In December 2019, the ACOG will release committee opinion 794 covering quantitative blood loss in obstetrics. Does QBL use ALONE improve clinical outcomes? The answer may surprise you! Nonetheless, there is great value in utilizing obstetric hemorrhage toolkits/bundles such as the California Maternal Quality Care collaborative strategy. In the session, we will review the use of QBL in practice in why having it as part of a larger toolkit helps reduce maternal morbidity and mortality.

Breast-feeding mastitis is a common occurrence and a source of disruption of breast-feeding and negatively affects quality-of-life. In this session, we will review the Academy of Breastfeeding Medicine’s treatment protocol for the condition. When is abscess identification required? What about drainage? We will answer these questions and more in this episode!

Obesity is a known modifiable risk factor for complications of pregnancy- both antepartum and intrapartum. Data has confirmed a direct link/risk of stillbirth with obesity. In this session, we will review the data on this link as well as the effect of gestational age on the risk of stillbirth. We will also briefly review the ACOG practice bulletin on gestational diabetes and how this may relate to obesity’s risk of stillbirth. This podcast will also summarize the (conflicting) data on elective induction of labor at term as an attempt to reduce the risk of stillbirth in the obese population.

Periviable birth is defined as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When is the earliest time to consider antenatal steroids for fetal lung maturation, and what about magnesium sulfate for neuroprotection? When should tocolytics be utilized? And when is the earliest just stational age to consider a C-section for fetal benefit? In this session, we will cover these questions according to the ACOG consensus statement #6.

MTHFR... Yep, it gets blamed for a variety of health and pregnancy concerns. But does the data actually confirm the presence of adverse pregnancy and adverse health issues with MTHFR variants? In this session, we will review the difference between the 2 most common variants (C677T, A1298C) and true MUTATIONS. We will also review statements from the ACOG, ACMG, SMFM, as well as the Canadian Guidelines regarding MTHFR screening.

Persistent cough, congestion, low-grade fever… Yep, typical symptoms of acute bronchitis! The CDC and the American College of Physicians have published guidelines on antibiotic stewardship regarding acute bronchitis. When are antibiotics indicated? What about beta-agonist therapy? Do mucolytics work? In this podcast we will review the presentation, etiology, and treatment algorithm of this common clinical diagnosis.

“Never events“, “Sentinel events”, and “Near misses”. These terms strike fear in any healthcare provider! The National Quality Forum, the Agency for Healthcare Quality and Research, and the Joint Commission, all have stressed the importance of patient safety in the operating room and medical wards. In this podcast we will review alarming statistics regarding preventable medical errors, and remind ourselves of ways to keep patient safe.

That’s right… We’re talking about vaginal lubricants! In general, there are 3 main categories: water-based, silicone based, and oil based. Each has their own advantages and disadvantages. Some lubes can actually place the patient at risk of pregnancy if used with a latex condom! In this podcast, we will cover the “lube library“ so that we can better inform our patients since education is key!

Mirror syndrome (first described in 1892) is another term for what is also known as Ballantyne Syndrome or triple edema. Maternal mirror syndrome is a rare consequence of fetal hydrops. By convention, delivery is recommended in pregnancies complicated by mirror syndrome due to grave fetal prognosis. Severe maternal morbidity has also been described. In this session, we will review the clinical presentation, similarities to preeclampsia, and management of this grave complication.

On October 25, 2019, the American Journal of Perinatology published the results of the PROLONG Trial. This study demonstrated no statistical difference in the co-primary outcome of preterm birth less than 35 0/7 weeks of gestation (P = 0.72) and neonatal composite index (P = 0.73) with 17-OHP use. Similarly, the rate of preterm birth less than 37 weeks and less than 32 weeks were not different. On October 25, 2019, the ACOG released a practice advisory about this. Let’s summarize this now.

The rate of sepsis appears to be increasing. Maternal sepsis is a significant cause of maternal morbidity and mortality. Sepsis is not a specific illness, but a syndrome that includes organ dysfunction caused by this regulated host response to infection. In this session we will review the SOFA score and it’s utilization. Is fever necessary for a diagnosis of sepsis? Which antibiotics should be used? What is the rate of IV fluid resuscitation? Are steroids contraindicated in the septic patient? We will answer these questions and more in this episode which summarizes the SMFM expert series #47, sepsis in pregnancy.

N2O is a nonflammable, tasteless, odorless gas. It was first synthesized by the English scientist and theologian Joseph Priestly in 1772, and was first used as a labor analgesic by Stanislav Klikovich in Poland in 1881. Although much more frequently used in the UK and Canada, interest in nitrous oxide for labor pain management is increasing in the USA. What is its mechanism of action? Is it effective? What are the contraindications? Let’s review this topic...NOW.