Dr. Chapa’s OBGYN Clinical Pearls

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Vag Miso vs Vag Dino: New Meta-analysis (Aug 2026) Aug 22, 2026

Show notes

ACOG recommends the use of oral or vaginal misoprostol, vaginal dinoprostone (either gel or insert), or mechanical methods for cervical ripening. Plus, it states, “Combination methods (pharmacologic and mechanical) are also effective”. The July 2026 ACOG CPG 9 states this regarding vaginal misoprostol compared to vaginal dinoprostone for labor induction: “Vaginal dinoprostone is effective for cervical ripening; however, vaginal misoprostol has higher efficacy and less need for oxytocin augmentation. The Cochrane database systematic review in 2010 that compared vaginal misoprostol with vaginal dinoprostone in 38 trials (7,022 participants) showed a lower rate of failure to achieve vaginal delivery in 24 hours (RR 0.77) and reduced need for oxytocin augmentation with misoprostol (RR 0.68). There were no differences in the rates of cesarean delivery or tachysystole with FHR changes”. Now, as of August 19, 2026, a new meta-analysis from BJOG is examining this comparison (vaginal miso vs vaginal dino) again. Did they find the same thing? Listen in for details.

1. G. Andersson, B. Greenfield, A. Hunt, et al., “ Vaginal Misoprostol Compared to Vaginal Dinoprostone for Induction of Labour: A Systematic Review and Meta-Analysis,” BJOG: An International Journal of Obstetrics & Gynaecology (2026): 1–12, https://doi.org/10.1111/1471-0528.70314.

2. ACOG Clinical Practice Guideline No. 9: Cervical Ripening in Pregnancy

Estrogen’s Protection Against Breast CA: The Underappreciated Data Aug 19, 2026

Show notes

Today, we are taking a deep dive into a medical truth thatsounds completely counterintuitive, almost upside down, based on everything you think you know about women's health. But here’s the kicker: it’s actually nothing new at all. For over two decades, ever since the landmark Women’sHealth Initiative (WHI) study made global headlines back in 2002, the blanket narrative surrounding menopausal hormone therapy has been clear and persistent: hormones equal breast cancer risk. But there is a massive asterisk in thatscience that got completely lost in the media noise. While combination therapy with conjugated equine estrogens paired with medroxyprogesterone acetate (CEE +MPA) did show an increased risk, the story for estrogen-only therapy (mainly CEE) in women wh had a hysterectomy is entirely different. In fact, an overwhelming mountain of growing data shows that estrogen-only therapy is protectiveagainst both breast cancer incidence and breast cancer mortality. In this episode, we’re unpacking the latest high-level evidence that cements this crucial distinction. We'll examine the broad statistical landscape, including a comprehensive meta-analysis by Qing et al. (officially set for the December 2026 issue of Annals of Medicine, following its ahead-of-print release in March 2026). Their work breaks down how randomized controlled trial data consistentlypoint to estrogen-only therapy having a protective effect, in stark contrast to combination therapy. We'll also dive into a brand-new Clinical Perspective published in mid-August 2026 in Obstetrics & Gynecology (the Green Journal) by Drs. Andrew Kaunitz and Jason Wright. They call urgent attention to this phenomenon, highlighting RCT meta-analyses that demonstrate a 23% reduction in breast cancer incidence with estrogen alone (RR = 0.77), alongside striking cohort data showing a dramatic risk reduction even in high-risk populations, like carriers of the BRCA mutation. Listenin for details.

1. Wu Q, Shen L, Hu S, Yang R, Wang Y, Xue D, SunY, Ma H, Dai Z. Relationship between menopausal hormone therapy and incidencerisk of breast cancer: systematic review and meta-analysis. Ann Med. 2026Dec;58(1):2640244. doi: 10.1080/07853890.2026.2640244. Epub 2026 Mar.

2. Kaunitz, Wright. Menopausal Estrogen Therapy andRisk of Breast Cancer. Obstet Gynecol. Aug 2026

3. Chlebowski RT, Aragaki AK, Pan K, et al.Randomized Trials of Estrogen-Alone and Breast Cancer Incidence: AMeta-Analysis. Breast Cancer Research and Treatment. 2024.

4. Writing Group for the Women's Health InitiativeInvestigators. (2002). Risks and benefits of estrogen plus progestin in healthypostmenopausal women: Principal results from the Women's Health Initiativerandomized controlled trial. JAMA, 288(3), 321–333.

SC v IV Insulin Intrapartum Aug 16, 2026

Show notes

Historically, continuous intravenous (IV) insulin infusions were established as the standard of care for pregestational diabetes (Type 1 and Type 2 DM) during labor to prevent acute intrapartum hyperglycemia and minimize the risk of neonatal hypoglycemia. Intravenous insulin offers rapid titration, immediate onset, and a short half-life, allowing precise real-time glycemic control during the physiological stress and fluctuating metabolic demands of labor. Maintaining euglycemia intrapartum is emphasized because elevated maternal blood glucose levels cross the placenta, inducing fetal hyperinsulinemia, which acutely increases the risk of severe post-delivery neonatal hypoglycemia, which can be problematic. Although IV insulin protocols are widely used and are recommended in many practice guidelines, the evidence supporting their superiority over other approaches is limited. Subcutaneous (SC) insulin administration represents a potential alternative strategy to intrapartum glucose management. Continuation of SC insulin, including insulin pump therapy, has been studied most extensively among individuals with type 1 diabetes. However, evidence guiding intrapartum insulin management remains limited for patients with gestational or type 2 diabetes, who represent the majority of pregnancies complicated by diabetes. Institutional protocols frequently default to IV insulin despite limited comparative evidence with SC insulin and the increased workflow burden associated with infusion-based management. Now, a new retrospective study published in SMFM’s PREGANCY journal (25 July 2026; Seattle, Washington) is looking to give routine intrapartum SC insulin some validity. What did the data show? Listen in for details.

1. Savitsky, L.M., Barr, C., Katz, R., Martinez, N., Henderson, J., Saleh, T., White, L. and Simmons, L. (2026), Streamlining intrapartum glycemic control: Subcutaneous insulin for intrapartum diabetes management. Pregnancy, 2: e70371. https://doi.org/10.1002/pmf2.70371

Intro to REVI EXTEND IMPLANT (Not a sponsor) Aug 12, 2026

Show notes

Urge urinary incontinence (UUI) places a significant emotional and physical burden on women affected. Sacral neuromodulation has been and remains a well-established implant-based therapy for UUI. The concept originated in the early 1970s from sacral anterior root stimulation research for neurogenic bladder, with human clinical trials beginning in 1982. Medtronic's InterStim device received FDA approval in 1997 for UUI, and in 1999 for urgency-frequency and nonobstructive urinary retention. This was a game changer for affected women. Now, as of August 5, 2026, the FDA has granted 510(k) clearance for a new, less invasive neuromodulation implant- placed in the ANKLE. This is the Revi Extend Implant system (BlueWind Medical). What was the phase 3 data on this? What does the “wearable controller device” look like? Listen in for details.

1. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. JAMA. 2017;318(16):1592–1604. doi:10.1001/jama.2017.12137

2. Amundsen CL, Sutherland SE, Heesakkers JPFA, et al. Three-year efficacy and safety of Revi implantable tibial neuromodulation from the pivotal OASIS study. J Urol. 2026;216(2):219-229. doi:10.1097/JU.0000000000005062

3. BlueWind Medical receives FDA 510(k) clearance for Revi Extend implant. News release. BlueWind Medical Ltd. August 5, 2026. Accessed August 5, 2026. https://www.businesswire.com/news/home/20260805290667/en/BlueWind-Medical-Receives-FDA-510k-Clearance-for-Revi-Extend-Implant

The QBL Paradox: Precision vs. Performance in OB Hemorrhage Aug 09, 2026

Show notes

Today, we are taking a deep dive into an intervention that almost every labor and delivery unit in North America has adopted over the last decade: Quantitative Blood Loss, or QBL. ACOG first recommended quantitative blood loss assessment in Committee Opinion Number 794, published in December 2019. This opinion recommended that every birthing facility implement a standardized, quantitative method for measuring cumulative blood loss at all deliveries, replacing visual estimation as the default approach. This built on earlier ACOG efforts, including the 2015 reVITALize initiative, which standardized obstetric data definitions and defined postpartum hemorrhage using cumulative measured blood loss thresholds (≥1,000 mL regardless of delivery route, or blood loss accompanied by signs/symptoms of hypovolemia). We’ve all weighed sponges, measured calibrated drapes, and run the math. But here’s the million-dollar question: Does measuring blood loss accurately, on its own, actually improve outcomes for patients? The answer is YES….and NO at the same time. Listen in for details as we discuss new data (July 2026 in AJOG) on this topic.

1. White A, Burns RN, Pruszynski JE, Ravindra D, Fin KX, Montgomery T, Jestes E, Ambia AM, Anyaehie B, Duryea EL. Establishing Normal Blood Loss Thresholds at the Time of Delivery Based on Quantitative Blood Loss. Am J Obstet Gynecol. 2026 Jul. DOI: 10.1016/j.ajog.2026.07.028. S0002-9378(26)00395-9. YMOB 16849.

2. Quantitative Blood Loss in Obstetric Hemorrhage: ACOG COMMITTEE OPINION, Number 794.Obstetrics and Gynecology. 2019. Committee on Obstetric Practice

3. Coomarasamy A, Devall AJ, Bell S, et al. Diagnosis and Treatment of Postpartum Haemorrhage: A Race Against Time. Lancet. 2026.

Routine US for RPOC After 2nd Trimester Loss? Aug 05, 2026

Show notes

Today, we’re stepping into one of the most clinicallydelicate and emotionally heavy scenarios you can encounter in women's healthcare: a mid-pregnancy loss, say right around that 18 to 20-week mark. It’s a situation where the clinical room feels still, the emotional weight is immense, and every decision you make as a clinician carries profound gravity. Picture the scenario: The delivery has occurred. Both the fetus and the placenta have delivered, and upon gross visual examination on the delivery tray, the placenta appears intact. The immediate crisis of delivery has passed. But as theattending provider, you’re now standing at a critical management fork in the road. Do you routinely order an ultrasound before discharge to confirm the uterine cavity is truly clear? Or do you take a selective, symptom-driven approach, reserving uterine US imaging for patients who present with post-delivery warning signs like unexpected hemorrhage, severe pain, or fever? It sounds like a straightforward question, but in practice, it sparks intensedebate. Listen in, as we review professional society guidelines and the latest published data.

1. Fox CE, et al. Mid‐trimester Pregnancy Loss GuidelineConsensus Panel. Triage and care for women with symptoms or diagnosis of pregnancy loss between 14 + 0 and 21 + 6 weeks' gestation. Int J Gynaecol Obstet. 2026 Jan;172(1):25-50. doi: 10.1002/ijgo.70621.

2. Incognito GG, et al. Ultrasound Assessment ofRetained Products of Conception (RPOC): Insights from the Current Literature. J Clin Med. 2025 Aug 19;14(16):5864. doi: 10.3390/jcm14165864.

3. ACOG PB 135: Second Trimester Abortion

4. Sundararajan S, Roy S, Polanski LT. The accuracyof ultrasound scan in diagnosing retained products of conception: a systematicreview and meta-analysis. Am J Obstet Gynecol. 2024 May;230(5):512-531.e3.

A Mechanic’s Vision: The OdonAssist™ Device (Not Ready for US Approval) Aug 02, 2026

Show notes

Today, I want to tell you a story that sounds like it was completely made up for a movie script, but it’s 100% real. Imagine an automotive mechanic in Argentina. He has zero medical training, no background in obstetrics, and no clinical degree. One night, he sees a simple party trick on YouTube: how to get a lost cork out of the inside of an empty wine bottle using nothing more than an inflated plastic bag. Most people would laugh, finish their glass of wine, and move on. But this mechanic, Jorge Odón, looked at that plastic bag and had a radical thought: Could this same basic physics principle be used to safely deliver a trapped baby during second-stage labor? Fast forward through years of engineering refinements, global partnerships, and early clinical pilots, and we get the Odón device- or OdonAssist™. It is, without a doubt, one of the most creative and innovative mechanical concepts to hit the field of operative vaginal delivery in generations. Instead of rigid metal blades applying direct compression, or high-pressure suction cups on the scalp, it uses an inflatable pneumatic cuff wrapped inside a lubricated, double-layered polyethylene sleeve. The inner layer grips the fetal vertex, while the outer layer glides smoothly against the vaginal walls, replacing high friction with plastic-on-plastic sliding action. But, and this is a big "but", as clinicians, we don't practice medicine based on good ideas or clever engineering alone. We practice based on rigorous, reproducible evidence on efficacy and safety. And that’s where the narrative gets complicated. Although the device recently secured CE mark approval in Europe, it is not FDA approved in the United States. Why? Because despite nearly two decades of development, it is still facing a major shortage of large-scale Phase 3 comparative data (non-inferiority data). And the data it does have is not quite as impressive as its design would imply. Listen in for details.

1. Mottet N, et al. Safety and efficacy of the OdonAssist inflatable device for assisted vaginal birth: the BESANCON ASSIST study. American Journal of Obstetrics & Gynecology, 2023; 230, S947-S958

2. Hotton EJ, Lenguerrand E, Wade J, et al. The OdonAssist inflatable device for assisted vaginal birth—the ASSIST II study (United Kingdom). Am J Obstet Gynecol. 2024;230(3S):S932-S946.e3.

3. https://www.mnhi.com/odonassist (CE approval)\

4. ACOG PB 219; 2020.

When Data Gaps Exist: OB HSV Suppression? Jul 30, 2026

Show notes

ACOG first recommended antiviral suppressive therapy at 36 weeks of gestation for women with a history of genital herpes in 2007, with the publication of Practice Bulletin No. 82 ("Management of Herpes in Pregnancy," June 2007). This was the first ACOG practice bulletin specifically dedicated to genital herpes management in pregnancy, and it established the 36-week suppressive therapy recommendation based on the RCTs available at that time (including the Watts 2003, Sheffield 2006, and Andrews 2006 trials). The recommendation was subsequently reaffirmed and updated in Practice Bulletin No. 220, published in May 2020, which is the current version. However, these trials had patients who ultimately delivered at/after 38 weeks. In a patient with a history of genital HSV for whom suppression is recommended but who will have a medically indicated delivery at 37 weeks, say for a hypertension disorder of pregnancy, is 36 week initiation of HSV antiviral medication enough time for suppression? There is a gap in high quality data on this. In this episode, we will review the published data and reach a clinical decision as to whether one week suppression is enough, or if initiation earlier is reasonable.

1. ACOG PB 82

2. ACOG PB 220

(MIPI) Multidose Ibuprofen Prior to IUD? Jul 27, 2026

Show notes

Today, we’re diving straight into a topic that hits close to home for millions of patients and providers alike: IUD insertion pain, and more importantly, how we can actually make it better. Now, if you’ve been practicing or following clinical guidelines for a while, you know the frustrating backstory here. For years, the standard advice was simple: "Just take 800 milligrams of ibuprofen an hour before your appointment." But a 2015 double-blinded, randomized placebo-controlled clinical trial showed that taking a single dose of 800 mg within an hour before insertion did not relieve procedural pain. That was published in the journal Contraception in 2015. This left clinicians wishing for better options. Fast forward to 2024, when the CDC updated its guidelines to formally recommend local analgesia, like lidocaine blocks or topical use, to help manage insertion pain. That was a huge, long-overdue win for patient-centered care. But local numbing isn't the only tool we should be looking at. What if the issue with oral NSAIDs wasn't the medication itself, but how and when we dosed it? That brings us to a brand-new study published in the American Journal of Obstetrics and Gynecology (AJOG), August 2026. Researchers looked at a preemptive, multidose ibuprofen regimen- starting the day before insertion to reach sustained, therapeutic blood levels ahead of time. And the results? They offer some new insights into how we can stack our pain control strategies. So, let's break down what this study found, how it builds on our CDC guidance, and what it means for our clinical practice starting at our next IUD placement. Let’s jump in.

1. Bednarek PH, Creinin MD, Reeves MF, et al. Contraception. 2015;91(3):193–197.

2. Ouyang C, Lamvu G, Quach H, et al. Multidose Ibuprofen Prior to Intrauterine device insertion (MIPI): a triple blinded randomized controlled trial. American Journal of Obstetrics & Gynecology, August 2026; 235, 330-337

3. Management of Premenstrual Disorders: ACOG Clinical Practice Guideline No.7 Obstetrics and Gynecology. 2023. Committee on Clinical Practice Guidelines–Gynecology

4. McKenna KA, Fogleman CD. Dysmenorrhea.American Family Physician. 2021.

Ferritin at iOB: Told Ya! (Aug 2026 Data) Jul 24, 2026

Show notes

Podcast family, we pride ourselves on this show on being avant-garde and forward thinking on the topics we choose. For example, on February the 20th, 2026, we released an episode called “New Data: Screen Maternal Ferritin with Prenatal Care?” In that episode we reviewed a publication from the previous month (January 2026) that was released in Lancet Hematology. This study made the case for screening for early iron deficiency, even without anemia, with serum ferritin at the initiation of prenatal care. This was a multicenter, 2-arm, randomized controlled trial. Earlier identification of low serum ferritin prevented iron deficiency anemia in the third trimester. That's a win! Back then, we also stated how Australia has been leading the charge on this with the Australian HOW. That stands for Hematology in Obstetrics and Women's Health. This Australian consensus committee now recommends screening for iron deficiency, not just iron deficiency anemia, at the initiation of prenatal care, at 24 to 28 weeks, and then again at the third trimester when necessary. And now, as of August 2026, we have additional supportive data that including serum ferritin at the initial OB visit is evidence-based and best for the patient! In this episode we will review this brand-new, prospective cohort study published as a Research Letter in the AJOG August 2026.

1. Australian HOW: Iron optimisation in pregnancy: a Haematology in Obstetric and Women's Health Collaborative consensus statement; https://onlinelibrary.wiley.com/doi/10.1111/imj.16602

2. Konecke N, Jackson T, Angeles I. et al. The association between first trimester iron deficiency without anemia and the development of iron-deficiency anemia prior to childbirth. American Journal of Obstetrics & Gynecology, 2026; 235, e36-e38

3. ACOG Clinical Practice Update: An Update to Clinical Guidance for Delayed Umbilical Cord Clamping After Birth in Preterm Neonates. Obstet Gynecol. 2025 Jul 24;146(3):442-444.

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