Dr. Chapa’s OBGYN Clinical Pearls

Latest Episodes:

Does Perineal Massage Prevent SVD Lacs? New Data. Aug 12, 2023

Show notes

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.

Understanding ZURZUVAE™ (zuranolone): The First Oral Med for PPD Aug 10, 2023

Show notes

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.

Brand New TXA at CS Data: Shout out to KC et al! Aug 08, 2023

Show notes

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. 👏👏👏👏

Vag E2 After Breast CA: Nah or Yeah? Aug 07, 2023

Show notes

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.

To Vag Prep or Not to Prep: That is the Question (Aug 2023 Data) Aug 04, 2023

Show notes

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.

VTE Med Prophylaxis After SVD? Aug 04, 2023

Show notes

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.

Kratom & Pregnancy Aug 01, 2023

Show notes

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.

The “Rule of 55” For HDP: A Critical Review of a New Meta-Analysis Jul 30, 2023

Show notes

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.

NEW HPV Vaccine ADVISORY: Use After CIN2+ Therapy (PRACTICE ADVISORY; July 2023) Jul 28, 2023

Show notes

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.

Amniotic Fluid Injections? 😳💉💉💉 Jul 26, 2023

Show notes

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. 💉💉💉

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