Dr. Chapa’s OBGYN Clinical Pearls

Latest Episodes:

Slowed Fetal Growth Trajectory & Neonatal Outcomes May 08, 2023

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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

FASD and Paternal ETOH Use May 06, 2023

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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 Related Maternal Fever (ERMF) May 03, 2023

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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.

MH in L&D: Recognize & Act May 01, 2023

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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.

Daily Dilemmas, Easy Answers! Apr 29, 2023

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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!

CGM in Diabetic Pregnancies Apr 27, 2023

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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.

Literature References! Apr 26, 2023

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

Incidental HCG in Menopause? Apr 26, 2023

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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.

Max Misoprostol Total Dose For Ripening? Apr 24, 2023

Show notes

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.

IUPC Pros &Cons vs EUM Apr 23, 2023

Show notes

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.

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