Dr. Chapa’s OBGYN Clinical Pearls

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 i...

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...

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 intri...

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 Gardas...

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 pr...

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...

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...

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 reco...

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 the...

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 answe...

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 & c...

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...

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 relea...

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 wil...

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...

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...