Dr. Chapa’s Clinical Pearls‪.‬ Dr. Chapa’s Clinical Pearls

First off, let’s all agree that everyone has a different STYLE of sexual intimacy, and that’s OK. Yep, we all understand that there's always been a lot of sexual act “diversity” in the world… and throughout history. But there is a more recent trend that has increased in popularity, some surveys attribute it to its representation in pornography, that may be dangerous. This was in recent print as of July 3, 2024! This is "sexual choking”. But this term is not accurate because it actually is a form of strangulation. The increase in practice is mostly seen in teenagers and young adults. In this episode, we will discuss a real-world scenario that one of our podcast family members asked me about just the other day. This OBGYN physician was on call and one of her patients, a 21-year-old, non-pregnant, otherwise healthy, and THIN (yes, that was a factor in this case, and we will discuss why) presented with LOC during sex whose partner stated “she had a seizure” during sex. But this was no ordinary seizure. She had no history of epilepsy and was not on any medications. The “seizure” happened after sexual choking. Sexual choking is a big concern as it exposes the brain to recurrent episodes of hypoxia. We now have data showing there are real negative effects from this activity. Plus, we need to discuss this as it may also be a normalization, inappropriately, of sexual violence. In this episode, we will take a look at this alarming data and discuss why we need to ask about these sexual practices in a compassionate, empathic, and open way.

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.