AFLP vs Preeclampsia with Severe/HELLP

Here is a real-world clinical case with a tricky differential: Our team recently readmitted a patient 6 days postpartum/post C-section (which was done for ICP and fetal macrosomia at close to 4500 grams, with A2GDM). She had elevated blood pressures, a frontal headache, some midepigastric pain/RUQ discomfort. Pretty clear picture right: sounds like preeclampsia (PreE) with severe features based on BP elevation and symptoms. So, we started her on mag-sulfate per protocol. Well, her transaminases were in the 400-600s, which was significantly higher than they were at delivery. They then peaked the next day at 900! OK, it still meets criteria for PreE with severe features. But could this also be postpartum Acute fatty Liver of Pregnancy (AFLP)? The clinical picture of these 2 conditions may overlap but there are distinct differences here. AFLP is potentially fatal, so we have to get that diagnosis correct. How can we distinguish AFLP from PreE with severe features or HELLP? Listen in for details.1. https://www.preeclampsia.org/the-news/health-information/acute-fatty-liver-of-pregnancy-can-be-confused-with-preeclampsia-and-hellp-syndrome2. Yemde A Jr, Kawathalkar A, Bhalerao A. Acute Fatty Liver of Pregnancy: A Diagnostic Challenge. Cureus. 2023 Mar 26;15(3):e36708. doi: 10.7759/cureus.36708. PMID: 37113350; PMCID: PMC10129069.3. Maalbi O, Elachhab N, Elkabbaj A, Arfaoui M, Hindi S, Lahbabi S, Oudghiri N, Tachinante R. Management of Acute Fatty Liver of Pregnancy: A Retrospective Study of 12 Cases Compared With Data in the Literature. Cureus. 2025 Jun 11;17(6):e85753. doi: 10.7759/cureus.85753. PMID: 40656400; PMCID: PMC12247011.4. Siwatch S, De A, Kaur B, et al. Safety and Efficacy of Plasmapheresis in Treatment of Acute Fatty Liver of Pregnancy-a Systematic Review and Meta-Analysis.Frontiers in Medicine. 2024;11:1433324. doi:10.3389/fmed.2024.1433324.5. Sarkar M, Brady CW, Fleckenstein J, et al.6. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases.Hepatology (Baltimore, Md.). 2021;73(1):318-365. doi:10.1002/hep.31559.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

I was recently asked to OPINE on the labor management for a patient who was receiving IV Pitocin for augmentation, who experienced a placental abruption. One physician stated that in "his opinion", Pitocin increased the risk of placental abruption intrapartum, a point which the original treating physician refuted. So, I was asked to be the "referee" on the play. IV Pitocin can result in some maternal-fetal complications but is abruption one of them as a stand-alone complication. Was the first reviewer's opinion correct? Listen in for details.1. Ben-Aroya Z, Yochai D, Silberstein T, Friger M, Hallak M, Katz M, Mazor M. Oxytocin use in grand-multiparous patients: safety and complications. J Matern Fetal Med. 2001 Oct;10(5):328-31. doi: 10.1080/714904358. PMID: 11730496.2. Morikawa M, Cho K, Yamada T, et al. Do Uterotonic Drugs Increase Risk of Abruptio Placentae and Eclampsia? Archives of Gynecology and Obstetrics. 2014;289(5):987-91. doi:10.1007/s00404-013-3101-8.3. ACOG: First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8. Obstetrics and Gynecology. 2024;143(1):144-162. doi:10.1097/AOG.0000000000005447.4. Pitocin. FDA Drug Label. Food and Drug Administration Updated date: 2024-08-125. Litorp H, Sunny AK, Kc A. Augmentation of Labor With Oxytocin and Its Association With Delivery Outcomes: A Large-Scale Cohort Study in 12 Public Hospitals in Nepal.Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(4):684-693. doi:10.1111/aogs.13919.

Current guidelines recommend universal collection of a vaginal-rectal swab for GBS colonization at 36-37 weeks and 6 days for the identification of patients who require intrapartum IV antibiotic coverage to prevent early onset neonatal GBS infection/sepsis. Recently, we had a patient in clinic whose GBS culture at 36 weeks was negative. Good right? Well, the patient was on amoxicillin at the time for pharyngitis. Did that course of oral PCN based therapy affect the GBS culture result? Should we believe that culture or could it be a false negative, demanding rescreen after therapy completion? There is currently a GAP here in the guidance. In this episode we will cover this controversial scenario, look at the data, and provide a real-world implementable approach to this case.1. Kim DD, Page SM, McKenna DS, Kim CM. Neonatal Group B Streptococcus Sepsis After Negative Screen in a Patient Taking Oral Antibiotics. Obstetrics and Gynecology. 2005;105(5 Pt 2):1259-61. doi:10.1097/01.AOG.0000159040.51773.bf.2. ACOG CO Number 797 (Replaces Committee Opinion No. 782, June 2019.); 20203. Mackay G, House MD, Bloch E, Wolfberg AJ. A GBS culture collected shortly after GBS prophylaxis may be inaccurate. J Matern Fetal Neonatal Med. 2012 Jun;25(6):736-8. doi: 10.3109/14767058.2011.596961. Epub 2011 Aug 1. PMID: 21801141.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On March 7, 2025, we released an episode summarizing key aspects of a NEJM publication regarding male partner therapy for women with recurrent BV. Although that study had limitations, the results were very surprising. Now, on 10/16/25 (7 months later), the ACOG has a new Clinical Practice Update (CPU) on this very issue. In this episode we will briefly summarize that March 2025 NEJM publication and highlight the TWO updated clinical recommendations from the ACOG regarding male partner therapy for the prevention of BV in women. PLUS, we will briefly discuss why although male partner therapy should be considered, partner EPT is “not recommended” at this time by the ACOG. 1. ACOG CLINICAL PRACTICE UPDATE: Concurrent Sexual Partner Therapy to Prevent Bacterial Vaginosis Recurrence Obstetrics & Gynecology ():10.1097/AOG.0000000000006102, October 16, 2025. | DOI: 10.1097/AOG.00000000000061022. Chapa Clinical Pearls March 2025 Episode: https://open.spotify.com/episode/4sW9tTe9CdYVQsCRBjqQQP3. Vodstrcil LA, Plummer EL, Fairley CK, Hocking JS, Law MG, Petoumenos K, et al. Male-partner treatment to prevent recurrence of bacterial vaginosis. N Engl J Med 2025;392:947–57. doi: 10.1056/NEJMoa2405404STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Podcast family, as we have said on many previous occasions, we get episode suggestions from either real-world patient encounters, from things that are hot in press, and/or from podcasts family member suggestions. Recently, one of our podcast family members asked me about the utility ofperforming pelvic floor muscle therapy (PFMT) antepartum. Is this evidence-based? Does performing PFMT help with postpartum urinary incontinence? Not all PFMTs are Kegel exercises! In this episode, we will review peripartum urinary incontinence and answer the question, “Is there value in teaching antepartum PFMT?”. We will summarize key concepts from the Oct 2025 Narrative Review on thissubject from the Green Journal (Obstet Gynecol).1.     Siddique, Moiuri MD, MPH; Hickman, Lisa MD;Giugale, Lauren MD. Peripartum Urinary Incontinence and Overactive Bladder.Obstetrics & Gynecology 146(4):p 466-472, October 2025. | DOI:10.1097/AOG.00000000000059932.     Woodley SJ, Lawrenson P, Boyle R, et al. PelvicFloor Muscle Training for Preventing and Treating Urinary and Faecal Incontinence in Antenatal and Postnatal Women. The Cochrane Database of SystematicReviews. 2020;5:CD007471. doi:10.1002/14651858.CD007471.pub4.3.     Pelvic Floor Muscle Training to Prevent andTreat Urinary and Fecal Incontinence in Antenatal and Postnatal Patients. AmericanAcademy of Family Physicians (2021). Practice Guideline STRONG COFFEE PROMO: 20% Off Strong CoffeeCompany https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In the 09/1/2018 Society for Academic Specialists in General Obstetrics and Gynecology’s (SASGOG’s) Pearls of Exxcellence publication, “Management of Preeclampsia at Term”, it states: “If hypertension management requires acute IV treatment, it is often prudent to initiate oral labetalol or EXTENDED-release nifedipine to maintain blood pressures below the severe range. Intrapartum blood pressure management and consultation should not delay progress towards delivery. Fetal monitoring should be continuous.” In the original ACOG CO 692 from 2017, oral nifedipine was first referenced as an alternative to IV meds GIVEN INTRAPARTUM, stating, “Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available.” This may be given orally as 10mg, 20mg, and 20 mg separated in time by 20 minutes per dose. Notice it says “immediate release oral nifedipine”. But what about EXTENDED release nifedipine intrapartum as stated by the SASGOG? Is that an option after immediate attentive and therapy has been given with IV anti-hypertensives? Listen in for details.1. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period: Committee Opinion, Number 692. Obstetrics & Gynecology 129(4):p e90-e95, April 2017. | DOI: 10.1097/AOG.00000000000020192. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260. doi: 10.1097/AOG.0000000000003891. PMID: 32443079.3. Cleary EM, Racchi NW, Patton KG, Kudrimoti M, Costantine MM, Rood KM. Trial of Intrapartum Extended-Release Nifedipine to Prevent Severe Hypertension Among Pregnant Individuals With Preeclampsia With Severe Features. Hypertension. 2023 Feb;80(2):335-342. doi: 10.1161/HYPERTENSIONAHA.122.19751. Epub 2022 Oct 3. PMID: 36189646.STRONG COFFEE PROMO: 20% Off Strong Coffee Company ⁠https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Fetal gastroschisis is a congenital defect of the abdominal wall, typically located to the right of a normally inserted umbilical cord, through which the fetal intestines and sometimes other abdominal organs herniate directly into the amniotic cavity. This condition is usually isolated, not associated with other major anomalies, and is reliably diagnosed prenatally by ultrasound. Does this require antenatal fetal surveillance? In this episode, we will cover the prevalence, diagnosis, classification, and management of this congenital anomaly. 1. Ferreira RG, Mendonça CR, Gonçalves Ramos LL, de Abreu Tacon FS, Naves do Amaral W, Ruano R. Gastroschisis: a systematic review of diagnosis, prognosis and treatment. J Matern Fetal Neonatal Med. 2022 Dec;35(25):6199-6212. doi: 10.1080/14767058.2021.1909563. Epub 2021 Apr 25. PMID: 33899664.2. Pontes KFM, Muniz TD, Caldas JVJ, Acácio GL, Lapa DA, Rolo LC, Araujo Júnior E. Fetal Gastroschisis: Review From Diagnosis to Delivery. J Clin Ultrasound. 2025 Jun;53(5):1122-1130. doi: 10.1002/jcu.23976. Epub 2025 Mar 28. PMID: 40152061.3. Muniz TD, Rolo LC, Araujo Júnior E. Gastroschisis: embriology, pathogenesis, risk factors, prognosis, and ultrasonographic markers for adverse neonatal outcomes. J Ultrasound. 2024 Jun;27(2):241-250. doi: 10.1007/s40477-024-00887-8. Epub 2024 Mar 29. PMID: 38553588; PMCID: PMC11178761.STRONG COFFEE PROMO: 20% Off Strong Coffee Company ⁠https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

On October 9, 2025, the ACOG released a clinical practice update (CPU) regarding Zouranolone and brexanolone. As postpartum depression is an area of continued research and need for therapeutics, any new clinical practice update on the subject is welcome. So what's new in this update?! Well…the answer will surprise you. Listen in for details on the CPU, and a mini-review of the concerns for Zuranolone. 1. ACOG CPU Oct 9, 2025: Zuranolone and Brexanolone for the Treatment of Postpartum Depression 2. ACOG PA Aug 2023: Zuranolone for the Treatment of Postpartum Depression 3. Clinical Practice Guideline No. 5, Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum (Obstet Gynecol 2023;141:1262–88)STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

Sometimes you hear something that makes you just stop and say, “What did you say?!”. Yep, in this episode we will give evidence-based answers to three questions that I heard TODAY that made me stop and ask, “What did you say?”. In this episode we will cover: 1. Umbilical cord blood collection from a monochorionic twin gestation, 2. Predictability of the mBPP compared to full BPP, and 3. Breastfeeding during postpartum cannabis use (this last one is not so intuitive as you would think, and there is new ACOG guidance on this which we will review). Listen in for details!1. ACOG PB 229; 20212. ACOG CC #10: Cannabis Use During Pregnancy and Lactation3. Kaufman DA, Lucke AM, Cummings JJ. Postnatal Cord Blood Sampling: Clinical Report.Pediatrics. 2025;155(6):e2025071811. doi:10.1542/peds.2025-071811.4. Simpson L, Khati NJ, Deshmukh SP, et al. ACR Appropriateness Criteria Assessment of Fetal Well-Being. Journal of the American College of Radiology : JACR. 2016;13(12 Pt A):1483-1493. doi:10.1016/j.jacr.2016.08.028.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG

In July 2023, the ACOG released a Practice Advisory stating, “Based on data on the benefit of adjunct HPV vaccination, ACOG recommends adherence to the current Centers for Disease Control and Prevention (CDC) recommendations for vaccinations of individuals aged 9–26 years, and to consider adjuvant HPV vaccination for immunocompetent previously unvaccinated people aged 27–45 years who are undergoing treatment for CIN 2+”. The possible beneficial effect of peri-treatment HPV vaccination goes back to the early 2010s. But science is always changing, and MEDICINE MOVES FAST. In September 2025, the Lancet’s Obstetrics, Gynecology, and Women’s Health journal published the VACCIN trial to test that guidance. These authors found that, “Although previous studies, including meta-analyses and observational studies, have shown that adjuvant HPV vaccination reduces the recurrence of cervical dysplasia after surgical treatment, our trial suggests that adjuvant HPV vaccination is not effective in reducing the recurrence of CIN 2–3 lesions, contradicting the conclusions of previous works”. They have also called for a REVISION to prior guidance. This is FASCINATING. Listen in for details. 1. ACOG PA July 2023, “Adjuvant Human Papillomavirus Vaccination for Patients Undergoing Treatment for Cervical Intraepithelial Neoplasia 2+”2. Adjuvant prophylactic human papillomavirus vaccination for prevention of recurrent high-grade cervical intraepithelial neoplasia lesions in women undergoing lesion surgical treatment (VACCIN): a multicentre, phase 4 randomised placebo-controlled trial in the Netherlands: https://www.sciencedirect.com/science/article/pii/S305050382500007X#:~:text=To%20our%20knowledge%2C%20this%20is,the%20conclusions%20of%20previous%20works.STRONG COFFEE PROMO: 20% Off Strong Coffee Company https://strongcoffeecompany.com/discount/CHAPANOSPINOBG