Does BMI Affect Vag Miso Cervical Ripening? (IMPROVE Subanalysis)

The ACOG 2025 guideline specifically recommends either oral or vaginal misoprostol for cervical ripening; it does not include buccal administration among its endorsed routes. With the rising rates of both obesity and labor induction, understanding the optimal agents for induction in obese patients is crucial. In a new study released ahead of print on March 4, 2026, in the AJOG, investigators from Indianapolis released findings from a secondary analysis of the IMPROVE trial (2019, AJOG) looking at the effect of obesity on buccal vs vaginal doses of misoprostol for cervical ripening. Listen in for details.1. Haas DM, Daggy J, Flannery KM, Dorr ML, Bonsack C, Bhamidipalli SS, Pierson RC, Lathrop A, Towns R, Ngo N, Head A, Morgan S, Quinney SK. A comparison of vaginal versus buccal misoprostol for cervical ripening in women for labor induction at term (the IMPROVE trial): a triple-masked randomized controlled trial. Am J Obstet Gynecol. 2019 Sep;221(3):259.e1-259.e16. doi: 10.1016/j.ajog.2019.04.037. Epub 2019 May 7. PMID: 31075246; PMCID: PMC7692024.2. ACOG July 2025: Cervical Ripening in Pregnancy, ACOG Clinical Practice Guideline No. 93. Bynarowicz, Taylor M. et al. The impact of body mass index on misoprostol dosing for labor induction: a comparison of vaginal and buccal dosage formsAmerican Journal of Obstetrics & Gynecology, Volume 0, Issue 0: https://www.ajog.org/article/S0002-9378(26)00126-2/fulltext4. Etrusco A, Sfregola G, Zendoli F, et al. Effect of Maternal Age and Body Mass Index on Induction of Labor Using Oral Misoprostol in Late-Term Pregnancies: A Retrospective Cross-Sectional Study. Gynecologic and Obstetric Investigation. 2024. 5. Prostaglandin Versus Mechanical Dilation and the Effect of Maternal Obesity on Failure to Achieve Active Labor: A Cohort Study.6. Beckwith L, Magner K, Kritzer S, Warshak CR. The Journal of Maternal-Fetal & Neonatal Medicine : The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2017.

In this quickie episode, we will answer a question from one of our podcast family members: “Can a virgin get BV?”. It’s a complicated question, that needs explanation. PLUS, we will relate this to a former “event” from a past president- so listen until the end!1. Kim ES, Waltmann A, Duncan JA, Hood-Pishchany I.Advances in Treating Bacterial Vaginosis: Recognizing Sexual Transmission and Pipeline of Therapies. Current Opinion in Infectious Diseases. 2026. 2. Liu D, Zhang X, Zhao X, et al. Bacterial Vaginosis: Advancing Insights Into Microbial Dysbiosis. Critical Reviews in Microbiology. 2026. 3. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. The Epidemiology of Bacterial Vaginosis in Relation to Sexual Behaviour. BMC Infectious Diseases. 2010. 4. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. The Epidemiology of Bacterial Vaginosis in Relation to Sexual Behaviour. BMC Infectious Diseases. 2010.

For preterm prelabor rupture of membranes, the standard protocol for latency augmentation has remained IV amoxicillin and erythromycin for 2 days, followed by oral amoxicillin and erythromycin for 5 additional days. Nonetheless, azithromycinhas largely replaced erythromycin in PPROM management due to supply shortages and tolerability.  Previous retrospective studies (2019) have found no difference in latency between single-dose and multi-day azithromycin regimens, but these studies did not measure actual drugconcentrations at the site of action. In that 2019 retrospective study, there was also no difference in incidence of chorioamnionitis, or neonatal outcomes when comparing different dosing regimens of the azithromycin with erythromycin, with the exception of respiratory distress syndrome being more common in the 5 day azithromycin group. However, a 2024 single-center,retrospective study from Annals Pharmacotherapy found significantly higher rates of histologic chorioamnionitis with single-dose azithromycin compared to 5-day regimens(62.6% vs 46.4%, P=0.006), despite similar latency periods. So, it’s complicated. A 2025 systematic review of international guidelines found that 6 out of 17 clinical practice guidelines acknowledged uncertainty about the optimal antibiotic regimen. This was published in the AJOG. In this episode, wewill review a new publication from March 2026 in the AJOG which sought to compare the pharmacokinetic parameters of 1 g once vs 500 mg daily dosing of azithromycin in the setting of preterm prelabor rupture of membranes and simulate various dosing regimens to identify the optimal regimen that maintains amniotic fluid concentration of azithromycin over the minimum inhibitory concentration of common GU pathogens associated with intraamniotic infection orinflammation. But there is a BIG limitation. Listen in for details. 1.    Navathe R, Schoen CN, Heidari P, Bachilova S, Ward A, Tepper J, Visintainer P, Hoffman MK, Smith S, Berghella V, Roman A. Azithromycin vs erythromycin for the management of preterm premature rupture of membranes. Am J Obstet Gynecol. 2019 Aug;221(2):144.e1-144.e8. doi: 10.1016/j.ajog.2019.03.009. Epub 2019 Mar 20.PMID: 30904320.2.    Kua S, Roman A, Harbinson L, Groom K, Whitehead C. Systematic review of nationaland international clinical practice guidelines for management of preterm prelabor rupture of membranes. Am J Obstet Gynecol. 2025 Nov 22:S0002-9378(25)00866-X. 3.    Day KN, Vircks JA, Henricks CE, Reaves KM, Holmes AK, Florio KL. Latency Antibiotics in Preterm Prelabor Rupture of Membranes: A Comparison of Azithromycin Regimens. Ann Pharmacother. 2024 Mar;58(3):234-240. doi:10.1177/10600280231181135. Epub 2023 Jun 26. PMID: 38124306.4.   Boelig, Rupsa C. et al. Azithromycin in preterm prematurerupture of membranes: population pharmacokinetics and dose optimization. AmericanJournal of Obstetrics & Gynecology, March 2026.  SPONSER SITE: Visit www.perspectivemedical for more information on the Hemorrhage View C-Section Drape

Well podcast family welcome to the first installment of what will be a periodic recurrence, of our episode called, “QUICKIE”. These are meant to be quick snippet episodes to give a quick fact or medical /clinical reminder in contrast to our regular episodes which are a little bit more in detail and lengthy. In this first installment of our first QUICKIE episode, we're going to tackle the distinction between the diagnosis of fetal growth restriction based on abdominal circumference vs estimated fetal weight and how this affects management.1. ACOG CO 8312. ACOG PB 227

Probiotics. They are often marketed as the end of all and be all for all our health issues. And they CAN do some real good. There is NO DOUBT a connection with overall heath and gut health…and NO ONE can deny that. But probiotics gets grey for some women’s health issues. A new prospective, single-arm, non-blinded, multicenter study across 31 hospitals in Japan is making some pretty dramatic claims regarding oral probiotics and recurrent spontaneous preterm birth (ePUB). Can oral probiotics reduce spontaneous recurrent preterm birth? Listen in for details. 1. Prevention of Recurrent Spontaneous Preterm Delivery Using Probiotics: Results from a Prospective, Single-Arm, Multicenter Trial. PPP trial Collaborators et al.American Journal of Obstetrics & Gynecology, Volume 0, Issue 02. Grev J, Berg M, Soll R. Maternal probiotic supplementation for prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2018 Dec 12;12(12):CD012519. doi: 10.1002/14651858.CD012519.pub2. PMID: 30548483; PMCID: PMC6516999.3. Jarde A, Lewis-Mikhael AM, Moayyedi P, Stearns JC, Collins SM, Beyene J, McDonald SD. Pregnancy outcomes in women taking probiotics or prebiotics: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2018 Jan 8;18(1):14. doi: 10.1186/s12884-017-1629-5. PMID: 29310610; PMCID: PMC5759212.4. Othman M, Neilson JP, Alfirevic Z. Probiotics for preventing preterm labour. Cochrane Database Syst Rev. 2007 Jan 24;2007(1):CD005941. doi: 10.1002/14651858.CD005941.pub2. PMID: 17253567; PMCID: PMC9006117.5. Timing of Probiotic Milk Consumption During Pregnancy and Effects on the Incidence of Preeclampsia and Preterm Delivery: A Prospective Observational Cohort Study in Norway.6. Nordqvist M, Jacobsson B, Brantsæter AL, Myhre R, Nilsson S, Sengpiel V. Timing of probiotic milk consumption during pregnancy and effects on the incidence of preeclampsia and preterm delivery: a prospective observational cohort study in Norway. BMJ Open. 2018 Jan 23;8(1):e018021. doi: 10.1136/bmjopen-2017-018021. PMID: 29362253; PMCID: PMC5780685.7. Gao Q, Sun Y, Qu Y, Li F, Li P. The effect of probiotic supplementation during pregnancy on pregnancy complications: An umbrella meta-analysis. Medicine (Baltimore). 2025 Dec 19;104(51):e46409. doi: 10.1097/MD.0000000000046409. PMID: 41430994; PMCID: PMC12727282.SPONSOR WEBSITE: Visit perspectivemedical.org to learn more about the Hemorrhage View C-Section Drape

Neither the ACOG nor SMFM recommend strict bed rest for preterm birth prevention, or nor preeclampsia. Yet tradition often conflicts with evidence. A prior 2009 survey of MFM specialists, published in the AJOG, on the use of bed rest revealed that 71% used activity restriction in their practice for arrested preterm labor, despite the majority believing it had minimal or no benefit. The authors concluded, “Because most obstetricians in our survey indicated they would prescribe bed rest believing it was associated with minimal or no benefit, it is possible that even if a randomized, prospective trial showed no benefit associated with bed rest, it would still remain a common recommendation.” This brings us to a brand new publication from the Green Journal which is an ancillary study of two randomized trials of preterm birth prevention in women with a short cervical length. These authors sought to evaluate the amount of physical activity in patients at high risk for preterm birth and pregnancy latency and preterm birth. What did they find? It is a bit shocking. Listen in for details.1. Fox, Nathan S. et al. The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes. American Journal of Obstetrics & Gynecology, Volume 200, Issue 2, 165.e1 - 165.e6 https://www.ajog.org/article/S0002-9378(08)00909-5/fulltext2. Sciscione, Anthony C. DO; Booker, Whitney A. for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network, Bethesda, Maryland. Activity Restriction in Pregnancy and the Risk of Early Delivery: The AWARE Study. Obstetrics & Gynecology ():10.1097/AOG.0000000000006225, February 19, 2026. | DOI: 10.1097/AOG.0000000000006225 https://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=9900&issue=00000&article=01460&type=FulltextVisit our SPONSOR’s Webpage for information on the Hemorrhage View C-Section Drape: www.perspectivemedical.org

A study published in Nature Communications, published Feb 19, 2026, found that “pregnancy physically alters a woman’s brain, with a second pregnancy bringing even more profound effects.” The researchers “performed brain scans on 110 women. Some were first-time mothers, others second-time moms, and some nulliparous women. Results showed that during a first pregnancy, the greatest changes occur in the structure and activity of the ‘default mode network’ – the brain system responsible for self-reflection and mind wandering. Are these changes bad? Are they associated with long term hard? Are they adaptive? It’s a complex question, with real answers. Listen in for details.1. Straathof, M., Halmans, S., Pouwels, P.J.W. et al. The effects of a second pregnancy on women’s brain structure and function. Nat Commun 17, 1495 (2026). https://doi.org/10.1038/s41467-026-69370-82. de Lange AG, Kaufmann T, van der Meer D, et al. Population-Based Neuroimaging Reveals Traces of Childbirth in the Maternal Brain. Proceedings of the National Academy of Sciences of the United States of America. 2019.3. Aleknaviciute J, Evans TE, Aribas E, et al.)Long-Term Association of Pregnancy and Maternal Brain Structure: The Rotterdam Study. European Journal of Epidemiology. 2022.4. Jung JH, Lee GW, Lee JH, et al. Multiparity, Brain Atrophy, and Cognitive Decline. Frontiers in Aging Neuroscience. 2020.5. Hu A, Xiong L, Wei H, et al. Association of Menarche, Menopause, and Reproductive History With Cognitive Performance in Older US Women: A Cross-Sectional Study From NHANES 2011-2014. BMC Public Health. 2025.6. Orchard ER, Ward PGD, Sforazzini F, et al. Relationship Between Parenthood and Cortical Thickness in Late Adulthood. PloS One. 20207. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy Leads to Long-Lasting Changes in Human Brain Structure. Nature Neuroscience. 2017.8. de Lange AG, Barth C, Kaufmann T, et al. Women's Brain Aging: Effects of Sex-Hormone Exposure, Pregnancies, and Genetic Risk for Alzheimer's Disease. Human Brain Mapping. 2020.Visit our SPONSOR's LINK to learn more about the Hemorrhage view CS Drape: https://www.perspectivemedical.org/

Approximately 5–10% of all breast cancers are hereditary, and among those, BRCA1 and BRCA2 mutations are responsible for about 60% of cases. Yet, overall, only about 1-2% of all breast cancers in the general population are caused by BRCA mutations. Once childbearing is complete, the NCCN recommends risk-reducing BSO in patients carrying these mutations. But what about the uterus? Since childbearing is complete, and the ovaries are now removed, the sole purpose of the uterus- which is to initiate, nourish, and grow a child -is no longer applicable. Is there a call for inclusion of a hysterectomy at time of risk reducing BSO? This has vast and important implications regarding subsequent hormone therapy. In this episode, which comes from one of our podcast family members, we will dive into the latest data pushing towards the inclusion of hysterectomy at time of prophylactic BSO. It's fascinating data from just last year (2025, in the Journal of the NCI). Listen in for details.1. Kotsopoulos J, Seca M, Gronwald J, et al. Menopausal Hormone Therapy and the Risk of Breast Cancer in Women With a Pathogenic Variant in BRCA1 or BRCA2. Journal of the National Cancer Institute. 2025. 2. Kotsopoulos J, Gronwald J, Karlan BY, et al. Hormone Replacement Therapy After Oophorectomy and Breast Cancer Risk Among BRCA1 Mutation Carriers. JAMA Oncology. 2018

The ACOG states that, “Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality and should be treated with iron supplementation in addition to prenatal vitamins. In addition, there may be an association between maternal iron deficiency anemia and postpartum depression, with poor results in mental and psychomotor performance testing in offspring”. Screening for anemia is included in most prenatal lab sets. However, up to 42% of women who enter prenatal care are iron deficient BEFORE anemia is detected. Iron deficiency itself, even without anemia, has also been linked to pregnancy morbidity. The ACOG currently does not have a statement endorsing universal ferritin screening in pregnancy outside of established anemia, but new data is challenging this (Jan 2026, Lancet). Listen in for details. 1. ACOG PB 2332. Wasim T, Bushra N, Nasrin T, Humayun S, Tajammul A, Khawaja KI, Irshad S, Fatima S, Yasin A, Zamora J, Cano-Ibáñez N, Fernandez-Felix BM, Khan KS; Ferritin screening and iron treatment for maternal anaemia and fetal growth restriction prevention (FAIR) Study Group. Intravenous iron for non-anaemic iron deficiency in pregnancy: a multicentre, two-arm, randomised controlled trial. Lancet Haematol. 2026 Jan;13(1):e22-e29. doi: 10.1016/S2352-3026(25)00315-1. PMID: 41482443.3. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2024.15196

We recently covered an SMFM abstract that was presented at the annual Pregnancy Meeting held in early February 2026. The authors were from my Alma Mater, UT Southwestern/Parkland Hospital. This was a well-done study comparing 162 milligrams aspirin to 81 milligrams of aspirin. The results were very encouraging! However, aspirin definitely has an awkward acumen. It would be wonderful if ALL the data just leaned in the same direction... but it doesn’t! Enter our podcast family member, and my friend Alex. Alex sent me an incredible and insightful message which was a rebuttal to my Southwestern colleagues’ findings. In this episode you'll hear Alex's rebuttal and clinical conundrum, and we will explain why these two seemingly paradoxical findings makes sense. Listen in for details.1. Khander, Amrin MD; Thomas, Charlene MS; Matthews, Kathy MD; Christos, Paul DrPH; Alcus, Claire BA; Alam, Tanvir BS; Bush, Leah BA; Deshmukh, Diksha BA; Chasen, Stephen T. MD; Riley, Laura E. MD; Skupski, Daniel W. MD; August, Phyllis MD, MPH; Malha, Line MD, MS. Comparison of 162 mg and 81 mg Aspirin for Prevention of Preeclampsia: A Randomized Controlled Trial. Obstetrics & Gynecology 147(1):p 87-96, January 2026. | DOI: 10.1097/AOG.0000000000006100