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No one goes to Hank's for spreadsheets. They go for a darn good pizza. Lately, though, the shop's been quiet, so Hank decides to bring back the $1 slice. He asks Copilot in Microsoft Excel to look at his sales and costs and help him see if he can afford it. Copilot shows Hank where the money's going and which little extras make the Dollar Slice work. Now Hanks has a line out the door. Hank makes the pizza, Copilot handles the spreadsheets. Learn more@m365copilot.com work everything hits different after
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In 2018 the arrive trial was published in the New England Journal and we really have never been able to recover from that. Now this was one of the largest randomized multi site studies that looked at either labor induction between 39 weeks and 0 and 39 weeks and four days or or expectant management for low risk nulliparous women. And the results were striking. There was a significantly lower rate of C section in those undergoing elective induction as compared to those undergoing expectant management. Those also lower rates of gestational hypertension and preeclampsia. Those are both good things. However, the cost of that was increased length of stay on the labor and delivery unit. Now I've been there guys, I know you have too where you take over call and you're like we have a null gravid patient who is low risk, nothing going on. Who is zero, who is there for induction. Yeah, so we prepare for the long haul. After all, that's what the ARRIVE trial said to do, right? Well, not necessarily. And since that time there's been a lot of people trying to walk back those implications to prevent saturation of nullogravid low risk pregnant women who sit there and labor and delivery for their induction when they're just not favorable. For example, in January of 2025 in the green Journal, ACOG released its practice guideline update on quote the management of full term nulliparous women without a medical indication for delivery. This was a clinical practice Update. This was January 2025. In other words, seven years later after labor and delivery unit are now being bombarded by low risk nullogravid patients. ACOG says, look, we really don't know what the best time for delivery is as long as they're still in that bucket of full term. Let me read you the first sentence of this clinical practice update from 2025, quote, the optimal timing for delivery in full term pregnancies 39 weeks and 0 to 40 and 6 has not been determined, end quote. So there it is. The optimal timing for delivery in full term pregnancies between 39 and 40 and 6 has not been determined. In other words, they say, look, hospitals should come up with their own plans. It should be part of shared decision making. Characteristics of the patient like their cervical dilation, all of these things should be taken into account when the patient is in the full term. Now what I mean by bucket is remember that from 37 weeks all the way to 42, there's different buckets. So there's early term, that's 37 up to 38 and 6, full term which is 39 and 0 to 40 and 6, late term, 41 and 0 to 41 and 6 and then of course post term which is 42 weeks and 0 and beyond. So the question is, if you can't get a patient in at 39 weeks. There's new publication here where I'm going, guys, there's a brand new study that was just accepted ahead of print, meaning it hasn't officially come out yet. This was accepted on June 26, 2026, guys, not even officially out yet. In the gray journal, this comes out of Israel. And even though it's a large population based cold war study, one of the big limitations, well there's two that it's retrospectives. Remember you can't prove causation here. You can look for associations and it's from a single center. Now I've been at this center years ago. I was invited to be faculty. Phenomenal location. I'm very thankful to have been part of the faculty there as a guest for some time. This is out of Ben Gurion University of the Negev in Beersheba, Israel. A phenomenal place. But it is single site, so single site and retrospective. So those are the limitations. And even the authors here, guys, as soon as we come back from the intro, give a big, big disclosure, I'm going to tell you what that disclosure is, everybody freaks out. I'll give you that disclosure here as soon as we come back from the intro. But here's what they were looking at in a term gestation bucket in other words, 39 and 0 to 40 and 6, does it matter if the patient delivers at 39 or 0? Or maybe it's a little bit better to deliver between 40 weeks and 0 and 40 and 6. In other words, in the whole one bucket, a full term, there may be or maybe not some advantages to the child in terms of long term morbidity. Is that a thing? So that's what this study sought to answer. Okay, so in all those who delivered at full term, so this is not preterm, this is not late term, just in that, in that bucket of 39 and 0 up to 40 and 6. And then if you follow those children up to 18 years, remember retrospective studies. So it's got some limitations. But up to 18 years, were there any big issues here in terms of chronic morbidities? Even though they were all in one bucket of full term even, isn't that nice? It gives us some brand new ideas here that are thought generating. That's all it is, thought generating. Remember the one big caveat I'm going to tell you here when we come back from the intro. So this is what we're trying to get at. If you have a patient who you just can't get into labor and delivery and there's no other medical issues going on, she has no morbidity and she's low risk. Just because you can't get her in at 39 and 0, relax, you're not giving her substandard service. If you wait until 40 weeks, she is still full term because she still sits in the bucket. And according to this study, there may be some advantages to waiting. So let me just say this right here, our practice, that's exactly what we've moved to. Yes, we offer a patient 39 week induction electively if they are favorable. But if they are not favorable, we say, hey, we're going to buy some time, we're going to reexamine here at 40 weeks. We're going to try to give you some more time here so that your cervix is not starting from zero. So we're trying to get your bishop to be a higher number so that when you get to labor and delivery, you're actually doing something and relax, you're still in the bucket a full term all the way until 40 and 6. So this study is surprising in what they found and allows us to have this conversation with the patient that, hey, just because you're 39 and just because you entered the bucket of full term doesn't mean you automatically have to be out at that time. Remember ACOG's statement quote the optimal timing for delivery for full term pregnancies has not been determined, end quote. Well now this study, even though it's retrospective and single center, gives us some potential discussion points with a patient in terms of long term morbidity for the child up to the age of 18. Now they look for several things and only two here were found to have some association. I'll tell you what those are when we come back from the intro in just a minute. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast Podcast Family. I'm inviting you to elevate your coffee routine with the strong coffee company that is striving to reach our natural greatness. I use it. It's coffee 2.0. It has protein MCTS for energy and mental clarity and adaptogens. This is one of my favorite coffees. It comes in regular black and latte mixes. And now you get 20% off. Can you go through the link in our show notes? That's right, just for being a podcast family member, go to strongcoffeecompany.com discount chopano spinobg for your 20% discount. The link is in our show notes. So I find this study fascinating because we all kind of have this internal dilemma of, oh, she's 39 weeks. I'm supposed to do something because of the ARRIVE trial, supposed to offer her induction and man labor and deliveries. I'm telling you, nothing like being saturated with nulligravid low risk inductions and they're not moving. It's a real problem. And so I'm thankful that, well, seven years later, ACOG released the clinical practice update that, hey, relax, it's all right. As long as they're still in the bucket of full term, it can be okay. We don't have to be out at 39 and 0. Quote, Patients should receive counseling regarding the potential benefits and risks of induction and at or beyond 39 weeks of gestation compared with expectant management, end quote. That was the main finding of that clinical practice update back in January of 2025. Of course we'll put that reference in our show notes. But this is where this brand new publication, not yet officially out yet, comes into play here because on June 26, 2026, out of the Gray Journal, the title of this retrospective study was, quote, Gestational Age at Full Term Delivery and Long Term Offspring Morbidity in Low Risk Pregnancies A Population Based Cohort Study end Quote, that's when this study was published. All right, so June 26, 2026. It's a good question. Even though you're all in that one slice of the bucket of full term, there has been some studies, at least from an embryological standpoint, that just because you're full term, a 39 week and 0 isn't the same as a 40 week and 0 child. There's still some increase, a maturation that's happening in utero. And so potentially there's some immune, you know, functions that are still finding their way to maturity in the child right now. Everybody gets that at 41 weeks. That's where you really need to start, you know, asking the patient, oh, I think we need to be done here because the placenta is going to start to wear out, gets calcified, it's senescence. And by 42 weeks, there's definitely an increased risk of stillbirth at post term pregnancies. So you got to start moving there. Okay, but between full term 39 and 0 and 40 and 6, the risk of stillbirth is really not much different in that one slice. So the question is, is there any impact on long term offspring morbidity based on when they deliver either earlier in the full term bucket at 39 or a little bit later in the full term bucket up to 40 and 6? Once again, this is a retrospective study. Is it out of Israel? And so because it's retrospective and observational, as we already said in the intro, you can't prove causation here. This is just some things to consider here that are thought provoking as associations, even the author says. I'm gonna give you this big caveat here and I'm gonna show you the results here and we're gonna be done. But here's a big issue, okay? Before you say Choppa said we should deliver at 40 and 6, that's not what I'm saying. I'm saying if she's favorable and she accepts induction, fine, go ahead and do it at 39 and 0 if that's the way that she wants to go. But if she's not, it's all right. There may be potentially some associated benefits to waiting. So it's all to talk us off the ledge, both as clinicians and to the patient, that they're not missing out because they didn't get their 39 week induction. Okay, now remember, we're talking about low risk patients here. We're not talking about those who have a medical indication. If they have a medical indication, follow the Indications for induction per the college. I mean that makes sense. We're talking about they have nothing going on and especially if they're nullogravid. That's one thing to consider. I always found this interesting because the ARRIVE trial. Guys, before we get into this new study, just remember that the ARRIVE trial was only looking at nulligravid patients and somehow we extrapolated that to everybody, including multigravid patients. That's not known. It was only in nulligravid patients. Ooh, almost. While lubid is alive, it went down the windpipe there. Sorry, I got too excited. But isn't that interesting? That study was never meant to be extrapolated to everybody. It was just looking at low risk, no long gravid patients. Even in the clinical practice update, it states, with this current evidence, AKA the ARRIVE trial, it is unclear whether these findings would apply to other patient subsets like multi parish individuals or those undergoing a trial of labor after cesarean, or those with other medical indications for delivery, end quote. So it's right there. Somehow this came. Everybody gets an induction at 39. The arrive trial was like, y' all came up with that yourself. We just wanted to do this in low risk nulligravid patients. Interesting. Okay, All I'm saying is not that it's wrong to offer inductions to everybody at 39, is that, that's not, that was never the intent of arrive. Just, just to be clear. Okay? And I'm not saying that again, that's in ACOG's clinical practice update from 2025. So having said that, this new study, because it's retrospective and single site and can only find associations, they have this big caveat. So listen here because after this I'm going to tell you the result and just something to consider as a thought provoking conversation. Quote. Given the retrospective and observational design of this study, these findings are hypothesis generating. Okay, let's stop there for a minute. Hypothesis generating means you put your hand on your chin and you go, hmm, that's interesting. That's all it is, hypothesis generating. You don't really have to put your hand on your chin, but you know, the point is you go, oh, that's okay, I'll consider that. They go on to say, quote, this does not imply a casual relationship. Okay. In other words, that we can't say that one, one plus this gives you that it's not a causation relationship. Right? So it's not looking for causation and they go on. And it should not be used to alter current clinical management or guidelines regarding delivery at 39 weeks. End quote. So just thoughts. Just. Just food for thought. So if you're saying, wait a minute, it's retrospective, it's single center, it's hypothesis generating, it doesn't prove a casual relationship, meaning causation. So why did you publish this? Because it's okay to not offer a patient induction at 39 weeks because the arrived trial said so. The arrive trial never said that. It just said just something to consider that it did lower rates of C section. It did in fact lower rates of gestational hypertension and preeclampsia at the expense of longer lengths of stay. Okay.
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Eczema is unpredictable. But you can flare less with ebglis, a once monthly treatment for moderate to severe eczema after an initial four month or longer dosing phase. About 4 in 10 people taking EBGLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing.
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Ebglus Lebrekizumab LBKZ, a 250mg injection, is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis, that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies. Eglis can be used with or without topical corticosteroids. Don't use if you are allergic to ebglis. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EBGLIS. Before starting EBGLIS. Tell your doctor if. If you have a parasitic infection.
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Ask your doctor about EBGLIS and visit or call 1-800-LILYRX or 1-800-545-5979.
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That's all. So it is all right if the schedule is full and you can't get your low risk. No long gravitation schedule for a 39 week induction. Relax. There may be some advantages here. And let me show you what these according to this retrospective study seem to be. So they looked for women who delivered. Again, we're talking about low risk nullah pairs women. No motives. Okay. And no twins, by the way. This was singleton fetuses. So low risk nullah pairs, singleton phoenix. They all had to be Vertex presentation. So head down. We're not talking about breaches. Who delivered between 1991 and 2021? Yo, 30 year span. All right, That's a lot of chart review. I mean, good God, man. I mean, I've done chart reviews. We're doing one retrospective study right now with folks in our emergency department. We're doing three years, homie. Like, that's all I'm doing. Okay, this is 1991 to 2021, 30 years. Okay, so all deliveries, regardless of whether they were induced or spontaneous. They said if you're a low risk nulla gravid with a singleton fetus and a vertex presentation and you delivered at full term, meaning 39 and 0 up to 40 and 6. Let's see what happened. And then of course, they did multi variable regression to look for some outcomes here. And what they wanted to see is did it matter when you delivered in that full term bucket for six major morbidity categories? Right. Was there some changes in respiratory, cardiac, neurological, infectious, endocrine or malignant changes? Right, those were the six. Let's say it again. Respiratory, cardiac, so heart and lungs. Neurological, infectious, endocrine and malignant. Were there any changes to that following these kiddos up until age 18? Okay, now remember, it's not prospective retrospective. In all, they had about 30,000 deliveries. And of those, they looked at those, those buckets between full term if you delivered earlier in the bucket or late. So let me just give you the results here because it just food for thought. Quote. A statistically significant association was observed between gestational age at delivery and long term infectious morbidity. So remember, one of the six morbidities was being hospitalized for some kind of serious infectious issue. Remember that embryological premise or that theory that even though you're full term, 39 and 0 is different than 40 and 6 because there's, there's still some immune response issues that are still cooking in the pie and in the child until later on full term. Right. So in this study, they found a statistically significant association with infectious morbidity. In other words, those babies who were delivered at 40 to 41 weeks had a lower observed incidence of infectious morbidity compared with Those delivered at 39 weeks. And this association yo consistent across the entire follow up period through age 18. What? So again, if a patient says, I'm supposed to be induced at 39 and you go, Honey, your cervix is zero and hard as a rock, I don't think anything's going to happen. And let me tell you about this retrospective study that found it may be best maybe if we just kind of let you hang out, let you simmer, simmer in your endocrine status until your cervix starts to do something, to maybe let's say 40 up to 40 and 6. And I agree we should really try to get out before late term, but maybe give your service a little bit more time to do something. Because according to this retrospective study, even though it doesn't prove causation, there was a significantly reduced finding of infectious morbidity when those babies were delivered at 40 to 41 weeks. What? Now hold on. Because the infectious was one of the buckets that was, it showed a positive association. The other bucket that showed a positive association was respiratory morbidity, quote. While lower rates of respiratory morbidity were Observed in the 40 to 41 week group up to age 5, this difference was no longer apparent by age 18. So the two things out of the six different morbidities that they looked at, the ones that kind of stood out as maybe there's an advantage to weight is lower risk of infectious morbidity. Again, that goes still into the innate immunity theory and overall infectious morbidity. Although the respiratory morbidity was only significant up to age five. And in terms of the other four major morbidity buckets, no, there was no significant difference between those in terms of long term morbidities for cardiac, neurological, endocrine or malignant morbidities. So at least for these two things, acute respiratory issues, respiratory morbidity and infectious morbidity may be an advantage to waiting towards the later half of the full term bucket. Everyone, now that we've covered that, and I read that exactly right as it was in the publication, we should all be asking ourselves what kind of admissions were those for those infectious and respiratory issues? I mean, what, what was that? Well, we don't have that information because this is published as a research letter. Research letters in grade journal are very directed, they're very short. I mean this thing's like three pages long. So the advantage of that is it's very short and you get right to the point. The disadvantage is we don't have that information. So remember this was retrospective using ICD9 codes and they used 9 because it went all the way back before ICD10 to look at big data mining topics. Right? So those were the six domains and those were the two that popped out. But that's all we know. So that is a big limitation here of this study. Is that interesting or what? So this marries guys with the January 2025 Clinical Practice Update that says we currently don't know the best time to deliver. Is it 39 and 0? Is it 46? This adds to that. Even though it's just hypothesis generated and isn't meant to change any practice plans, it at least gives us some idea that maybe waiting until the little bit later half of full term potentially could be advantageous for the child in terms of full immunity development. Surprising, right? I mean, it really is surprising. So if we get away from thinking about 39 and 0 as the absolute sweet spot, which was never what the ARAV trial was trying to say was actually between 39 and 0 and 39 and 4, it just says if you can still deliver in that slice of the pie before the risk of oligo and placental senescence and stilber starts to rise, which it does start to rise at 41 weeks and above, then potentially we get some better maturation of the entire fetus and its systems, not just the lungs, meaning innate immunity, then potentially there's some advantage there. Now, if the patient is four centimeters and kind of hanging out and she's 39 and 0 with good dates, you know, why not, I mean, give it a try. It's going to go. The cervix is at least doing something and has a higher bishop score than somebody who is a rock hard cerVix. It's like 12 centimeters long. I mean, you know what I'm saying? It's not really 12 centimeters long. I mean it's super long, it's posterior and it's hard as a rock. And it is green as a green vegetable to go. Yeah, let's get you in labor and delivery, honey. You're gonna have that child in four hours. That's a lie. It's just not realistic. And so rather than having a prolonged stay in labor and delivery that taxes the hospital system and taxes the patient and her physiology, just something to consider. Talk amongst yourselves, discuss this with a cup of coffee and use this potentially as a journal club. Why not? Article in press, June 26, 2026 has not officially come out yet in the Gray Journal. The title is Gestational Age at Full Term Delivery and Long Term Offering Morbidity and Low Risk Pregnancies. A population based cohort study, even though it's just thought provoking, hypothesis generating and isn't meant to change current clinical practice, and it does give us something to consider. Podcast family, as always, we're super thankful for you. We're glad you're part of our podcast community. And now that. We've done all that. Michael, you know what to do. Come on, let's take it home. This is Dr. Chapma's obgyn no spin podcast, Sam.