BOGO! (With Hanna, PGY1)

Summary

Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode Title: BOGO! (With Hanna, PGY1)
Guest: Hanna, PGY1 Resident
Date: May 12, 2026

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Episode Overview

This episode of "Dr. Chapa’s OBGYN Clinical Pearls" features a lively, on-the-fly discussion between Dr. Chapa and Hanna, a first-year OB/GYN resident who is also pregnant and on call. The episode, described as a "BOGO" (buy one, get one free) special, tackles two practical clinical questions encountered during recent rounds:

1. Should magnesium sulfate (Mag) be administered in normotensive HELLP syndrome patients?
2. Do patients with iatrogenic bladder injury and Foley catheter after cesarean section require prophylactic antibiotics?

The conversation is evidence-based, clinically focused, and peppered with personal anecdotes and humor to keep medical education engaging.

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Key Discussion Points & Insights

1. Magnesium Sulfate in Normotensive HELLP Syndrome

[02:15 - 11:00]

• Recap of HELLP Acronym:
  • Hemolysis
  • Elevated Liver Enzymes
  • Low Platelets
• Clinical Scenario:
  • Patient with laboratory signs of HELLP but normal blood pressure; the team debates Mag administration.
• Expert Clarification:
  • Dr. Chapa emphasizes that even normotensive patients with HELLP are at seizure risk due to underlying vasculopathy. Therefore, Mag is indicated.
  • Historical note: Previously called "atypical preeclampsia" or "atypical HELLP."
• Mississippi Classification:
  • Three classes based on platelet count:
    • Class 1: <50,000
    • Class 2: 50,000–100,000
    • Class 3: 100,000–150,000
  • Criticism: Focus on lab values, but all forms are severe.
• Mississippi Protocol:
  • Advocates for Mag, blood pressure control, and corticosteroids (particularly high-dose dexamethasone [Dex]).
• Controversy on Steroid Use:
  • While Dex improves lab values (platelet count, liver function), it does not decrease morbidity or mortality. There's risk of masking the severity.
  • Quote (Dr. Chapa, 10:06):

    "You can get a false sense of security. It's very similar to intrahepatic cholestasis... you can fix the numbers, but the overall condition, the overall risk, does not change."

  • ACOG and SMFM: Steroid use is controversial; if used, clinicians should be aware it doesn’t eliminate risk.
• Clear Take Home:
  • Mag should be given to HELLP patients regardless of blood pressure, as they remain at risk for seizures.

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2. Prophylactic Antibiotics After Iatrogenic Bladder Injury & Foley Placement

[11:00 - 14:28]

• Clinical Scenario:
  • Patient sustained bladder muscularis injury during a C-section (due to adhesions) but the Foley bulb remained in the mucosa.
  • The patient required minimum seven days of Foley drainage.
  • Team questioned whether prophylactic antibiotics are necessary during the catheter period.
• Guideline Review:
  • ACOG, IDSA (Infectious Diseases Society of America), and AUA (American Urological Association) all suggest that prophylactic antibiotics are generally not indicated solely for an indwelling Foley after surgical injury.
  • Only administer antibiotics if infection symptoms develop.
  • Quote (Dr. Chapa, 13:06):

    "Prophylactic antibiotics is just not needed now... even the AUA says we just don't have clear data that there's a huge benefit for this, at the risk of increasing microbial resistance."

• Foley Duration & Considerations:
  • Minimum 7 days, some sources suggest up to 14, but 7 is the standard.
  • Optional: Post-removal cystogram to check for leaks (controversial).
• Clinical Plan:
  • No prophylactic antibiotics; outpatient Foley with follow-up at seven days.
• Resident Reflection (Hanna):
  • Quote (Hanna, 14:28):

    "So interesting. Love it."

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Notable Quotes & Memorable Moments

• Hanna on Intern Life and Pregnancy:
  • [01:59]

    "I feel great, thank you."

• Dr. Chapa on Pregnant Residents’ Dedication:
  • [05:23]

    "I forgot I was pregnant."

  • [05:44]

    "Even our interns that are pregnant can jump up and click their heels. I said never do that again."

• Clinical Pearls on HELLP:
  • [07:44]

    "Even though their pressures may be fine, they may have that vasculopathy in the brain which causes neuronal instability. So they are still absolutely at risk for seizures."

• Quick Clinical Takeaways:
  • Magnesium for all forms of HELLP.
  • Avoid unnecessary antibiotics in patients with indwelling Foley after bladder injury.

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Important Timestamps

• [02:15] – Introduction of HELLP case and initial mag question
• [03:47] – Bladder injury case setup and antibiotic question
• [07:44] – Clarification: Mag for normotensive HELLP
• [08:49] – Mississippi classification of HELLP
• [09:40] – Discussion of corticosteroids, Mag, and BP control
• [10:06] – Controversy around Dex and masking severity
• [11:00] – Transition to iatrogenic bladder injury discussion
• [13:06] – Summary answer: No routine antibiotics needed
• [14:28] – Final reflections and podcast wrap-up

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Tone & Language

The tone is energetic, conversational, and focused on practical "pearls" for learners and clinicians. Dr. Chapa keeps things light and relatable, while Hanna adds the perspective of a hardworking first-year resident. Jokes about BOGO sales and lighthearted banter underline the episode’s commitment to making medical education fun and memorable.

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Summary Table

| Issue | Clinical Question | Key Takeaway | |--------------------------------------|------------------------------------------|------------------------------------------------------------------------| | Normotensive HELLP Syndrome | Is Mag indicated? | Yes, always give Mag regardless of BP | | Iatrogenic Bladder Injury w/ Foley | Use prophylactic antibiotics? | No, unless infection symptoms arise |

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Conclusion

This "BOGO" episode delivers concise, evidence-based answers to common yet challenging clinical scenarios—perfect for busy learners and practicing providers. In summary: normotensive HELLP patients should get magnesium sulfate, and prophylactic antibiotics are not required for patients with an indwelling Foley after bladder injury unless signs of infection develop. The episode closes with thanks to listeners and a shout-out to the dedication of resident physicians everywhere.

Transcript

[A]

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[B]

Podcast. Family. As we have always said, some of the ideas for the show come out of real clinical situations. From round something we saw in clinic. Somebody asked a weird question. I'm like, oh, we should do that. So of course I'm gonna bump whatever it was we were gonna do just last night. We did the Hunter virus, which is all over the media and it should be. It's a big deal. But in this episode, we're gonna call this a bogo. Buy one room of flooring and get another room free.

[C]

Buy one, get one half off everything.

[B]

That is buy one, get one free. Which is actually great because you're not paying anything for it. So it's an extra freebie. So this is our BOGO episode and I've got a special guest because it's always fun when you talk to somebody. So I wanna introduce you to one of our great PGY ones. I mean, thank you. Stellar. And I'll get into a special situation with her in just a minute. But first, this is Hannah. Hi. So, Hannah, it's hard for anybody to take call. It's hard for anybody to be an intern, but it's even harder. So I want you all to hear me before we get into our BOGO episode when we all complain, especially the dudes. So, guys, it's hard. I get it. Everyone has it hard. Being an intern kind of sucks, but it's even tougher when you're an intern who's pregnant. I mean, it's just tough. So, Hannah, I gotta tell you, you do a great job. Congrats for just always having enthusiasm. You're in the game and pregnant. You feel okay?

[C]

I feel great, thank you.

[B]

So what we're gonna do is a couple of things, and that's in this episode. I'm gonna tackle two things that really came up during rounds. The first has to do with help, because we have a patient with help. And Hannah, what does help stand for?

[C]

Hemolysis, elevated liver enzymes, and low platelets.

[B]

So we've talked about this and we actually have an episode in the past called Fear the Help. Help is bad. I mean, we should really fear help. It's an odd issue, but here's what the conundrum was when I had checkout just this morning. We switched over around 7am so I'm gonna set this up, and then I'm gonna give you our second issue that we're gonna talk about. Remember, Bogo, buy one room of flooring and get another room free.

[C]

Buy one, get one half off everything.

[B]

Buy one, get one free. So we're gonna talk about the first issue with help. Then we'll talk about the other one, which is the real deal at C section. But there was a specific question that came up with help, and it had to do with magnesium. Hannah, tell me about this.

[C]

We had this patient this morning who had the low platelets. She had the elevated liver enzymes. However, her blood pressures had been low overnight. And so we were questioning whether to start it or not.

[B]

Okay, do you all get this? Right? So Mag as a peripheral vasodilator. The question is, if we give her mag and she's totally normal, like not even borderline, is that even needed? So that's a good question we're gonna tackle. Is Mag always needed with normotensive? That's the catch, guys. Normotensive help. Hannah's gonna get into that in just a minute after the break. And then we're gonna talk about this whole issue of iatrogenic bladder injury. It happens at C section, especially when there's a lot of adhesion. You gotta get that bladder down. Hannah just set up that case for us. What happened? And we have a real patient with this, of course, protecting hipaa, but what's the question that we had the. That we're gonna get into right after our intro?

[C]

Yes. So this patient had a bladder injury during section. They were lysing adhesions, as you have to do to get the baby out sometimes. And they cut through the muscularis layer all the way down to the mucosa, the epithelium. And she had to have a Foley in. And so we were wondering if we should give prophylactic antibiotics for the duration of the Foley.

[B]

Y' all see how real world that is? So that's a question, right? Because we do need standard is kind of let the bladder heal, take the tension off the wall. So you let that bladder drain. And I'm not talking about deserosalization. I mean, this was kind of a, you know, almost a through and through. Just the inner layer of the. Of the epithelium there of the mucosa was intact. So this was a violation of the bladder muscularis. So everybody gets that. It's not Questioned about bladder drainage. The question was, what is the current guidance from idsa, from the aua, from ACOG regarding the use of prophylactic antibiotics? After all, Han, I mean, this patient just delivered. We don't want her to get, you know, you know, Pilo, for heaven's sakes, that'd be one additional problem in her post op care. So that's where we're gonna be going. We're gonna cover these two issues. One is mag in the normal tense of help. And then the second is, what do we do with antibiotics in the indwelling Foley patient because of iatrogenic bladder energy? What do you think, Hannah?

[C]

I think that's a great idea.

[B]

Now, as one thing, as Hannah, as we all get busy and we all forget that you know where we are and we lose ourselves a little bit. The residents were kind of having fun today, and one of our senior residents kind of jumped up and clicked his heels like, ha, it's a brand new week. And Hannah, in all of her pregnancy, totally jumped, clicked her heels and then said, what?

[C]

I don't even remember.

[B]

I forgot I was pregnant. Oh, yeah, don't you hate ladies when you forget you're pregnant? I mean, that's when you're so much in the game. So that's the kind of dedication. Yes. Even our interns that are pregnant can jump up and click their heels. I said never do that again. All right, podcast family, we're gonna do this as Bogo. Buy one room of flooring and get another room free.

[C]

Buy one, get one half off everything.

[B]

We're gonna cover two things coming up next. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN. No spin.

[A]

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[D]

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[A]

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[B]

All right everybody. So me and Hannah are back and we're going to start off with the whole issue on mag. In the normotensive help patient. Remember help just by labs. Hemolysis, which is either low haptoglobin increase in LDH traditionally greater than what, Hannah?

[C]

600.

[B]

That is correct. Greater than 600. Elevated liver enzymes without other pathology and then low platelet. So that's constellation of issues just by lab boom. Your help even if you're normal. I learned that Hannah, back in the day that was called atypical preeclampsia or atypical help because you were normotensive. But it happens. So Hannah, let me ask you this. In these patients who have atypical help or atypical preeclampsia because they have this lab manifestation but they're no motensive, do we give them mag?

[C]

Yes, sir.

[B]

Yeah. And the issue is, is that even though their pressures may be fine, they may have that vasculopathy in the brain which causes neuronal instability. So they are still. Absolutely. So here's the take home guys at risk for seizures. And this morning after we took over, y', all, look how things work. She's reading the help textbook. What does this patient do in terms of her blood pressure? Hannah?

[C]

She threw two elevated pressures.

[B]

You see guys, so even though they start as normotensive, something is happening. Fear the help. So absolutely they did get a little bit of hypertension even though they weren't severe. 140's over 90s. Absolutely. Got started on mag. But people have trying to figure out help for a while. We've got several episodes on it. But Back in the 90s, University of Mississippi had a classification scheme called the Mississippi criteria. But it took a lot of heat because they're like, well, what do we do with that? You're calling something that's already bad, like not as bad and then super bad. It's just bad, period. But. But, Hannah, tell me a little bit about the Mississippi classification system that's been around since the 90s.

[C]

Yeah. So they broke it down into three classes. Class one being most severe platelets under 50,000. Class two was kind of intermediate, moderate, it was 50,000 to 100,000. And then they decided class three was 100,000 to 150. And this was the least severe.

[B]

Yeah, but nonetheless, they were all bad. So the Mississippi criteria was just based on. On the platelet nitre as a big reflection, of course, of microangiopathic disease. But this had to be remembered. It's not just about a platelets. They already had to show signs of hemolysis. They needed an elevated ldh, so they had to meet the criteria. But this issue took a lot of heat because of one main issue that they wanted to give patients and still do the center of the mag treatment for help, according to Mississippi is mag, blood pressure control. And what, Hannah?

[C]

Corticosteroids.

[B]

That's it. So they gave these patients high dose Dex. That's the triad of the Mississippi protocol for help. Steroids, blood pressure control. That makes sense. And mag. That makes sense. But the issue with Dex, there was something controversial with this. Even the Cochrane review said, well, hold on here, you got to punch your brakes a little bit on Dex. And what's the controversy, Hannah?

[C]

It kind of masks the syndrome is what I understand that you were talking about this morning.

[B]

Yeah, a little bit. In terms of. Well, you can change your numbers. Dex without a question will help with platelet increase, it will help with hepatic injury resolution. Your numbers get better. However. Here's the catch, guys. It does nothing to reduce the overall morbidity and potentially mortality of the condition. So you can get a false sense of security. It's very similar to intrahepatic cholestasis. Why is that handy? Tell me the similarity between those two.

[C]

Yeah, so if you medicate people who have ihcp, it can kind of again, mask what's going on in their body. They're still having these bile acids internally that can affect the conduction system, but you're seeing lower numbers, and so it can kind of skew.

[B]

Yeah, that's exactly right, guys. And again, not saying that you shouldn't use ursodiol with intrahepatic cholestasis. That's for symptom control. But it can give you a false sense of security. Like, oh, your bile acids were 50, now they're back down under 10. I have fixed you, but you haven't you never take that card away. They are always a cholestatic patient. So it can give a false sense of security. Same thing with Dex. You can fix the numbers, but the overall condition, the overall risk of perinatal death, the overall risk of maternal morbidity and even mortality does not change. So that's why ACOG says, you know, steroids for help. A little controversial. Even SMFM says you can do it, but know why you're doing it. If you want to try to do it to fix platelets, fine, but it doesn't take the patient out of harm's way. So once again, we've covered very quickly, University of Mississippi and their kind of their protocol for help syndrome, whether it's hypertensive or not, which is corticosteroids, mag and systolic blood pressure. But we've answered the main question, which was do we give normotensive help patients mag in and the answer, Hannah, is yes, absolutely, because it is still part intimately related to preeclampsia with severe features. Okay, we're doing this super fast because we are literally on call and we've got patients cooking. But our senior resident is doing his job. We hope so. He's a great guy. So anyway, we just snuck away for a little bit because this was so good. We wanted to get this out. The whole issue of iatrogenic bladder injury. And don't you all be there like, oh, I've never done that. Then you're not operating. Because we operate a lot and it happens. This poor patient had a previous delivery that was a classical section. Horrible outcome because it was just around, you know, 23 weeks. Heartbreaking. But there was a lot of post surgical adhesions where the bladder dome was tacked up high and there was no way around it. It was a roadblock in the middle of the road. Had to get through the road to get the child out. So they went through accidentally, the bladder dome through the muscularis, but the Foley bulb remained within the mucosa. So almost a through and through. The patient, by convention, is going to get a seven day minimum Foley drainage. But the question is, do these patients need prophylactic antibiotics? Hannah, after we reviewed this in the morning, what's the take home message from that?

[C]

No, it's not always required.

[B]

Yeah, absolutely. Even though, you know, it's a foreign body and there's no question they're at risk for infection. Both acog, the adsa, that's the Infectious Disease Society of America and even the aua, they're like, you probably don't need it now. If they develop symptoms, that's different. But prophylactic antibiotics is just not needed now. How many days minimum, Hannah, do you think we should do this?

[C]

About seven days?

[B]

Yes, for sure. And some say seven, some say 10, some say 14, but the minimum is seven. Some also say we should do a voiding cystogram to look for any leak at the end. That's, you know, controversial as well. But the whole take home is, even the AUA says we just don't have clear summary data, that there's a huge benefit for this at the risk of increasing microbial resistance. So, Hannah, are we, are we not going to give her antibiotics?

[C]

We are not.

[B]

We are not. So she's going to go home with her Foley. She's already aware of this. We'll give her a little leg bad so it's not as intrusive and then we will see her back once she is discharged for seven days to see if we will continue there or take it out at that time. But no, the take home answer is we do not do prophylactic antibiotics with an indwelling Foley just because of surgical injury to the bladder. Hannah, how about that for fast?

[C]

So interesting. Love it.

[B]

And now we got to get back to our call. But guys, again on the fly. This was not what we were supposed to do, but these two things again from today's case list. Normal intensive help and the use of mag and use of antibiotics with an indwelling Foley. I just thought, man. Super good. So on your drive to work or home, Hannah will be your companion. All right, podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Hannah, last word.

[C]

Thanks for having me.

[B]

All right, everyone, we'll see you on the next episode of the no Spin podcast. This is Dr. Chapma's obgyn no no spin podcast.