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Foreign. Most of us have seen the film Wally. Parts of the film portray obese humans. In the future, relying on robots. While relying on robots could be the case one day, the obese part seems to be coming true. A According to a recent study from the Lancet Medical Journal, nearly 3/4 of U.S. adults are obese. Nearly 3/4 of US adults are obese. That is astounding. And is getting worse. And you know, there's a variety of reasons for that, and we're not going to get into those reasons, but we are going to focus on this overweight slash obesity issue because it affects healthcare, it affects your overall wellness, even mental health. Now, I have to be careful here because I love me some fat food also. So I have to be very, very cognizant of what I'm eating to maintain appropriate weight. I try to be within my appropriate bmi. Thankfully I am, but, you know, I have to be aware of that. I have to work and burn things off and it's difficult. I get that. But being obese affects things that we do, even in labor and delivery. Now, we know, of course, that obesity is hard. Patients are living with obesity. Sorry, that's me. Politically and technically correct. Patients living with obesity makes monitoring hard. Patients living with obesity have longer labors, they have higher perinatal morbidity. We understand this. But as it relates to labor and delivery, here's the question that a new sub analysis of an old study was trying to answer, since we're getting bigger. Okay. In the US Specifically, we've got a lot of listeners in Canada, so I know you're. The population is different, but even there, BMIs have been creeping up as well. And we've got listeners in the uk same issue. All right, but in the US how does obesity affect our labor induction, specifically cervical ripening? Okay, now this is something that was recently released in ajog and it hasn't even officially come out yet. It came out ahead of print on March 4, 2026. All right, so on March 4, 2026, we have this new sub analysis of a previous study released in the same journal AJOG, back in 2019 that was called the IMPROVE study. That IMPROVED study was really deep and it even made its way. The findings made its way into ACOG's 2025 guideline on cervical ripening and induction. Okay. And we're going to touch on all of that in the break. But here's a question, and here's where we get into here. Does BMI affect vaginal misoprostol cytotec Cervical ripening. Now, notice I'm focusing on the vaginal. Even though this new publication, which isn't even officially out yet again, it came out ahead of print on March 4, 2026, compared two different routes. It compared vaginal, which most people dig. Okay, I'm good with that. Whether they do 25 or 50 micrograms. Okay, fine. And buccal. Oral buccal means you kind of put it in your pouch like a little Zen pack or tobacco, which we shouldn't do either of those. But nonetheless, the point is buccally, so it gets kind of quick plasma absorption, quite a quick peek in. Into the. Into the bloodstream. Okay, now here's a catch. I got to say this right here in the intro. Even though this new sub analysis, which just came out and is a sub analysis of a previous trial called the Improve trial back in 2019, even though it uses buccal form, ACOG does not endorse the buccal formulation for cervical ripening. Okay. It says, hey, if you want to do oral, perfect. If you want to do vaginal, knock yourself out. But buccal. And we're going to get into this after the intro. It does not include buccal dosing because of safety concerns. We don't have good data. And. And they quote the exact study that we're about to talk about in their 2025, summer of 2025, guidance on cervical ripening. Okay. We're gonna. We're gonna review all of this very quickly, and then we're just very quickly gonna dive into the results of this sub analysis of the Improve trial. The Improve trial was out of Indianapolis. Very well done. We'll remind ourselves of what that was just briefly, and then we'll dive into this brand new AJOG publication. Here's a question. Here's the question I'm trying to set up. Even though it talks about buccal, and we don't really do that, so we'll just kind of, you know, realize and recognize those results. Tip our hat to that. How do you do? We'll tip our hat to that. But we really want to do is figure out the vaginal part, because that's what people mainly do in the US Vaginal cytotechemisoprostol for cervical ripening. Does obesity matter? We're gonna take more doses because she's obese. Do we need higher doses? This is a good question to ask as obesity ris in the US So that's where we're going. Does BMI affect vaginal misoprostal cervical ripening. This is a sub analysis of the improved study from the Gray Journal. We'll be right back. This is Dr. Chapa's ob gyn no spin podcast. Is she a great big fat person? Oh, that quote by Buffalo Bill in Silence of the Lambs would get the whole show canceled today. Yes, Buffalo Bill is not the most PC person around. Was she a great big fat person? Oh, my goodness. It puts the lotion in the basket. All right, so all to say is. And again, that's not mean mean or anything. It's just I. I don't know why producer Michaels thought Silence of the Lambs, which is kind of disturbing. I think maybe needs counseling. Nonetheless, let's get back to what we're talking about before we get canceled. They've tried that before. All right, so let's get back to what we're talking about. Oh, my goodness. We're talking about obesity or people living with obesity and how it affects labor induction. Now, this new study that is released ahead of print in the Gray Journal specifically was looking at buccal, which is not an ACOG endorsed method. I'll tell you why in a bit versus vaginal. However, ACOG does endorse another route of misoprosto use which is oral. Okay, so we've got two ways of misoprosto use according to the college for cervical ripeninglabor induction in termination. Singleton intact membrane patients. All right, so you gotta remember that term singleton intact membrane patients. And it says that in this new clinical guidance from the summer of 2025 by the college. This is for intact. And I've got an episode on how the Bishop score doesn't apply if you are ruptured even with pprom. Okay, so if you know nothing wrong with doing a BISHOP score, you can do that, but you don't really need to do any cervical ripening if the patient is already ruptured. You can go straigh to Pitocin regardless of BISHOP score because the data says so. Now you can give a cervical ripening agent for those who are ruptured. It's just probably unnecessary. There's no real advantage there because they already are bathed, so to speak, in terms of their cervical milieu with prostaglandins because they're ruptured. All right, so this new clinical guidance that just came out in the summer of 2025 from the college reminds us that term singleton intact membranes. You can use either pharmacological with oral or vaginal misoprost, or mechanical, or a combination of the Two which is either a cervical balloon with either misoprostol or a cervical balloon with oxytocin. Right now there's very scant data and ACOG does not recommend the balloon with dinoprostone. The insert under the combined methods that's recommended for use by the college. It's either the balloon with pit or the balloon with cytotec. Okay. All to say is that ACOG in its again new guidance From July of 2025 does not include buccal or buccal, depending on where you are in the country. Right? Some say buccal, some say buccal. All to say is obesity. Absolutely. Let me spoil it here. Absolutely affects anything systemic because of volume of distribution. That should be a no brainer. We understand this. Right? So I'm going to give you the data here in a minute. So anytime you have to go through the system to get to the uterus, you're going to get behind if there's a larger bmi. So spoiler alert in this sub analysis of the improved study which was in the grade journal in 2019. I'll touch on that in a minute. Yes, larger BMIs obviously took more doses to ripen. They had longer inductions, they needed more pitocin because it was a systemic medication compared to vaginal. So vaginal is the way to go. However. However, even though buccal or buccal isn't really endorsed by the college, it has implications for oral medication because oral cytotec follows the same pattern of distribution as buccal. Okay. In general, so higher BMIs, even though this study, I want to be very clear, did not include oral, it was in the cheek or vaginal. But oral follows the same dynamics. Okay, so oral dosing is definitely affected by bmi, with higher maternal BMI correlating with prolonged labor inductions with those with oral medication. Now this has been looked at oral combined versus vaginal and vaginal always wins regardless of bmi. That's why there's an advantage to first uterine or first cervical pass by placing it in the vagina. Okay, so even though this study, which is sub analysis of improved trial looked at buco versus vaginal oral medication, oral cytotec also follows prolonged dosing compared to non obese patients. Okay, so this is why when you read the ACOG guidance and says oh, I can do oral or vaginal. Yes, with a caveat that you got to take into account patient characteristics. Of course never use a prostaglandin if they have a prior section. But BMI also can limit Oral medication, just as it can for buccal medication or buccal medication. Okay, close your eyes. Exhale. Feel your body relax. And let go of whatever you're carrying today. 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So, as a quick recap, In July of 2025, ACOG's Clinical Practice Update recommended either pharmacological, mechanical, or combination methods for cerservical ripening, but it did not include buccal. And the reason it didn't include buccal was because of what we're talking about right now. The original IMPROVE study from 2019 is in this 2025 guidance from the college. Now, IMPROVE was a very detailed randomized trial, but with an N of 300. So it wasn't like thousands of patients, but n of 300 following or comparing vaginal misoprostol to buccal misoprostol. And they found that vaginal always wins. Vaginal also had lower rates of C section. Vaginal had lower rates of C section for fetal heart rate abnormalities. So because of the improved study that actually made its way into the July 2025 guidance from the college, saying, bucal, if you want to do that, hey, you're on your own. But we don't really recommend that because there's safer routes, either oral, of course, with BMI characteristics taken into account, or vaginal. Okay, so yes, the improve study is actually in the July 2025 guidance from the college. And that improve study is exactly what this new publication is based upon, because this is a sub analysis of that original study which showed that buccal didn't work. Well, vaginal worked better and it was safer. But now they're going to take a look at it based on BMI characteristics. So it is a secondary analysis of this RCT that was actually triple blinded and placebo controlled for vaginal versus buccal misoprostol. It was amazing. It was a very well done study. So kudos to those physicians and investigators in Indianapolis who put this together. Okay, let me just give you the short of it because I've kind of already told you what's going on here. Vaginal winds, okay? Vaginal winds. BMI affects things that go into the mouth either buccally or orally. And the vagina is immune because the vagina through cervical placement has a first uterine pass where BMI didn't seem to matter. Okay. Now this was roughly about 300 patients that had this secondary review and the primary outcome. Let me just it to you here and then we'll start wrapping this up because I just want to tell you again, even though we have our quickie episodes, and this is definitely not a quickie because going through a lot of data, I still want to get this done within ideally 25 to 30 minutes. Okay? So short of it is, in this new sub analysis of improve quote, obese and morbidly obese participants required more doses of buccal misoprostol to achieve active labor compared to non obese, which that shouldn't be surprising to anyone. We get that because of volume of distribution. But here's the catch quote. However, there was no difference in doses between the obese and non obese for those who had it administered vaginally phenomenal. In other words, what you place in the vagina. Vagina's like, hey, I don't care. I don't care what's going on on the outside in terms of bmi, because we're working here with an immediate neighborhood, which is the cervix and the uterus. That's why it's called the first uterine pass. Okay. You avoid the volume of distribution through bmi. So let me say that again, quote. However, there was no difference in doses necessary for active labor when administered vaginally. That's great. They go on to say, quote, Additionally, the mean time to delivery tended to be shorter in the non obese group that received buccal misoprostol compared to the obese and morbidly obese group. End quote. Again, not surprising at all. And the last thing quote, this difference was not observed in the vaginal dosing group. End quote. Short answer, vaginal wins for higher bmi. Vaginal wins now. So remember, our title here is does BMI affect vaginal miso for cervical ripening labor induction? No, it doesn't. But BMI definitely affects buccal and definitely affects oral because of volume of distribution. It's got to go all over the place just to hit the uterus and cervix. So this is a nice secondary review of improve. Kudos again to the authors that put this together to take a look at this because this is super, super real world as BMIs increase throughout throughout the country. So their tweetable statement in the draft because this isn't officially out, their tweetable statement is, quote, more doses of buccal misoprostol are required to achieve active labor in obese compared to non obese patients undergoing labor induction. No difference in number of dosages was observed for the vaginal route. End quote. So only in Women's Health can you say the vagina wins and it makes sense. I'll guess. Unless it's a weird, probably inappropriate, HR referenced joke that would get you sent to HR real quick. The vagina always wins. So consider that when you're doing cervical ripening, if you're doing oral or buccal, which is not ACOG endorsed at the moment, consider that in your decision making. Vagia, Vagia. What the hell? Vagina. Oh. Always wins and or cervical ripening with a mechanical method, either alone or with misoprosil or oxytocin. Wow, I had some kind of weird words in this one. Did you notice that? Michael, what is going on? Honestly, can. I can't tell you what I think it is. I. It's like midday right now when we're recording this. I've typically had like four cups of coffee before that because it helps me concentrate and focus. I've only had two and look how it's affecting my speech, man. I mean, I think this is a thing and it's your fault. You rushed me for I missed my cup of coffee because you were making me come here. So all to say, there you go. This is coming out soon in the Gray Journal. The title is the impact of Body Mass index on Misoprostol Dosing for Labor Induction. A Comparison of Vaginal and Buccal Dosage forms. Podcast family, we care for you. We're glad you're part of our podcast community. And now that we've done all that, I'm going to get my next cup of coffee and we're gonna take it home. This is Dr. Chapma's obgyn no spin podcast.