Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: OB Cough Induced Rib Fracture? YEP. It’s a Thing.
Date: February 2, 2026
Host: Dr. Chapa

Overview

This engaging episode of Dr. Chapa’s “OBGYN Clinical Pearls” explores an unusual, but clinically relevant, phenomenon: cough-induced rib fractures during pregnancy. Using a real case from his practice, Dr. Chapa delves into the mechanisms, diagnostic challenges, and management strategies for this rare occurrence. Through evidence-based discussion, Dr. Chapa emphasizes the value of considering rare “zebras” in clinical practice—while also reinforcing the importance of careful diagnosis, patient safety, and thoroughness.

Key Discussion Points & Insights

1. “Horses vs. Zebras”: Thinking Beyond the Common Diagnoses

• Quote (00:09): “When you hear horse hooves, think of horses, not zebras... but sometimes when you hear horse hooves, they're not horses. It's actually a zebra.” – Dr. Chapa
  • Dr. Chapa opens with the well-known medical adage, encouraging clinicians to stay open-minded for rare but possible diagnoses, especially when standard presentations don’t fit.

2. Case Presentation: The Unusual Rib Fracture (01:00 – 04:00)

• Case Details:
  • Healthy, multigravida woman at 34 weeks gestation.
  • Developed sudden, sharp left chest pain after coughing during her lunch break.
  • No trauma, no bruising, no history suggestive of abuse, nor other risk factors.
• Initial Diagnostics:
  • X-ray negative; clinical suspicion remained high.
  • On further review and CT imaging, a small non-displaced rib fracture was found.
• Quote (01:34): “She went out from work... and she coughed and. Oh, immediately... stabbing pain on her left side of her chest.”
• Quote (03:05): “The initial X Ray was read out as negative... So we got a further scan, and the CT scan very clearly saw the fracture.”

3. Mechanisms and Predisposing Factors (06:47 – 09:50)

• Physical Changes in Pregnancy:
  • Third trimester anatomical shifts increase pressure and alter rib cage mechanics.
  • Ligamentous relaxation and changes in abdominal wall dynamics make ribs more vulnerable.
• Literature Review:
  • Case reports date back to 1979 and 1998 documenting cough-induced rib fractures in pregnancy.
  • Largest review cited 35 cases, most in third trimester, with ribs 8-11 being most affected.
• Quote (07:44): “Just based on the exact same transmission of force at the right time. Specifically, the small ribs, AKA the floating ribs, are more prone to injury, especially with their little distal tips.”

4. Differential Diagnosis and Safety Considerations (09:50 – 12:50)

• Rule Out Trauma & Abuse:
  • Importance of checking for bruising, injury mechanism, and abuse.
  • Need to differentiate from metastasis or pathological fractures.
• Bone Remodeling in Pregnancy:
  • Increased bone resorption as a physiological response; bone formation decreases.
  • Bone turnover markers unreliable during pregnancy.
• Quote (11:38): “Pregnancy itself... causes bone resorption in the woman. Now, I know that sounds scary, but we've known this for about, oh, over 20 years... Bone resorption markers are not representative of what's actually going on in the body because they are totally thrown off in pregnancy.”

5. Calcium, Vitamin D, and Bone Health Perspective (12:50 – 15:15)

• Supplementation:
  • Especially important in teens or women with low sun exposure or low weight-bearing activity.
  • Vitamin D deficiency common; reasonable to screen, but guidelines are variable.
• Breastfeeding Considerations:
  • Recommends continued calcium and vitamin D intake postpartum, especially if breastfeeding.
• Quote (14:22): “Especially if they're going to breastfeed, they should take extra vitamin D and calcium along with weight bearing exercise to help protect their bone.”

6. Management Strategies (15:15 – 17:30)

• Conservative Treatment:
  • Non-displaced fractures: focus on multimodal pain control (acetaminophen preferred, NSAIDs limited to before 28 weeks).
  • Encourage pulmonary hygiene to avoid complications (e.g., incentive spirometry to prevent atelectasis).
• Quote (15:55): “As long as it's not displaced, ... the first line for a non displaced rib fracture is as it is for anybody... it's multimodal pain control with limitation of course on opioids.”
• Key Management Takeaways:
  • No need for bone turnover markers.
  • Conservative care is mainstay unless complications arise.

7. Memorable Moments & Clinical Pearls

• Recurrent Mantra (00:36, 03:02, 03:52, 18:32): “One rib. One rib.” – Dr. Chapa
  • Used throughout as a catchy refrain highlighting the case’s oddity.
• Clinical Pearl:
  • Stay cautious about discarding unusual presentations just because they seem rare—occasionally, they really are “zebras.”
• Quote (18:35): “Sometimes things that we hear are... bizarre and that they truly are zebras. So just because somebody has never heard of it doesn't mean it doesn't exist.”

Important Timestamps

| Timestamp | Segment Description | |-------------|-----------------------------------------------------| | 00:09 | “Horses, Not Zebras” adage, opening remarks | | 01:00 – 04:00 | Case presentation and diagnostic journey | | 06:47 – 09:50 | Mechanisms, literature history, and evidence | | 09:50 – 12:50 | Differential diagnosis and bone health in pregnancy| | 12:50 – 14:22 | Calcium, Vitamin D, and clinical guidance | | 15:15 – 17:30 | Management, conservative care, follow-up advice | | 18:32 – 18:35 | Closing clinical pearl: sometimes it is a zebra |

Takeaway

Dr. Chapa highlights the importance of not dismissing rare diagnoses, even in routine clinical scenarios. Cough-induced rib fractures in pregnancy, though rare, are documented and should be considered in the right clinical context. Detailed evaluation, judicious use of imaging, a solid understanding of physiologic changes in pregnancy, and a conservative, safety-first management approach are key. And above all: “When you hear horse hooves… sometimes, it really is a zebra.”