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Dr. Chapa’s OBGYN Clinical Pearls
TWOFER! (Quickie #4): A. Placental Grading, B. GBS discordant Results
00:21:07
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- [00:00]
Dr. Smith
Foreign. In true form. At times we do a two for one, and this time, I guess it's a three for one. Because even though we're covering two topics, we're going to try to do this very quickly. So it's actually part of our Quickies series. I think this is quickie number four. Is that right? I think it's four. Just go with it. Yes, it's four. All right. Our quickie number four. And we're going to get to that in just a moment. But our two topics that we're going to cover are pretty interesting and they are very real world. Yep, it's a twofer. A twofer. So in this episode, we're going to cover two things. One is actually something that I trained with and we're going to ask this question, is this still a thing or. Or not? And what I trained with was an issue called placental grading. Now, this happened just the other day in clinic. We were doing. I was in ultrasound clinic and somebody said, oh, I got a patient who's 34 weeks, but I see a grade three placenta. So my first response was, oh, hell, what does that matter? The truth is, it does matter because some reports and some radiologists, some technicians may still report that. So we need to figure out what do we do with that and does that actually matter? How, what does that matter? The grading of a placenta was a big thing until a systematic review and meta analysis said otherwise. We're going to explain what would explain What a grade 0, 1, 2 and 3 placenta mean and what to do with that. The second quick thing on our Quickie episode, again, trying to be very quick here is super interesting. And just this just happened today in clinic. So a patient had an appropriately timed GBS swab. It was done at 36 weeks and it came out positive. Now, the resident forgot to ask about penicillin allergy. It's all right. Nobody's perfect. I get it. So we don't have sensitivities because this patient has penicillin allergy. Okay, so there's two things to do here. One, really go in depth. And was this a real allergy or not? Most people don't have it, yada yada. But nonetheless, we still gotta track that through. You can do penicillin desensitization, but she's already 30. Yeah, six weeks. You know, we're not going to fit her in into a desensitization clinic for that. Or third, which was not my plan, but was done anyway, was that they repeated the culture this time. Checking the box to do sensitivities. Okay, now let me. Here's a conundrum. So both done, you know, 36 weeks ish, a couple of days apart. But the first GBS culture was positive. The repeat was then negative. So here's the question. What do we do with that? And which one is right? Is the patient a GBS carrier or is she not? So we're going to do this as a twofer. A twofer? Yep, it's a twofer. And we're going to knock this out as quickly as possible. So the first one has to do with placental grading. What do we do with a grade three placenta in the preterm patients? Hell, what does that matters? It mattered enough for us to learn it as core learning of our ultrasound training when I was a resident. But we're gonna get into that in this episode. And then if you have two conflicting results, either two cultures in the index pregnancy or maybe the first one was a pcr, which is not the gold standard. The gold standard is a rectovaginal swab for culture with a PCR being left for those patients at term who show up to L and D and don't have a culture result yet. Resulted or done. You can do a point of care PCR that is at term as a secondary option, not the first line. And that's according to ACOG's committee opinion, which we'll get into so very quickly. Just wanted to set that up. That's what we're going to be talking about here in our quick twofer segment. Twofer. It is a twofer. I think I've set it up enough. We'll be right back. Podcast family. Welcome to another quickie episode of the Clinical Pearl's no Spin podcast.
- [04:33]
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Dr. Smith
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Dr. Smith
So as we get ready to do our twofer, let's start first with this whole issue of placental grading. Now, if some of you all are still in training and you're like, I've never heard of this thing, I trust me, super popular. It was a thing once. And some of you may be like, wait, what's wrong with this? We actually grade the placentas. Well, if you're doing that, you pretty much need to stop because it's very historic and a lot of things in medicine get passed down by history. And that's okay. I mean, the tradition is great, but sometimes some of the things that are traditional aren't really evidence based. So back in the day, that was the granum classification. I trained with that. Okay, okay, so granum is spelled G R A N N U M granum. That was a way to look at the placenta during ultrasound and give it a characteristic table and plot it as either grade 0, 1, 2 and 3, with 3 being quote, end quote, very mature, meaning it had well defined cotyledons with acceptations in between each, meaning they were calcified. You could see calcified nodules in it or dispersed like on a breast mammogram. You see a little stippling of calcification versus the grade zero. The immature placenta was very homogeneous, didn't have any kind of septations. You couldn't see the true little mounds, the little mountains that separated it, so to speak. And everything kind of looked like one solid snowstorm. Gray. Okay, so zero was very immature and grade three was a very mature placenta. Now, here was the thought, and there was actually some data to this. I mean, this was in the 1980s and 1990s. And no, I was not a resident at that time. How old do you think I am? Damn. But this is where it started. In the 1980s and 1990s, there was actually some data that, oh my goodness. Seen early, a grade three placenta, meaning at or under 34 weeks, implied placental senescence. Okay. Placental aging. And in theory increased the relative risk of things like iugr, which now we just called FGR or fetal distress or maternal hypertensive disorders like preeclampsia. Okay. The issue was, is that these were mainly based on retrospective studies. So they had an adverse outcome. They had to do a delivery, for example, for preeclampsia with severe features, placenta was sent off and like, oh, well, now, looking back at this ultrasound, clearly there's calcifications and whatnot, but it wasn't a placenta by itself. It was reflecting vasculopathy because of another condition like the hypertensive disorder. Okay? But in the 1980s, 1990s, there was this thought that placental grading could loosely and as an isolated marker, be linked to adverse neonatal adverse issues. Okay? However, in 2018, and guys, think about this. I mean, it died, like, in the early 2000s, but in 2018, that's not long ago. A systematic review and meta analysis was published on this, which actually surprised me when this came out, because I thought this died a long time ago. But no, there it is in 2018. And systematic review and meta analysis found that a grade three placenta did not predispose to fetal distress, low APGAR scores, or need for neonatal resuscitation or even NICU admission as an isolated standalone finding. Okay? In other words, a grade three placenta may be found with other maternal comorbidities, but in and of itself means nothing. So here's the question we're gonna get into in just a minute. What do we do with this? Do we need to do serial growths? Do we need to put the patient antepartum fetal surveillance when we see this? Or do we go, huh, that's interesting. It's an incidental finding. We're gonna note it maybe, or not note it and just go, it's irrelevant, and move on. What do we do when we see a grade three placenta in the preterm interval? And, you know, most of this is a concern at or under 34 weeks, because if you see this at 40 weeks, well, it's like, duh. I mean, that's just. That's just what the placenta does. But is an isolated grade three placenta, meaning a mature appearing ultrasonogr characteristics and markers. If that is found, is that a standalone indication of something bad? The answer is no. There is no pathological or clinical correlation between a greater placenta and neonatal outcomes. So here it is, right off the bat. There are no specific interventions or recommendations from ACOG or SMFM on what to do with a grade three placenta found preterm. Now, again, this died early 2000s, but there was, in 2018, that reassurance that we just don't have to do anything. Now, if there is a need for serial growth ultrasounds, like FGR maybe there is maternal hypertensive disorder. She has a 2 gestational diabetic. Her BMI is either too small or too large. There's plenty of reasons that could qualify for a rate of growth. And although it is completely reasonable to do that, I'm not opposed to that. There is no formal guideline for that from a professional organization. So if you see a grade three placenta at 28 weeks, even though it's not really a thing and there's no professional guidance, I think it's fine. It's okay to go. You know what? We're not gonna put you on surveillance because that's not an ACOG approved or endorsed indication for outpatient fetal surveillance. But, you know, it's fine. It's reasonable. If the placenta is looking kind of jank, why don't we just track growth and let that be the determining factor? More likely than not, when you see a grade three placenta, it could be that there's another comorbid condition. So look for something, guys. This is very similar to decreased fetal movement. Remember, we've talked about decreased fetal movement, that it is not a standalone indication for delivery or induction. Okay? You don't have to get out just because of decreased fetal movement. It is, however, an indication to look for things, and that's exactly the same thing here. A grade three placenta is not an indication for delivery. It's not. Not an indication in and of itself for antepartum fetal surveillance, but it's reasonable to look for some maternal comorbidities. Check the record. Look again. Look at the emr. Does she have hypertension? Is there something else going on? And even though there's no professional guidance for it, it's okay. It's reasonable to do a rate of growth ultrasound and track fetal growth in three to four weeks. I think that's fine. But to be very clear, there is no societal recommendation on what to do with a grade three placenta since grading of the placenta is no longer done to begin with. So this is why we played in the beginning, the intro, that little clip of oh, what? You know what? What does it matter? Well, it kind of does because you don't want to necessarily ignore it. But I think doing a rate of growth, and there's been some expert commentaries on this as well, I mean, that's okay. That's pretty reasonable to do. Oh, hell, what does that matters? It can matter because the placenta is jank, especially under 30 weeks, you don't want to ignore a potential problem. So even though There is no formal intervention based on that. At the most conservative, it's reasonable to do rate of growth, but it is not. I'll say this again, it is not an indication for antepartum fetal surveillance in and of itself. So acog of course notes that endopartum fetal surveillance is for any condition, whether that's maternal, fetal or placental, that could lead to a stillbirth risk that exceeds 0.8 per thousand. That's when. That's when you do antepartic fetal surveillance. And why 0.8 per thousand? Because that is the false negative rate of a biophysical profile or a modified bpp. Okay, we've covered this before.
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- [14:48]
Dr. Smith
So you have to exceed that by some maternal, fetal or placental condition. You have to exceed that stillbirth rate to go. Now it's valid. And there's no data that a grade three placenta in and of itself does that. So the cutoff if you ever ask what's the cutoff stillbirth risk to do antepartum fetal surveillance? According to the college, the stillbirth risk has to exceed the False negative. Rate of biophysical profile or a modified because they're the same is 0.8 per 1,000. Okay, so isolated placental calcifications or a grade three placenta don't meet that criteria. That 2018 systematic review and meta analysis found that a grade three placenta does not predispose to any adverse maternal or fetal conditions. So as far as we know right now, just let it go. You can document it. I think that's reasonable. And again, I think the most conservative thing to do is to do a rate of growth in three to four weeks. But you don't necessarily have to do surveillance. This systematic review and meta analysis that we've been talking about comes from an international source. It is from the official journal of the European association of Perinatal Medicine, the Federation of Asia and the Oceania Perinatal Society. What? Yeah. So it's not us. This is an international body. Of course. I'll post this in our reference list. But this is the title is to ignore or not to ignore placental calcifications on prenatal ultrasound. And their answer is, there's no formal guidance for what to do. Surveillance is overkill. But it is possibly reasonable to do rate of growth knowing that there is no specific guidance, because nobody does this anymore. Okay, so does it matter? Well, not so much, but it shouldn't necessarily be ignored either. Oh, hell, what does that matter? All right, calm down. Calm down. So that's first section. Section number two on our quickie has to do with gbs. So, y', all, as a quick reminder, this is why when you're swabbing the little poopy poopy area or the vajayjay, you always ask the patient. By the way, let's make small talk as I'm checking your poopy area and your vajayjay. Do you have any allergy to penicillin? They go, yeah, I get a little rash. Can you breathe? Are you okay? Yes. Well, then we're going to keep going because there's low risk and high risk, right? Low risk for anaphylaxis and high risk. And not all rashes are high risk. Have to be vacuopapillar, specifically itching and. Or have respiratory issues. That's all addressed in ACOG's committee opinion on prevention of GBS, early onset neonatal sepsis. Remember that the swabbing and the intrapartum prophylaxis that we do is only trying to prevent early onset neonatal disease or infection with gbs. It does nothing for late Onset GBS infection, that's a separate issue. However, this is still hot in press in the New England Journal of Medicine. Just In February of 2026, there was a brand new publication. The title was Group B Streptococcal Disease. So it's not, you know, in the green journal or the gray or the pink. It's in the New England Journal. But I found that interesting that even the New England Journal's like, yeah, we should probably take a look at this. But there's nothing new in that it covers exactly what we've already known. And that's okay. So here's a quick answer. So once again, if we have a patient who has penicillin allergy, send off that initial culture for sensitivities, because you don't want to lose that value in a result if it's positive. So that's what happened in our case. Right. So a patient came in, she had a culture for GBS and it was positive. But we did not include sensitivities in a patient with penicillin allergy. So the resident collected another one and this one came out negative. So now we've got a discrepancy. It could very well also be a pcr, which some places do. And I want to be very clear here, pcr, while very, very good, I mean, it's looking for the DNA of GBS strep a galactia. But that is not the standard of care for GBS early onset disease prevention. It is still rectovaginal, cult based, culture based, and PCR is left as a point of care test for patients who present at term with unknown GBS results. Okay, now if they've got risk factors, you follow risk factors, but if they don't, it is reasonable to do PCR at time of presentation, knowing you do not get sensitivities with that. Okay, so they've got some gaps. So in this case, let's say a patient had an early PCR and that was positive, but you want to do it right, so you do a swab and now it's negative. Or for example, in our case, where both cultures were done, but when it's positive and one is negative, which do you believe? So let me give you the answer just so we can wrap this up, because this is just a quickie episode. Because GBS is so devastating to the newborn in the early neonatal interval, if that index pregnancy has a positive GBS in any count in the urine, or somehow it's found by a retrovaginal swab, that pregnancy is GBS colonized. That's it. So what I told the resident is, look, unfortunately it didn't grow anything. So we can't even use the sensitivities because the second one didn't grow anything. So we have to default to vanc. She's called GBS positive. That second GBS negative culture does not erase the fact that she was a carrier earlier on. Remember, GBS culture is good for five weeks. And yes, it can be transient, so it may be transiently negative now, but it may be positive when she delivers. So once positive, she is positive for that index pregnancy and not having sensitivities, then we either have to be comfortable that she doesn't have high risk anaphylactic reaction to penicillin, and we can give her an ampicillin derivative or Ancef. And if we're not comfortable with that, then she has to go directly to vancomycin. Since clinda, we'd have to prove sensitivity to that. So it left us in a bind. Right. This is why always ask the patient if she has a penicillin allergy. So you can get it with that index culture that first time. And if it's high risk, then consider an alternative like clinda if you prove sensitive. If not, you got to go to vancomycin. And if it's not a high risk allergy, then something like an Ancef or ampicillin could be considered if the patient is okay with that. And there's no suspicion, again, of airway compromise as a risk factor. So, yes, having a positive GBS result for the index pregnancy always wins. It does not eliminate that result if it's redone later. I found that kind of interesting, so I wanted to put that out there. And again, from February 2026, Group B Streptococcal disease out of the New England Journal just came out, so I wanted to cover that. So, podcast family. This is relatively fast. We've covered two things as a very quick twofer, because sometimes we do that twofer. It's a twofer. And so we're done with this one. We've covered placental grading. Not a thing anymore. Not a thing anymore. Not a standalone risk factor for adverse neonatal issues. But it is reasonable. It's okay. It's reasonable if you see that. To do rate of growth ultrasounds, but it's not a standalone indication to do antepartum fetal surveillance, which is why it's not listed in the ACOGs indications for outpatient fetal surveillance. And then we cover GBs result once GBs positive for that index pregnancy, always GBs positive. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, let's take it home. Podcast family, welcome to another quickie episode of the Clinical Pearls no Spin podcast.