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- [00:00]
A
Foreign. As I've said many times before, sometimes we get ideas for the show based on real world situations and real world conversations or real world dilemmas. Well, this episode stems directly from that. Now, it wasn't a dilemma, but just this morning, as point of reference, I am on call this week. So this morning, when I was with the resident team, I had three questions that each one of them, each one of them stopped me in my tracks. And my typical response was, what did you say? I mean, literally, I was like, what did you say? What is happening? I'm gonna tell you the three things that were asked to me. One was by one of our labor and delivery nurses who said, hey, I just wanted to clarify something that I heard somebody on your team say before you got here. This was actually last week, and I wanted to get clarification on this. And so she told me what. What she heard. And of course, my response, true to form, was, what did you say? What did you say? No, no, no, no. I was like, oh, my gosh, if the residents think that we need to pump the brakes on that and explain. Then I had my second issue. And so let me just set this up. The first question had to do with a monochorionic twin gestation at birth. Okay. Monochorionic twin gestation at birth. And my nurse said, hey, just throwing this out and talk to the residents because I heard somebody say, again, this was last week, that for cord blood on a monochorionic twin gestation, okay, so we know that's monochorionic, both babies, same sex. So by defacto, then it's. It's monozygous, you know, identical. But she said, hey, I heard that somebody said, you only need to collect cord blood on one of them since the babies only are identical, since they're monozygotic. In other words, monochorionic. To which I said.
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B
What did you say?
- [02:09]
A
What is happening? So we're going to discuss. Do you need to collect blood, two cord bloods from the two babies on a monochorionic twin gestation. We're going to get into that because I had to rectify this issue. Almost popped a blood vessel in my brain. Second has to do with an MBPP modified biophysical profile versus a full biophysical profile. So somebody who sent to labor and delivery for the typical workup of decreased fetal movement, which we just covered in a previous episode. And this resident said, hey, are you a modified biophysical person or a full biophysical person? And again, my answer, exactly the same as the monochorionic cord blood issue was exactly my same response.
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B
What did you say?
- [02:54]
A
What did you say? Have I not taught you better than this? So we're going to talk about the rate of stillbirth after a modified biophysical profile is at the same as a full biophysical profile. What does the data say? And then after my mini tirade, because I know that I've programmed this into the residents, they settled with one of those two options. And then the third has to do with something that was just covered by ACOG's recent guidance in September of 2025. Now, meaning? Well, to protect the patient, one of the residents said, well, you know, the patient smokes cannabis. She smoked cannabis during delivery. I'm sorry, not during delivery. That'd be weird. We don't allow cannabis in the hospital. I mean, smoked cannabis throughout her pregnancy. And so the resident said, so I told her, you know, she's not allowed to breastfeed, you know, if she's gonna continue cannabis. And that's great. I love the patient advocacy for patient protect, to protect the baby against potential cannabis THC enter into the breast milk. But I had to say, what did you say? Wait, wait, what did you say? Can you breastfeed? So that turned up this question. Is breastfeeding allowed? Assuming that that's the only illicit issue going on, is breastfeeding allowed if cannabis is going to continue in the postpartum interval? Now, let me just say very clearly, of course, advise patient not to do that, advise them not to do that during pregnancy and advise not to do that postpartum, especially around the child. But the question is around lactation, because our resident said that lactation, breastfeeding not allowed with continued cannabis use.
- [04:36]
B
What did you say?
- [04:38]
A
So I said, what did you say? So is that correct? Well, we just have recent guidance from the college, from ACOG, September 2025, we're going to address this. I mean, I don't really like the answer, but it is a valid, data driven answer and it's kind of weird initially when you hear it. So there's two things. Number one is the patient education and the advisement not to smoke cannabis either during pregnancy, which we're supposed to screen for, or in the postpartum interval. And the second has to do with, can you breastfeed if they don't stop, but at least don't do it in the presence of the child if they smoke cannabis. Is lactation allowed or not? We're going to talk about that. But I thought this was interesting, so I decided to call this episode Appropriately enough. What did you say?
- [05:26]
B
What did you say?
- [05:27]
A
Yep. So that's where we're going to go. We're going to tackle three things. Do you, in fact need to collect two cord bloods from a monochorionic monozygotic twin pregnancy? I'm going to answer that. See, I'm already getting irritated. Number two is a modified biophysical. Just as good as a full biophysical. They are. There's data from clinical trials and from ACOG guidance about that. And then number three is, can lactation continue even if cannabis use continues in the postpartum interval? Assuming, of course, that she's not smoking. Smoking a doobie as she's putting the baby onto, you know, to the breast. To breastfeed. That would be ill advised. So that's what we're going to answer in this quick episode called. What did you say?
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B
What did you say?
- [06:12]
A
We'll be right back. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapas, OBGYN no Spin podcast.
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B
What can I get you?
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A
I'd like a large coffee.
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B
Okay. So hot coffee.
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A
Hot coffee. Okay. Room for cream. Totally leave room for cream.
- [07:10]
B
Why are you talking like that?
- [07:11]
A
Why are you talking like that? Well, going to a coffee shop has become kind of an adventure and kind of an ordeal, hasn't it? I mean, from our beloved baristas who ask you if you want room for coffee, room for cream. I can do it. To just the $10 cup of coffee, y'. All. There's a better way. So I'm thankful that the Strong Coffee Company has partnered with our podcast. That is strong as in striving to reach our natural greatness. Striving to reach our natural greatness. That is the Strong Coffee Company. And now for our podcast listeners alone, there is a 20 discount for anything that you order online, y'. All. They have Adaptogen coffee gummies. What? So in addition to the regular whole bean variety and the instant mix, from lattes to collagen to L theanine and the gummies, I, I actually, I, I love these things because right before I go into like a long case or something, I knew it was gonna be complicated, man. They actually have nootropic Adaptogen coffee gummies. And now you can buy that with 20% discount only via the link in our show notes. But I always get a kick out of that. Would you like room for cream? Yeah, I like room for crime. You can avoid all that by ordering your coffee online. So, Strong Coffee Company, thank you so much for Your partnership, our podcast community, that's the strong coffee company with the link in our show notes. All right, first on our list of.
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B
What did you say?
- [08:50]
A
What did you say? Is the issue of cord blood on a monochorionic monozygous twin pregnancy. Now, it is true. Let me just be the devil's advocate here. It makes sense at first assessment that you would probably only need to collect cord blood on one of the cords because they're identical, right? I mean, same blood type. So isn't that what you're looking for? You're looking for type in rh. And so that would make sense. They're both the same blood type, they come from one zygote. So monochorionic, monozygous twin pregnancy, you would make sense. Then it would make sense that you just need to collect blood from one. But no, no, no, no, no, no, no. The American Academy of Pediatrics does recommend cord blood sampling for newborn testing performed individually for each infant, regardless of placental configuration. And the reason is, is that you're doing cord blood assessment to look for the zygosity or genetic information. Now, that begs a second question. If you have a one zygote that splits, hence there are monozygous twins, and they're identical. Are they exactly homologous in terms of their genetic material? And the answer is no. Now, by and large, of course they're identical. I mean, they carry the vast majority of identical DNA. But there are some small changes that can occur after the split post twinning where either epigenetic or true mutational changes can happen so that the DNA profile of one twin is not necessarily that of the other. So these are two different people, which requires two different cord blood assessments. So I get that. And intuitively you would think, well, they're identical. You're looking for a type in rh, they're going to be the same blood type, I'll give you that. But when looking for infectious conditions, when looking for potential antibodies in one child, not in the other, when looking for hemoglobin, hematocrit values or whatever from one to the other, you need to collect two separate. Two separate samples of cord blood, even though it is one placenta. Okay? So the indication for cord blood sampling for newborn testing has nothing to do with zygosity and has nothing to do with the configuration of the placenta. So they have to be treated individually for each individual lab test. And especially if there's some other high risk condition going on, each specific child needs their own blood cord sent for blood type, antibody screen, and whatever else you're looking for. Now, remember, we're talking about cord blood. I am not talking about cord gas assessment. Obviously, those are each done independently to look at the acid base and metabolic status of the child. I'm talking about cord blood, like a cord. You open up the cord, my blood goes into the little sterile cup, and then you send that off to study. So even though it is one placenta, even though they come from one zygote and they should be genetically the same, it is absolutely a standard practice and standard of care. And that's out of the American Academy of Pediatrics, a guidebook that for newborn testing, cord blood sampling should be done individually for each infant, regardless of placental configuration. Again, that's not my deal. That comes out of the clinical report from pediatrics, the title of which is Postnatal cord blood sampling. That was published first, initially 2024, and then again redone in 2025. So clinical report, postnatal cord blood sampling. Even though it's one placenta, even though they're genetically more or less similar, though it's not universally all the same DNA, there are some epigenetic and potentially some post zygotic, post twinning mutations that can happen at an individual level. You do need to collect cord blood from each individual, from each child. Okay, now, I know this is kind of weird because I had. Actually, I never thought about this. I mean, you just did. You just collect cord blood from both. Until again, one of. You know, one of my labor and delivery nurses just this morning said you need to address this with the residents because somehow, somewhere, they were under the impression that just one cord blood is okay. Absolutely not. You should have seen my face. I almost almost popped the head gauge and almost lost it.
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B
What did you say?
- [13:29]
A
What did you say? No. Each child definitely needs its own cord blood assessment. All right, I think we've finished that one. Now let's get into our second issue, which has to do with mbpp. Modified biophysical profile versus a full biophysical profile. Is one better than the other? And I've mentioned this. We've had several, of course, episodes on endopartum fetal surveillance. And we've covered ACOG's guidance on this, which is ACOG Practice Bulletin 229. That is antepartum fetal surveillance. That is kind of the theory behind antepartum surveillance. Then there's the other guidance, which is indications for outpatient antepart and fetal surveillance. Those are two separate ones, but it's practice bulletin two to nine that initially came out in 2021, that, that has these numbers in there. Now, let me just tell you as we get to remember our new motto here, tell you what you need to know. Move on. The risk of stillbirth after a reactive modified biophysical profile. Okay, Based on all the data, and it's in this guidance here from acog, the number that they pull out is out of randomized trials and observational studies that show that the rate of stillbirth after a reactive modified biophysical profile is 0.8 per thousand. 0.8 per thousand. In other words, it's really, really low. Using the NST as an acute marker, a fetal hypoxia, and then of course, a fluid assessment as a maximum vertical pocket over afi because MVP is preferred as a chronic marker. If both of those are reassuring, the rate of stillbirth is 0.8 per 1000. Extremely small. Now, the rate of stillbirth after a reactive full biophysical profile is absolutely 100% the same. It is 0.8 per thousand. So as I told my residents all the time, you're going to do a modify, do an NST and then check a maximal vertical pocket. And if it's between 2 and 8, NST is reactive, you're good. It's fine. The reason why the full biophysical profile exists is because if either one the NST or the fluid is off, then you may need the full biophysical profile to give you a true interpretation. Okay. Knowing of course, that a minus two for fluid on a modified if you have oligo, then that's a flag in and of itself, which could potentially be okay to do an induced an induction for delivery as early as 36 weeks. According to ACOG's guidance on medically indicated late preterm and early term delivery. Because of the potential for cord accident, not on one value. We bring them in, we give them some IV fluids, make sure they're not ruptured, get a full history, do a full exam, including a sterile spec exam, they're not leaking, and then recheck it because it may just be if the baby's lying in such a way that it's hogging up all the space. All right? I mean, that's theoretically possible. So we recheck it in about four to six hours. And if it is repetitive, repetitively low, then isolated oligo is an indication for 36 weeks delivery or later, if that's when you find it. Okay, so if you're doing a modified and both are normal, you're good. The rate of stillbirth is absolutely the same compared to the full. But if one of those numbers is off, you may need the full to interpret, knowing, of course, that oligo can be a hard stop because of the potential for cord accidents. Okay, so, yes, that comes out of ACOG's practice bulletin number 229. And so after the resident, you know, asked me and I went through this little tirade, exactly what I'm telling you now, they're like, all right, man, I got it. We will get then the modified biophysical, which of course, thankfully was normal. But it's not just this ACOG guidance. I mean, there really is lots of good data here that even though the full biophysical profile has been significantly more studied than the modified, the data that does exist for modified puts the risk of stillbirth pretty much the same as a foal when it's normal. Okay, so it's perfectly fine for clinical decision making with antepartum fetal surveillance. Do a modified. Although I get that especially in a residency program, our residents do need to know how to do a full. So there are times where we'll just throw out and say, hey, just do a full biophysical. Just keep your skills up to make sure you know how to get all the markers. So I understand that. But from a practical evidence based standpoint, a modified biophysical profile has the same chance for stillbirth as a full if they're both reassuring, which is 0.8 per thousand. Okay, so that takes care of that one. The last issue that we're gonna talk about very quickly is the issue on cannabis. See, I told you we're gonna move quickly here. And the question was if a patient is going to smoke the wacky weed, AKA Mary Jane, a little bit of cannabis. The old term of that was marijuana. Okay, we covered that in the past. Why we don't call it marijuana anymore because it can be offensive. Not going to get into that. But cannabis is actually the more technically correct anyway because it relates to the plant. So, anyway, so cannabis, if they're going to smoke cannabis in the postpartum interval, can a patient still breastfeed? Because my resident initially, again, doing her part to protect the child and intuitively said, no, you can't.
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What did you say?
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A
What did you say? Because oddly enough, yes, you still can. According to ACOG's brand new guidance from September 2025, which was clinical consensus number 10. And in all disclosure, I was still part of the OB consensus committee that helped review this to launch this. This came out early September 2020. Five ahead of print and then officially came out this month, October 2025. So it's available now for public review. It's called Cannabis Used during Pregnancy and Lactation. Number one, the take home was screen everybody for it. Number two, yes, cannabis is lipid soluble, it does get into breast milk, but it's about 10% of what it is in maternal serum. Knowing that there's a lot of factors that go into that. The potency of the thc, the frequency of use, and the time from taking cannabis or inhaling cannabis and then actually breastfeeding. So ACOG does have a statement here that says, because of the widespread known benefit of lactation. Okay, this is kind of, intuitively, this is kind of weird to accept, but it's true. Because of the benefit, overall benefit for breastfeeding, a patient who elects to continue lactating, lactating, who elects to continue using cannabis, can continue to lactate, can continue to breastfeed. It's okay. So of course, we'd prefer that they don't do that during lactation. So we should advise patients that the best is, of course, to not do it, because some THC does get into breast milk, but it is not. That does not make it a contraindication to lactation. So according to the college, the official stance is, number one, discourage patients from doing this during lactation. However, continued cannabis use in the postpartum interval is not. Say that again. Is not considered a contraindication to breastfeeding. With, again, some caveats that if you're going to, you know, do a little toki tokey, try not to do that as you're holding the child to your breast so the kid doesn't get secondhand smoke, for God's sakes. Okay, so, yeah, I mean, wild. Even though there is some concentration of THC in breast milk at about 10% maternal circulation, the widespread benefit of breastfeeding and the limited data that we have regarding harms of cannabis use during lactation, as of right now, it's all right. You should not consider continued cannabis use a contraindication. Let me read this directly from the college and we'll call it a day. Quote, obstetrician, gynecologists and other health care professionals should advise cessation of cannabis use during pregnancy and lactation. Here it is, guys. However, continued cannabis use is not a contraindication to breastfeeding, and lactation should be encouraged regardless of cannabis use. See, intuitively, that doesn't make a lot of sense right off the bat.
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B
Did you say.
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A
What did you say? Are you saying that they can continue to use marijuana and breastfeed?
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B
What did you say?
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A
What did you say? Yes, because the benefit of lactation is so good as long as, once again, they're not taking a little dooby dooby at the same time that the kid's on the breast so the kid doesn't get wacky. Wacky by secondhand smoke. Podcast family, we have covered three clinical situations. Cord blood with a monochorionic twin gestation. We've covered MBPP versus the full bpp, and we've covered that, yes, you can breastfeed, even if you're doing little Mary Jane.
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B
What did you say?
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A
During the postpartum interval? All right, Podcast family, I think I have worn out that anchorman clip enough. That was Will Ferrell.
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B
What did you say?
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A
What did you say? And we'll call it a wrap. Podcast family, as always, we care for you. We love you. We thank you for being part of our podcast community. We thank you for all of the great support that you've given us. And having said all that, Michael, come on now. Let's take it home.
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B
What did you say?
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I said, let's take it home. Podcast family, we're thankful for all of the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode.