Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 11.4 Syphilis and lots more!
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We examine why U.S. maternal mortality headlines mislead, showing overdose and violence dominate early postpartum deaths while obstetric causes decline. We then cover strong evidence for opportunistic salpingectomy, debunk a shaky Cochrane-fueled home birth claim, clarify Nexplanon’s five-year approval and bleeding management, confirm no Tylenol-autism link, and walk through modern syphilis testing in pregnancy before closing with pragmatic magnesium use after delivery.
• overdose and violence as leading postpartum deaths
• pitfalls of cross-country maternal mortality comparisons
• fentanyl trends and infant risk
• opportunistic salpingectomy reduces ovarian cancer risk
• how bad meta-analyses distort home birth safety claims
• intent-to-treat and risk matching in birth setting data
• Nexplanon five-year efficacy and bleeding treatments
• no association between acetaminophen and autism
• syphilis screening algorithms and pregnancy timing
• magnesium postpartum as seizure prophylaxis, not BP treatment
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram
0:00 Setting The Agenda: What Really Kills Moms
0:33 Redefining Maternal Mortality And Comparisons
2:11 Violence, Overdose, And Postpartum Risk
5:33 State Variability And Media Narratives
8:15 Data On Drugs, Fentanyl, And Infant Harm
11:06 Opportunistic Salpingectomy: New Evidence
14:06 Population Study And Risk Reduction Ranges
16:16 Cochrane Review And Home Birth Claims
20:24 Why Bad Meta-Analyses Mislead
24:15 Real-World Data And Intent-To-Treat For Birth Setting
28:02 Pain, Epidurals, And Cultural Narratives
31:00 Nexplanon Five Years And Bleeding Fixes
35:21 Tylenol And Autism: Meta-Analysis Revisited
38:04 Syphilis Testing In Pregnancy: Why It’s Hard
42:25 Traditional Vs Reverse Algorithms Explained
47:05 Managing Discordant Results And Reinfection
50:11 History, Ethics, And Tuskegee Lessons
54:15 Listener Question: Magnesium Duration Postpartum
59:05 Clinical Judgment Over Dogma And Wrap
Follow us on Instagram @thinkingaboutobgyn.
Setting The Agenda: What Really Kills Moms
SPEAKER_00Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Antonia Roberts discussing syphilis and new articles.
SPEAKER_01Howard.
SPEAKER_02Antonia.
SPEAKER_01What are we thinking about on today's episode?
SPEAKER_02Well, we've got some updates over a lot of things we've been discussing over the years, some new literature, and we've got a great letter from a listener, and we might talk about syphilis.
SPEAKER_01Oh, exciting.
Redefining Maternal Mortality And Comparisons
SPEAKER_02Yeah. Okay, well, first up is this is actually a correspondence piece published in the February 11th, 2026 New England Journal of Medicine. It's really a letter to the editor or research article, but it's entitled Overdose, Homicide, and Suicide as Causes of Maternal Death in the United States. We've talked about this issue of maternal mortality in the U.S. a lot over the last years and the unfair comparisons that are often made between U.S. maternal mortality rates and rates in other developed countries. I think our continuing point has been that these comparisons are often unfair and are apple to oranges comparisons.
SPEAKER_01Yeah, Europe and Asia tend to focus on classifying a death as maternal mortality only when it's directly physiologically related to the pregnancy. So that could mean things like hypertensive disorders of pregnancy or postpartum hemorrhage or peripartum sepsis. Whereas our maternal mortality review committees in the US include those things too, but also have a more expansive and in some cases a more variable definition, which can vary from state to state. And that can include other things like suicides, drug overdoses, anything, any a lot of other types of death that just happen to occur during pregnancy or the postpartum state.
Violence, Overdose, And Postpartum Risk
SPEAKER_02And this idea is misunderstood even by a lot of people who should know better in the United States. There's a popular blogger in OBGYN who just this week his post and article is about definitions of U.S. maternal mortality, probably responding to the same article we're responding to. And he gives a definition of maternal mortality that is really the European definition, that it is deaths due to those direct obstetric causes that you just mentioned within 42 days of birth, and not all the other things. He actually says it's explicitly not suicides and drug overdoses, but that varies by state and by maternal mortality review committee. So we don't actually use a strict definition, and that's a lot of the point that I think people, even well-intentioned people, don't understand. But this letter, which is written by faculty at Columbia, points out that the classic dogma is that the leading causes of maternal death in the U.S. are cardiovascular disease, hypertension, hemorrhage, and infection. The authors looked at all the maternal deaths they could find in the first 42 days, that six-week time period after delivery, between 2018 and 2023, and they found 7,901 deaths in that six-year time period, and they concluded that the leading cause of maternal deaths, so not maternal mortality, again, these definitions are wishy-washy, but of maternal deaths in the first six weeks after delivery was unintentional drug overdose, and number two was violence, which they defined as homicide or suicide by any means. Of those homicides were twice as likely as suicides. Now, this is of course just in the first six weeks postpartum, so this is that international definition of 42 days. Violence and overdose accounted in that time period for 2018 deaths, and then the next four causes, which are those classic cardiovascular disease, hypertension, infection, and hemorrhage, they added up to 2,141 deaths.
SPEAKER_01Yeah, so almost the same amount for all of those medical causes together compared to just those drug and violence deaths. So that that's pretty significant. And that's just in the first six weeks. We tend to see that those drug and violent at least the drug deaths increase more after that, between six weeks and one year postpartum. And I think the importance of that is most of those obstetric causes of maternal death that the letter writer from Columbia and then that the European and Asian countries tend to focus on, they really just happen in the first six weeks. They don't really happen anymore when you get past that time period. But when you expand the postpartum time frame to one year out, then those medical deaths will decline dramatically and really just be almost fully eclipsed by deaths from drug overdose or violence.
State Variability And Media Narratives
SPEAKER_02Yeah. And again, the issue is that this varies by state. So a particular maternal mortality review committee in one state might meet and decide that a patient's murder by her partner was related to the pregnancy, that there was some issue motivated, conditional on the pregnancy that led to the murder, or that the suicide in the same way was related to postpartum or peripartum mood disorders, or substance abuse was related to peripartum mood disorders or to the act of being pregnant, and then classify those this as pregnancy related, which then counts them as maternal mortality in the classic definition that's used to compare. And that was the point that I think the blogger I was mentioning missed altogether, was he made a good faith assumption that we're comparing apples to apples without really looking into it, perhaps. And then another state might choose not to do that. So there aren't in the United States universal standards or definitions for this. And in Europe and in Asia, almost never are those sorts of deaths attributed to pregnancy-related causes. So ironically, in the United States, we've had a plateauing or even rising maternal mortality because we've been changing continuously over the last 25 years how we account for these deaths and how we track them, and certainly since the introduction of the universal death certificate checkbox, which indicates the pregnancy status or recent pregnancy status of the deceased person. But the reality is the causes of death that are directly related to things like cardiovascular disease and hypertension and infection and hemorrhage have been dramatically dropping over the last 25 years. And when you look at them specifically, they're as low or lower than virtually any other country in the world.
Data On Drugs, Fentanyl, And Infant Harm
SPEAKER_01Yeah, the media really needs to pick up on this and highlight this and stop making inconsistent comparisons because if Europe or Asia are not tracking these drug overdose steps and including them, then it's not an equivalent comparison. But if they overlook that and tell a story of how the sky is falling, all the US moms are dying because US healthcare sucks, or whatever their message is, then they're gonna get more sales and more clicks on their stories, and they're gonna benefit much more than saying, oh, it the sky is beautiful and maternal mortality is doing so much better in the US, that's just not as likely to sell as much. Maybe it should, but it typically doesn't. And that's just consumer human psychology, I think. But the conclusion is that these non-obstetric causes of death are the leading cause of maternal mortality in the US. So we need to frame our conversations around this appropriately so that we can actually address those causes. And since that data isn't really tracked in other countries, we can't make fair comparisons. And we also can't look to those other countries for ideas on how to reduce these types of maternal deaths. And of course, these become very complicated and multidisciplinary efforts just to understand why they are happening, let alone to intervene and effectively prevent them. So, for example, we do have some good insights. There, there's a study in JAMA we can link into link to into which drugs are most often involved in maternal drug deaths, at least for this most recent study, it was fentanyl and other synthetics. And then we also know from that same research that the death rates related to drugs, pregnancy and postpartum do correlate with those in the general non-pregnant population of similar aged females. So it's a population problem. And obviously, drugs and violence killing moms is also a huge risk to the infants. And unfortunately, there has been a significant increase in infant deaths related to drugs that's gone along with the increased maternal drug-related mortality rates. So it would be great for that similar type of research and attention to be done in other countries too, to see what if there's a place that truly does have low rates, we could look to them and see what they're doing right or what we could glean from them. But we don't have that right now.
SPEAKER_02And that's a strength, perhaps, of what how we've been dealing with this issue in the United States is finding all of these cases, categorizing them, getting this data, and then we can learn how to address the problems that are really the leading causes. I think the frustration is always that people focus on some of these other issues, which are relatively down the list when we're not tackling the issues you're discussing. And I would grant that it's I have no data to contradict the idea that the U.S. does lead the world in drug-related and violence-related deaths among pregnant people. The issue is that it's not what people think of when we talk about this. They're not thinking when they see the headline that, oh gosh, we've got rising fentanyl deaths or suicides or homicides among pregnant women. They're thinking that we're doing a bad job in the hospital and women are dying of hemorrhage or something like that. And so that conversation has to change if we're going to make progress. So the fact is for the direct obstetric things, we have a great maternal mortality numbers and we have a great system. And but it very well may be that we're the worst in the world or one of the worst in the developed countries for these other issues, but we're not focusing on it. And every time the media slaughters us and gets gets this issue backwards, we don't address research dollars and public focus and community programs and everything else on the real problems that are facing pregnant women and children, as you said.
Opportunistic Salpingectomy: New Evidence
SPEAKER_01Yeah, it's attention, but not the right kind of attention. So in this recent study that you had brought up, this still does include COVID pandemic years. So of course the maternal mortality did spike up during then from COVID. So if you exclude those deaths, which then came back down again, the gap between drug overdose and violence and other obstetric or medical causes of death grows a lot larger.
SPEAKER_02Yeah, they are the leading causes, and they're more than everything else added together when you get rid of the COVID deaths, which they included under infection. Okay, well, this adds to the conversation that we've been trying to lead here for a few years and hopefully will spark a lot of conversation.
SPEAKER_01All right, let's move on to another topic. We've also been following the evolving literature about opportunistic salpingectomy for preventing ovarian cancer. We know that risk reducing oporectomy and even opportunistic oporectomy at certain ages is preventative, and we've assumed that salpingectomy alone can also be. But here's some pretty good data now. So there's a couple of new pieces out about this. The first is from JAMA, February 2nd, 2026. And this is a consensus statement from the European Society of Gynecologic Oncology about opportunistic salp injectomy for preventing tubo ovarian carcinoma. They did a literature review of 129 relevant studies to author their consensus statement, and they concluded that the current body of observational studies do indicate a risk reduction ranging from 42 up to 80%. And we've known for a long time this seems to come without any major side effects or complications like diminished ovarian function or any major surgical risks. There, there's of course some minor ones, but not nothing along the lines of hysterectomy or even just ophorectomy. So this review looks at what's already out there, and a lot of it is mixed literature, and there is a wide range here, for 40 to 80 percent, and a lower level of confidence in it, but even so, 40, 40 to 80 percent risk reduction is hugely important.
Population Study And Risk Reduction Ranges
SPEAKER_02Okay, yeah. And then on the same day in Jam and Network Open, another article was published related to this. It was another research letter entitled Serious Ovarian Cancer Following Opportunistic Bilateral Salpingectomy. So this is a new retrospective study that wasn't included in the literature review that you just went over. And the authors here did a population-based retrospective cohort study of all people who underwent a hysterectomy or tubal permanent contraception procedure, is what they called it in British Columbia, between 2008 and 2020. And they had over 85,000 patients, about half of whom underwent an opportunistic salpingectomy procedure, and roughly half who did not. Now they have several years of follow-up now from these patients, and there's, of course, a longer-term follow-up for the patients who didn't have an opportunistic procedure, reflecting the fact that they adopted opportunistic salpingectomy over the study time period in those years and became more prevalent later. So that might be important in interpreting this data because essentially the people who didn't get an opportunistic procedure are older and have more follow-up. But they did find, in comparing them, a 78% reduction in serosovarian cancer in the patients who had an opportunistic salpingectomy.
SPEAKER_01Right. So that intervention or that study cohort of salpingectomies is a little younger, not followed for as many years. So it may be that over time that we do see an increase in rate than what we've been able to see so far. So that 78% number might drop a little bit. I think that's why right now we can't do much better than saying 42 to 80%. But even if it drops, even to 40% risk reduction, the salpingectomy become still becomes an incredibly important tool for preventing ovarian cancer.
SPEAKER_02Agreed, yeah. And we're seeing declining rates of ovarian cancer on a population level. And ovarian cancer mortality has also been declining. But of course, we're also doing more genetic testing and other risk-reducing surgeries, risk reducing ovarectomy, and our treatments for ovarian cancer are improving. So this is a battle on many fronts, but it is getting better.
SPEAKER_01All right. Well, let's keep moving on. Did you know there's a Cochrane review that's looking at planned hospital births compared with planned home births for low-risk pregnant women?
SPEAKER_02Well, I read something about that in a popular news article that you and I shared that cited that Cochrane review. And then I went and checked out this Cochrane review because I wasn't aware of it.
SPEAKER_01Okay. Well, I'm sure it has been getting pushed around on social media, maybe because of that article. But so it was on AOL.com, and the article was titled, My Wife Gave Birth at Home Without a Midwife. It taught us one important lesson, and we'll give a link to it. I'll say offhand that sounds like a very clickbaity-y type of article, which unfortunate unfortunately it it works because it got us to look at it.
Cochrane Review And Home Birth Claims
SPEAKER_02But so they had a free birth, which then really isn't even related to the premise of the Cochrane review, if it's really a free birth.
SPEAKER_01Yeah. So anyway, but they had a free birth, but the author talks about their decision to have this essentially free birth, and he cited this Cochrane review and summarized it as saying that recent studies show that giving birth in a hospital doesn't usually lower the chances of mothers or babies getting sick or dying, but it does lead to more medical interventions and more complications from those interventions.
SPEAKER_02Well, back of the envelope thinking, I guess, for lots of doctors and residents and med students and lay folks is that Cochrane reviews are the highest level of evidence. So I guess he's saying, Mr. AOL.com, that Cochrane reviewed multiple high-quality studies and found that the risk of perinatal and maternal morbidity and mortality is no different, but that planned home birth results in fewer medical interventions and complications from those medical interventions.
SPEAKER_01That's what he's saying here.
SPEAKER_02Okay. Well, that's news to me because that contradicts every single published trial we've ever had. But this gets into the problem with Cochrane reviews and a lot of what we're seeing happening in the last few years with meta-analysis to systematic reviews in general. And we've talked about this briefly before, but Cochrane reviews in particular are really horrible at evaluating mixed method research type data. What I mean by that is Cochrane is built on a foundation of including high-quality randomized controlled trials in their analysis. So if you're studying the effects of statin drugs on cardiovascular risk or something like that, then these are going to be a large number of placebo-controlled randomized controlled trials that can be included in a review and evaluated in one of these types of systematic ways. But when it comes to things related to, say, childbirth, well, we don't have a ton of randomized controlled trials, and we're forced to deal with cohort data and retrospective data of various types and various qualities and various biases, and then try to evaluate and summarize that data. And so this Cochrane review, when it was published, which was listed as a conclusion change related to previous reviews of the same subject, it was a it was first published came out in 2012 and by the same author team, I think. And the author, by the way, who is a midwife activist, this made the rounds back in 2012 and more recently, but the author said in the media that this review showed, in no uncertain terms, this was a definitive statement, that quote, birth is no reason to go to the hospital.
SPEAKER_01Okay, so this is the study that this AOL.com free birth article author guy cited. So tell us about the studies that they include in this Cochrane review.
SPEAKER_02Well, not studies. I'm sorry if I misled you. It's one study with 11 participants.
SPEAKER_01Okay. That seems shady, at least a little bit. Why would anyone try doing a systematic review and meta-analysis on one study of 11 patients? That's a case series. That's like Dr. Wakefield with the autism.
Why Bad Meta-Analyses Mislead
SPEAKER_02Yeah, wasn't it 11 there too? I can't remember, but it's about that number. Yeah. Yeah, it is a case series. It's a joke. And taking, you see the danger of doing a meta-analysis on two or three or four low-quality studies, or in this case, a Cochrane review of one study with 11 patients in it. And then, but then you give it the imprimature of the highest level of scientific evidence, at least for the back of the envelope thinkers, and it's very dangerous, and this sort of thing should not be published, but they're published every day. Even in the Green Journal and the Gray Journal, you're seeing systematic reviews of a handful of low quality studies that are just inadequate to even be meta-analyzed. So we're living in an age now, though, where this bad science and bad publication practices are coming back and harming people. So we're going to double down on this concept a little bit this year. This study had of eleven women, had zero cesareans and zero operative assisted births, so can't make a comment about that, I guess. Even if you could, it wouldn't be statistically significant. And all of the numbers for secondary outcomes, again, were too small to do any statistics with. Imagine randomizing 11 people. Well, you got five in this arm and six in that arm, and you're trying to make conclusions about NICU admission rates or apgar scores or rates of epesiotomy or cesareans. It's this is one of the most absurd things I've ever seen. The authors of the Cochran review even admit, of course, they can't get it published unless they put the words in. They admit that the data is too small to draw any conclusions from it. But that didn't stop them from going out and making media appearances saying that their review proved that women don't need to go to the hospital, and then some lay person who writes for AOL.com can read this and potentially endanger his newborn child and partner because he doesn't understand that this is predicated upon faulty techniques and bad science.
SPEAKER_01That really is so disingenuous. And then that just rolls down from Cochrane to AOL to that author.
SPEAKER_02To TikTok and Instagram.
SPEAKER_01Yeah, yeah. My suggestion to Cochrane, if they're listening, is if your conclusion is data's too small to draw any conclusions, just don't do the review. Just focus on the things that have good data. But anyway, they actually could have had more data. They excluded some. They excluded six studies, I think, from that review. So what what did those studies say? Well, honestly.
Real-World Data And Intent-To-Treat For Birth Setting
SPEAKER_02Yeah, most of those studies aren't even relevant. And it's interesting, too, you know, how they even pick which studies they excluded. This is where bias of the author team comes in, because there's a lot of things they could have included. There's lots of lots of data sets, retrospective data sets and things out there. They really only had one study that they excluded that was even relevant. So that one was a 1994 study published in JAMA Pediatrics that looked at the outcomes of 59 infants born alive out of the hospital, and then they just compared them, so it's not prospective, but they compared them to a matched cohort of 151 infants born in the hospital, and they concluded that unattended out-of-hospital birth results in increased neonatal morbidity that's likely preventable by simple hospital interventions. They also excluded a trial from 1995 focusing on intermittent versus continuous monitoring in labor and looked at neurologic outcomes that showed no difference. But we already know that. They excluded a 2009 study, which was actually just a survey asking whether or not women were willing to participate in a randomized controlled trial. And this was in Holland, I believe, which has a large a group of a large percentage of their population born at home. And they found that women don't want to enter into a randomized controlled trial about whether they're willing to give birth, which of course is a limitation of even considering doing a randomized control trial on this topic. And so that's where you have to accept the fact that you need controlled cohort studies where you take people who elected to deliver at home versus match cohorts in a hospital setting and get enough of them to measure meaningful outcome differences. You're not going to have a prospective trial on this subject in all likelihood. Another was a trial of midwife-led care, but this was basically in a hospital. They had rooms in a hospital that were meant to simulate the home, so it's a birthing center. And the last two, I don't know why they even included them. One was about a transfer service and one was about vitamin K. So they really only had one trial that was any sort of neonatal comparison to in-hospital versus out-of-spital births. And of course it found that the out-of-hospital births were more dangerous, so they excluded it.
SPEAKER_01Okay. Well, I guess most of those excluded studies were veering a little further away from the research question. I still think they could have added the JAMA pediatrics one with the 59 out-of-hospital infants and the 151 hospital infants.
SPEAKER_02Yeah, that would have like 10 times the number of infants in there with the analysis.
SPEAKER_01Yeah. Well, so those were excluded, but there is still other data, right? We have other data that at least this AOL author could have pulled upon.
SPEAKER_02Right. And of course, ACOG has a statement about this, and there are data sets. Our best data comes from the CDC National Vital Statistics System. And to understand this data, you have to first deal with the fact that the population of women who intentionally deliver outside of the hospital are generally very low risk and healthier and more affluent and things like that compared to those who deliver in the hospital. And secondly, you have to structure your analysis really from an intent to treat perspective because many of the home birthing patients who develop complications, antipartum or intrapartum, they end up in the hospital before delivery. And so they delivered in the hospital, but their intent was to deliver at home.
SPEAKER_01Right. So if you just use some quick calculations off the cuff, you might see a birth attributed to the hospital setting and count that as a complication against hospitals. But actually that birth started at home and was brought in emergently at the last minute after things had already started going wrong. So you only catch that if you do an intent-to-treat analysis. And that would attribute whatever the complication might have been cesarean, operative delivery, fourth-degree tear, neonatal seizures, NICU, or whatever it was. That would be attributed to where the birth process was started. And it's good to analyze it both ways, because then that does give us more insight into whether planning a home birth, maybe at least with certain risk factors present, either does or doesn't increase the risk of birth complications that that could require emergency transfer.
Pain, Epidurals, And Cultural Narratives
SPEAKER_02Yeah. And you have to be really diligent about matching patients' risk factors. You can't just take a C-section rate of a cohort of women who gave birth at home and then compare it to the national or regional published cesarean section rate in the hospital, and that's another apples to oranges comparison. But my real point about all of this is that there's so much bias and that once a paper gets published in something like the Cochrane Review, which that review has been I've actually written about that years ago before, it's been around for almost two decades, and it does a lot of damage and it doesn't go away. And it it's a total joke, but it's weaponized by this community of more radical free birthers and everybody else, and ultimately it harms mothers and children. It's amazing that the authors in that paper itself even say that there's no conclusions that can be drawn because the data is insufficient, which is really the reason why Cochrane publishes it, by the way, is to highlight the fact that we don't have good studies. That's how you're supposed to take that in a non-disingenuous way. But then you can't then the authors then can't go on a podcast and do interviews and media releases and claim that somehow they've proven definitively that home birth is better than hospital birth. And we're seeing this on all fronts now. There's so much low-quality science published, and much of it by biased activists in pay-to-publish journals with inadequate peer review, and and then these articles become weaponized against us on a TikTok reel where somebody says, I'm practicing, I'm telling you something that's evidence-based article below, which nobody ever clicks on. So we're going to talk about these things more and double down on it, because I think our own profession sometimes doesn't know the difference between high quality and a low-quality study.
Nexplanon Five Years And Bleeding Fixes
SPEAKER_01Yeah, I think med students and residents are taught to have probably way too much faith in the Cochrane brand and other similarly big names in science publishing. And this is one good example of why that might be that respect might be misguided in some cases. You can trust, but trust but verify it is a good rule of thumb. And then just in favor of hospital births on a more lighter note, or maybe just a more superficial note, you you don't get epidurals at home. And if I've had patients tell me that they want to do a home birth because they don't want to tap out and or whuss out or whatever their wording is and get an epidural. Like they want to they want to go unmedicated and they don't want to even give themselves the option of asking for an epidural when things get really painful. And I've had more than one patient say that to me. And I'm hoping that if anyone's thinking about that, just think about how how bad is the worst possible pain that you've and maybe some people have gone through unmedicated labor before, but it doesn't get better the next time around. And then a lot of patients that are primiperous or they've had an epidural in the past, they've never truly felt the full active labor pains. I would just say don't deprive yourself of the option. You can go unmedicated, maybe pick a place that has a lot of non-epidural type of pain adjuncts and nice low intervention options, but at least leave yourself that option available. I'll just personally say it's I think the epidural is one of the best decisions I've made in my labor process. It I think it made things go smoother and the experience much better. I don't think there's anything to be gained or any virtue in screaming your head off, thrashing around, but just being in complete agony just by choice, if you don't have to be. The epidurals are very safe and they don't cause autism. They don't mess up the baby, they just reduce the pain when they work well. So at least give yourself that option. Don't make that the reason that you're picking a home birth. But there is a lot of better reasons also not to pick a home birth. So that that's my unsolicited two cents on that.
SPEAKER_02Yeah. And we should do an episode where we talk about the whole history and the reasons why people are against medicated births. And just to get some controversial letters, emails uh, I will say that the real story there is a lot of it is predicated upon Genesis 316 that said that the curse of Eve was to suffer in childbirth. And the history of the anti-pain relief and anti-epidural and natural birth movement, whether people realize it or not, is predicated off of the religious belief that it's a sin to get pain relief during labor based upon Genesis 3.16. But maybe we'll go into that in a in detail in another episode. So I also think someone should send you a message and call you a wuss for getting an epidural. I'd like to hear your response if they called you, well, you just had a baby, a third baby, and then you have a nice epidural.
SPEAKER_01It was the best.
SPEAKER_02Well, you're you're a wuss. You're a wuss.
SPEAKER_01I think that could be a very amusing conversation. And yeah, it might be interesting. I'm sure with AI we can actually look up is there any religious denomination that has a formal stance on epidurals? I doubt there is, but that yeah, that that could be a fun rabbit hole for another day. But I even outside of religious dogma, I think there is that underlying, maybe irrational thought that a lot of women think like it's somehow a failure to not go through full-on unmedicated labor. But that's not true. I'm just gonna say that's not true. So let's move on from childbirth to preventing pregnancy. Did we mention yet that the next one on now is officially approved for five years?
SPEAKER_02Oh yeah. No, that that's a big deal then, I guess, isn't it?
SPEAKER_01Yeah, so the trial that showed that it is effective for five years, it found no pregnancies in years four or five of use. We typically will cite a failure rate of one in three thousand. And honestly, that that's even probably an overestimate. But now we can tell people that officially they can keep it the full five years. We've already been telling people that's what the data shows, but now we also have the FDA approval. So I think the biggest problem with the Next Panon is still always going to be that irregular bleeding that's frustrating both patients and providers.
SPEAKER_02Yeah. I will mention that there's another part of that FDA thing about the a RIMS program for NextPenon. So most of us who do these will have to do a little bit of paperwork in the next few months to get the RIMS qualification for NextPenon. But yes, five years. And the bleeding is the most frustrating part, but there's a new randomized control trial in the Gray Journal from January 2026 that looked at using norothesterone for prolonged uterine bleeding associated with Nexpinon. So they gave patients 10 milligrams a day until they stopped bleeding, and then for a couple days more, or a total of up to 30 days. And yeah, this worked much better than placebo, of course, and they found that it stopped the bleeding, but it didn't prevent recurrent bleeding.
Tylenol And Autism: Meta-Analysis Revisited
SPEAKER_01Right. The this study was done in Europe, and just so the listeners know, norefisterone is just the European name for norothindrone that we use in the US. So this would be like giving the patient 10 milligrams of norothindrone per day. We have also looked at using combin combined oral contraceptive pills for preventing or treating breakthrough bleeding on the next one. And this does seem to be very effective at getting it to stop while they're using it at least. And we've also tried NSAIDs. This has some impact, but less so than the birth control pills. Temoxifen has also been used for this. I haven't personally tried it for that for that indication. And it is highly effective, but not an ideal long-term solution and likely has a lot more side effects. Doxycycline is another one used for up to five days at a time with some moderate success. And TXA tranxamic acid has also been looked at. It doesn't seem to do much here in this kind of a setting. We typically think of it as something that makes heavy bleeding less heavy, but not so much a fix for spotting or lighter bleeding that's just irregular.
SPEAKER_02Yeah, I think the doxycycline is something that's often overlooked. So doxycycline is a matrix metalloprotonase inhibitor. So a small study found that 100 milligrams twice a day was just as effective as hormonal contraceptives, in fact, in terms of stopping a bleeding episode. Metalloprotonases are enzymes that break down the uterine lining, but we have some good ways of stopping bleeding, and oral contraceptive pills are probably the best. The problem, again, though, as you mentioned, is that it you stop it, but then it comes back and they are consistently irregular. But it is okay to continue patients on oral contraceptives, combined oral contraceptives, and keep the next one on and do both at the same time.
SPEAKER_01Okay. Another important update, we're switching topics again, is Tylenol and autism risk. There was an article published online in Lancet January 16th, 2026, that looked at prenatal acetaminophen exposure and child neurodevelopment, and they included 17 studies in this meta-analysis. And importantly, they did include sibling comparison studies.
SPEAKER_02Right. We talked about that study last year that RFK made popular that specifically excluded the sibling comparison studies, our very best studies. Again, the problem with systematic reviews and meta-analysis is that the biased author gets to choose what they include and don't include. So these folks just basically redid the study and did it appropriately and included all the data, not just the data that was favorable to some biased perspective.
SPEAKER_01Aaron Ross Powell Yeah. And when they did that, they found there was no association between acetaminophen use in pregnancy and autism spectrum disorder or intellectual disabilities of any kind.
Syphilis Testing In Pregnancy: Why It’s Hard
SPEAKER_02Right. Okay, well, we're going to have to do an episode about how folks are essentially weaponizing systematic reviews by manipulating, again, which studies are included or excluded, and by using shady methodologies to prove really whatever conclusion they want to prove. Meta-analyses and systematic reviews just don't mean what they used to be. And just as a teaser, I'll remind listeners that one high-quality level one randomized controlled trial outranks systematic reviews or meta-analysis of heterogeneous data. That's actually level two. And so it is very fair in many cases to say we have this one high-quality trial, and I don't care what the systematic review says, but we'll have to do that some other time.
SPEAKER_01I think we just did an episode showing that point, didn't we?
SPEAKER_02Touche. Yeah. But we'll go into more detail, more scientific rigor.
SPEAKER_01Okay. Sounds good. All right. Well, I've been wanting to review syphilis testing in pregnancy for a little while, just for my own edification, but I think it could also be a good topic to bring up here because it's not straightforward at all. And it's been coming up more in clinical practice lately compared to when I was in training. And ACOG recently updated its guidance about syphilis testing. There is a really great new, I think it's a clinical expert series article on this that answered a lot of my questions. Because frankly, these are hard things to reference on the fly. There's not really quick bullet points. And a lot of times when I've come across some question about syphilis in the clinic, I'll pull up the CDC guideline and it's like a hundred pages. And it's just hard to wade through in the moment. Syphilis is a weird, just different kind of bacteria. And although the disease is pretty ancient in human civilization, it was fairly rare in our populations in daily practice until recently. For some probably multifactorial reasons, it's been on the rise again. And it can be very bad for a pregnancy. So it's becoming more important and more relevant for us to be really up to speed and polish our expertise on syphilis. So what one of my basic questions was why is syphilis testing different than testing for all the other types of infections we typically test for? Like we can usually check antibodies or do a culture or something, and it's not exactly that with syphilis. We have to use indirect serology to detect it because it does not grow well in a typical bacterial culture. It's finicky, it's a sneaky type of bacteria. And it might be for those same reasons that it it's more limited. It only affects humans and it's only spread through intimate contact or like blood-to-blood type of contact, rather than being a lot more like airborne or sitting on a like you don't catch it from sitting on a public toilet seat, for example.
SPEAKER_02Well, I had somebody tell me that's how they got it. I guess that was wrong.
SPEAKER_01Oh.
SPEAKER_02Never mind.
SPEAKER_01Yeah, that's that's not right. So so it's hard, it's harder to spread, but then it's harder to detect as well. So the indirect serology that we have now is flawed and imperfect. We're basically looking for indirect, we're looking for shadows of syphilis rather than syphilis itself. So that could be an antibody that our own bodies made or a marker of cell damage from an infected cell because we can't easily look at the pathogen itself. So that's my first point. And that was one of the things addressed in this article.
SPEAKER_02Yeah, it can grow in our bodies, but it doesn't grow in the lab very well. So there is a PCR test out there, but it's not currently the gold standard for screening.
SPEAKER_01Yeah, and it's not that researchers haven't tried to find a way to culture it. Like maybe it just needs a different type of conditions. But one article I found on this, not this green journal one, but a different one, discusses the challenges. I'll just read a direct quote. Treponemopaladum is a microaerobe and is very sensitive to atmospheric levels of oxygen. And in addition, it's physically fragile and easily damaged. So the cultures have to be pipetted gently to avoid aeration of cultures or damage to the bacteria. And even seeing it under a microscope isn't definitive because it looks the same as other spirochetes. So someone could have a different type of spirochete infection, and you can't tell those apart under the microscope. So indirect methods that we do have, they all can be confounded by prior infection or false positives.
Traditional Vs Reverse Algorithms Explained
SPEAKER_02Yeah, because they're looking at indirect evidence, as you said, the shadows, not the actual suspect. So antibody tests in general are the worst tests, types of tests we have in medicine. So people have to resist the urge of thinking of antibody tests in the same way as they might think of another lab test like a CBC or a TSH. They're full of false positives and false negatives in some cases. But you have the non-treponemal tests, which are classically RPR and VDRL, and these measure biomarkers that are released when the bacteria damage the cells. These are quantitative and they're reported as a titer. And so they can help you understand the level of current disease activity because of that titer, and also compare and trend it over time. And then you have the trepanemal tests, which detect antibodies specifically against trepanemopalatum, and these are qualitative. They're either going to be positive or negative. But if someone's affected one time ever, they usually stay positive for life, even if you've had successful treatment, and the syphilis itself has been completely eliminated. So that's a problem for both tests.
SPEAKER_01Yeah. So there is a lot of morbidly interesting and some even some unethical history relating to syphilis, we might get to here. But once they finally came up with a very basic treatment, which is penicillin, then it became something a lot more uncommon to see, especially in its advanced stages. And so it's not something that that we typically tend to think of immediately when a lot of those more nonspecific symptoms present. Like if someone has a generalized rash, I've never Never had it be syphilis. And I don't think, oh, immediately syphilis at the top of my list. Usually I think allergic reaction or any other number of things that are actually more common today. But the CDC's 2024 STI surveillance report highlighted a new crisis level of infection cases. And that included a surge in congenital syphilis. And we have to view this as a public health failure because most of those congenital syphilis cases would be preventable if we had timely prenatal care and testing, because we can treat it easily with penicillin. But because the symptoms of syphilis can mimic all sorts of other diseases. So there's the rash, there's neurologic if issues, and sometimes it's asymptomatic. It's often missed in the primary care setting or the initial contact with healthcare until it's advanced, unless screening has been done. So we have to do a really good job about screening early and often, especially in pregnancy, to prevent congenital syphilis because that can be devastating. It can cause stillbirths or neonatal deaths or permanent, permanent malformations that are very serious.
SPEAKER_02Right. So we've started testing mostly now in the first at the first perenatal visit, and then again in the third, and then again upon admission to the hospital. And ACOG now endorses this. That's one of the changes recently to the practice, is getting at least three tests. And in our training, it used to be maybe just got one at the first OB visit. But then how we test can vary and is changing perhaps. So there is a traditional method, and then there's reversed screening algorithms, and that's causing a lot of confusion as well.
Managing Discordant Results And Reinfection
SPEAKER_01Yeah, and that's why it's important to understand these tests. So the traditional algorithm has the first step as the non-treponemal test, the RPR or the VDRL, which, if that's positive, can reflect to a titer. And then also if it's positive, then the next step would be to do a trepanemal test. And there are multiple options there as well, which kind of adds to the confusion. There's a TPPA, there is an FTA ABS, then there's a chemiluminescence or enzyme immunoassay. And if we start, if I start trying to read into what's the difference between all these trepanemal tests, I'm gonna start getting a headache. But the key point is they're trepanemal tests, they are qualitative only, positive or negative only. And once positive, they're positive for life. So that's one thing that they all share in common. So the pro of the traditional method is that it'll identify the active cases quickly by giving you a titer. So someone with a high titer likely is the real deal with a syphilis infection and not a false positive or not a persistent positive test result from a prior cured infection. But the con of the traditional method is it can also miss cases, especially if they're early or late in the syphilis process. And so that is one art, that's one reason why you do it multiple times in pregnancy. But now there's a reverse algorithm, which instead starts with the trepanemal test, like essentially the antibody test. And if that's positive, then the second step is doing the RPR or VDRL that can reflex to a titer. And a lot of labs are switching to this reverse algorithm because it's thought that it can catch more, it can catch more cases. It's practically easier for the lab to do their part in doing the test. They're more sensitive and they can be automated more easily. But the con is a higher rate of discordant results because remember, anyone that's ever had syphilis in the past is always gonna pop positive on this one. And then if you have discordant results where the antibody is positive, the RPR is negative, then you're gonna have to do another tiebreaker test. And that's usually a different type of trepanemal test.
History, Ethics, And Tuskegee Lessons
SPEAKER_02Okay, yeah. Clear as mud, right? Okay. I think a lot of folks have thought of the screening, this the traditional method as a screening test, meaning like your RPR and VDRL, and then a diagnostic test, as if the point of it was to save time and money by getting a screening test and then do a confirmatory test where you start with the indirect and then you move into the definitive test. Because that's what we do with HIV, where you start with a screening antibody test and then maybe you do a Western blot or something more definitive. And so people have made that analogy. But the key to this is understanding and being comfortable with the fact that's not true. Neither the direct or the indirect tests are good tests, they're not ideal tests, and they both have their limitations. The antibody tests, which have traditionally been the second step, are actually associated with more false positives, which is what's going to happen when you use a more sensitive test. So you can't think of the treponemal specific tests as definitive diagnostic tools. And really there is no definitive diagnostic test that's in itself limited to itself reliable. So we're essentially doing two lower quality tests with different sensitivities and specificities in some sequence, and the sequence has, depending on which way you do it, has its own pros and cons, and then combining them into one bigger test to get a better answer. And so it's just a question of where could you be missing cases and when is that important? So in the traditional method where we start with indirect tests, we're probably missing both some latent cases, some advanced cases, and the very early cases. She might have gotten syphilis with the same sexual contact that caused the pregnancy, and you're seeing her in the office six weeks later. And you may miss that with that initial indirect test because that cellular damage that gives off that biomarker hasn't been done yet. But you might have picked it up with a trepanema antibody test, the CIA or any of those tests. And so, but on the other hand, if they've got active disease, you may pick it up early because they have a high tider when they come in. So there's pros and cons to both of this.
SPEAKER_01Yeah, the author of that clinical expert series talks about emphasizing getting a history. And so finding out what's the sexual history, do any of their former partners have syphilis? And then also an exam to look for those classic genital ulcers and maybe even different types of rashes on the other part of the body. And again, that's not something we think about in the routine prenatal clinic, like, hey, let me check you for syphilis. But she says some people might not have the symptoms yet because the ulcers are classically painless. So that's definitely something to think about, especially if you have a higher risk population. And then so if you know that the patient has had syphilis in the past and then they've, especially if they've been treated, you really should skip that trepanemal test if you're if you're doing the reverse algorithm, because you know it's going to be positive. It's not going to help you identify a new infection or give you any new information of how to manage this patient. So you would want to start with the non-treponemal test. So the RPR typically check the titer. And at this point, we're not screening anymore that this is someone who has prior syphilis. We're looking for disease activity. And then hopefully we have prior titer values from when they completed treatment. And we can compare this new titer to the previous one. And any floorfold increase would suggest they've been reinfected or their treatment failed. Either way, they need to be treated immediately. So, for example, if the titer went from one in two, which is low, to one in eight, which is much higher, then retreat immediately. And we should always err on the side of over-treating. If we're in doubt, just treat with the penicillin. It's way better to over-treat than to miss a case and let it develop into congenital syphilis.
SPEAKER_02Yeah, I can't emphasize enough the rate of false positive uh results for both tests. And it's hard to know why someone might have a false positive in most cases, but you don't need to know why. It's not important. Pregnancy itself can cause what's called a biologic false positive. But so can lupus or recent vaccinations or IV drug use. There's lots of things. But if the trepanemal specific test is negative, then the patient doesn't have syphilis, even if they have a positive indirect test. So we have to appreciate the stigma and negative emotions that patients can have when a syphilis test comes back positive and be careful to avoid shaming them, particularly when we're going to do more tests now with reverse screening that have more false positives. But we'll put a link to that article you keep talking about. It's from the January 2026 Green Journal, and it's definitely worth reading and bookmarking for this, especially if you're dealing with a lot of syphilis, but also if you're not, because the one time you see it every year, you're going to need to go back and read.
SPEAKER_01Right. Well, I'm sure you have some great historical tidbits about syphilis.
Listener Question: Magnesium Duration Postpartum
SPEAKER_02Oh, yeah, it's an ancient disease, isn't it? So, well, because syphilis used to be more common in the population than it is now, a lot of organized medical activity, many cultures over thousands of years, has been centered around treating syphilis in some way. For some perspective, we still have less syphilis now than we did in centuries past, but we've had a recent uptake, and that's part of the urgency about this now, and we're seeing it affect pregnancies in ways that you and I haven't seen in our careers, but our grandparents certainly did. Now, okay, history number one. In the mid-19th century, there was an Irish surgeon named Abraham Caulies who noticed that a mother who gave birth to a syphilitic infant never seemed to contract the disease from her child, even when breastfeeding, but if a healthy wet nurse breastfed the baby, she would develop symptoms immediately. So eventually this gave rise to Cauley's Law, which recognized that the mothers had either immunity, which I think is what they thought, or latent infection, which is what we know. We didn't know back then at Abraham Cauley's time what the cause of syphilis was. Of course, today we understand that, in fact, the mother and the baby are infected, but the infection in the mother was just latent, but then became active in the non-cephalitic wet nurse. Before penicillin, the treatments were often much more dangerous than the disease. So mercury was very commonly used, and people would rub mercury on their skin or inhale the vapors of mercury, and this led to tooth loss and renal failure and neurologic damage itself, maybe worse than the tertiary syphilis. So there was this expression around a night with Venus, a lifetime with mercury, which I guess was meant to warn people about the dangers of sex. But mercury was used for about 400 years as a standard treatment. Also, arsenic was used. So people were desperate to do something. In the 1920s, Dr. Julius Wagner Yarig won a Nobel Prize for injecting syphilis patients with malaria. And this worked because they would get high fevers from the malaria, and that would kill the trepanema. And then once the syphilis was cured, then he would give them quinine to treat the malaria.
SPEAKER_01That sounds crazy. Like you cannot make that up. And crazier still, that actually did work, and that he won a Nobel Prize for it. But but we shouldn't get too excited about this guy's genius. If you read more about him, he had a lot of other practices and beliefs that were questionable. And seems like maybe he almost stumbled upon this treatment on accident when he was actually trying to use a malarial fever to treat mental illness. And he had a dark history with eugenics and forced sterilization and anti-Semitism during the Nazi regime, even though his first wife was Jewish and he was denied entry into the Nazi party for that reason.
SPEAKER_02Maybe he needed some malaria. Well, never fear. We eventually discovered penicillin and stopped doing crazy stuff like intentionally giving people malaria. And just in time, because syphilis spread like wildfire during World War II as troops went all around the world and prostitution was common, and then they came home and brought syphilis back. In the mid-1940s, a physician at Mayo named Wallace Harrell wrote a book called Penicillin and Other Antibiotic Agents that largely focused on treating syphilis with penicillin is standardized the approach that became popular in the 1950s and 60s.
SPEAKER_01Wallace Harrell, is there any relation?
SPEAKER_02Well, yes, in fact there is. So years ago, I contacted his son, who was still working at Mayo, and we figured out specifically how we were related. But anyway, syphilis today is very treatable. And although we're worried about emerging resistance and things like that, it's we've still got a good handle on it if we can find the cases.
SPEAKER_01So many famous people in history have had syphilis too, as people can hopefully imagine just from what we've said so far. It really is reasonable to assume that almost everybody had it, that either was sexually active or they was a wet nurse. Yeah. So Al Capone got out of prison because of his neuro syphilis. Some people think Mary Todd Lincoln had it, but we'll never know. Okay, she did.
SPEAKER_02Okay. I don't think we're going to claim it's a rule on this podcast. We're not going to claim that Mary Todd Lincoln had syphilis. We this podcast officially rejects the idea that Mary Todd Lincoln had syphilis because that would mean honest Abe had it, and we're not going to say that.
SPEAKER_01Okay. Fine. We'll cross Mary Todd Lincoln and Abe Lincoln off the list for now. But other otherwise, I think other people have to be fair game. Oscar Wilde, Vincent Van Gogh, just about every famous artist or m musician you can imagine had it at some point in their lives.
Clinical Judgment Over Dogma And Wrap
SPEAKER_02A lot of tertiary syphilis on that list. Yeah. Neuro neuro syphilis. Yep. And of course, the other historical thing that we should mention is a Tuskegee syphilis study that ran from 1932 to 1972. So for 40 years, the government tracked 600 black men, many of whom had syphilis. They didn't all have syphilis, but many of whom had syphilis. And they would help withheld treatment for syphilis, even though, of course, in that time period penicillin became available and became a sanity care. But they withheld treatment so they could observe the natural progression of the disease. And so we've talked before about this and also the forced sterilizations that occurred by the U.S. government in the 1970s. And it's always striking to me that like that wasn't that long ago. Like forced sterilizations by the U.S. government in the 1970s wasn't that long ago. But that the Tuskegee experiments are the primary reason today why we have institutional review boards and very arduous informed consent protocols for any kind of studies that we do because of the legacy of Tuskegee.
SPEAKER_01Aaron Powell And why there's so much distrust. Yeah, obviously that's very shameful.
SPEAKER_02That's why we have the sterilization consent because the U.S. government was forcing Native women to be sterilized even in the 1970s. So distrust of the U.S. government and health-related issues isn't new.
SPEAKER_01Okay. Well, do we have time for a uh listener question?
SPEAKER_02We'll fit it in. It's a good question.
SPEAKER_01Okay. All right. Well, here it is. Maybe try to shorten it. I had a patient with pre-eclampsia with severe features who I delivered. I gave her magnesium. Her blood pressures improved significantly after delivery, and she was feeling much better. So I discontinued her mag before 24 hours postpartum. She has since then recently been readmitted with postpartum preeclampsia with severe features, headache, and elevated blood pressures. The colleague of mine who readmitted her admonished me for only having done 12-ish, 12 or so hours of postpartum magnesium instead of 24. It's my understanding, though, that magnesium is seizure prophylaxis. It's not treatment for preeclampsia, nor would it have prevented her postpartum preeclampsia or her readmission. Am I wrong? Please advise, would love your thoughts. Signed musing about magnesium.
SPEAKER_02That's a good one. Musing about magnesium. Well, this is a great question. And I think a great example of how so many of us have lost our ways about understanding the evidence basis or the pathophysiology for what we do and the magnitude of effect for our interventions. Like we think that baby astrona might do something, but it doesn't do what we think it does, and tocolytics might do a little something, but not like we we have to keep in mind what the evidence basis is for what we do, because not doing so breeds dogmatism and creep of impact. So culturally, you see folks all the time act like magnesium is a treatment for blood pressure, and they might even delay blood pressure medications for the patient until the magnesium is started because they assume that the magnesium will treat the blood pressure or things like that. But it is just seizure prophylaxis. People learn dogmatically in residency that every preoclamptic should get magnesium for 24 hours postpartum, and then they believe that it has more power or more evidence or does more things than the scientific evidence would support. So they just have it drilled in their head in residency. And so I we really encourage people to learn the evidence basis for what things do and what it does and doesn't do, and how strong or how weak the evidence is. This is just a pattern for a lot of things.
SPEAKER_01Right. So it's quite a stretch to assume that the patient's continuing troubles with preeclampsia postpartum were due to not getting a few more hours of mag sulfate in the immediate postpartum period. I think maybe if she had a seizure at hour 22 after delivery and the mag was stopped before, then yes, there could be a legitimate criticism about stopping it early because the attention is to prevent seizures. But this patient in this question didn't have a seizure. She had elevated blood pressure and I guess headaches, I think they said, yeah. So we discussed way back in season three that the current ACOG bulletin does talk about continuing mag for 24 hours postpartum for preeclampsia with severe features. That was last updated in 2020. And it also discusses the fact that there's very little data about the ideal dosage of magnesium for this purpose. And the 24-hour recommendation is just based on some of the previous studies. That's the time period that they set. They weren't really studying what is the optimal amount of time. They set it as 24, and we just go by that.
SPEAKER_02Yeah. And Maddie and I last year talked about some of the studies about different dosage regimens that have existed and the two different protocols that there's disagreement over. So the problem here about the timing and duration is an issue of power, meaning powering enough data to make a definitive decision. So there are several smaller studies that show no difference between, I say, a 24-hour and a 12-hour protocol, or a 24-hour protocol and a protocol that uses some clinical criteria to discontinue it, like no need for antihypertensives and good urine output and no headache, for example. But they're all smaller studies. So in in the same way, it's with smaller studies, it's difficult to measure the untoward side effects like pulmonary edema or something that you would need hundreds or even thousands of women's in an RCT to see the difference. So the issue is that no one's ever going to do a study in all likelihood that randomizes women just for the purpose of deciding how long they should get mag, whether it's 12 hours or 24 hours. So people just stick to 24 hours to minimize the perceived legal or other risks. But there are some trials. So there was actually a study in 2025 that randomized women to 12 versus 24 hours. They had just 116 patients, but they found that the women who didn't get MAG for as long, the shorter group, well, they felt better and they did a little bit better. And they actually had three women in the 24-hour group have a seizure, but only one in the 12-hour group. But of course, it's just too small to be statistically significant. And that's the most recent of these sorts of studies, but they go way back. There are several little trials like that over the years. Fontenot in 2005 found no seizures in either arm of their small study. Maya in 2007 found no difference in seizure rates between short and long duration. A 2006 study found that as soon as the patient was starting to diurese, you could stop the MAG, and there was no difference in seizure rates. But they're all, unfortunately, smaller studies that, yeah, arguably are underpowered to find a difference in seizures. So people continue to recommend the status quo. And I also want to talk sometime this year about this inertial will of practice and how we get attached to some standard of care, maybe without evidence, think fetal monitoring or tocolytics or something like that. And then it's really hard to stop it because no one does the absolute definitive study in the limitations of something already being a standard of care to stop it. And this is an example of that. So it's a true statement to say that the 12 hour studies are under power to draw a definitive conclusion, but it's also a true statement to say that we don't have any evidence that 24 hours is better than 12 hours.
SPEAKER_01It can be a philosoph philosophical difference too. Because on one hand, someone can say there's no evidence that 24 hours is More effective and it's associated with more side effects. But someone else can look at that same information and say there's no evidence that 12 hours is equally effective and who cares about the side effects. And that difference comes up a lot on this podcast, whether people realize it or not. It's a difference between tending towards over-treatment versus under-treatment where there's any shadow of a doubt. But when it's between over or under-treatment, you always remind us first do no harm.
SPEAKER_02Yeah. Another one last year is this whole thing about who how many people should get Lovinox or or something postpartum. And it's the same kind of thing. Like even though people do studies that show that it's not helpful, other people discount the potential harms of it, like more wound infections or things like that, because maybe there's somebody it might help. And I think that's why people use tocolytics, is because even though high quality systematic studies show no benefit, well, maybe there is a one person who does benefit and to heck with the side effects or whatever. But so it is philosophical in that sense. And my philosophy is don't give an intervention, don't do a surgery, don't give a medicine, don't do anything unless you can prove that it's effective.
SPEAKER_01Well, in any event, to answer our listener question, it's common and acceptable nowadays for people to stop magnesium in stable patients at 12 hours. There's certainly no evidence or even a suggestion of evidence that it that it would have prevented this patient's readmission to continue it through the 24-hour mark. And we should also mention along these same lines, there's no evidence that giving them magnesium when they're readmitted is worthwhile. This could be another thing that we're doing to cover ourselves medico-legally just in case that patient seizures seizes during her readmission. But there are a couple of studies on this. Maybe we can also get to that some other time.
SPEAKER_02And the other thing about being overly dogmatic is there might be a patient that you continue MAGON for 30 or 36 hours. But it's 24 hours and they still they have a headache.
SPEAKER_01It's got severe.
SPEAKER_02Scotomata or whatever, like continue it. We're use your clinical judgment. And especially where the data doesn't support one way or the other, people are allowed to use their clinical judgment. And you have a patient you started magnesium on because they had a couple of elevator pressures and that was really their only symptom, and you threw them on some medicine and they delivered and their pressures are perfectly normal without meds and they're perfectly fine. Stop it at 12 hours and don't feel bad about it.
SPEAKER_01All right. Well, I think that probably does it for today. Why don't we wrap up?
SPEAKER_02More than an hour.
SPEAKER_01More than enough.
SPEAKER_02All right, we'll see everybody in a couple weeks.
SPEAKER_00Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.