HY lecture notes:
External cephalic version is manual manipulation of a breech fetus into cephalic engagement after 36 weeks of pregnancy. Before this point, the fetus can spontaneously revert to cephalic engagement. There’s increased risk of uterine rupture, particularly if done after the 37th week.
Diabetic mom can cause fetal macrosomia (big baby) –> greater than 4000g –> associated with polyhydramnios –> polyuria by the fetus due to hyperglycemia –> main risk to fetus is clavicular fracture due to shoulder dystocia –> anterior shoulder gets caught behind pubic symphysis –> do McRoberts maneuver for the mom –> flexion of maternal hips + apply suprapubic pressure –> can cause vaginal laceration for the mom –> if they give you bleeding after a McRoberts, choose vaginal laceration over uterine atony, especially if they tell you the uterus is palpable and firm.
Uterine atony is otherwise the most common cause of postpartum bleeding –> do uterine massage, followed by oxytocin.
Infants of diabetic moms are at increased risk of VSD + truncus arteriosus + transposition of great vessels –> also at increased risk of:
- Hypocalcemia (increased muscle tone + QT changes on ECG)
- Hypomagnesemia (just be aware)
- Hypoglycemia (due to fetal insulin levels being high; insulin does not cross placenta; fetus received high levels of glucose from mom –> then following birth the high glucose source is removed but the fetal insulin remains high –> hypoglycemia –> jittery baby or seizure)
- Polycythemia
- Hyperbilirubinemia
“Celes”
Cystocele –> Anterior superior vaginal wall
Urethrocele –> Anterior inferior vaginal wall
Enterocele –> Posterior superior vaginal wall
Rectocele –> Posterior inferior vaginal wall
Be aware that “high on the vaginal wall” also means “superior”; “low on the vaginal wall” means “inferior.”
They have a Q floating around on obgyn form 6 where they say a woman with urine leakage per vaginum –> on physical exam the vaginal wall appears well supported, but a cotton-tip applicator placed in the urethral meatus rotates 45 degrees when the patient coughs (weird, but just know that’s urethrocele –> probably implies that despite the apparent well-supported vaginal wall, the movement of the applicator suggests the vaginal wall is still weak).
Hx of many pregnancies + downward movement of vesicourethral junction –> stress incontinence.
Tx of stress incontinence –> pelvic floor exercises (Kegel); if insufficient –> mid-urethral sling.
Hyperactive detrusor or detrusor instability –> urge incontinence.
Need to run to bathroom when sticking key in a door –> urge incontinence.
Incontinence in multiple sclerosis patient or perimenopausal –> urge incontinence.
Tx of urge incontinence –> oxybutynin (muscarinic cholinergic antagonist) or mirabegron (beta-3 agonist); do not use these drugs for stress incontinence.
Incontinence + high post-void volume (usually 3-400 in question; normal is <50 mL) –> overflow incontinence.
Incontinence in diabetes –> overflow incontinence due to neurogenic bladder.
Tx for overflow incontinence in diabetes –> bethanacol (muscarinic cholinergic agonist).
Incontinence in BPH à–>overflow incontinence due to outlet obstruction –> eventual neurogenic bladder.
Tx for overflow incontinence in BPH –> insert catheter first before antibiotics (even if there’s bacteriuria; HY!); then give alpha-1 blocker and/or 5-alpha-reductase inhibitor; then TURP if necessary.
