Student Loan Update After Supreme Court - with Mike Foley

/

We’re back once more with Mike Foley, CFP, CSLP, to bring us another update on the student loan saga. Unfortunately that forgiveness isn’t going to happen, but there are a lot of other changes upcoming… including returning to payments! Mike lays it out for us:

What are the major updates?

  • Student loans are back on - interest returning in September, with payments likely resuming in October.

  • No Biden forgiveness.

    • But no impact to PSLF rules, either.

  • New PSLF rules are active.

  • No more interest capitalization when changing repayment plans or enrolling.

  • New “SAVE” plan.

    • Replacing the REPAYE

    • Lowers the monthly payment by changing the discretionary income calculation.

      • No unpaid interest!

      • Able to file taxes separately from spouse.

      • Weighted average calculatoion for undergraduate and graduate loans:

        • 5% for undergrad

        • 10% for graduate

    • Will start later this summer.

      • Those on REPAYE will automatically switch over to SAVE

      • Married borrowers can file separately — unsure if this will recalculate payment adversely for some married borrowers.

        • Some spouses with higher loan balances could see increase in payments.

  • PAYE and ICR programs going away.

    • Tough break for those going for long-term taxable forgiveness and have loans pre-2014.

    • Also tough for those with high incomes and just a few years away from PSLF.

  • New “On Ramp” program

    • No defaults until Sept. 2024 — interest will still accrue, though.

  • Losing out on REPAYE, and then switching to IBR or PAYE strategy:

    • Limited to just 5 years on REPAYE/SAVE to get interest subsidies before losing out on being able to switch to a plan that can be done in 20 years like the new IBR or PAYE.

    • Those who have loans pre-2014 — need to switch to PAYE or forever hold your peace!

What should we do before loans turn back on?

  • Update your contact info at student aid.gov and with your loan servicer.

  • Link your bank account to your new loan servicer — likely changed during COVID.

  • Check your payment amount due on your loan servicer website.

    • Don’t just automatically rectify your income — earliest you need to rectify if already enrolled in a program would be 6 months after payments resume — so you may be able to make payments still based on your 2019 income!

Any loopholes to look out for?

  • Are you unemployed during the summer between residency/fellowship and your job?

    • May be a good time to re-certify while you’re unemployed.

  • Are you looking to pay off your loans?

    • May want to consider reporting lower income for a few years while you can, to take advantage of interest subsidies through new SAVE program.

  • Did you work for a qualifying PSLF institution prior to med school while you had undergrad loans outstanding?

    • Potentially able to consolidate loans and get PSLF or IDR credits, if you complete before end of year.

Getting in touch:

More info:

Disclosure:

Michael is a comprehensive financial advisor who runs his practice out of Scottsdale, Arizona, under North Star Resource Group. Michael was trained at Duke University and holds his Certified Financial Planner designation alongside his Certified Student Loan Professional designation. Although Michael serves a diverse group of clients with their financial and student loan needs, with two physician parents, Michael has found a specialty in working with those in the healthcare space.  Michael is a registered representative and investment advisor representative of Securian Financial Services. Securities and investment advisory services offered through Securian Financial Services, Inc. Member FINRA/SIPC. North Star Resource Group is independently owned and operated. 6720 N Scottsdale Rd Ste 290, Scottsdale, AZ 85253. Financial Professionals do not provide tax or legal advice and this should not be considered as such. Please consult a tax or legal professional for advice regarding your specific situation.

Common Aneuploidies

/

Additional episodes that might be helpful for today:

What is aneuploidy?

  • The occurrence of one or more extra or missing chromosomes leading to an unbalanced complement.

  • Screening for aneuploidy occurs with either serum screening or cell free DNA.

    • Diagnostic testing for aneuploidy is done with chorionic villus sampling or amniocentesis.

      • As we discussed on the screening 2 episode; fluorescent in situ hybridization (FISH) can evaluate initially for common aneuploidies.

      • Karyotypes are the confirmatory testing for common aneuploidy, as well as other ways to get aneuploidy we’ll review (triploidy, balanced translocations).

      • Microarray can find other major aneuploidies, but can’t find triploidy or balanced translocations.

How does aneuploidy occur?

  • Meiosis is the process of cell division that produces gametes – eggs and sperm. 

    • Goal is to create daughter cells with a haploid chromosome number (in humans – 23).

    • The two gametes generally fuse to create a diploid zygote with 46 chromosomes.

      • If there’s an issue in the cell division process for a gamete, they may come into this fusion with an extra or missing chromosome.

    • Remember in cell division, we have multiple phases: prophase, metaphase, anaphase, telophase.

      • We’ll break it down simply into the stages you need to remember to get those bonus points!

  • Meiosis is broken into two phases: meiosis I and meiosis II.

    • In meiosis I, the starting cell is diploid – but after replication, ends up with 4n chromatids (held in 2n chromosome pairs, or sister chromatids). 

      • In prophase I, each pair of chromosomes lines up and matches with a homologous partner. This allows for the phenomenon of crossing over, where homologous portions of the chromosomes can rearrange and exchange portions of their DNA.

        • This is where things can get dicey for a particular type of uncommon aneuploidy, known as a translocation. 

          • That is, rather than recombining with a portion of the homologous chromosome, it attaches to a different chromosome.

          • These translocations can be:

            • Balanced, where the genetic information is not gained or lost, but just rearranged differently. 

              • So for example: A piece of chromosome 21 joins onto chromosome 14, and a piece of chromosome 14 joins onto the break at 21. 

                • The cell at this point still technically is diploid – but there can be problems with this later on!

            • Unbalanced, where the genetic information is split unequally.

              • In the same example: a piece of chromosome 21 joins onto 14, but the piece from 14 is lost.

          • A particular type of translocation is known as a Robertsonian translocation, which is where the full long arms of two acrocentric chromosomes are joined together.

            • The acrocentric chromosomes are where the short arms are extremely short - these are 13, 14, 15, 21, and 22 in humans.

            • One of the most discussed is a 14:21 translocation, which is responsible for some Down syndrome.

              • These translocations typically result in familial cases of aneuploidy, as a parent may be a balanced carrier of an abnormal chromosome – issues don’t arise for aneuploidy until they start trying to have children, and the chromosome complement ends up unbalanced in offspring.

      • In the female reproductive cycle, eggs arrest in the cell cycle at prophase I, and only complete the remainder of meiosis prior to that egg’s ovulation.

        • So an egg can be arrested for 30-40 years! 

        • Ultimately, with this extended pause, meiosis I in oocytes is where the majority of nondisjunction events occur.

      • To complete meiosis I:

        • Metaphase I: the homologous pair lines up across the metaphase plate (like a cell equator) to prepare for division

        • Anaphase I: the homologues are separated to the opposite ends of the cell

          • Or not, if they can’t be separated! – This is nondisjunction.

        • Telophase I: the new cells are haploid in chromosome pairs.

    • We then move to meiosis II, where the sister chromatids are split into haploid pairs:

      • Metaphase II: the sister chromatids line up across the metaphase plate.

      • Anaphase II: the sister chromatids are separated to the opposite ends of the cell.

        • This is another point where nondisjunction can occur (less common than in meiosis I, though)!

      • Telophase II: the new cells are haploid with 23 single chromosomes (no longer in pairs).

The robertsonian translocation and gamete production

Trisomy 21: Down Syndrome

  • Syndrome resulting from the addition of an extra chromosome 21. 

  • Most common aneuploidy: affects about 1 in 700 births in the USA.

  • Occurs via:

    • Nondisjunction event: 95% of occurrences

    • Robertsonian translocation: 5% of occurrences

    • Mosaicism: infrequent (~1-2% max)

      • This is where some cell lines have aneuploidy, and others do not. This occurs usually in early mitosis of the zygote, where the embryo during cell division recognizes the extra chromosome and tries to “kick it out” with aneuploidy rescue. We won’t spend too much time on that today! 

  • Prenatal testing characteristics of trisomy 21:

    • Cell free DNA: excellent test performance with 99% sensitivity and specificity.

      • However, false positives still occur frequently, particularly in low-prevalence populations (i.e., around 50% false-positive risk in women aged 25).

    • Serum screening: 

      • Low msAFP

      • Low estriol

      • High HCG

      • High inhibin A

    • Ultrasound:

      • 1st trimester: elevated NT (64-70%), absent/hypoplastic nasal bone.

      • 2nd trimester:

        • Various soft markers all have significance for T21: pyelectasis, echogenic bowel, echogenic cardiac focus, short femur.

        • Most significant soft marker: thickened nuchal fold (LR 11-18 for T21)

        • Practically pathognomonic findings:

          • “Double bubble sign” – duodenal atresia - familiarize yourself with this ultrasound as it’s very commonly tested!

          • Cardiac anomalies in ~50% – particularly significant / common are atrioventricular septal defects.

DOUBLE BUBBLE - RADIOPAEDIA

Trisomy 18: Edward syndrome 

  • Syndrome resulting from additional chromosome 18.

  • Frequency: about 1 in 2k - 6k live births in USA.

  • Occurs via:

    • Nondisjunction event: over 95% of cases

    • Mosaicism: around 4-5% of cases

    • Translocations: rare, but has been reported.

  • Prenatal testing characteristics:

    • Cell free DNA: good, with over 96% sensitivity and over 99% specificity.

      • However, given its infrequency, the positive-predictive value can still be low – 40% PPV in a woman at age 35. 

    • Serum screening:

      • All analytes decrease (though inhibin A can be normal).

    • Ultrasound:

      • 1st trimester: elevated NT, absent / hypoplastic nasal bone.

      • 2nd trimester: multiple characteristic signs:

        • Choroid plexus cysts are the most common soft-marker (though non-specific)

        • “Strawberry skull” – flattened occiput, pointed frontal bones

        • Clenched hands with overlapping fingers

        • Rocker-bottom feet

        • Cardiac anomalies

        • Esophageal atresia, diaphragmatic hernias

        • Growth restriction

STRAWBERRY SKULL

Trisomy 13: Patau syndrome

  • Syndrome resulting from additional chromosome 13

  • Frequency: about 1 in 10k-16k live births in USA

  • Occurs via:

    • Nondisjunction event: most common

    • Chromosome 13 is one of the acrocentric chromosomes so Robertsonian translocation can occur and familial forms have been reported.

    • Mosaicism is also possible.

  • Prenatal testing characteristics:

    • Cell free DNA: similar story to trisomy 18. Sensitivity is around 91% and specificity over 99%.

      • Given the low prevalence, positive-predictive values can still be low – around 20% for a woman at age 35. 

    • Serum screening:

      • No well-defined pattern, but elevated msAFP may be present given common CNS and other anomalies present in this syndrome.

    • Ultrasound:

      • 1st trimester: elevated NT, absent / hypoplastic nasal bone

      • 2nd trimester: multiple characteristic signs, but remember: midline and CNS are classic:

        • Holoprosencephaly: failure to divide brain into cerebral hemispheres (so no midline falx cerebri)

        • Facial anomalies: cleft lip/palate, proboscis, micropthalmia/anopthalmia or cyclops eye

        • Cardiac abnormalities - up to 80%

        • Omphalocele

        • Enlarged echogenic kidneys or horseshoe kidney

ALOBAR HOLOPROSENCEPALY - RADIOPAEDIA

Monosomy X: Turner Syndrome

  • Syndrome results from a missing sex chromosome - so 45, XO.

    • 80% of the time this is paternally derived – one of the few circumstances this is the case!

  • Frequency: 1 in 2k-5k live births

  • Occurs via:

    • Nondisjunction event: most common

      • On the paternal side, given the mismatch of X and Y, the Y chromosome can be subject to “getting lost” in meiosis.

    • Mosaicism can also occur with Turner syndrome in about 50% of individuals

      • Cell lines are able to be mixed as 45, XO/46, XX, or 45, XO / 46, XY most commonly

        • If Y chromosome is detected, gonadectomy is advised to reduce risk of gonadoblastoma in later life. 

  • Prenatal testing characteristics:

    • Cell free DNA: overall has about 90% sensitivity and over 99% specificity.

      • Similarly: PPV is limited by prevalence

      • cfDNA also has difficulty with mosaicism and delineating this specifically. 

    • Ultrasound:

      • The most commonly tested finding: cystic hygroma

        • Present in 1st and/or 2nd trimester

        • Can also present with more generalized edema

      • Horseshoe kidney, cardiac abnormalities may also be present.

CYSTIC HYGROMA - RADIOPAEDIA

Constipation

/

What is constipation?

  • Infrequent and difficult defection.

    • Formally, constipation gets defined as three or fewer bowel movements per week.

  • In North America, chronic constipation is quite prevalent: estimated around 15%.

  • Chronic constipation is more prevalent in females, and in those over age 65.

    • However, pregnancy is another common time period for constipation to occur.

  • Before we get too deep into a discussion on stool, know we’ll be making mention today of the Bristol stool chart. 

    • Many of the diagnoses and considerations surrounding constipation, diarrhea, and IBS use this scale. It’s worth reviewing – probably the last time you looked was medical school! We’ll have one on the website.

WIKIPEDIA

Here are actual criteria to make a diagnosis of functional constipation known as the Rome IV criteria:

  • Functional constipation must be three months with:

    • 1) Loose stools rarely present without the use of laxatives

    • 2) Insufficient criteria to diagnose irritable bowel syndrome (IBS)

    • 3) Two or more of the following symptoms:

      • Straining during more than 25% of defecations

      • Lumpy or hard stools (Bristol scale 1 or 2) in more than 25% of defecations

      • Sensation of incomplete evacuation for more than 25% of defecations.

      • Sensation of anorectal obstruction/blockage for more than 25% of defecations.

      • Manual maneuvers to facilitate more than 25% of defecations (i.e., splinting or digital evacuation)

      • Fewer than three spontaneous bowel movements per week.

  • In terms of causes, there are three broad categories:

    • Normal transit constipation, which includes functional chronic constipation and IBS. 

    • Slow transit constipation, which can be due to a variety of factors like: 

      • medications that slow colonic transit (i.e., opioids) or 

      • medical disorders or conditions such as different systemic or neuromuscular diseases (i.e., severe diabetes, anorexia nervosa, pregnancy) or diseases of the colon (i.e., colorectal cancer, Hirschsprung’s disease)

    • Pelvic floor disorders, such as pelvic floor dysfunction after injury or trauma, or pelvic organ prolapse.

  • Constipation is usually not a life-threatening issue.

    • It is a major quality of life issue though!

    • Severe constipation can lead to colonic dilatation and perforation.

How to approach the patient with constipation

  • Start with history:

    • Get a sense of the problem, and whether there might be any major red flags:

      • Evaluate medications that may slow colonic transit.

        • Common meds that slow transit include:

          • Opioids, 

          • Antihistamines, 

          • Certain antidepressants and antipsychotics, 

          • Iron supplements,

          • Aluminum-based antacids, 

          • Serotonin antagonists (i.e., ondansetron/Zofran), 

          • and some antihypertensives like calcium channel blockers (i.e., nifedipine).

      • Ask about major red flags for colon cancer:

        • Presence of hematochezia, or positive fecal occult blood tests

        • Weight loss of > 10 lbs

        • Family history of colon cancer or inflammatory bowel disease

        • Acute onset of constipation particularly in older adults

      • Consider other medical conditions that may contribute to constipation, depending on the patient’s age and medical status:

        • Diabetes mellitus or other neuropathic disorders

        • Multiple sclerosis, Parkinson disease

        • Spinal cord injuries

        • Hypothyroidism

        • Pregnancy

        • Panhypopituitarism (i.e., Sheehan syndrome after postpartum hemorrhage)

        • Irritable bowel syndrome

          • IBS specifically encompasses abdominal pain that is recurrent, and can be associated with changes in stool (diarrhea or constipation).

          • The Rome IV criteria for IBS are having > 1 day per week of recurrent abdominal pain for at least three months, along with two or more of the following:

            • The pain is related to defecation (either increasing or relieving pain)

            • The pain is associated with a change in stool frequency

            • The pain is associated with a change in stool form (appearance on Bristol scale)

  • Consider a physical exam:

    • In most patients, a general physical exam is not super helpful.

    • A pelvic and rectal exam may be quite useful in those with chronic constipation:

      • Can identify evidence of chronic constipation, such as skin tags, fissures, hemorrhoids, or a fistula near the anus.

      • Can evaluate for prolapse and pelvic floor dysfunction.

        • Inspecting the anus, can ask the patient to squeeze like they’re holding a bowel movement to look for contraction of the sphincter and gluteal muscles.

        • Check for anal wink reflex to make sure sacral nerves intact.

        • Digital rectal exam to assess rectal tone, tenderness, and relaxation when finger is expelled.

  • In most patients with new complaints of constipation and no red flag symptoms, a trial of laxatives is appropriate before other major diagnostic workup.

    • Talk more about laxatives and treatments later!

  • If your patient needs some additional testing, others to consider (though probably with our GI colleagues!)

    • Anorectal manometry: a probe with sensors in the rectum to measure rectal and anal pressure, and the gradient with evacuation and squeeze. Similar in principle to urodynamics in urogynecology.

      • Can be accompanied with various tests such as a balloon expulsion test or balloon rectal sensitivity test, which can provide additional information.

    • Defecography: a radiocontrast study to evaluate what occurs during evacuation of rectal content to look for signs of prolapse or obstruction.

    • Sitz marker study or Nuclear medicine scintigraphy: radioopaque markers or tracers are swallowed and radiographs taken at certain intervals to evaluate transit within the bowel and colon.

Treating Constipation

  • There are loads of treatment options for constipation, so we’ll break them down mechanistically.

  • Fiber

    • First line treatment, and soluble fibers are recommended (beans, psyllium, oat bran, barley)

      • Soluble fibers attract water and turn to a gel-substance during digestion.

      • Insoluble fibers (wheat bran, vegetables, whole grain) add bulk to stool and help food pass more quickly.

        • Soluble fibers are generally preferred for constipation and are what are sold as supplements (i.e., psyllium is Metamucil and Benefiber). 

        • Soluble fibers can increase gas production though, and so in those with IBS and slow-transit constipation, it can be difficult to encourage compliance.

          • This can be modulated by starting with small amounts and slowly titrating upwards.

    • Recommended daily intake is >25g/day for women, and >35g/day for men.

  • Osmotic laxatives

    • These laxatives act as hyperosmolar solutions that are not systemically absorbed, and thus add water into the stool in order to increase stool frequency.

      • Examples: polyethylene glycol (GoLytely, MiraLax); lactulose; sorbitol; milk of magnesia, magnesium citrate.

    • They are highly effective and titratable to effect.

    • Excess use in patients with renal and cardiac dysfunction can lead to electrolyte abnormalities.

  • Stimulant laxatives

    • These alter electrolyte transport mechanisms in the intestinal mucosa, thus increasing their motor activity.

      • Examples: bisacodyl (Dulcolax), senna, sodium picosulfate

    • They are generally well-tolerated, but can produce abdominal discomfort in some patients due to the “irritation” effect on the intestines.

      • Some of these can be associated with developing hypokalemia, salt depletion, and significant enteric protein-wasting, so are not encouraged to be used chronically.

    • Some folks can develop tolerance to these medications, so are also not encouraged to be used chronically so that tolerance does not develop.

  • Biofeedback and Pelvic Floor Treatment

    • Pelvic floor PT, biofeedback training, and pelvic floor therapies with colorectal surgeons or urogynecologists can also be effective, especially if patients have symptoms of rectocele.

    • Other positioning tools for pelvic floor dysfunction include things like the “squatty potty” to encourage puborectalis muscle / sphincter relaxation.

  • Suppositories, Enemas, and Disimpaction

    • Bisacodyl suppositories are easy to use and can be considered first.

      • They can effectively liquefy stool and clear impaction in the rectum.

    • Various enemas exist: tap water, mineral oil, soap suds, phosphate, milk & molasses)

      • It is most important to focus on side effects - i.e., fleets enemas (phosphate) can lead to hyperphosphatemia, particularly in patients with kidney disease.

    • Manual disimpaction

      • Never fun, and not a lot of guidance on the best method – break stool up with your well-lubricated finger, and extract it, until the hardened stool is cleared.

      • Best followed up with a mineral oil enema or milk and molasses enema – will soften stool and provide lubrication.

        • If disimpaction is not successful, water-soluble contrast enema should be considered with fluoroscopy to evaluate for obstruction and rarely GI may need to be consulted for flexible or rigid sigmoidoscopy to evacuate stool.

  • What about docusate (Colace)?

    • Not the best evidence… likely no impact.

    • Journal of Hospital Medicine 2019: Things We Do For No Reason: Prescribing Colace for Constipation in Hospitalized Adults

      • Potentially over $100 million spent on colace annually across North America in hospitalized populations.

      • Multiple negative studies in randomized trials show that it does not improve or prevent constipation.

      • Recommend de-implementing it from order sets and hospital formularies.

Diabetes V: Intrapartum and Postpartum Glucose Management

/

Great! Your patient is here in labor or for induction… now what?

  • Glycemic goals - why do we have them and what are they? 

    • Why do we have them? 

      • It is a good idea to avoid hyperglycemia in labor due to risk of fetal hypoxemia and neonatal hypoglycemia 

      • Fetal hypoxemia 

        • Some evidence that fetal hypoxia can result from diabetes with uncontrolled blood sugars 

        • Also increased blood sugars that lead to ketoacidosis can increase fetal acidosis and hypoxia 

      • Neonatal hypoglycemia 

        • Increased maternal blood sugars increases fetal production of insulin 

        • High levels of insulin after delivery with no exposure to maternal blood sugar → hypoglycemia and NICU admission 

    • What are they? 

      • Initially, there was recommendation by ACOG that blood sugar be between 60 -100 mg/dL

      • However, there was a study that showed that tight control maternal control did not results in better initial neonatal glucose concentrations compared to a more liberalized management strategy 

      • Hamel H et al 2019, Obstet Gynecol: https://pubmed.ncbi.nlm.nih.gov/31135731/

      • The goals can be different depending on your institution, but based on the above study, the goal is to be between 60 - 120 mg/dL 

      • Based on ACOG’s Practice Bulletin, goal should be <110 mg/dL 

  • How often should we monitor blood sugar? 

    • ACOG recommends checking blood sugar levels q1 hour in active labor 

    • If not on an insulin drip and during labor, please follow the protocol at your hospital, as certain hospitals have adopted a more liberalized form of glucose management 

    • One example of protocol: 

      • If not in active labor, can check blood sugar every 4 hours 

      • In active labor, can check every 2 hours, but if needs treatment → recheck in 1 hour after treatment 

    • If we follow Hamel et al’s protocol, the plan is to check every 4 hours, but to check more frequently if treatment is needed 

Example protocol - acog practice bulletin, pregestational diabetes mellitus

Treating Hyperglycemia

  • Use insulin! 

      • Coming in for scheduled induction/cesarean: we usually ask patients to take half the dose of long acting insulin.

        • Example: patient is on 20 NPH during the day and 40 NPH at night. They are coming in for a 7 am induction and will not be eating much during labor 

        • Patient should be instructed to take 40 NPH the night prior (to help with fasting), and can be given or should take 10 u NPH that morning, as patient likely will not be eating much during the day they are being induced 

        • Do not take short acting insulin the day of if patient is not eating 

    • In patients who come in laboring:

      • Ask patients what insulin they have taken that day 

      • If still in labor and time for long acting insulin, if patient is not eating, can plan for half of the long acting insulin 

    Ok, so that takes care of long acting insulin, but what if the patient is having elevated blood sugars during labor? 

    • Short acting insulin 

      • If a patient is having elevated blood sugars above protocol, they can be given short acting insulin to bring down their blood sugars 

      • How much to give: 

        • This will come down to the patient, but this is a good time to remember the rules we taught you before! 

        • Type 1s: use the rule of 1800: 1800 / TDD insulin (units) = expected ICF

        • Type 2/GDM: use the rule of 1500: 1500 / TDD insulin (units) = expected ICF

          1. So if I’m taking 50 units total of insulin per day, as a T2DM/GDM I would have a correction factor of 30 - meaning 1u of insulin would bring my blood sugar down about 30 mg/dL

          2. This is helpful for the floor - if you need to cover someone, knowing their total daily insulin dose (or approximating using their weight) can help you provide more reliable amounts of insulin. 

        • You may also have protocols within your hospital with certain types of sliding scales 

    • Insulin drip 

      • Who needs an insulin drip? 

        • Patients whose blood sugars are difficult to control 

          1. Very high blood sugars (>200 mg/dL) 

          2. Those who require multiple treatments with short acting insulin (> 2 times, usually)

          3. Those who have an insulin pump that cannot be used in the hospital 

      • How do I manage an insulin drip? 

        • Most of the time, insulin drips should be co-managed either with endocrinology or with MFM - so ask for help! 

        • We cover this in our episode for diabetic ketoacidosis!

        • As a brief overview: the insulin in a drip is usually regular or rapid-acting insulin 

          1. Most of the time, if the blood sugar is <200mg/dL, there is a protocol in the hospital to follow for labor 

          2. Can usually start at 1-1.5u/hr, but if patient is in DKA or has very high blood sugars, can also start at 0.1u/kg/hr or even first start with a bolus of 0.1u/kg 

        • Blood sugar should be checked every hour and insulin drip can be adjusted up and down by 1u/hr depending on blood sugar control 

  • Hypoglycemia - Low blood sugars 

    • If patient is not eating or patients with T1DM, they will need to placed on some form of dextrose so that they do not go into DKA; pregnant patients are also more likely to be in euglycemic DKA 

    • Again, there is usually a protocol in the hospital, but these patients should be placed on D5NS if not eating and in active labor or if blood sugar drops <70 mg/dL 

    • These can follow the usual maintenance fluid calculations, using the 4-2-1 formula for how much fluid is needed per hour 

      • 4 mL/kg/hr for the first 10 kg 

      • 2 ml/kg/hr for the second 10 kg 

      • 1 ml/kg/hr for the remainder 

      • Example 

        • For a patient who weighs 70kg: 

          1. 40 ml/hr (4*10) + 20 ml/hr (2*10) + 50 ml/hr (1*50) = 110 ml/hr 

    • Another method to calculate is 2.5mg of dextrose/kg/min 

    • For everyone who is getting insulin, you should order an as needed D50 injection or D25 injection depending on what your hospital has 

      • This is in the event of acute hypoglycemia or who may be unresponsive and not able to take PO 

    • If someone is able to take PO, you should follow the 15/15 rule: basically, consume 15g of glucose and check blood sugar in 15 minutes 

      • Usually 3 glucose tablets 

      • Approximately 4 oz of regular juice or soda

Let’s say we get our patient through labor and birth … what about the postpartum period? 


  • Insulin requirements postpartum 

    • Insulin requirements go down significantly postpartum, especially if the patient is breastfeeding 

    • If the patient was on insulin prior to pregnancy, they should return to their prepregnancy insulin regimen 

    • If patients were not on insulin, but were diagnosed with T2DM during their pregnancy, then during recovery in the hospital, our general recommendation depends on pre-pregnancy or early pregnancy A1C 

      • For T2DM, patients with A1C > 9.0%, they should generally stay on insulin 

      • If <9.0%, then can have discussion with endocrinology and MFM to try oral medications, and would need to be safe during breastfeeding if patient desires to breastfeed 

        • Hopefully this plan was made as an outpatient! 

      • General consensus for continuing insulin is to half their long acting insulin and then put them on a sliding scale 

      • After approximately 24 hours, calculate how much sliding scale they needed, and this can be turned into short acting insulin if needed 

      • Consult endocrinology and MFM for guidance, and also make sure patient has endocrinology or PCP follow up 

Persistent Vulvar Pain

/

Reading: Committee Opinion No. 673 - Persistent Vulvar Pain 

What is persistent vulvar pain? 

    • Persistent vulvar pain is a complex disorder and often very frustrating to both the patient and the provider 

    • Because it is difficult to treat and even with appropriate treatment, pain may not resolve completely 

  • Terminology and Classification - from 2015 Consensus Terminology and Classification of Persistent Vulvar Pain 

    • From the International Society for Study of Vulvovaginal Disease: 

      • Can be caused by a specific disorder or it can be idiopathic 

      • Idiopathic vulvar pain = vulvodynia

    • Vulvar pain caused by specific disorder: 

      • Infectious (ie. recurrent candidiasis, herpes) 

      • Inflammatory (lichen sclerosus, lichen planus, etc.) 

      • Neoplastic (ie. Paget disease, SCC) 

      • Neurologic (postherpetic neuralgia, nerve compress or injury) 

      • Trauma

      • Iatrogenic (postoperative, chemotherapy, radiation) 

      • Hormonal deficiencies (ie. genitourinary syndrome of menopause, lactational amenorrhea) 

    • Vulvodynia = vulvar discomfort, most often reported as burning pain, which occurs in the absence of relevant visible findings or a specific, clinically identifiable neurological disorder for at least 3 months 

      • Descriptors 

        • Localized (ie. vestibulodynia, clitorodynia), general, or mixed (can be localized or generalized) 

        • Provoked (ie. insertional, contact), spontaneous, or mixed (provoked and spontaneous) 

        • Onset (primary or secondary) 

        • Temporal pattern (intermittent, persistent, constant, immediate, delay) 

How do we evaluate what the cause of vulvar pain is? 

  • Exclude other causes before assigning vulvodynia 

    • Vulvodynia = diagnosis of exclusion 

  • History

    • Do your normal OPQRS – how long has the patient been having pain? Where is it? 

    • Also obtain medical and surgical history

    • Sexual history - make sure to ask permission 

    • Allergies 

    • Previous treatment 

  • Physical exam 

    • Know your anatomy!  

UPTODATE

  • Cotton swab test

    • Using a cotton swab and moving across the labia → start on thighs → labia majora → interlabial sulci. Then test vestibule in the 2, 4, 6, 8, 10 o’clock position 

  • R/o infection  

    • Wet mount, vaginal pH, fungal culture, and gram stain 

  • Vulvoscopy - usually not needed 

  • If there is concern, you can also biopsy an area - can find dermatoses 

  • Musculoskeletal evaluation 

    • Palpation of the different muscles within the pelvis to see if there is referred pain

    • Palpation of the pubovaginalis portion of the levator ani, obturator internus, and urethrovaginal sphincter 

Treatment 

  • Unfortunately, the evidence for treating vulvodynia is based on clinical experience and observational studies - few randomized studies exist 

    • If there is obvious cutaneous or mucosal disease present 

    • If there is not, do the cotton swab test 

      • If no areas of tenderness then consider alternative diagnosis 

      • If there is tenderness or burning with cotton swab test, do a yeast culture 

        • Positive yeast culture: antifungal 

        • If negative, or if antifungal does not provide adequate relief, move to:

          • Vulvar care measures

            • Cotton underwear and no underwear at night 

            • Avoid vulvar irritants and douching 

            • Mild soaps for bathing, or anti-allergenic soaps, do not apply directly to vulva 

            • Apply preservative free emollient (ie. coconut oil) 

            • Switch to 100% cotton menstrual pads 

            • Use water based lube for intercourse 

            • Cool gel to vulvar area for relief 

          • Topical medications - ie. estrogen cream, tricyclic antidepressants can be compounded 

          • Oral medications - TCAs and anticonvulsants; use one drug at a time 

            • TCAs should be used for up to 3 weeks to assess adequate pain control 

          • Injections (ie. botox for trigger point injections, can also use steroids for trigger point injections ) 

          • Biofeedback/physical therapy - assess for pelvic floor dysfunction 

          • Dietary modification 

          • CBT 

          • Sexual counseling 

        • If still no adequate relief and localized pain → can consider surgery with vestibulectomy 

          • Should only be done if other treatments have failed 

          • Success rate is 60-90% compared to 40-80% for nonsurgical interventions 

        • If generalized pain - consider increasing the dose of medication, combining meds, etc.