1. Dysmenorrhea + menorrhagia: 
-Likely DDx: fibroids vs endometriosis (esp if +dysparenuria) vs adenomyosis vs chronic PID.
-In an adolescent who has severe menorrhagia at onset of menses, test for vWB disease-- but do so before you start OCPs, as it can compromise the results.
-OCPs treat menorrhagia, but  not dysmenorrhea.
-Mirena IUD is very effective at treating menorrhagia associated with fibroids, and threating pain (via endometrial atrophy, uterine size shrinking-- fibroids don't get smaller, but uterus overall does)
2. Treatments for PMS:
-Danazol: androgenic, with progesterone effects. Lowers estrogen, prevents ovulation-- but has pro-androgenic effects (hirsuitism, lowers HDLs, weight gain)
-GnRH agonists: like leupron/leuprolide lower estrogen and prevent ovulation, but have menopause-like side effects (hot flashes, vaginal dryness)
-Continuous or intermittent SSRIs: intermittent can take from start of luteal phase to beginning of menses (14 days), or from start of symptoms to beginning of menses or 3 days. Intermittent SSRIs at low doses are effective, compared to continuous, and have fewer side effects. Both fluoxetine and sertraline have been well studied; venlafaxine probably works too.

3. Folic acid supplements in pregnancy: 

-400ug/day if low risk

-1mg/day if mom has diabetes (interferes w folate uptake)

-4mg/day if there is high risk (family history of neural tube defect)

4. Prenatal & early pregnancy labs: 

-H&H to check for anemia 

-T&S, check for Rh antibodies if Rh-

-U/S is indicated only for dating if the patient isn't certain of her LMP

-Infectious disease screen: hiv, hep b, syphilis, gc/chlamydia, varicella/rubella titers

-1st trimester screen is offered to everyone, at 10-13 weeks 

-Quad screen - done to everyone 15-20 weeks 

5. GBS & pregnancy: 

-If mom is GBS positive: give IV penicillin during labor, 2 doses, 4 hours apart 

-If a first trimester urine screen comes + for GBS, you should treat it because there is so much GBS that it's getting into the urine

-If you do not know if a woman has GBS or not and she comes in in labor, do not presumably treat with penicillin unless the following risk factors are present: premature <37 weeks, prolonged ROM, fever in mom. 

6. Treat asymptomatic bacteriuria in pregnant ladies because there is a much higher risk of urinary reflux and pyelonephritis. The baby sitting on the bladder pushing pressure up, sitting on ureters causing obstruction and promoting reflux. 

-After treating you test to cure. 

-If someone has recurrent UTI or pyelo, they get prophylaxis for the rest of the pregnancy. 

-Tx with macrobid (bid) or Keflex (tid). CIPRO IS CONTRAINDICATED IN PREGNANCY

7. Nausea and pregnacy: 

-Progesterone is the hormone that causes hormone-driven nausea. It causes smooth muslce relaxation, which slows gut motility (evolutionary hypothesis: increase absorption of nutrients?). Additionally, progesterone relaxes the smooth muscles of uterus, preventing premature labor. It can also relax muscles in blood vessels, leading to syncope and dizziness. 

-Nausea will usually go away by second trimester. 

-Non pharmacologic treatments for early nausea: sea bands, smell of lemon, taste of ginger. Acupuncture and guided imagery are very effective as well. Naturalstandard.com is a good database of herbal remedies. 

-Pharmacotherapy for severe nausea: vitamin B6 TID, hydroxyzine, Reglan, zofran. 

-Everyone is nauseous in the third trimester, because the baby is pressing on the stomach and causing reflux. Treat this as you would treat GERD-- tums first, then H2 blockers, then PPIs. 

8. URI and pregnancy: 

-Prolonged fever in pregnancy is bad, as it leads to preterm labor 

-No NSAIDs as they could close the ductus

-Tylenol is safe

-No sudafed or other OTC cold medicines with vasoconstrictive effects

-If a pregnant woman has a viral URI, she is at increased risk of bacterial superinfection as pregnancy is an immunosuppressed state. 

9. Gestational Diabetes: 

-USPSTF recommends screening in everyone after 24 weeks, earlier 

-If someone has gestational DM, they should check their sugars 4x day, fasting and 2h postprandial, aiming for less than 95 fasting less than 120 post prand.

-Tx with glyburide, regular/NPH insulin. Metformin is OK in pregnancy. 

-If diet is really poor, can try diet changes, but diabetes is dangerous in pregnancy so don't give someone too much time, especially if it's late in the pregnancy. 

Statins and ace inhibitors are teratogens. Metformin/glyburide is ok. Get a1c under 7 with insulin. 

10. Pre Eclampsia

-Dx with 24 hr urine P-Cr ratio, and 2 BP measurements 6 hours apart, need to be systolic >160 or diastolic > 110

-There is some evidence that spot p-cr ratio may be effective in diagnosing if it is positive, but a negative spot p-cr does not rule out pre-eclampsia and you have to do the 24 hour. 

-CBC to look at platelets, LFTs to r/o HELLP syndrome. BMP to look at renal function. 

-Give mag to prevent seizures. 

-If she is seizing, give mag to break the seizure, as no other antiepileptics work in eclampsia 

-If you need to deliver, give mom IM or IV steroids to speed up fetal lung maturation; oral or inhaled steroids will not help. Be careful if there is a possible history of psychosis

-In general, in hypertension in pregnancy, the threshold to treat is 160/100. She won't stroke out with anything less, and won't have long term effects of HTN in 8 months. Labetalol, methyl dopa first line.