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Female reproductive system

Central nervous system Hypothalamus Pituitary Ovaries Uterus, breasts, skin, vagina

Duration of the normal menstrual cycle Modal duration Duration of menstruation Blood loss during normal menstrual cycle

from 21 to 35 days 28 days from 2 to 8 days from 30 to 80 ml

Estrogen 1. Causes proliferation of endometrium and vaginal epithelium. 2. Increases excitability of myometrium. 3. Increases secretion of cervical mucus. 4. Causes uterine growth in pregnancy. 5. Promotes development and growth of ductal system on mammary glands. 6. Promotes production of prolactin during pregnancy. 7. Together with gonadotropins stimulates growth of ovarian follicle and release of ovum. 8. Stimulates LH surge at menstrual cycle. 9. Causes sodium and water resorption from kidney tubules. 10. Promotes calcium metabolism and bone growth.

Progesterone 1. Promotes secretory changes in endometrium. 2. Decreases secretion of cervical mucus. 3. Promotes deposition of glycogen in endometrium. 4. Influences transport of fertilized ovum into uterus. 5. Promotes development of lobules during pregnancy in preparation for lactation. 6. Causes development and growth of corpus luteum during menstrual cycle and pregnancy. 7. Increases basal body temperature by 0,4-0,6 °C after ovulation.

FSH 1. Initiates and stimulates development of ovarian follicles. 2. Promotes estrogen production and secretion by ovarian follicles. 3. Increases production of collagenasa ensyme, which is responsible for ovulation. 4. Promotes production of aromatasa ensyme, which converts androgens into estrogens.

LH 1. Causes final growth of graafian follicle. 2. Stimulates ovulation. 3. Aids in formation of corpus luteum from ruptured follicle. 4. Promotes production of progesterone by the corpus luteum.

GnRH 1. Increases production of FSH and LH, if their blood level is low. 2. Maintains normal cycle function of the entire female reproductive system by means of periodical surges.

Physiologic adaptation during pregnancy
Period from conception to delivery 40 weeks long 280 days 10 obstetrical months One obstetrical month is one moon month and consists of 28 days

Reproductive system Weight of uterus Volume of uterus Breasts increases from 70 g to 1200 g increases from 10 ml to 6 liters become larger and darker

Cardiovascular system Size of heart Workload of heart Cardiac output Murmur Blood volume Ratio of plasma to red cell mass Hemoglobin or hematocrit Cardiac output Venous pressure in lower extremities Pulse rate Blood pressure increases increases increases may be present increases by 50 % increases decreases increases up to 30 % increases increases from 70 to 85 decreases before 20 w. may increase after 20 w.

Respiratory system Subcostal angle Transverse diameter of thoracic cage Level of diaphragm Tidal volume Respiratory rate during delivery Minute volume Oxygen consumption becomes wider increases by 2 cm rises by 4 cm rises from 500 to 700 ml increases by 50-60 increases by 37 % increases by 14 % Urinary system Kidneys Peristaltic activity Glomerular filtration Protein and glucose Body weight become heavier, larger decreases increases by 30 to 50 % may be found in urina increases by about 10 kg Musculoskeletal system Woman’s center of gravity Lordosis Aching, numbness, weakness Neck Shoulders is displaced increases may be present is flexed are slumped Renal calyces, renal pelvis and ureters are dilated

Sacroiliac, sacrococcygeal, pubic joints are soft, mobile Skin Skin pigmentation Chloasma Striae increases may be present may be present

Endocrinology of pregnancy Estriol rises 1000 times leads to increase uteroplacental blood flow increases uterine motility Progesterone suppresses maternal immunology prevents rejection of trophoblast decreases uterine motility relaxes smooth muscles stimulates endometrial decidual cells Human Chorionic Gonadotropin (HCG) increases before 20 weeks decreases after 20 weeks supports corpus luteum Human Placental Lactogen important for metabolic processes increases levels of insulin in woman supplies nutrients to fetus Prostaglandin E2 is contained in uterine cervix, amniotic fluid softens uterine cervix Prostaglandin F2a is contained in myometrium, fetal membranes promotes cervical dilatation promotes contractions of myometrium Prolactin Oxytocin stimulates lactation is produced by hypothalamus stimulates uterine contraction increases intensity of contraction stimulates milk ejection

Causes of delivery start
Uterine stretch theory Pressure theory Placental aging theory Changes in estrogen/progesterone ratio Prostaglandins stimulate the onset of labor

Etiology of congenital malformations: 1. genetic: chromosomal abnormalities or mutant genes 2. environmental: infection, radiation, chemicals, maternal disease 3. multifactorial: interaction between genetic and environmental influences Birth defect = congenital malformation = congenital anomaly

Classification of birth defects Malformation complete or partial absence of a structure alterations of its normal configuration occurs at 3th to 8th week Disruptions morphological alteration of already formed structures occurs during II and III trimesters Deformations mechanical force on part of fetus occurs during II and III trimesters

Alcohol At least one characteristic from each of the following three categories must be present for diagnosis of the alcohol syndrome: 1. Growth retardation before or after birth. 2. Facial anomalies, including microcephaly, microphtalmia or short palpebral fissures, maxillary hypoplasia, thin upper lip. 3. Central nervous system dysfunction (neurological abnormality, mental deficiency, developmental delay).

Smoking 1. Reduced birth weight 2. Spontaneous abortion (SAB) 3. Increased death rates during delivery and early neonatal period 4. Premature rupture of membranes, bacterial infection of amniotic fluid and anterpartum bleeding 5. Sudden infant death (SID) 6. Disorders of respiratory system 7. Cleft lip and palate

Marijuana Marijuana = cannabis = hashish = grass = dagga = kif 1. Growth retardation of fetus 2. Meconium problems 3. Abnormally short or long labor 4. Reduction in the amount of milk Cocaine 1. Spontaneous abortion (SAB) 2. Premature delivery 3. Decreased weight of fetus 4. Microcephaly 5. Pregnancy-induced hypertension and placental abruption Radiation 1. Microcephaly 2. Mental and growth retardation 3. Agenesia 4. Leukemia Drugs Penicillin Tetracyclines Quinolones Aminoglicocides Anticoagulants does not promote teratogenic effect promote retardation of bone growth produce bone malformations promote deafness of newborn promote chondrodysplasia

Pregnancy-induced hypertension

Diastolic blood pressure Systolic pressure

90 mm Hg or greater at or above 140 mm Hg

if blood pressure before pregnancy is unknown

Rise in diastolic pressure Rise in systolic pressure

at least 15 mm Hg at least 30 mm Hg

if blood pressure before pregnancy is known

Classical triad 1. Hypertension 2. Proteinuria 3. Edema

Classification of American College of Obstetricians and Gynecologists 1. Pregnancy-induced hypertension: Preeclampsia Mild preeclampsia Severe preeclampsia Eclampsia 2. Chronic hypertension preceeding pregnancy 3. Chronic hypertension with superimposed pregnancy-induced hypertension Superimposed preeclampsia Superimposed eclampsia

Russian classification 1. Hestosis Edema without hypertension Hypertension with edema and/or proteinuria Preeclampsia Eclampsia 2. Chronic hypertension (severe preeclampsia) (eclampsia) (no analogy in America) (mild preeclampsia)

Proteinuria

more than 300 mg of protein in a 24-hour urine specimen more than 1+ protein on dipstick

Edema

swelling or excessive weight gain

Severe preeclampsia

Blood pressure Proteinuria

> 160/110 mm Hg > 2 g in 24-hour urine collection or 3+ in random specimen

Oligouria Platelets Hemolytic anemia Increased bilirubin level Headache Visual disturbances Epigastric pain Pulmonary edema Cyanosis Fetal growth retardation

< 400 ml per day < 100000 in 1 ml may be present may be present is present are present may be present may be present may be present is present

Risk factors of preeclampsia

- primigravid status - family history of preeclampsia or eclampsia - previous preeclampsia or eclampsia - women younger than 20 or older than 30 years - preexisting hypertensive vascular, autoimmune or renal diseases - diabetes mellitus - multiple gestation - nonimmune or alloimmune fetal hydrops - triploidy - hydatidiform mole

Etiology of preeclampsia

Immunogenetic theory Angiotensin-renin theory Prostacyclin-thromboxane theory Oxygen free radicals and lipid peroxidation theory Alterations in spiral arteries of a placenta Fetal gray cells theory Central nervous system multifocal petechial hemorrages

vasoconstrictive ischemia edema Kidneys swelling of glomerular capillaries endothelial and mesangial cells subendothelial deposits of fibrinoid reduction of renal blood flow reduction of glomerular filtration Plasma levels of creatininenormal or slightly increased Urea nitrogen Plasma uric acid level Liver normal or slightly increased increases preportal fibrin deposition zonal necrosis bleeding or subcapsular hematoma Cardiopulmonary system hypovolemia hemoconcentration pulmonary edema

HELLP-syndrome HEmolysis, Liver dysfunction and Low Platelets Disseminated intravascular coagulopathy (DIC)

Management Mild preeclampsia

1. Rest in the lateral position 2. Visit of a nurse every day monitoring for preeclampsia monitoring fetal movement monitoring blood pressure maternal urine for proteinuria 3. Visits to doctor twice a week fetal biophysical test USE every 2 weeks 4. Delivery 5. Preeclampsia becomes worse at 37-38 weeks hospitalization

Severe preeclampsia

1. Hospitalization 2. Treatment of hypertension 3. Prevention of convulsions 4. Glucocorticoid treatment to enhance fetal lung maturity 5. Choice of delivery date and method

Treatment of hypertension

Hydralazine Labetalol Methyldopa

5-10 mg intravenously 50 mg intravenously 250 mg 3 times a day per os

Prevention of convulsions

Magnesium sulfate

during labor first 24 hours postpartum a loading dose of 4 g per hour IV a maintenance dose of 2-3 g per hour

Choice of delivery method and date

Severe preeclampsia

> 37 weeks < 36 weeks < 24 weeks

immediately in 2-3 days immediately

Vaginal delivery Cesarean section

fetal well-being and cervical ripeness fetal or maternal worsening

Phases of eclampsia 1. Fibrillar twitching 2. Tonic convulsions 3. Clonic convulsions 4. Permission Complications 1. Intracranial hemorrhage 2. Cranial edema 3. Retina edema 4. Detachment of retina 5. Abrupture of placenta 6. Renal insufficiency 7. Fetal death 8. Maternal death

Protocol of treating eclampsia 1. Turn patient into lateral position (it prevents aspiration) 2. Establish airway and administer oxygen 3. Administer 4-6 g of magnesium sulfate intravenously over 10-15 min followed by 2 g/hr maintenance 4. Obtain arterial blood gas measurement and chest x-ray 5. If convulsions are controlled and maternal condition is stable, initiate delivery 6. Continue to administer magnesium sulfate for at least 24 hr after delivery or last convulsion 7. Other examinations and treatment can be used, if the woman has some complications of eclampsia.

Cardiovascular changes during pregnancy

Blood volume Cardiac output Maximum Size of ventricles

increases by 40 to 60 % increases by 40 to 50 % at 26 to 32 weeks increase

Cardiovascular changes during labor

Blood volume Maternal cardiac output Blood pressure Venous return Stroke volume Heart rate

increases with each contraction increases increases decreases in the second stage decreases increases

Complications Abortions Premature delivery Interuterine growth retardation Fetal death Heart decompensation Maternal death

Symptoms of heart disease Severe dyspnea Syncope with exertion Chest pain related to exertion Heart enlargement Diastolic, presystolic or continuous heart murmur Cyanosis Clubbing

The New York Heart Association classification

1. Class I: asymptomatic. 2. Class II: symptoms with greater than normal activity. 3. Class III: symptoms with normal physical activity. 4. Class IV: symptoms at bed rest.

Class I and II

favorable prognosis pulmonary edema may

occur

Class III

decompensation may occur death may occur bed rest during pregnancy abortion is preferred

Class IV

high risk of death use contraceptives

prevent pregnancy

Management during pregnancy
• Care of a cardiologist and an obstetrician • Hospitalization in cardiac hospital before 12 weeks of gestation • Use New York Heart Association classification • Limitation of physical activity • Diet • Endocarditis prophylaxis • Drug therapy • Ultrasound examination at 22-24 weeks • Treatment of other complications • Hospitalization before delivery on 37th week

Class I or II ⇓ Examinaton in obstetric out-patient department every 2 weeks ⇓ Second hospitalization in 26-28 weeks ⇓ ⇓ No decompensation Decompensation ⇓ ⇓ obstetric out-patient department immediate delivery ⇓ delivery on 37th week Class III or IV ⇓ Hospitalization in a cardiac hospital up to 28 weeks ⇓ Hospitalization in a birth clinic till delivery ⇓ ⇓ No decompensation Decompensation ⇓ ⇓

delivery on 37th week

immediate delivery

Intrapartum management Placement left lateral position sitting position NEVER in supine Anesthesia promedolum phentanilum sodium oxybutiratum epydural anesthesia Monitoring maternal pulse respiratory rate fetal monitoring Vaginal delivery Forceps delivery Cesarean section Drugs class I and II class III class III and IV cardiotonics oxygen oxytocin

Mitral stenosis

Baculev’s classification 1. Mild stenosis (opening between left atrium and ventricle more than 2 cm) 2. Moderate stenosis (more than 1,5 cm and less than 2 cm) 3. Severe stenosis (less than 1,5 cm)

Mild stenosis Moderate stenosis

good prognosis maternal mortality rate 3% worsening in pregnancy atrial fibrilation pulmonary edema surgical commissurotomy before pregnancy or on 16-22th week or cesarean section with commissurotomy

Severe stenosis

bad prognosis

Absolute indications Placenta previa Placental abruption Fetal distress Cephalopelvic disproportion Dysfunctional labor Malpresentation Severe somatic diseases Failed induction in labor Active genital herpes Prolapse of umbilical cord Malignant tumor Pelvis tumor Conjoined twins Some selective indications Breech presentation Repeated cesarean Severe Rh immunization Prior vaginal colporrhaphy Previous infertility Previous miscarriages In vitro fertilization Multiple gestation

Contraindications Fetal death or gestation earlier than 28 weeks Acute infection of the woman Note that all contraindications are not important if the woman has an absolute indication

Complications:

Endometritis Wound infection Sepsis Peritonitis Hemorrhage Aspiration Atelectasis Urinary tract infection Thrombophlebitis Pulmonary embolism Intestinal obstruction Failure of the uterine scar

Abnormal myometrial invasion by the placenta

Types of cesarean section Transperitoneal approach Extraperitoneal approach Classical incision (in upper segment of the uterus) Low segment incision : vertical incision transverse incision J-shaped and T-shaped incisions

Anesthesia Inhalation anesthesia Regional block anesthesia (epidural anesthesia)

Prophylaxis of infection Each cesarean section single dose of a broadspectrum antibiotic IV prolonged antibiotic therapy

Duration of labor more than 18 hours Rupture of the membranes more than 12 hours Vaginal examinations more than 3 Acute respiratory or other infection

Vaginal birth after previous cesarean 1. One prior low-segment transverse cesarean 2. Clinically adequate pelvis in relation to fetus size 3. No other uterine scars, anomalies or previous rupture 4. Normal ultrasound indications 5. No obstetric complications demanded a CS 6. Patient consent 7. Fetal and maternal monitoring during delivery

POSTPARTUM INFECTION
Risk factors 1. Method of delivery 2. Labor 3. Rupture of membranes (ROM) 4. Number of vaginal examinations 5. Internal fetal monitoring 6. Anemia 7. Obesity 8. Diabetes Microbiology Aerobes Escherichia coli Klebsiella Proteus Group B Streptococcus Enterococcus Bacteroides Fuzobacterium Peptococcus Forms of postpartum endometritis 1. Purulent endometritis (classic endometritis) 2. Endometritis with decidual necrosis 3. Endometritis with retained placental fragments

Anaerobes

Mastitis 1. Serous mastitis 2. Infiltration of mamma 3. Purulent mastitis Septic pelvic thrombophlebitis Factors predisposing to venous thrombosis: 1. Changes in circulating coagulation factors 2. Alterations in the vein wall 3. Stasis of blood flow

Sepsis Systematic inflammatory response syndrome (SIRS) Symptoms temperature of more than 38 °C or less than 36 °C heart rate of > 90 beats per min tachypnea more than 20 per min Pa CO2 less than 32 mm Hg white blood cell count of > 12,0·109 or < 4,0·109cells/l

Management 1. Correct hemodynamic abnormalities: - restore intravascular volume through large-bore IV catheter (200 ml per 10 min) - urine catheter - improve blood pressure and perfusion by administering dopamine or dobutamine: a. dilute one ampule (200mg) in 200 ml of 5 % glucose to give a concentration of 800 µg/ml, b. begin infusion at a rate of 2-5 µg/kg/min; - digitalize the patient: a loading dose of 0.75 mg of digoxin divided in three doses, 4-6 hours apart, followed by a daily maintenance dose of 0.125 – 0.375 mg/day 2. Treat the infection: - administer antibiotics covering all potential pathogens in the source of infection - determine the source - surgery (hysterectomy, the source being uterus) 3. Support the respiratory system: - administer oxygen - monitor arterial blood gases frequently to detect onset of respiratory failure - use mechanical ventilation as early as possible 4. Correct coagulation abnormalities: - cryoprecipitate, fresh-frozen plasma, fresh whole blood, platelet in patients with disrupted circulation - heparin, if the woman has hypercoagulation

Classification of contraception 1. Periodic abstinence: - calendar rhythm method - basal body temperature method - cervical mucus method 2. Mechanical barrier methods: - male condom - diaphragm - cervical cap - spermicides 3 3. Oral contraception 4 - combinative - progestin only 4. Hormonal implants 5. Hormonal injections 6. Hormonal ring 7. Hormonal plaster 8. Intrauterine devices - intact - antiseptic - hormonal 9. Sterilization: - female - male 8. Emergency contraception

Periodic abstinence • Calendar rhythm method 1. A human ovum is capable of being fertilized for only about 24 hours after ovulation 2. Spermatozoa can retain their fertilizing ability for only 48 hours after coitus 3. Ovulation usually occurs 12 to 16 days before the onset of the subsequent menses Fertile period in 28th day cycle from 11th to 18th day

Fertile period in cycle of another duration: subtract 14 days from the date of the first day of subsequent menses – this is the approximate ovulation date Fertile period is from 5 days before to 3 days after the approximate ovulation date

• Basal body temperature method Couple should abstain from coitus from the onset of menses until the third day of elevated basal temperature • Cervical mucus method Abstinence is required from the first day of wet, slippery mucus to the third day after its disappearance

Oral contraception 1. Combinative Oral Contraceptives contain estrogen (ethinyl estradiol) and one of progestins (levonorgestrel, desogestrel, norgestimate) Types of COCs: - monophasic - biphasic - triphasic 2. Progestin-only Oral Contraceptives contain only progestin Effects on the reproductive system 1. Block the functioning of the hypothalamas and pituitary 2. Change the cervical mucus to retard sperm penetration 3. Alteration of uterine tubal motility Contraindications: -estrogen-dependent neoplasma -breast cancer -undiagnosed genital bleeding -pituitary prolactinoma -active liver diseases -history of deep vein thrombosis -history of pulmonary embolism -vascular and coronary diseases -untreated hypertension -diabetes -age greater than 35 years and cigarette smoking

Intrauterine devices (IUD) Contraindications acute somatic diseases acute pelvic inflammatory diseases history of extrauterine pregnancy women who have never had delivery cervical ulcer or cancer uterine cancer or bleeding

Emergency contraception 1. Oral emergency contraceptive “postinor” 2. Copper IUD Despite all disadvantages of different methods of contraception, the risk from abortion is higher than from any method of contraception!

Spontaneous abortion Causes of spontaneous abortion: 1. Genetic factors 2. Hormonal factors 3. Immunologic factors 4. Severe somatic diseases 5. Infection 6. Structural uterine defects 7. Cervical incompetence Types of spontaneous abortion: 1. Threatened miscarriage 2. Inevitable and incomplete miscarriage 3. Complete miscarriage 4. Missed miscarriage 5. Septic miscarriage 6. Recurrent miscarriage The initial evaluation and management of septic abortion: - physical and pelvic examination; - complete blood cell count and determination of electrolyte, blood urea nitrogen and creatinine levels; - smears from cervix for Gram stain; - aerobic and anaerobic cultures of endocervix and blood; - Folley catheter; - fluids intravenously; - administration of 0.5 ml of tetanus toxoid.

Causes of the preterm labor: 1. Alteration in systemic or local levels of steroid hormones 2. High level of oxytocin influences oxytocin receptors and promotes the onset of preterm labor 3. Infections from vagina and cervix stimulate release of prostaglandins from the amniotic membranes 4. Preterm rupture of the membranes in most cases leads to uterine contractions and preterm delivery Risks for preterm labor: 1. Younger and older ages 2. Prior preterm delivery 3. Vaginal infection 4. Twins, polyhydramnion 5. Cervical incompetence Management: 1. Bed rest in Tredlandburg’s position with higher level of legs 2. Tocolisis: - no-spanium (drotaverinum) - 2%-2ml IV or IM every 6 hours; - magnesium sulfatis - 25 % - 10 ml IV or IM every 6 hours; - β-mimetic drugs (partusistenum, ritodrinum and gynipralum) 1 or 2 mg IV in sol. natrium chloridi during 6 hours and then 0,5 or 1 mg per os every 4 hours till 37th week of gestation 3. Prostaglandin synthetase inhibitors - indomethacinum in 2550 mg per os or per rectum every 6 hours 4. Glucocorticoids (dexamethazone or celestone - 4 mg every 12 hours during 2 days) 5. Antibiotics 6. Atraumatic delivery

Dysfunctional labor hypotonic inertia hypertonic inertia incoordinate contractions

Risks of dysfunctional labor: 1. Women older than 30 2. Severe diseases 3. Obesity 4. Prior abortions (1 or more) 5. Infertility or recurrent miscarriage 6. Preterm labor 7. Premature rupture of membrane 8. Multiple gestation 8. Polyhydramnion 9. Malpresentation 10. Small or large baby 11. Cephalopelvic disproportion 12. Ulcer of the cervix and diatermocoagulation of ulcer 13. Emotional stress 14. Prior cesarean section or other uterine operations 15. Excessive use of spasmolitic or myotonic drugs in the labor 16. Epidural anesthesia

Hypotonic inertia Primary hypotonic inertia Tocolisis and narcotic drugs to stop or normalize uterine contractions: promedolum 2%-1 ml + atropinum 0,1%-1 ml + relanium (sybazonum, seduxenum) 0,5 % - 2 ml + dimedrolum 1% - 1 ml IM. If the woman cannot sleep 0,5 -1 hours after that, natrium oxybutiratum 20%-20 ml IV slowly (during 20 minutes). Secondary hypotonic inertia Amniotomy and oxytocin or prostaglandins IV (1 or 2 mg of prostaglandin F2a or 5 ED (1ml) of oxytocin intravenously in solution of 5 % 500 ml glucose from 1 ml per minute to 4 ml per minute during 3-4 hours)

Complications of primary and secondary hypotonic inertia: 1. Fetal distress 2. Fetal death 3. Uterine rupture 4. Postpartum bleeding 5. Postpartum infection

Hypertonic inertia Stop the infusion of oxytocin immediately and introduce a spasmolitic drug (for example, no-spanium or atropinum IM or IV). Use epidural anethesia. Use episiotomy. In the third stage of delivery - oxytocin IV to prevent the postpartum bleeding. In case of constriction ring: If cervical dilation is less than 6 cm and amniotic membranes are present - medicinal rest with natrium oxybutiratum. If cervical dilation is more than 6 cm or rupture of membranes has occured - epidural anesthesia. In all cases, fetal heart rate must be monitored. If after treatment constriction ring is present, cesarean section should be used. Complications of hypertonic inertia: 1. Uterine rupture 2. Fetal distress 3. Fetal death 4. Postpartum bleeding 5. Premature separation of placenta

Incoordinate contractions If the fetus does not suffer from hypoxia, epidural anesthesia or medicinal rest with natrium oxybutiratum may be used. In unsuccessful cases or cases of fetal distress, cesarean section should be used.

Prophylaxis of dysfunctional labor Prophylaxis before pregnancy: 1. Prevent abortions 2. Treat obesity and somatic diseases 3. Use conservative methods to treat cervical ulcer, do not use diatermocoagulation. Prophylaxis of dysfunctional labor during pregnancy: 1. Special exercises to strengthen abdominal muscles and pelvic floor begining with 24 weeks of gestation. 2. Use polyvitamins during the second half of pregnancy. 3. Hospitalize women of high risk at 38-39th week. In hospital estrogens (synoestrolum or folliculinum in dose 20000 ED IM every 8 hours during 3-5 days before EDC), vitamins B1, B6, and C. Prophylaxis of dysfunctional labor in delivery: 1. Estrogens every 4 hours 2. Amniotomy in case of oligohydramnion or polyhydramnion 3. Spasmolitics not more often than every 2-3 hours

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