Prolonged

Prolonged Pregnancy
Pregnancy
(Evidence
(Evidence Based)
Based)

Dr. Ashraf Fouda

Ob./Gyn. Consultant
Damietta Specialized Hospital
 Sources
 RCOG 2003
 ACOG (SEPTEMBER
( 2004)
 COCHRANE LIBRARY 2006
 AFP (AMERICAN FAMILY
PHYSICIAN) (May 15, 2005)
 PUBMED (MEDLINE)
 DEFINITION
Prolonged pregnancy
( postterm pregnancy ) It
is one that has lasted longer than
42 weeks or 294 days beyond the
first day of the last menstrual period

) WHO & FIGO (

 DEFINITION
 Postdatism is pregnancy lasting
beyond the estimated due date at
40 weeks.
 “Postmature” is reserved for the
pathologic syndrome in which the
fetus experiences placental
insufficiency and resultant IUGR .
 Post-maturity syndrome
 Representing 20 % cases of prolonged
pregnancy and is associated with :
1. Meconium -stained amniotic fluid,
2. Oligohydramnios
3. Fetal distress
4. Evidence of loss of subcutaneous fat
and
5. Dry, cracked skin
Reflecting placental insufficiency.
 Etiologic Factors
 The most frequent cause is an
error in dating.
 When truly exists, the cause usually
is unknown.
 Primiparity and prior postterm
pregnancy are the most common
identifiable risk factors.
 Etiologic Factors
 Rarely, it may be associated with
placental sulfatase deficiency or fetal
anencephaly.
 Male sex also has been associated.
 Genetic predisposition may play a
role .
 EPIDEMIOLOGY

 Using the definition of 294 days,

the incidence

of postterm pregnancy is 9 - 10 %.
 Risks to the Fetus

 The perinatal mortality:

> 42 weeks twice that at term

> 43 weeks > 6-fold that at term

 Risks to the Fetus
 In some cases, the risks appear to be due
to uteroplacental insufficiency,
resulting in fetal hypoxia , meconium
aspiration, growth restriction, and
oligohydramnios .
 Fetal distress and meconium release were
twice as common (at or after 42 weeks)
than at term.
 There was an eight-fold increase in
meconium aspiration
 Macrosomia
- In other cases, continued growth of the
fetus leads to macrosomia,
increasing the risk of
labor abnormalities, shoulder
dystocia with resultant risks of
orthopedic or neurologic injury.
- Macrosomia is far more common in
postterm than term pregnancies .
 Oligohydramnios
 It is a marker for fetal compromise and

it puts the fetus at risk for cord accidents.

 U/S diagnosis :

 No vertical pocket > 2 cm or

 Amniotic fluid index (AFI) 5 cm or less .

 It is considered an indication for delivery.

 Risks to the Fetus
 Fetuses born postterm also are at increased
risk of : Sudden
infant death syndrome
(death within the first year of life).
 Some of these deaths clearly result from
peripartum complications
(such as meconium aspiration
syndrome), but most have no known cause.
 Maternal risks
1) Labor dystocia
2) Severe perineal injury
related to macrosomia
3) Doubling in the rate of cesarean
delivery.
4) A source of extreme anxiety
for the pregnant woman.
 Gestational age calculation
 Gest. age must be assessed carefully
to avoid delivery of a preterm infant.
 Women who attend late for ANC may
be of uncertain gestation and may be
over-represented in populations of
postterm pregnancies.
 Dating by the last menstrual period (LMP)
alone has a tendency to overestimate
the gestational age.
 Gestational age calculation
 Because actual dates of conception are
rarely known,
the LMP is used as the reference point.
 This can make the accuracy of gest. age
determination unreliable because of :
1. Irregular menses .

2. Recent cessation of birth control pills.

3. Inconsistent ovulation times.

Routine early pregnancy ultrasound
♣ Reduces the number of women who
require induction of labour for apparent
postterm pregnancy .
♣ It is recommended that all pregnant
ladies (and certainly those who do not
have regular menses), should have an
ultrasound examination for gestational
age determination, prior to 20 weeks
RCOG,COCHRANE
 Ultrasound biometry margins of error
 Crown-rump length (CRL) till 12 weeks is
3-5 days,
 Biparietal diameter (BPD) at 12-20 weeks is
1 week,
 BPD at 20-30 weeks is 2 weeks, and
 BPD after 30 weeks is 3 weeks.
 If there is more than a one week
discrepancy between the LMP and the
ultrasound findings, the ultrasound data
should be used to determine the EDD .
 Transcerebellar diameter
 When composite biometry is not consistent
in all of the parameters (i.e. BPD, head
circumference, abdominal circumference,
femur length), using the
transcerebellar diameter is a way to more
accurately date a pregnancy
 The diameter in millimeters corresponds
to weeks of
gestation up to 24 weeks.
Transcerebellar diameter
 The available evidences are
strongly in support that dating
by Early
ultrasonography alone
is the most
accurate method for predicting
EDD.
RCOG (GRADE A)
 Routine early pregnancy ultrasound
 The use of early ultra­sound alone to
calculate the rate of postterm
pregnancy in women who delivered
spontaneously significantly
reduced the postterm rate
from 10 % to 1.5 %.
RCOG (GRADE A)
 Are there interventions that decrease
?the rate of postterm pregnancy
 Accurate dating on the basis of
ultrasonography performed early in
pregnancy .
 Breast and nipple stimulation at term
have not been shown to affect the
incidence of postterm pregnancy.
 Sweeping of the membranes at term :
the data are
still conflicting .
ACOG Guidelines 2004
 Management options depend on:
1) Gestational age,
2) Absence/presence of maternal risk factors
and / or
3) Evidence of fetal compromise, and
4) Maternal preferences .
 Successful management depends on
effective counselling of women
and their full involvement in the
decision making process.
Historically, prolonged pregnancy has
been managed in 2 ways , either :

a. Inducing labour at 41-42 weeks

gestation or
b. Awaiting the onset of spontaneous
labour, while monitoring the fetal
wellbeing .
 The decision is difficult and should
not be taken lightly.
Routine induction of labour
at 41 weeks
 Although postterm pregnancy is defined
as a pregnancy of 42 weeks or more of
gestation, several large multicenter
randomized studies reported
favorable outcomes with routine
induction as early as the beginning of 41
weeks of gestation.

Cochrane 2006
Routine induction of labour
at 41 weeks
 A recent review in the Cochrane Library
concluded that
routine induction in low-risk
pregnancies at or after 41 weeks'
gestation is associated with :
1. A reduction in perinatal mortality,
2. No increase in the rate of instrumental
or cesarean delivery.
RCOG Grade A
 Routine induction of labour
at 41 weeks
 Contrary to what many obstetricians believe,
induction of labor for prolonged pregnancy
does not increase the rate of cesarean
section, rather, it decreases it.
 The risk of fetal distress from uteroplacental
insufficiency due to prolonged pregnancy can
be reduced by induction of labor, even to the
point of preventing perinatal death from
asphyxia.
 ANTEPARTUM FETAL
SURVEILLANCE
 There is insufficient evidence to indicate
whether routine antenatal surveillance
of low-risk patients between
40 and 42 weeks of gestation
improves perinatal outcome
but it is
often performed during this period.
ANTEPARTUM FETAL SURVEILLANCE    

 The condition of the fetus can change

quickly and thus, monitoring should be
at frequent intervals, and that none
of the tests are immune from false
positives, false negatives
 Boehm et al, demonstrated that twice-
weekly testing of patients at risk for fetal
distress was superior to weekly testing.
 FETAL SURVEILLANCE
A modified biophysical profile
consisting of a:
 non stress test and an
 amniotic fluid index
have been shown to
be as sensitive as a full biophysical
profile. RCOG Grade A
 Induction of labour or
expectant management?
 Favorable cervix : Labor generally is
induced because the risk of failed
induction and subsequent cesarean
delivery is low.
 Unfavorable cervix :a : small advantage
to labor induction using cervical ripening
agents (prostaglandins), when indicated,
regardless of parity or
method of induction. ACOG 2004 (Level C)
Management from 40-41 weeks gestation

A .Healthy, uncomplicated pregnancy and

fetal growth/ amniotic fluid normal:

 No evidence to support elective

induction of labour

 No evidence to support use of serial

antenatal monitoring :
non stress test (NST) or
amniotic fluid index (AFI) .
Management at 40 - 41 weeks gestation

B. Presence of maternal risk factors or

evidence of fetal compromise :

 Recommend cervical ripening

as necessary and

induction of labour
 Management at 41 weeks gestation
A. Healthy, uncomplicated pregnancy

 Inform the woman of the options and

risks/ benefits of labour induction versus
expectant management, and
offer her labour induction.
 Establish the cervical (Bishop) Score
and ensure a ripening agent
(prostaglandin) prior to induction.
Management at 41 weeks gestation
B. If mother declines induction ,
then provide expectant management:
 Daily fetal movement counts
 Non stress test (NST) and Amniotic fluid
index (AFI) twice/ week to 42 weeks.
 If the NST or AFI is abnormal ,
then initiate induction immediately

Induce at 42 weeks
even if NST and AFI are normal.
 Management during labour and delivery

۞ Consider amniotomy to diagnose

thick meconium.
۞ If meconium is present then consider
risk of meconium aspiration , continuous
fetal assessment with electronic fetal
monitoring (EFM) is recommended.
۞ Be prepared for shoulder dystocia and
neonatal resuscitation at delivery.
Key Clinical Recommendations

 Labour induction at 41 weeks

gestation is recommended over
expectant management in women
with postterm pregnancy to reduce
the rate of cesarean delivery &
perinatal mortality .
)RCOG Grade A(
 Key Clinical Recommendations
 If Expectant management (41-
42 weeks) is chosen,
the fetus should be monitored with
twice weekly non-stress test ,
amniotic fluid index .
- However, evidence of
benefit is lacking.
(RCOG Grade C )
 Key Clinical Recommendations
 Prostaglandin can be used in postterm
pregnancies to promote cervical ripening
and induce labor.
 Delivery should be effected if there is
evidence of :
 fetal compromise or
 oligohydramnios.
ACOG 2004 (Level A)