Pos$erm

 Pregnancy  
 Defini1on  of  Terms  
•  Postdated  pregnancy  –  not  recommended  
•  Postmature  pregnancy    
§  reserved  for  the  rela1vely  uncommon  specific  
clinical  fetal  syndrome  in  which  the  infant  has  
recognizable  clinical  features  indica1ng  a  
pathologically  prolonged  pregnancy    
§  Pos,erm  or  Prolonged  pregnancy  –  preferred  
§  42  completed  weeks—294  days—  or  more  from  
the  first  day  of  the  last  menstrual  period  
•  The  defini1on  of  pos$erm  pregnancy  as  one  
that  persists  for  42  weeks  or  more  from  the  
onset  of  a  menstrual  period  assumes  that  the  
last  menses  was  followed  by  ovula1on  2  
weeks  later.    

•  That  said,  some  pregnancies  may  not  actually  

be  pos$erm,  but  rather  are  the  result  of  an  
error  in  gesta1onal  age  es1ma1on  because  of  
faulty  menstrual  date  recall  or  delayed  
ovula1on.    
 
•  These  varia1ons  in  the  menstrual  cycle  
may  par1ally  explain  why  a  rela1vely  
small  propor1on  of  fetuses  delivered  
pos$erm  have  evidence  of  postmaturity  
syndrome.    
 
•  Sonographic  evalua1on  of  gesta1onal  
age  during  pregnancy  has  been  used  to  
add  precision.    
 
 Predisposing  factors  
•  Maternal  
§  There  are  contradictory  findings  concerning  
maternal  demographic  factors  such  as  parity,  prior  
pos$erm  birth,  socioeconomic  class,  and  age  as  
risks  for  pos$erm  pregnancy.    
§  Fetal  
§  anencephaly,  adrenal  hypoplasia,  and  X-­‐linked  
placental  sulfatase  deficiency    
 Perinatal  Mortality  
•  rates  increase  aKer  the  expected  due  date  has  
passed    
PATHOPHYSIOLOGY  
Postmaturity  syndrome  
Placental  dysfunc1on  
Fetal  distress  and  Oligohydramnios  
Fetal  growth  restric1on  
Postmaturity  Syndrome  
•  wrinkled,  patchy,  peeling  
skin  
•  a  long,  thin  body  
sugges1ng  was1ng    
•  infant  is  open-­‐eyed,  
unusually  alert,  and  
appears  old  and  worried    
•  skin  wrinkling  can  be  
par1cularly  prominent  on  
the  palms  and  soles  
•  nails  are  typically  long  
Postmaturity  Syndrome  
•  the  skin  changes  of  
postmaturity  are  due  
to  loss  of  the  
protec1ve  effects  of  
vernix  caseosa    
•  also  a$ributed  to  
placental  senescence    
Fetal  Distress  and  Oligohydramnios  
•  amnionic  fluid  volume  normally  con1nues  to  decrease  
aKer  38  weeks    
•  both  antepartum  fetal  jeopardy  and  intrapartum  fetal  
distress  were  found  to  be  the  consequence  of  cord  
compression  associated  with  oligohydramnios    
§  Prolonged  decelera1ons  
§  Variable  decelera1ons  
§  Saltatory  baseline  
§  meconium  release  into  an  already  reduced  amnionic  
fluid  volume  results  in  thick,  viscous  meconium  that  may  
cause  meconium  aspira-on  syndrome    
 Fetal  Growth  Restric1on  
•  S1llbirths  are  more  common  among  growth-­‐
restricted  infants  delivered  aKer  42  weeks    
COMPLICATIONS  
Oligohydramnios  
Macrosomia  
Medical  or  Obstetrical  Complica1ons  
 Oligohydramnios  
•  Regardless  of  the  criteria  used  to  diagnose  
oligohydramnios  in  pos$erm  pregnancies,  
most  inves1gators  have  found  an  increased  
incidence  of  some  sort  of  “fetal  distress”  
during  labor    
 Macrosomia  
•  The  American  College  of  Obstetricians  and  
Gynecologists  (2013b)  has  concluded  that  current  
evidence  does  not  support  induc>on  of  women  
at  term  with  suspected  fetal  macrosomia.    
§  vaginal  delivery  is  not  contraindicated  for  women  
with  an  es1mated  fetal  weight  up  to  5000g  
§  Cesarean  delivery  is  recommended  for  es1mated  fetal  
weights  greater  than  4500g  if  there  is  prolonged  
second-­‐stage  labor  or  arrest  of  descent.    
 Medical  or  Obstetrical  Complica1ons  
•  In  the  event  of  a  medical  or  other  obstetrical  
complica1on,  it  is  generally  not  recommended  
that  a  pregnancy  be  allowed  to  con1nue  past  
42  weeks.    
§  gesta1onal  hypertensive  disorders,  prior  cesarean  
delivery,  and  diabetes    
 
MANAGEMENT  
The  decision  centers  on  whether  labor  induc1on  is  warranted  or  if  
expectant  management  with  fetal  surveillance  is  best.    
 
 Prognos1c  factors  for  successful  induc1on  

•  Favorability  of  cervix  

§  Bishop  score  >9:  favorable  for  induc1on  
 
•  Sta1on  of  vertex  
§  the  higher  the  sta1on  is  at  the  1me  of  labor  
induc1on,  the  higher  the  rate  of  Cesarean  delivery  
 Induc1on  vs  Fetal  Tes1ng  
•  there  is  insufficient  evidence  to  recommend  a  
management  strategy  between  40  and  42  
completed  weeks.    
•  although  not  considered  mandatory,  ini1a1on  
of  fetal  surveillance  at  41  weeks  is  a  
reasonable  op1on    
•  aKer  comple1ng  42  weeks,  recommenda1ons  
are  for  either  antenatal  tes1ng  or  labor  
induc1on  
 Induc1on  vs  Fetal  Tes1ng  
•  Fetal  Tes1ng  
§  fetal  movement  coun1ng  
§  NST  2-­‐3x/week  
§  amnio1c  fluid  volume  determina1on  2-­‐3x/week  
 Intrapartum  Management  
•  Monitor  FHR  and  UCs  electronically  
•  Role  of  amniotomy?  (has  both  +  and  –  effect)  
§  Further  reduc1on  in  fluid  volume  can  enhance  the  
possibility  of  cord  compression  
§  Amniotomy  aids  iden1fica1on  of  thick  meconium  
 Intrapartum  Management  
•  Thickly  meconium-­‐stained  AF  
§  aspira1on  may  cause  severe  pulmonary  dysfunc1on  
and  neonatal  death  
§  amnioinfusion  during  labor  has  been  proposed  as  a  
way  of  dilu1ng  meconium  to  decrease  the  incidence  
of  aspira1on  syndrome    
§  ACOG:  amnioinfusion  does  not  prevent  meconium  
aspira>on,  however,  it  remains  a  reasonable  treatment  
approach  for  repe11ve  variable  decelera1ons    
§  for  the  nulliparous  woman  who  is  in  early  labor  with  thick,  
meconium-­‐stained  amnionic  fluid  and  remote  from  delivery,  
strong  considera1on  should  be  given  to  prompt  cesarean  
delivery