Salute Vivamus 2023 | Central Philippine University | College of Medicine

Obstetrics: S01L08

Post-term Pregnancy
Dr. Ma. Sisa Balagosa-Fernandez | 09-30-2021 | TTh | 03:00-04:30 PM
• Limp upon delivery
OUTLINE
• Decreased subcutaneous fat due to loss of vernix caseosa
I. Introduction IX. Management • Tolerates labor poorly, frequently acidotic at birth resulting to
A. Features of Post A. Principles poor APGAR score
Mature Infant B. Conservative ® Due to many pathophysiologic changes in fetus and
B. Factors associated Management placenta
with post-term C. Active Management
pregnancy D. Antepartum evaluation
C. Sequelae of post- and Management
term pregnancy E. Indication for
II. Pathology Intervention
A. Normal Pregnancy F. Mode of Delivery
B. Degenerative Changes G. Cervical Ripening
in the Placenta H. Pharmacological
III. Epidemiology Management
IV. Complications of Post- I. Contraindication of
term pregnancy Labor Induction
V. Etiology J. Intrapartum
VI. Categories of Post Management
term Pregnancy X. Recommendations
VII. Risk Factors XI. Additional Notes
VIII. Diagnosis A. Complications
A. Maternal and Fetal B. Benefits of Transcervical Figure 1. Postmaturity syndrome with a neonate delivered at 43 weeks AOG
and Neonatal Risks Amnioinfusion
and Complications XII. References FACTORS ASSOCIATED WITH POST TERM
B. Incidence of Fetal XIII. Appendix PREGNANCY
Mortality in all Groups
FACTOR DISCUSSION
Inaccurate or unknown Most common cause; more common with
I. INTRODUCTION dates late or no prenatal care
Irregular ovulation; Results in overestimation of gestational
• Post term pregnancy variation in length of age
® Pregnancies that have exceeded a duration considered to follicular phase
be the upper limit of normal Decreased production of 16α-
® Pregnancy >42 weeks AOG, from the first day of Anencephaly hydroxydehydroepiandrosterone beta-
menstruation or 294 days since the first day of LMP sulfate, a precursor of estriol
® Associated with increased morbidity and mortality both for Fetal adrenal Decreased fetal production of estriol
neonatal and maternal hypoplasia precursors
Placental sulfatase X-linked disease prevents placenta
• Post date deficiency conversion of sulfated estrogen precursors
® AOG that has gone beyond the EDC but <42 weeks Extrauterine Pregnancy not in uterus, no labor
• Post maturity pregnancy (Usually abdominal pregnancy, survives
® Refers to an infant with identifiable features indicating a more than 40 weeks)
pathologically prolonged gestation Table 1. Factors associated with post term pregnancy
• Term
® Is more or less 280 days or 40 weeks B. SEQ UELAE OF POST TERM PREGNANCY
® Coincides with Estimated Day of Confinement
• 1st trimester sonography PLACENTAL DYSFUNCTION
® most accurate method to confirm gestational age • Fibrinoid necrosis & accelerated atherosclerosis
• Also known as “Placenta senescence” or “Placental
ESTIMATED GESTATIONAL AGE insufficiency”
• Some calculations reflect an error in gestational age estimation • Placental apoptosis significantly greater at 41 to 42 completed
because of faulty menstrual recall or delayed ovulation. weeks
• Kisspeptin:
A. POSTMATURITY SYNDROME FEATURES ® Upregulated proapoptotic gene
• Results to compromised fetal oxygenation leading to fetal
• Wrinkled, patchy, peeling skin dysfunction
• Wrinkles on the skin especially on palms and soles • Erythropoietin stimulation (ViVa)
• (+) meconium staining on skin and nails (nails are long) ® Fetal oxygenation decreased in some post term gestations
• Body is long and thin leading to stimulation of erythropoietin
• With open eyes immediately after birth, unusually alert, and ® Increase in cord blood erythropoietin in pregnancies 41
appears old and worried weeks or more
• “Old Man’s Facies”
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FETAL DISTRESS o Lead to Ante/Intra-partum distress
• Secondary to cord compression associated with § 25% of prolonged pregnancies
oligohydramnios ® Liver and Skin:
® Both antepartum fetal jeopardy and intrapartum fetal o Hypoperfusion
distress were found to be the consequence of cord o Catabolic processes
compression associated with oligohydramnios o Decrease in liver size
• Decrease in amniotic volume starts at 38 weeks AOG o Loss of subcutaneous fat/tissues
• The fetal distress is also due to a viscous meconium and nuchal o Lead to intrauterine growth restriction (IUGR)
cord compression resulting to an abnormal fetal heart rate • Reflex relaxation of anal sphincter secondary to hypoxia
pattern (non-reassuring FHR) • Meconium Aspiration Syndrome
® A compromised condition in prolonged gestation ® During the first breath and cry at delivery, the neonate may
• Meconium aspiration syndrome aspirate the meconium present in the oral cavity into the
® Caused by thick, viscous meconium which resulted from the smaller bronchioles
release of meconium into an already reduced amniotic fluid ® The meconium lodged into the lungs may not only cause
volume pneumonitis but also serve a “ball-valve” effect which
causes Spontaneous Neonatal Pneumothorax
FETAL GROWTH RESTRICTION AND STILLBIRTH • All of these lead to increased maternal and perinatal morbidity
• 1/3 of post term stillborn neonates were growth restricted
• Commonly seen in growth restricted babies delivered after the III. EPIDEMIOLOGY
42nd week AOG
• Prevalence in the Philippines:
II. PATHOPHYSIOLOGY ® UP-PGH: 7 out of 4983 live births (0.14%) reaches > 42
weeks AOG but only 3 infants (0.06%) were post term by
• When pregnancy becomes prolonged, there are two possible pediatric aging
changes in the Placenta: ® Torres & Mantaos 5 years review (2002-2008)
® Lead to Normal pregnancy (healthy placenta) o 0.83% incidence rate
® Undergo degenerative changes o A decline in the incidence is due to ultrasound for fetal
monitoring
A. NORMAL PREGNANCY • Perinatal morbidity and mortality are increased due to:
® Prolonged gestation with CPD (Cephalopelvic
• In the presence of normal placenta, there would be a disproportion)
progressive delivery of nutrients to the fetus leading to fetal ® Fetal anoxia, cerebral palsy, and neonatal seizure
macrosomia (Fetus >4500g in weight) o Worst case scenario is neonatal death
• Fetal Macrosomia would lead to:
® Fetal Trauma secondary to shoulder dystocia IV. COMPLICATIONS OF POST TERM
® Increase caesarean rate
® Perineal lacerations
PREGNANCY
® Worst: Distended uterus would lead to postpartum bleeding MATERNAL COMPLICATIONS FETAL AND NEONATAL
secondary to postpartum atony COMPLICATIONS
Operative delivery Macrosomia and fetal trauma
B. DEGENERATIVE CHANGES IN THE PLACENTA • Macrosomia • Due to shoulder dystocia
• Failure of induction and brachial plexus injury
• Brought about by Placental Insufficiency • Non-reassuring fetal heart rate • Most common, 75% of
• Diminution in the caliber of vessels pattern brought about by cord cases
compression
• Decreased Fetal Perfusion
Fetal hypoxia
• Fetal Hypoxia • Fetal distress
® Fetus will undergo reflex fetal redistribution of blood flow Infection and hemorrhage due
• Eventually leads to fetal
and energy to prolonged labor
death due to low oxygen
® First affected are the less vital organs by means of concentration of the fetus
vasoconstriction Psychological morbidity
o Liver • Due to maternal anxiety of Oligohydramnios and cord
o Kidneys having a passed Expected accident during delivery
o Subcutaneous tissues Date of Delivery (EDD)
Dysfunctional labor
o GIT by vasoconstriction
• Secondary to fetal macrosomia Meconium aspiration
® After which, it will affect the more vital organs by means of • Markedly distended uterus syndrome and neonatal
vasodilation leading to hypotonic uterine pneumothorax
o Brain contraction
o Heart IUGR with post maturity
Obstetric Trauma
o Adrenal gland by vasodilatation syndrome
• Pathophysiologic changes to: Post maturity syndrome
® Kidney: • Seen in 30% of patients
o Decreased renal blood flow Table 2. Complications of Post term pregnancy
o Decrease in fetal urine output NICE TO KNOW!
o Decreased amniotic fluid Oligohydramnios defined as Amniotic Fluid
o Oligohydramnios Index (AFI) ≤5 or a single deepest pocket <2
o Cord accident/compression
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V. ETIOLOGY ® Approx. 50% of women who have experienced prolonged
gestation are likely to have a subsequent prolonged
• Inaccurate or unknown dates gestation in their pregnancy.
• Irregular ovulation, variation in the length of follicular phase • Genetics
• Anencephaly ® Biologically determined
® Decrease production of 16α- ® Incidence is also increased if the mother is also delivered
hydroxydehydroepiandrosterone beta-sulfate, a precursor post term
of estradiol, decrease estrogen level, delayed parturition ® Increased level of Relaxin
• Fetal adrenal hypoplasia
• Placental sulfatase deficiency VIII. DIAGNOSIS
• Extrauterine Pregnancy
® Abdominal pregnancy can reach term or even post term • Gestational age must be validated using the following:
® Pregnancy is not in the uterus, patient will not go into labor ® (+) Pregnancy test
o (+) in 7 days after missed period
NICE TO KNOW! o Urine pregnancy test: (+) within 6 weeks of the LMP (2
“The most common cause of post term pregnancy is
weeks after the missed period)
commonly seen when you have patients with late
prenatal check-up or have no prenatal check-up at all.” o Serum pregnancy test: (+) the time of missed period
® Detection of the fetal heart rate
-Dr. Fernandez (2021) o Doppler: 10-12 weeks AOG
o Stethoscope: Nulliparous 20 weeks AOG, Multiparous 16
MATERNAL PERINATAL weeks AOG)
Fetal macrosomia Stillbirth ® Quickening
Oligohydramnios Postmaturity syndrome o Actual maternal perception of fetal movement
Preeclampsia NICU admission
o Nulliparous at 20 weeks AOG
Cesarean Delivery Meconium aspiration
o Multiparous at 16 weeks AOG
Shoulder dystocia Neonatal convulsions
Fetal jeopardy Hypoxic-ischemic encephalopathy ® Pelvic Examination
Postpartum hemorrhage Birth Injuries o Fundic height should be compatible with AOG after the
Perineal lacerations Childhood obesity 20th week
Table 3. Adverse maternal and perinatal outcomes associated with postterm o McDonald’s Rule!
pregnancy. ® Known date of Assisted Reproductive Technology
Intervention (knowledge of the date when the intervention
VI. CATEGORIES OF POST TERM was done)
PREGNANCY ® Transvaginal ultrasound between 7-11 weeks AOG
determining crown to rump length
• Those 40 weeks post conception
• Those of less advanced gestation but with inaccurately NICE TO KNOW!
estimated age of gestation due to: Rule of Thumb:
Accurate Dating is the key factor in the diagnosis of a
® Faulty recall of dates (erroneous LMP)
truly prolonged gestation.
® Oligo ovulation
® Late prenatal check up Management for post term pregnancy is prevention of
® Delayed ovulation pregnancy prolongation by labor induction with close
® Late ultrasound during pregnancy surveillance with active management by labor induction.
® Recent pregnancy
-Dr. Fernandez (2021)
® OCP used without resumption of menses
® Acute illness METHODS USED TO DETERMINE THE EDC
NICE TO KNOW! • Exact Date of the Last Menstrual Period (LMP)
When you prescribe oral contraceptive pill, the patient should be ® Need to be emphasized when is the first day of the LMP
menstruating (within the first 1-week menstrual period) Never give • Know the Date of Sexual Contact
an oral contraceptive pill to a patient with no menstruation! A • Early Ultrasound
mortal sin!
® Most reliable (especially if menstruation is irregular)
The importance of prenatal check-up should almost always be ® Gestational Sac (1st trimester)
encouraged on those patients who are desirous of getting pregnant. ® Crown Rump Length (CRL) (1st and 2nd trimester)
® Biparietal diameter with or without the femoral length (2nd
Ultrasound is the most accurate when done only on the 1st and 3rd trimester)
trimester

-Dr. Fernandez (2021)

NICE TO KNOW!
Ultrasound Milestone!
VII. RISK FACTORS FOR POST TERM 5 weeks AOG: Gestational Sac
PREGNANCY 5-6 weeks AOG: Yolk Sac
• Maternal obesity 6 weeks AOG: Embryo with FHR
7 weeks AOG: Amnion & Chorion
® BMI of 30-40 is associated with prolonged gestation
• Nulliparity
• History of post term delivery
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INCIDENCE OF FETAL MORTALITY FOR ALL B. CONSERVATIVE MANAGEMENT
GROUPS
• 40-41 weeks AOG: 1.1% • Used in those patients with uncertain AOG
• 43 weeks AOG: 2.2% • For favorable cervix and presence of any medical problem
• 44 weeks AOG: 6.6% related to post-term
® Perform induction of labor
IX. MANAGEMENT • For patient with unfavorable cervix
® Frequent Maternal-Fetal Antepartum surveillance at least
twice a week
A. PRINCIPLES
• Dilemma:
® What is the best fetal surveillance that should be done?
• Establish Accurate Date:
® How long are you going to wait to perform induction of
® Most important step
labor/intervention?
• Objectives:
® Prevent prolonged pregnancy by induction of labor C. ACTIVE MANAGEMENT
® Expectant management under close surveillance with
active management • Certain AOG
o In cases of pulmonary problems, like with non-reassuring
• For unripe Cervix
fetal heart rate (NRFHR) pattern, then go to active
• Artificial initiation of Labor:
management
® Cervical ripening
® Patient counseling:
o Induction of labor at 41 weeks OR ® Induction of labor using oxytocin
o Conservative management with antepartum surveillance
ACTIVE MANAGEMENT TRIAGE
§ Indicated for those who are uncertain of AOG
• Induce labor promptly with oxytocin and
• Prognostic factors for successful labor induction: rupture membrane
® Unfavorable Cervix Certain date
• Ideally, termination of pregnancy is at 41
with favorable
o Bishop’s Scoring weeks AOG (ViVa)
cervix (ripe
§ Bishop score <7 (Harris and coworkers, 1983) and inducible)
• In active phase of labor:
§ Bishop score of >5 favorable for induction ® Best time to rupture membrane to hasten
(Sumpaico) progress of labor
o No cervical dilatation: twofold increased CS rate for • Risk of failed induction is very high
dystocia • Ripen the cervix then induction of labor
o Cervical length ≤3 cm at TVS: predictive of successful Dates are • Suspected fetal macrosomia (>4500 grams):
induction certain with ® Do outright CS
unfavorable • In the presence of Normal Expected Fetal
o Cervical length ≤ 25mm: predictive of spontaneous labor cervix Weight:
or successful induction ® NST twice a week
® Cervical Ripening ® AFI determination
® Station of the Vertex ® Modified BPP
• Bishop’s Scoring • Management expectantly by NST twice a week
® Indicated prior to induction of labor and AFI determination
® Used to determine favorability/ripening of cervix in Dates are ® AFI <5 cm with diminished fetal movement
vaginal examination unsure should undergo labor induction
(Delivery not • Wait spontaneous labor
® If high score à cervix favorable (associated with an easier
indicated) • In indication of favorable cervix, do induction of
shorter induction) labor
® If low score à cervix unfavorable • In the presence of NRFHR patterns,
o Induction takes a longer period and more likely to fail termination of pregnancy via CS must be done.
o May end in emergency LSCS (low segment caesarean Table 5. Active management triage.
section)
D. ANTEPARTUM EVALUATION AND MANAGEMENT
SCORE 0 1 2 3
Dilation of cervix 0 1 or 2 3 or 4 5 or
more
PELVIC EXAM
Consistency of firm medium soft - • Check inducibility of the cervix through bishop scoring
cervix • A score of 5 or more is favorable for induction of labor
Length of >2 2-1 1-0.5 <0.5
Cervical Canal ANTENATAL FETAL SURVEILLANCE
Position of posterior central anterior - • Cardiotocography (CTG), NST (non-stress test), CST
Cervix (contraction stress test), full biophysical profile (BPS), modified
Station of -3 -2 -1 or 0 below
biophysical profile (NST and amniotic fluid index only), fetal
presenting part spines
Table 4. Bishop’s Scoring movement counting
• Preferably twice weekly
NOTE: ® Full/modified BPP, Amniotic Fluid volume assessment
Score >5: Cervix favorable for induction of labor (AFI), CST, pelvic exam
Score <5: Poor outcome for induction of labor • If high risk for IUGR
® Perform Doppler studies
Cervical dilatation is very important parameter out of the five.

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ULTRASOUND EVALUATION (PELVIC UTZ) ® Non-reassuring fetal heart rate (minimal variability, absent
® To detect fetal abnormalities, macrosomia/IUGR variability, or late deceleration)
® Monitor amniotic fluid volume ® Fetal Abnormalities such as hydrocephalus
o If oligohydramnios: admit patient and do induction of labor NOTE:
Plan of management of patients with post-term pregnancy
MATERNAL SURVEILLANCE should almost always be discussed with the patient.
• It is defined as the maternal perception of fetal movement
• The normal value: 5 movements in 1 hour or 10 movements in
2 hours after eating.
G. CERVICAL RIPENING
• How it is done is the mother should count the fetal kick within
• Used to improve the success rate of induction for patients with
1-2 hours’ time.
long or unfavorable cervix and poor Bishop’s scoring
• Used for the conservative management of Carbohydrate
Intolerance and Gestational Hypertension.
MECHANICAL
• Transcervical foley catheter with or without saline infusion
MATERNAL STATURE
® Not used here
• In cases of macrosomia
• Sweeping of membranes
• A portion of patients with short-stature have increased risk for
cephalo-pelvic disproportion. ® Cervical stripping: Insertion of fingers into the cervix to
manually stretch it à prostaglandins are produced (be extra
cautious because one can accidentally rupture the
BIOPHYSICAL PROFILE (BPP)
membrane or induce bleeding)
• BPP is usually done by a sonographer
® Causes pain, vaginal bleeding, irregular contractions
• Unfavorable cervix is defined with a Bishop Score of <7 without labor
according to Harris and Coworker (1983) • Laminaria tent
NORMAL ABNORMAL ® Inserted into the cervical canal, swells, and dilates within 24
PARAMETER hours
(2 PTS) (0 PTS)
Amniotic Fluid Fluid pockets of 2 cm Oligohydramnio ® Hydroscopic dilator is graduated depending on cervical size
Volume (AFV) in 2 axes s of patient.
NST Reactive Non-reactive ® Originally 6 mm and expands as time progresses due to
At least 1 episode of absorption of water and secretions
Fetal Breathing breathing lasting at No breathing
• The station of the fetal head within the pelvis is another
least 30 seconds
Fetal Limb
predictor of successful post term pregnancy induction: The
3 discrete movements ≤2 lower the station (-4 station) the higher rate.
Movement
At least 1 episode of
Fetal Tone
limb extension No movement H. PHARMACOLOGICAL MANAGEMENT
followed by flexion
Table 6. Biophysical profile PROSTAGLANDIN E2 (DINOPROSTONE) AND E1
SCORE INTERPRETATION MANAGEMENT (MISOPROSTOL)
8-10 Normal Repeat BPP as clinically • Misoprostol E1 was never approved by FDA
indicated ® Never use in live fetuses!
6 Suspect Chronic Repeat BPP in 4-6 hours • As per practice, doctors are more comfortable using
Hypoxia Prostaglandin E2 (ViVa)
0-4 Strongly suspect Deliver fetus if mature • Be cautious in using Prostaglandin E2
Chronic Hypoxia ® Its excessive use could lead to Uterine Hyperstimulation
Table 7. Interpretation of BPP leading to tachysystole which will lead to fetal distress

E. INDICATIONS FOR INTERVENTION OXYTOCIN

• Should not be given along with Prostaglandins as it may cause
• Terminate pregnancy in the presence of: tachycardia
® Ripe or favorable cervix
® Oligohydramnios EVENING PRIMROSE OIL
® Non-reassuring fetal heart rate pattern (do resuscitation) • Used alternatively
® Patient reaches 42 completed weeks • Given night prior to targeted date of delivery
® 6 capsules inserted vaginally
F. MODE OF DELIVERY ® After 6 hours, add 4 more capsules
® After another 6 hours, add 4 more capsules
• Individualize patients (case to case basis) ® Wait 6 hours
® Not all pregnancy that reach 42 will undergo CS. ® When the cervix is soft and inducible, induce labor
• Ideally and preferably vaginal by induction of labor
ACCEPTABLE METHODS FOR LABOR INDUCTION:
® Ripen first before induction of labor
• Oxytocin with or without amniotomy
• Caesarean Section: only for obstetrical indications
• Prostaglandin
® Macrosomia
® For cervical ripening
® CPD
® Dinoprostone gel and insert
® No misoprostol especially in live pregnancy
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 • CS should be done:
® Invasive Cervical Cancer
® Active Genital Herpes
• Normal AFI: 5-25

J. INTRAPARTUM MANAGEMENT

• Amniotomy
® Causes further reduction in fluid volume and enhances
possibility of cord compression
® Helps to identify presence of thick meconium
® Allows placement of scalp electrode and intrauterine
pressure catheter
® Complications:
o Non reassuring fetal heart rate
§ Variable deceleration
Figure 2. Algorithm for patients needing delivery
§ Poor variability
§ Late deceleration
§ Fetal tachycardia
§ Oligohydramnios
o Fetal trauma
§ Shoulder dystocia
o Intrapartal fetal distress
§ Variable deceleration from oligohydramnios, which
presents as non-reassuring fetal heart rate
o Meconium aspiration syndrome
§ After delivery of fetalhead
§ Suction meconium from nose and pharynx to prevent
aspiration

Figure 3. Algorithm for management of post-term pregnancy.
I. CONTRAINDICATIONS OF LABOR INDUCTION
• Vasa Previa or Placenta Previa
® Vasa Previa
o Encroachment of fetal vessels in the presenting
membrane
o It usually presents as profuse vaginal bleeding after the
rupture of the bag of water
® Placenta previa
o Painless vaginal bleeding on the 3rd trimester of
pregnancy
o Placenta that should be normally implanted in fundus is
implanted in the lower segment of uterus to a point that it
sometimes covers the entire cervical os
• Malpresentation (Transverse Fetal Lie, Breech)
• Umbilical Cord Prolapse
® It is an obstetrical emergency and intervention such as CS
delivery is expected
• Previous classical caesarean section
® 2 types of CS Section:
o Classical Caesarean Section
§ Vertical incision within the anterior uterus
§ When doing induction of labor, risk of uterine
rupture is high
o Low Segment Caesarean Section
§ Incision in lower uterine section (LUS)
§ Can undergo trial of labor
• Gynecological, Obstetrical or Medical conditions that
preclude vaginal birth
• Previous Myomectomy or Uterine Scar: (Especially Vertical
Scars)
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X. RECOMMENDATIONS
• Ensure appropriate dating
® Identify the exact last menstrual period
® Request ultrasound upon diagnosis of pregnancy
• Discuss the risk and the benefits to both the patient and the
family
• Intensive fetal surveillance at 41 weeks AOG
• Know the comorbidities associated with post term pregnancy
• USE THE TRIAGE METHOD
® Date is certain: induce labor
® Date is certain with unfavorable cervix: know the option
® Date is unsure: expectant management, close fetal
monitoring by twice a week AFI determination and NST
• Intensive fetal surveillance at 41 weeks AOG
XI. ADDITIONAL NOTES FROM UPCLASS
A. COMPLICATIONS
• Non reassuring fetal heart rate:
® Variable deceleration (Secondary to cord compression)
® Poor variability: Indicates asphyxiated fetus
® Late deceleration: After the peak of contraction, fetal heart
rate goes down (asphyxiated fetus)
® Fetal tachycardia: Maternal fever can cause fetal
tachycardia
® Oligohydramnios
• Fetal Trauma: Shoulder dystocia
• Intrapartal Fetal Distress: Variable Deceleration due to
Oligohydramnios and presents as non-reassuring fetal heart
rate
• Meconium Aspiration Syndrome: After Delivery of fetal head,
there would be suction meconium from nose and pharynx to
prevent aspiration
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B. BENEFITS OF TRANSCERVICAL AMNIOINFUSION

• Decrease incidence of Meconium Aspiration

• Relieves Severe or Repetitive Variable Deceleration
• Decreases need for CS
• Restores Physiologic amount of amniotic fluid
• May offer a safe, simple, and affordable approach to improve
outcome of Oligohydramnios

XII. REFERENCES
• Dr. Fernandez’s PowerPoint Presentation
• Lecture Recordings
• Sumpaico Textbook of Obstetrics, pp. 642-649
• Williams Obstetrics 25th Edition, Pp. 1882-1897.
• ViVa Trans

XIII. APPENDIX

Figure 4. Pathophysiology of post-term pregnancy

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