Prolonged Pregnancy

(Evidence 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. ³Postmature´ is reserved for the Postmature´ pathologic syndrome in which the fetus experiences placental insufficiency and resultant IUGR . 

2. cracked skin Reflecting placental insufficiency. Fetal distress 4. Dry. Evidence of loss of subcutaneous fat and 5. Meconium -stained amniotic fluid.PostPost-maturity syndrome  Representing 20 % cases of prolonged pregnancy and is associated with : 1. . Oligohydramnios 3.

  Primiparity and prior postterm pregnancy are the most common identifiable risk factors. . When truly exists. the cause usually is unknown.Etiologic Factors  The most frequent cause is an error in dating.

Etiologic Factors  Rarely. Genetic predisposition may play a role . it may be associated with placental sulfatase deficiency or fetal anencephaly. .   Male sex also has been associated.

. the incidence of postterm pregnancy is 9 .EPIDEMIOLOGY  Using the definition of 294 days. days.10 %.

Risks to the Fetus  The perinatal mortality: > 42 weeks twice that at term > 43 weeks > 6-fold that at term .

aspiration. resulting in fetal hypoxia . meconium restriction.Risks to the Fetus  In some cases. and oligohydramnios . to uteroplacental insufficiency. aspiration. Fetal distress and meconium release were twice as common (at or after 42 weeks) than at term. There was an eight-fold increase in eightmeconium aspiration   . growth restriction. the risks appear to be due insufficiency.

continued growth of the fetus leads to macrosomia. with resultant risks of orthopedic or neurologic injury. increasing the risk of labor abnormalities. .In other cases. .Macrosomia is far more common in postterm than term pregnancies . shoulder dystocia abnormalities.Macrosomia .

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.Oligohydramnios  It is a marker for fetal compromise and accidents.    .

 Some of these deaths clearly result from peripartum complications (such as meconium aspiration syndrome).Risks to the Fetus  Fetuses born postterm also are at increased risk of : Sudden infant death syndrome (death within the first year of life). . 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.

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 overover-represented in populations of postterm pregnancies. .Gestational age calculation  Gest.   Dating by the last menstrual period (LMP) alone has a tendency to overestimate the gestational age.

3.Gestational age calculation  Because actual dates of conception are rarely known. This can make the accuracy of gest. Irregular menses . age determination unreliable because of :  1. Recent cessation of birth control pills. 2. . the LMP is used as the reference point. Inconsistent ovulation times.

COCHRANE . 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.Routine early pregnancy ultrasound Reduces the number of women who require induction of labour for apparent postterm pregnancy . prior to 20 weeks RCOG.

week. BPD after 30 weeks is 3 weeks.Ultrasound biometry margins of error  CrownCrown-rump length (CRL) till 12 weeks is 3-5 days.     . weeks. the ultrasound data should be used to determine the EDD . BPD at 20-30 weeks is 2 weeks. and 20weeks. Biparietal diameter (BPD) at 12-20 weeks is 121 week. If there is more than a one week discrepancy between the LMP and the ultrasound findings.

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. femur length). BPD.e. abdominal circumference.Transcerebellar diameter  When composite biometry is not consistent in all of the parameters (i. . head circumference.

Transcerebellar diameter .

RCOG (GRADE A) . The available evidences strongly in support dating by are that Early ultrasonography alone is the most accurate method for predicting EDD. EDD.

RCOG (GRADE A) .5 %.Routine early pregnancy ultrasound  The use of early ultra-sound alone ultrato calculate the rate of postterm pregnancy in women who delivered spontaneously significantly reduced the postterm rate from 10 % to 1.

Sweeping of the membranes at term : the data are still conflicting .Are there interventions that decrease the rate of postterm pregnancy?  Accurate dating on the basis of ultrasonography performed early in pregnancy . ACOG Guidelines 2004   . Breast and nipple stimulation at term have not been shown to affect the incidence of postterm pregnancy.

. 2) Absence/presence of maternal risk factors and / or 3) Evidence of fetal compromise.  Successful management depends on effective counselling of women and their full involvement in the decision making process.Management options depend on: 1) Gestational age. and 4) Maternal preferences .

Awaiting the onset of spontaneous labour. while monitoring the fetal wellbeing . . prolonged pregnancy has been managed in 2 ways .  The decision is difficult and should not be taken lightly. either : a.Historically. Inducing labour at 41-42 weeks 41gestation or b.

several large multicenter randomized studies reported favorable outcomes with routine induction as early as the beginning of 41 weeks of gestation.Routine induction of labour at 41 weeks  Although postterm pregnancy is defined as a pregnancy of 42 weeks or more of gestation. Cochrane 2006 .

RCOG Grade A 1. . No increase in the rate of instrumental or cesarean delivery.Routine induction of labour at 41 weeks  A recent review in the Cochrane Library concluded that routine induction in low-risk lowpregnancies at or after 41 weeks' gestation is associated with : A reduction in perinatal mortality. 2.

 . even to labor. section.Routine induction of labour at 41 weeks  Contrary to what many obstetricians believe. the point of preventing perinatal death from asphyxia. it decreases it. The risk of fetal distress from uteroplacental insufficiency due to prolonged pregnancy can be reduced by induction of labor. rather. induction of labor for prolonged pregnancy does not increase the rate of cesarean section.

.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.

of the tests are immune from false positives. distress was superior to weekly testing. false negatives  Boehm et al. demonstrated that twicetwiceweekly testing of patients at risk for fetal testing. . monitoring should be at frequent intervals.ANTEPARTUM FETAL SURVEILLANCE  The condition of the fetus can change quickly and thus. and that none intervals.

FETAL SURVEILLANCE A modified biophysical profile consisting of a:  non stress test and  amniotic fluid index an have been shown to be as sensitive as a full biophysical profile. RCOG Grade A . profile.

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). ACOG 2004 (Level C)  . regardless of parity or method of induction. when indicated.

Management from 40-41 weeks gestation 40A .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) . .

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 40 .

and offer her labour induction. uncomplicated pregnancy Inform the woman of the options and risks/ benefits of labour induction versus expectant management. Healthy. Establish the cervical (Bishop) Score and ensure a ripening agent (prostaglandin) prior to induction. .Management at 41 weeks gestation A.

then initiate induction immediately Induce at 42 weeks even if NST and AFI are normal. then provide expectant management:  Daily fetal movement counts  Non stress test (NST) and Amniotic fluid index (AFI) twice/ week to 42 weeks. If mother declines induction .Management at 41 weeks gestation B.  If the NST or AFI is abnormal . .

If meconium is present then consider risk of meconium aspiration .Management during labour and delivery Consider amniotomy to diagnose meconium. Be prepared for shoulder dystocia and neonatal resuscitation at delivery. continuous fetal assessment with electronic fetal monitoring (EFM) is recommended. thick .

(RCOG Grade A) .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 .

the fetus should be monitored with twice weekly non-stress test . (RCOG Grade C ) .Key Clinical Recommendations  If Expectant management (41.However. . evidence of benefit is lacking. amniotic fluid index .42 weeks) is chosen.

 Delivery should be effected if there is evidence of :   fetal compromise oligohydramnios. or ACOG 2004 (Level A) .Key Clinical Recommendations  Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.