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Prolonged Pregnancy

Prepared by:

Dr. Gehanath Baral


MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
5th April, 2007
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 )


Incidence=10%
DEFINITION

1. Postdatism is pregnancy lasting beyond the


estimated due date at 40 weeks.

2. “Postmature” is reserved for the pathologic


syndrome in which the fetus experiences placental
insufficiency and resultant IUGR .
Post-maturity syndrome
1. Meconium -stained amniotic fluid,

2. Oligohydramnios

3. Fetal distress

4. Evidence of loss of subcutaneous fat and

5. Dry, cracked skin

Reflects placental insufficiency


Etiologic Factors
1. Usually unknown
2. Error in dating
3. Familial
4. Primiparity and prior postterm

5. Placental sulfatase deficiency

6. Fetal anencephaly
Risks to the Fetus
 Uteroplacental  Macrosomia
insufficiency 1. Prolonged labor  CPD,Less
1. Fetal hypoxia moulding
2. Meconium aspiration(8 x ) 2. Obstructed labor CPD,Less
1. Chemical pneumonia moulding
2. Atelectasis
3. Shoulder dystocia
3. Pulmonary
hypertension 4. Birth injury

3. Growth restriction(IUGR)  Pernatal death


4. Oligohydramnios:
> 42 weeks twice that at term
1. Cord compression
2. Malposition > 43 weeks > 6-fold that at
3. Malpresentation
term
5. Fetal distress and
meconium(2 x )
Clinical diagnosis
 Pregnancy dating by:
• Menstrual history
• Quickening
• USG
 Falling/Stationary wt.
 Decreasing fundal ht./abd.girth
 Uterus feels as full of fetus
 P/V:
• Soft Cx mature
• Hard skull bones mature
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Oligohydramnios

 U/S diagnosis :

 No vertical pocket > 2 cm or

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

 It is considered an indication for delivery.


Maternal risks

1) Labor dystocia

2) Severe perineal injury related to macrosomia

3) Doubling in the rate of cesarean delivery.

4) Maternal anxiety
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.
Ultrasound biometry margins of error
Error:
 Crown-rump length (CRL) till 12 weeks 3-5 days
 Biparietal diameter (BPD) at 12-20 weeks 1 week
 BPD at 20-30 weeks  2 weeks
 BPD after 30 weeks3 weeks
Value of USG:
1. If >1 week discrepancy between LMP & USG Use
USG data to determine the EDD
2. USG for gestational age determination prior to 20
weeksAccepted
Transcerebellar diameter

1. 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.

2. The diameter in millimeters corresponds to weeks of


gestation up to 24 weeks.
Transcerebellar diameter
Are there interventions that decrease
the rate of postterm pregnancy?
1. Accurate dating on the basis of
ultrasonography performed early in
pregnancy .

2. Breast and nipple stimulation at term


have not been shown to affect the
incidence of postterm pregnancy.

3. Sweeping of the membranes at term :


the data are still conflicting .
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 : depends on effective


counselling of women
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 .
Routine induction of labour
at 41 weeks
1. Favorable outcomes with routine induction as early as the
beginning of 41 weeks of gestation.

2. Routine induction in low-risk pregnancies at or after 41


weeks' gestation is associated with :

 A reduction in perinatal mortality,


 No increase in the rate of instrumental or cesarean
delivery.
3. Fetal distress from uteroplacental insufficiency due to prolonged
pregnancy can be reduced by induction of labor
ANTEPARTUM FETAL SURVEILLANCE
1. The condition of the fetus can change quickly at
frequent intervals.

2. Twice-weekly SURVEILLANCE

3. Modified biophysical profile:


1. Non stress test
2. Amniotic fluid index
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) .

Expectant treatment
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

 Offer her labour induction.

 Establish the cervical (Bishop) Score

 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

1. Consider amniotomy to diagnose thick meconium.

2. 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.
Indication of CS:
Post term + Complicating factors
1. CPD
2. Prev.CS
3. Malpresentation
4. Severe oligohydramnios / Anhydramnios
5. PET
6. APH
7. DM
8. Rh-ve

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