Postterm pregnancy

o Postterm pregnancy is a pregnancy that has extended beyond 42 weeks of

gestation.
o The prevalence of postterm pregnancy 5% to 10% of all pregnancies.
o associated with increased risk of fetal, maternal, and neonatal complications.
o condition is important and management remains a matter of concern for
clinicians.
 II DEFINITION
o Term gestation is defined as a pregnancy between 37 and 42 completed weeks
(260 to 294 days) after the first day of the last menstrual period (LMP).
o Postterm pregnancy begins when 42 completed (menstrual) weeks have elapsed.
o The first day of the LMP occurs approximately 2 weeks before conception in
a 28-day cycle.
III DETERMINING GESTATIONAL AGE

An accurate assessment of gestational age is essential to identify postterm

pregnancy.
III DETERMINING GESTATIONAL AGE
• several methods are used to determine gestational age:
A Naegele’s rule uses the first day of the LMP to calculate the estimated date of
confinement (EDC).
 B Quickening is the maternal perception of fetal movement and begins around
16 to 20 weeks of gestation.
 C Uterine size increases with gestational age.
D An electronic Doppler ultrasound may detect fetal heart tones as early as 10 to
11 weeks’ gestation.
E Ultrasound examination in the first trimester provides the most accurate
determination of gestational age.
Measurement of the crown–rump length (CRL) is accurate to within 5 to 7 days of the
actual gestational age.

The second- and third-trimester ultrasound uses several parameters for

determining gestational age. These parameters include the biparietal diameter (BPD), the
femur length (FL), and the abdominal circumference (AC).

The use of ultrasound in determining the EDC has been shown to decrease the incidence
of postterm pregnancy from 12% to 3%.
IV ETIOLOGY OF POSTTERM
PREGNANCY
• The most frequent cause of an apparent postterm pregnancy is error in determining the time of
ovulation and conception based on the reported LMP.

Frequently encountered problems:

 the patient’s failure to recall the date of her LMP
 variable length of the proliferative phase of the cycle
When postterm pregnancy truly exists, the cause is
usually unknown.
Common risk factors:
Nulliparity
 previous postterm pregnancy.
Male fetuses and obesity have also been shown to be associated with increases in prolongation
of pregnancy.
Parturition
Several disorders may result in delayed parturition and postterm pregnancy. These disorders are
all similar in that they are associated with low estrogen production.
Parturition (the process of giving birth) is a complex process that involves
events within:
 fetal brain
 adrenals
 placenta
 amnion
 chorion
Changes:
 maternal tissues
Decidua
 myometrium
 cervix.
The theorized mechanism of parturition begins with a stimulus in the fetal brain
activation of the fetal hypothalamic–pituitary axis.
 Adrenocorticotropic hormone production results in stimulation of the fetal
adrenal.
The fetal adrenal increases production of dehydroepiandrosterone sulfate
(DHEAS) and cortisol.
placental sulfatase in the placenta is required so to convert the DHEAS to
estradiol.
Estrogen increases myometrial activity, and cortisol stimulates prostaglandin
output in the placental tissues.
Prostaglandins are important for myometrial contractility.
 rare causes of postterm pregnancy include:

 Anencephaly is an absence of the fetal cranium with gross abnormalities associated with the
fetal brain.

Congenital primary fetal adrenal hypoplasia has been associated with prolonged gestation.

Placental sulfatase is required to convert fetal DHEAS to estrogen.

This is an X-linked disorder that affects male fetuses, occurring in 1 in 2,500 newborns.
V COMPLICATIONS OF POSTTERM PREGNANCY
Postterm pregnancies are associated with an increase in fetal, maternal, and neonatal
adverse events
increase in stillbirth rates
a higher incidence of meconium and meconium aspiration syndrome
prolonged labor
operative vaginal delivery
shoulder dystocia
Macrosomia
Oligohydramnios
fetal heart rate abnormalities
cesarean section
VMANAGEMENT OF THE POSTTERM
PREGNANCY
The goal of management of postterm pregnancy is to decrease the risk of an adverse perinatal
outcome (including stillbirth).

management strategies:
prevention of postterm pregnancy by inducing labor
expectant management under close surveillance

Older studies have suggested that routine induction of labor prior to 41 weeks increases the risk of cesarean delivery,
particularly in nulliparous women. The findings from randomized trials in the 1990s are equivocal on the advantages
or disadvantages of routine induction versus expectant management.
Therefore, both management strategies are acceptable.
VMANAGEMENT OF THE POSTTERM
PREGNANCY
Induction of Labor The success of labor induction is dependent on the characteristics of the
cervix.

Expectant management under close surveillance When expectant management is

undertaken, close surveillance is necessary.

testing generally occurs twice weekly between 41 and 42 weeks’ gestation. It can include the
nonstress test (NST), the contraction stress test (CST), or the biophysical profile (BPP).
1. The NST is a noninvasive test of fetal activity that correlates with fetal well-being. Fetal heart rate
(FHR) accelerations are observed during fetal movement.

records:
 the FHR
 fetal movements.

a. A reactive test requires two FHR accelerations of at least 15 beats’ amplitude of 15 seconds’ duration
in a 20-minute period.
b. In one study, 99% of oxytocin challenge tests were negative for signs of fetal distress when performed
after a reactive NST.
c. The most common cause for a nonreactive NST is a period of fetal inactivity or sleep
(in the healthy fetus is 40 minutes).
d. If the test is nonreactive after 40 minutes, a BPP or CST is indicated.
e. Approximately 25% of fetuses that have a nonreactive NST have a positive CST.
2. The CST is a test of FHR that indirectly measures placental function in response
to uterine contractions.
An intravenous infusion of oxytocin is used to stimulate uterine contractions.
The nipple stimulation test is an endogenous means of releasing oxytocin in
response to manual stimulation of the patient’s nipples. It can be viewed as a
noninvasive CST.
A CST result may be classified as negative, positive, or equivocal.
a. A negative CST consists of three uterine contractions of moderate intensity lasting 40 to 60 seconds
over a 10-minute period with no late decelerations in the FHR tracing.
• A positive CST has late decelerations associated with more than 50% of the uterine contractions.
• A CST with inconsistent late decelerations is considered equivocal.

b. More often, a favorable outcome follows a negative CST, but as many as 25% of fetuses may
experience intrapartum fetal distress after a negative CST.

c. CSTs have a 25% false-positive rate.

d. Studies have shown the incidence of perinatal death within 1 week of a negative CST to be less than 1
in 1,000. Most of these deaths are caused by cord accidents or abruptions.

e. A positive CST has been associated with an increased incidence of intrauterine death, late
decelerations in labor, low 5-minute APGAR scores, intrauterine growth retardation, and
meconium-stained amniotic fluid. The overall perinatal death rate after a positive CST is
between 7% and 15%.

f. If a patient over 41 weeks’ gestation undergoing a CST has an equivocal or positive result,
delivery should be strongly considered.
3. Biophysical profile is a composite of tests utilizing FHR tracing and
ultrasound designed to identify a compromised fetus during the
antepartum period

a. Components of the profile

(1) NST
(2) Fetal breathing
(3) Fetal tone
(4) Fetal motion
(5) Quantity of amniotic fluid
Bishop Scoring System Used for Assessment of Inducibility
Cervical Score Dilation Effacement (%) Station Consistency Position
 Management Based on BPP Score

10 Normal Repeat testing

8 Normal Repeat testing
6 Suspect chronic asphyxia If 36 weeks, deliver Repeat testing in 4–6 hours
4 Suspect chronic asphyxia If 32 weeks, deliver Repeat testing in 4–6 hours
0–2 Strongly suspect chronic asphyxia Extend testing to 120 minutes; if score 4,
deliver at any
gestational age
Management Based on BPP Score

Scoring of the profile.

• Each test is given either 2 or 0 points, for a maximum of ten points.
• An important feature in the postterm profile is the amniotic fluid index (AFI).
• Oligohydramnios (AFI less than 5) is an ominous sign that signifies placental
insufficiency and increased risk of poor perinatal outcome.
Term patients with oligohydramnios should be delivered.
 Timing of delivery
Delivery is indicated when the risks to the fetus, mother, or both is associated
with continuation of the pregnancy are greater than those faced during or after
delivery.
pregnant women with conditions such as diabetes or hypertension are at high risk
of maternal and fetal complications and are generally delivered by 40 weeks’
gestation.
 In low-risk women, induction of labor may be performed at 41 weeks if the
cervix is favorable.
 Timing of delivery

If the cervix is unfavorable, then expectant management with antepartum fetal
surveillance should be continued.
Any abnormal antenatal testing should lead to an intervention that either provides
reassurance or proceeds toward delivery.

Generally, at 42 weeks’ gestation, if the cervix remains unfavorable, prostaglandins

are administered to “ripen” the cervix for induction.

Intrapartum management includes continuous electronic FHR monitoring