POST TERM PREGNANCY

Compiled by:- Samuel Abebe

11/20/2023 post term 2

‘From inability to let well alone;

from too much zeal for the new and contempt for what is
old;
from putting knowledge before wisdom, science before art,
and cleverness before common sense;
from treating patients as cases;
and from making the cure of the disease more grievous than
the endurance of the same, Good Lord, deliver us.’
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OUTLINE
 Objective

 Introduction

 Etiology and risk factors

 Clinical manifestation and Diagnosis

 Complications and effects of post term pregnancy

 Investigations and Management

 Prevention
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Objectives
At the end of the session students should be able to:-
• Define post term pregnancy

• List possible maternal and fetal complications associated with

post term pregnancy.

• Outline a basic approach

 Evaluation for post-term pregnancy

 Management options for post-term pregnancy.

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Introduction
Definition:

Uniform criteria are lacking as to the precise definition.

Literally, any pregnancy which has passed beyond the expected date

of delivery, is called a prolonged or postdated pregnancy.

But for clinical purposes, a pregnancy continuing > 2 weeks of the

EDD(> 294 days) is called post-maturity or post-term pregnancy.

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Introduction ….
Incidence ranges between 4% and 14%.

Carries with it an increased risk of adverse outcome.

 Increased maternal and perinatal morbidity & mortality

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ETIOLOGY
 So long as the complex mechanism in initiation of labor

remains unknown,
the cause of the prolongation of pregnancy will remain obscure.
But certain factors are related with postmaturity.
1. Wrong dates—due to inaccurate LMP (most common)
2. Biological variability (Hereditary) may be seen in the family
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ETIOLOGY……..
3. Maternal factors:
Primiparity, previous prolonged pregnancy, sedentary habit,
elderly multipara
4. Fetal factors:
Congenital anomalies:
Anencephaly → abnormal fetal HPA axis and adrenal hypoplasia
→ diminished fetal cortisol response
5. Placental factors:
Sulfatase deficiency → low estrogen.
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CLINICAL MANIFESTATIONS
• The clinical presentation of postterm infants is based primarily on

fetal growth.
• Macrosomia —

These infants appear normal at birth, apart from their large size.

They often have accentuated physiologic desquamation of the skin

Postterm macrosomic infants are at risk for

Birth injury due to prolonged labor

Cephalopelvic disproportion

Shoulder dystocia
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CLINICAL MANIFESTATIONS…
• Fetal growth restriction —

Due to degenerating or poorly functioning placenta that is unable

to provide adequate nutrition and oxygenation.

• Increased perinatal mortality in postterm pregnancies.

• FGR in postterm pregnancy results in dysmaturity

syndrome:-
• Long, thin, SGA and malnourished infant

• Meconium stained, and

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CLINICAL MANIFESTATIONS…
Fetal growth restriction……
• In infants with dysmaturity,

• The skin appears loose, especially over the thighs and buttocks,

• Has prominent creases.

• Vernix caseosa is decreased or absent.

• Lanugo hair is sparse or absent, while scalp hair is increased.

• The nails typically are long.

• Have the appearance of increased alertness and a "wide-eyed" look.

• scaphoid abdomen
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Post maturity syndrome

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Diagnosis
Estimation of accurate gestational age by available best methods.

Clinical estimation of gestational age is inferior than ultrasound

LNMP is inaccurate in 10-40% of cases because of irregular

ovulation, oligomenorrhea & unable to recall LNMP

LMP is helpful when the menstrual cycle is regular.

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Diagnosis ….
• Diagnosis is based on accurate gestational dating.

• The most common methods to determine the gestational age are:

1) Knowledge of the date of the LNMP.

2) timing of intercourse
3) Early ultrasound assessment performed before the 24th week

of gestation (preferably CRL measurement before 14weeks).

Basing gestational age solely on the LMP generally results in an

overestimation of gestational age => higher frequency of

induction of labor
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Diagnosis ….
If LNMP is known and reliable,

• calculate the gestational age from the given date.

• The given LNMP is said to be reliable:

 If the date of onset of the LNMP is accurately recalled

 If she had at least three regular menstrual cycles before the LNMP, and

 If she was not using any form of hormonal contraceptives for at least 3

months prior to the LNMP.

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Diagnosis…
If LNMP is not known or not reliable,

Unreliable when
1. Pregnancy occurs during lactational amenorrhea or
2. Soon following withdrawal of the “pill”, confusion arises.

History:

• If date of quickening is recalled accurately, calculate the GA by

• adding 20 weeks in nullipara or

• 18 weeks in multipara to the weeks lapsed since the date of quickening.

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Diagnosis…
 Physical Examination:

• If there is a documented symphysis fundal height determination

in early pregnancy before 20 weeks

 Add lapsed weeks since the date of the fundal height

determination.
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Diagnosis…
The suggested clinical findings for postterm are:
• Weight record:

• Regular weight checking reveals stationary or falling weight.

• Girth of the abdomen:

• It diminishes gradually because of diminishing liquor.

• History of false pain:

• Appearance of false pain followed by its subsidence is suggestive.

• Obstetric palpation:

• Uterine size, size of the fetus and hardness of the skull bones.

• As the liquor amnii diminishes, the uterus feels “full of fetus”

— a feature usually associated with postmaturity

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Diagnosis …..
 If there is documented early detection of FHR, GA is determined by

adding the lapsed weeks since the date of the detected FHR .
• FHR is detected at the earliest using

• Fetoscope at 18-20 weeks and

• Doppler at 10-12 weeks.

Diagnostic Tests:

If there is a documented early positive pregnancy test, GA is determined by

6 weeks to the lapsed weeks since the date of the positive pregnancy test.
 The earliest possible time for urine pregnancy test to be positive is at 6 weeks from

LNMP.
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Gestational Age Calculation

• ACOG criteria:

1. Urine/ serum hcG positive first: 36 weeks has to lapse

2. FHB positive 1st : by Doppler (30 weeks), pinnards(20 wkS)

3. Ultrasound: 1st trmester- CRL, GS; 2nd trimester(11-20 wks)-

BPD, FL, AC.

4. Biochemical: L/S ratio, Phosphatidyl glycerol, Lamellar

body count, Shake test

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DIAGNOSIS…
• The following criteria have been used to establish the diagnosis

of postmaturity retrospectively.
Newborn
(1) General appearance:
• Baby looks thin and old. Skin is wrinkled.

• There is absence of vernix caseosa.

• Body and the cord are stained with greenish yellow color.

• Head is hard without much evidence of molding.

• Nails are protruding beyond the nail beds;

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(2) Weight
• often more than 3 kg and length is about 54 cm.

• Both are variable and even an IUGR baby may be born.

Liquor amnii:
Scanty and may be stained with meconium.
Placenta:
There is evidence of aging of the placenta manifested by excessive
infarction and calcification.
Cord:
There is diminished quantity of Wharton’s jelly which may precipitate
cord compression.
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COMPLICATIONS OF POST-TERM PREGNANCY

• Risk of placental insufficiency due to placental aging.

• This is manifested by placental calcification and infarction.

• Associated complications like HTN and DM aggravates the

pathology.
Fetal complication
During pregnancy—
There is diminished placental function, oligohydramnios and meconium
stained liquor.
These lead to fetal hypoxia and fetal distress.
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Fetal complication …….

During labor—
1. Fetal hypoxia and acidosis;
2. Labor dysfunction;
3. Meconium aspiration;
4. Risks of cord compression due to oligohydramnios;
5. Shoulder dystocia;
6. Increased incidence of birth trauma due to big size baby and
non-molding of head due to hardening of skull bones and
7. Increased incidence of operative delivery.
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Following birth—

(1) Chemical pneumonitis, atelectasis and pulmonary hypertension

are due to meconium aspiration;

(2) Hypoxia (low Apgar scores) and respiratory failure;

(3) Hypoglycemia and polycythemia and

(4) Increased NICU admissions.

Perinatal morbidity and mortality is calculated in terms of stillbirth.

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Dystocia
• Shoulder dystocia

 Is an obstetric emergency

 Caused by impaction of the anterior fetal shoulder behind the

symphysis pubis during the process of vaginal delivery

 Brachial plexus injury is one of the complication

Around 80% to 90% of brachial plexus injuries completely

resolve by age 1 year.

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Dytocia……
• Erb-Duchenne palsy,

 Paralysis, stretch, or tear injury to the upper roots of the brachial

plexus, at C5 and C6,

Results in paralysis of the deltoid and infraspinatus muscles and flexor

muscles of the forearm,

Causing the limb to hang limply close to the side, with the forearm

extended and internally rotated.

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Dystocia …….
• Klumpke paralysis, or paralysis of the hand

Finger function is usually retained.

Less frequently, damage is limited to the lower nerves of the brachial

plexus, C8 and T1.

Because most brachial injuries are mild, treatment is expectant with

splints and physical therapy in anticipation of complete or nearly

complete recovery in 3 to 6 months.

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Meconium Aspiration Syndrome

Meconium aspiration syndrome (MAS) is defined as
 Respiratory distress in newborn infants born through meconium-

stained amniotic fluid (MSAF) whose symptoms cannot be

otherwise explained.
• MAS lead to severe respiratory distress from

• mechanical obstruction of both small and large airways,

• as well as to meconium chemical pneumonitis.

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Pathophysiology of meconium aspiration syndrome

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MAS….
MAS is not limited to postterm pregnancies

 but prolonged pregnancy, particularly in the setting of oligohydramnios,

is a significant risk factor.

Meconium passage occurs in 12% to 22% of women in labor, with

aspiration occurring in up to 10% of these infants.

The incidence of meconium passage increases as pregnancy becomes

prolonged, as does the incidence of MAS.

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Oligohydramnios
 Refers to AFV that is less than expected for GA.

 Diagnosed by ultrasound examination.

 An adequate volume of amniotic fluid is critical to

 allow normal fetal movement and growth

 cushion the fetus and umbilical cord.

 Oligohydramnios can lead to:-

 fetal deformation,

 umbilical cord compression, and

 death.
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Oligohydramnios…….

• Oligohydramnios is associated with poor outcomes due to

Umbilical cord compression,

Uteroplacental insufficiency, and

Meconium aspiration.

• At term, oligohydramnios is an indication for delivery.

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Complications of dysmaturity syndrome…

MATERNAL RISKS:
• Increased Maternal morbidity due to:
- Induction
- Instrumental delivery
- Cesarean delivery

Post maturity per se does not put the mother at risk

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Complications of dysmaturity syndrome:

- Short term complications:

- seizure,

- respiratory insufficiency

- Metabolic complications: hypoglycemia, hypocalcemia,

polycythemia
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Complications of dysmaturity syndrome:

Long term complications:
• Neurodevelopmental complications

• Cerebral palsy (CP).

• Epilepsy

• Developmental outcome:- decreased cognitive scores

• Behavioral problems:- behavioral problems and attention

deficit disorder
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Effects of post term pregnancy

1. Dystocia
2. Severe perineal injury with macrosomia
3. Increased C/S delivery
4. Puerperal infection, PPH
5. Anxiety
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Investigations
Purpose of investigation:

• To confirm fetal maturity

• To detect evidence of placental insufficiency

1. Assessment of maturity

- Ultrasound/ ACOG criteria

- Amniocentesis
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Investigations…….
2. Assessment of fetal wellbeing:
 Fetal kick count by mother
 NST- twice weekly
 BPP/ Modified BPP
Amniotic fluid volume
 Doppler studies of umbilical arteries
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Management

• The mode of treatment is termination of pregnancy.

 Induction of labor:

 Performed at 42 weeks if the cervix is favorable or by priming.

 If the cervix is unfavorable (bishop score ≤5), ripen the cervix before

induction.

 Elective cesarean delivery if indicated.

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Management ….
• After 41 weeks of gestation the risk of perinatal mortality and

morbidity increases.
• Hence to reduce the risk initiate more frequent antepartum fetal

wellbeing assessment at 41 weeks.

• It can include:-

Fatal kick count: if less than 10 kicks/12 hrs or <3 kicks/

hour (morning, afternoon, evening) further testing is required.

 Non-stress test (NST) or BPP or modified BPP twice a week.
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Management …
• Intrapartum management:

 During labor and delivery the fetal condition should be

followed closely.
 FHB follow up with CTG or strict one to one follow up.
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Care during labor

Whether spontaneous or induced, the labor is expected to be

prolonged because of a big baby and poor molding of the head.

More analgesia is required for pain relief.

Careful fetal monitoring with available gadgets is to be done.

If fetal distress appears, prompt delivery either by cesarean

section or by forceps/ventouse is to be done.

Consider possibility of shoulder dystocia

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Prevention
1. Accurate dating by early ultrasound: decreased incidence by
70%
2. Manual nipple stimulation at term
3. Electrical breast stimulation
4. Sweeping of membranes near or at term.
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References
1. Dc duttas Textbook of Obstetrics including Perinatology and Contraception Eighth
Edition
2. Uptodate
3. Williams Obstetrics, 25th Edition F. Gary Cunningham, Kenneth J. Leveno, Steven
L. Bloom, Jodi S. Dashe, Barbara L. Hoffman, Brian M. Casey and Catherine Y.
Spong
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THE END !