POST TERM

PREGNANCY
Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
 – Cunningham FG, Leveno KJ, Bloom SL, Spong
CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
Reference JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 43 Postterm Pregnancy
 – 42 completed weeks—294 days— or more from the
first day of the last menstrual period
– two categories of pregnancies that reach 42 completed
POSTTERM weeks:
PREGNANCY – (1) those truly 40 weeks past conception
– (2) those of less-advanced gestation but with inaccurately
estimated gestational age

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffm an BL, Casey
BM, Sheffield JS (eds).W illiam ’s Obstetrics 24 th edition; 2014; chapter 43
Postterm Pregnancy
 TABLE 43-1. Pregnancy Outcomes in 56,317 Consecutive Singleton Pregnancies Delivered
at or Beyond 40 Weeks at Parkland Hospital from 1988 through 1998
Weeks’ Gestation
SECTION 11 40 41 42 p
Outcome (n = 29,136) (n = 16,386) (n = 10,795) valuea
Maternal outcomes (%)
Labor induction 2 7 35 < .001
Cesarean delivery
Dystocia 7 6 9 < .001
Fetal distress 2 3 4 < .001
PREGNANCY Perinatal outcomes (per 1000)
Neonatal ICU 4 5 6 < .001
OUTCOMES: Neonatal seizures 1 1 2 .12
Stillbirth 2 1 2 .84
Neonatal death 0.2 0.2 0.6 .17
a
p value is for the trend using 42 weeks as the referent.
ICU = intensive care unit.
Adapted from Alexander, 2000a.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffm an BL, Casey
Alexander and colleagues (2000a) reviewed 56,317
BM, Sheffield consec-illiam ’scompleted
JS (eds).W Obstetrics weeks compared
24 th edition; 2014; with the43cumulative probab
chapter
≥ 40 weeks
utive singleton pregnancies delivered atPostterm Pregnancy
between the perinatal index—of death when all ongoing pregnanc
1988 and 1998 at Parkland Hospital. As shown in Table 43-1, included in the denominator. As shown, delivery at 38
labor was induced in 35 percent of pregnancies completing had the lowest risk index for perinatal death.
PATHOPHYSIOLOGY
 – wrinkled, patchy, peeling skin:
prominent in palms and soles (2o
to the loss of protective effect of
vernix caseosa)
– a long, thin body suggesting
Postmaturity wasting
syndrome – advanced maturity: infant is open- FIG
ges

eyed, unusually alert, and appears

rat
old and worried. col
at l
tha
– nails are typically long
■
– severe growth restriction may be FIGURE 43-4 Postmaturity syndrome. Infant delivered at
Th
we
present. 43 weeks’ gestation with thick, viscous meconium coating the
desquamating skin. Note the long, thin appearance and wrinkling tum
to
of the hands.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield olig
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy cie
attributed the postmaturity syndrome to placental senescence, tor
although he did not find placental degeneration histologically. of
Still, the concept that postmaturity is due to placental insuffi- dec
ciency has persisted despite an absence of morphological or sig- fou
 – Placental senescence or placental
insufficiency
– placental apoptosis— is
significantly increased at 41 to 42
completed weeks compared with
that at 36 to 39 weeks
Placental – proapoptotic genes such as
kisspeptin were shown to be
dysfunction upregulated in postterm placenta
– decreased fetal oxygenation 2o to
placental aging

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 – Decreased amniotic
fluid volume during – Decreased amniotic
postterm fluid volume during
postterm
Fetal Distress – meconium release into
an already reduced
and amnionic fluid volume
Oligohydramnios – Cord compression
– thick, viscous meconium
that may cause
meconium aspiration – Fetal distress
syndrome

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 – Increased incidence of fetal growth restriction
– stillbirths were more common among growth-
Fetal Growth restricted infants who were delivered after 42
Disorders weeks.
– May also manifest as fetal macrosomia à
increased incidence of CS

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 – In the event of a medical or other obstetrical
complication, it is generally not recommended
that a pregnancy be allowed to continue past
Medical or 42 weeks.
Obstetrical – earlier delivery is indicated.
Complications – Common examples include gestational
hypertensive disorders, prior cesarean delivery,
and diabetes.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
Management
 –2 options:
Management
1. labor induction : more popular option
options 2. expectant management with fetal
surveillance

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 1. Unfavorable Cervix
– women in whom there was no cervical
Prognostic dilatation had a twofold increased cesarean
Factors for delivery rate for “dystocia.”
Successful – cervical length ≤ 3 cm measured with
Induction transvaginal sonography was predictive of
successful induction.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 526 Labor

TABLE 26-2. Bishop Scoring System Used for Assessment of Inducibility

Cervical Factor
Score Dilatation (cm) Effacement (%) Station (–3 to +2) Consistency Position
SECTION 7 0 Closed 0–30 –3 Firm Posterior
1 1–2 40–50 –2 Medium Midposition

Recall: 2
3
3–4
≥5
60–70
≥ 80
–1
+1, +2
Soft
—
Anterior
—

What is From Bishop, 1964.

BISHOP Laughon and coworkers (2011) attempted to simplify the 30 minutes. Doses may be repeated every 6 hours, with a ma
• A quantifiable method used to predict labor induction
Bishop score by performing a regression analysis on 5610 single- mum of three doses recommended in 24 hours.
score? ton, uncomplicated deliveries by nulliparas between 37 and
6/7 outcomes
0/7

41 weeks. Only cervical dilation, station, and effacement were

A 10-mg dinoprostone vaginal insert—Cervidil—is
approved for cervical ripening. This is a thin, flat, rectang
l al

• A Bishop score of 9 conveys a high likelihood for a

significantly associated with successful vaginal delivery. Thus,
a simplified Bishop score, which incorporated only these three
successful induction.
parameters, had a similar or improved positive- or negative-
• A Bishop score of 4 or less identifies an unfavorable cervix
predictive value compared with that of the original Bishop score.
Transvaginal sonographic measurement of cervical length
and may be an indication for cervical ripening.
has been evaluated as a Bishop score alternative. Hatfield and
associates (2007) performed a metaanalysis of 20 trials in
Cunningham
which cervical length was used to predict FG, Leveno KJ,
successful induction.
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
Because of study criteria heterogeneity—including the defini-
tion of “successful induction”—the authors concluded that the
lar polymeric wafer held within a small, white, mesh polyes
sac (Fig. 26-1). The sac has a long attached tail to allow ea
removal from the vagina. The insert provides slower release
medication—0.3 mg/hr—than the gel form. Cervidil is used
a single dose placed transversely in the posterior vaginal forn
Lubricant should be used sparingly, if at all, because it can co
the device and hinder dinoprostone release. Following ins
Bloom SL, Spong
tion, the CY, Dasheshould
woman JS, Hoffman BL, Casey
remain BM, Sheffield
recumbent for at least 2 hou
The insert is removed after 12 hours or with labor onset and
least 30 minutes before the administration of oxytocin.
 highly subjective. In either case, there are pharmacological and indication for cervical ripening.

TABLE 26-1. Some Commonly Used Regimens for Preinduction Cervical Ripening and/or Labor Induction
Techniques Agent Route/Dose Comments
Pharmacological
Prostaglandin E2 Dinoprostone gel, 0.5 mg Cervical 0.5 mg; repeat 1. Shorter I-D times with oxytocin infusion
(Prepidil) in 6 hr; permit 3 doses than oxytocin alone
total
Dinoprostone insert, Posterior fornix, 10 mg 1. Insert has shorter I-D times than gel
10 mg (Cervidil) 2. 6–12 hr interval from last insert to
oxytocin infusion

Prostaglandin E1a Misoprostol tablet, 100 Vaginal, 25 µg; repeat 1. Contractions within 30–60 min
or 200 µg (Cytotec)b 3–6 hr prn 2. Comparable success with oxytocin for
Oral, 50–100 µg; repeat ruptured membranes at term and/or
3–6 hr prn favorable cervix

Cervical
3. Tachysystole common with vaginal
doses > 25 µg
Mechanical
Transcervical 36F 30-mL balloon 1. Improves Bishop scores rapidly

Ripening Foley catheter 2. 80-mL balloon more effective

3. Combined with oxytocin infusion is
superior to PGE1 vaginally
4. Results improved with EASI with
possible decreased infection rate

Hygroscopic dilators Laminaria, magnesium 1. Rapidly improves Bishop score

sulfate 2. May not shorten I-D times with oxytocin
3. Uncomfortable, requires speculum and
placement on an examination table
a
Off-label use.
b
Tablets must be divided for 25- and 50-µg dose, but drug is evenly dispersed.
EASI = extraamnionic saline infusion at 30–40 mL/hr; I-D = induction-to-delivery.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 26
 – Sweeping or stripping of the
membranes can induce labor
and thereby prevent postterm
pregnancy
– Fingers separate the chorionic
membrane from the decidua of
the lower uterine segment
Cervical – membrane stripping at 38 to 40
Ripening weeks decreased the frequency
of postterm pregnancy.
– Drawbacks of membrane
stripping included pain, vaginal
bleeding, and irregular
contractions without labor.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 2. Station of Vertex
– Shin and colleagues (2004) studied 484
nulliparas who underwent induction after 41
Prognostic weeks:
Factors for – cesarean rates was directly related to station:
Successful – 6 % : if the vertex before induction was at −1
station
Induction – 20% : if vertex was station −2
– 43%: if vertex was station −3
– 77% : if vertex was station −4.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 – Evaluation includes:
Expectant 1. counting fetal movements each day
management 2. nonstress testing (NST) three times weekly
with fetal 3. amnionic fluid volume assessment two to
three times weekly with pockets < 3 cm
surveillance considered abnormal.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 Gyn
Completed 41 Weeks nium
No other complications appr
Th
appr
Some choose to initiate with
fetal surveillance wom
be g
pelv
Management Completed 42 Weeks toni
of Postterm to av
U
Pregnancy No complications Complications evidence for: Hos
(1) Fetal compromise but
(2) Oligohydramnios head
Fetal surveillancea Labor inductionb
of P
Amnionic fluid (Preferable with (Per
volume assessmenta favorable cervix) Labor inductionb Gyn
tum
FIGURE 43-10 Management
Cunningham of postterm
FG, Leveno KJ, Bloom SL, Spong CY, pregnancy.
Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
mec
a
See text for options Ame
b
 – Labor is a particularly dangerous time for the postterm
fetus.
– fetal heart rate and uterine contractions should be
monitored electronically for tracings consistent with
Intrapartum fetal compromise.
management – Amniotomy is controversial:
– Further reduction in fluid volume can enhance the possibility
of cord compression.
– amniotomy aids identification of thick meconium, which may
be dangerous to the fetus if aspirated.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
 – Identification of thick meconium in the amnionic fluid is
worrisome
– Aspiration of thick meconium may cause severe pulmonary
dysfunction and neonatal death
Intrapartum – amnioinfusion during labor has been proposed as a way of diluting
meconium to decrease the incidence of aspiration syndrome
management – if the woman is remote from delivery, strong consideration should
be given to prompt cesarean delivery, especially when
cephalopelvic disproportion is suspected or either hypotonic or
hypertonic dysfunctional labor is evident.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 43 Postterm Pregnancy
Thank you!
youtube channel: Ina Irabon
www.wordpress.com: Doc Ina OB Gyne