postterm pregnancy

Definition
Postterm pregnancy : is 42 completed weeks (294 days) or more from the first day of the last menstrual period. It is important to emphasize the phrase "42 completed weeks.
(American College of Obstetricians and Gynecologists (2004)

Post Maturity: Specific syndrome of infant associated with postterm pregnancy.

Estimated Gestational Age Using Menstrual Dates

Thus, there are two categories of pregnancies that reach 42 completed weeks: (1) those truly 40 weeks past conception, and (2) those of less advanced gestation but with inaccurately estimated gestational age.
menstrual dates are frequently inaccurate in predicting postterm pregnancy.

Sonographic at 16 to 18 weeks, or both of gestational age during pregnancy has been used to add precision

The tendency for some mothers to have repeated postterm births Previous 1 postterm : 27 % Previous 2 postterm : 39 %

BY LMP + USG : 1.1 %

inciden
By Last menstrual Periode : 7.5 %

By USG : 2.6 %

Risk factor
The most frequent cause is an error in dating ( the first day of last period) Primiparity and prior postterm pregnancy are the most common identifiable risk factors Decreased fetal estrogen production Placental sulfatase deficiency Anencephaly (Deficiency of ACTH in fetus) Fetal adrenal hypoplasia Male sex also has been associated. Genetic predisposition may play a role .

a decrease in the hormone progresterone in pregnancy is believed to change event that are more important in stimulating the endocrine processes on childbrith and use of oxitocin for of laborof in postterm increase biomolekuler theinduction sensitivity uterus oxytocin, its oxytocin believed suspect that oxytocin physiologically so pregnancy some authors that the occurence of hold an important role in on childbirth raises and the postterm The of progresteron In thisinfluence theory pregnancy proposed is that the the giver to going sign start influence of deliveryof is release oxytocin pregnant due to an of increased in fetal(from plasma neurohipofisis) cortisol levels. Fetal cortisol progresteron Theory of oxitocin women are so less advanced their pregnancy is affect thewho plasenta that productionin decreased secretion of progesteroneas and estrogen, later enlarged to the pregnancy increasing suspected one or the factor of postterm Theory of kortisol Pressureof on the ganglion of cervicaldefect plexus of the production prostaglandins. Fetal conginetal such as the causes contraction of the uterus stir. In anensephalus, fetuses, adrenal frankenhauser hipoplasia, and will absence of Uterus nerve pituitary gland in fetuses will causeis fetal produced not circumstances where there nocortisol pressure on the properly so thatshort pregnancy can take place thoughis the month. herediter plexus, the cord and the bottom still high as cause of the occurence of all of these suspested of mother experience postterm pregnancyof pregnancy gave birth to daughter postterm moment, then likely her daughter will experience pregnancy postterm

patofisiology

Risks factor
fetus Doubling of perinatal mortality Asphyxia, meconium aspiration,intrauterine sepsis Fetal macrosomia Fetal dysmaturity syndrome oligohidramnion Fetal trauma brachial plexus injuries, clavicle fracture mother Increased risk of labor abnormalities Anxiety Traumatic vaginal deliveryshoulder dystocia Increased CS rate PPH risk

Perinatal Mortality
Incidence of fetal mortality for all groups is as follows:
40-41 weeks gestation : 1.1% 43 weeks gestation : 2.2% 44 weeks gestation : 6.6% Fetuses born postterm also are at increased risk of : Sudden infant death syndrome (death within the first year of life). Some of these deaths clearly result from peripartum complications (such as meconium aspiration syndrome), but most have no known cause.

Placental Dysfunction
placental apoptosisprogrammed cell death was significantly increased at 41 to 42 completed weeks compared with that at 36 to 39 weeks. The clinical significance of such apoptosis is currently unclear. cord blood erythropoietin. stimulator of erythropoietin is decreased partial oxygen pressure. cord blood erythropoietin levels were significantly increased in pregnancies reaching 41 weeks or more.

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

oligohidramnion
The volume of amnionic fluid normally continues to decrease after 38 weeks and may become problematic diagnosis :

No vertical pocket > 2 cm or maximum-vertical amnionic fluid pocket measured 1 cm or less at 42 weeks Amniotic fluid index (AFI) 5 cm or less . It is considered an indication for delivery

 Moreover, meconium release into an already reduced amnionic fluid volume causes thick, viscous meconium that may cause meconium aspiration syndrome

macrosomia
In other cases, continued growth of the fetus leads to macrosomia, increasing the risk of labor abnormalities, shoulder dystocia with resultant risks of orthopedic or neurologic injury. Macrosomia is far more common in postterm than term pregnancies (45%) 10%-IU malnutrition

Postmaturity syndrome
Features include wrinkled, patchy, peeling skin; a long, thin body suggesting wasting; and advanced maturity because the infant is openeyed, unusually alert, and appears old and worried. Skin wrinkling can be particularly prominent on the palms and soles. The nails are typically long.

How can you assess the post-term fetus antenatally?

A. FHR testing: NST (non-stress test):
Non-invasive test of fetal activity that correlates with fetal well-being. Fetal heart rate accelerations are observed during fetal movement. External monitor is used to record FHR & mother precipitates by indicating fetal movement. NST can be reactive or non-reactive.

Contraction Stress test: not used anymore.

15

B. Biophysical profile (BPP): Composite of tests designed to identify a compromised fetus during antepartum period.

16

Biophysical Profile (BPP)

Parameter Amniotic Fluid Volume (AFV)* Normal (2 points) Fluid pockets of 2 cm in 2 axes. Abnormal (0 point) Oligohydramnios

NST
Breathing

Reactive.
At least 1 episode of breathing lasting at least 30 sec. 3 discrete movements. At least 1 episode of limb extension followed by flexion.

Non-reactive
No breathing

Limb movement Fetal tone

2 No movement
17

Score

Interpretation

Mx

8-10

Normal

Repeat BPP as clinically indicated Repeat BPP in 4-6 hours Deliver fetus if mature

Suspect chronic hypoxia Strongly suspect chronic asphyxia

0-4

18

How can you manage suspected post-dates pregnancy?

1. Determine gestational age dating. 2. Establish how favorable cervix is (dilated, effaced, soft). 3. Assess fetal well-being [e.g. with NSTs & amniotic fluid indices (AFIs)].

19

4.

Use the following triage method: Dates are certain & cervix is favorable. Neither the mother nor the fetus benefits from waiting induce labor promptly with IV oxytocin & rupture of membranes. Dates are certain but cervix is unfavorable. Risk of failed induction is high. If fetal macrosomia is suspected SC. Alternatively, if the estimated fetal weight (EFW) is normal, manage expectantly with twice-weekly NSTs & AFIs. Dates are unsure. Because its not known if the patient is post-dates, delivery is not indicated. Manage expectantly with twice-weekly NSTs & AFIs awaiting spontaneous labor.
20

5.

Intrapartum: Meconium staining: Prior to delivery Amnio-infusions After delivery of fetal head suctioning meconium from nose & pharynx to prevent aspiration. After delivery of entire fetus, but before the first neonatal breath aspirate neonatal tracheal meconium using laryngoscope.
21

 When macrosomia is suspected, should be performed to estimate fetal weight. Clinician should always be prepared to deal with a potential shoulder dystocia. Intrapartum asphyxia: Careful monitoring should be instituted when this is suspected.

22

When to Induce: Indications

Urgent / High Priority Non-reassuring status Chorioamnionitis PPROM at 35wks Severe Pre-eclampsia IUGR below 3% Anyone >42wks Medium Priority Fetal malformation Mild pre-eclampsia IUGR below 10% AFI 5-8 Multiple gestation >38wks

 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 . In the end of postterm pregnancy with oxytocin induction, patient must filled several terms, which is aterm pregnancy, normal pelvic size, no disproportion cephalopelvic, head presentation, cervix is ready (portio feels soft, flatening, and start to open). Beside that, size of pelvic should be done before.

Contraindications:
Placenta Previa and Vasa Fetal position: breech, transverse, mentum Polyhydramnios Abnormal FHTs

Is the cervix favorable?

Bishop < 6 = Unfavorable so Mechanical Cervial Ripening Stripping of membranes Laminaria Transcervial Foley Catheter- speculum exam, ring forcepts, 30cc foley , sterile saline Monitor FHT for reactivity, insert foley through cervial internal ostium Prostaglandin
Misoprostol (Cytotec) Gel Capsules 25mcg pv (4x every 6 hours)

Oxytocin Induction
Bishop score > or equal to 6 = Favorable Low Dose Active Management Start oxytocin at 8 milliunits/min and go up 4 miliunits/min by 15 mins (max 40 miliunits/min)

Bishop score > 5 induction bisshop < 5 Cervial Ripening

Identification of patients that need delivery

Ripe cervix Oligohydramnios Macrosomia Abnormal NST/BPP/CST Meconium stained liquor Unripe cx Normal fluid Normal NST/CST Normal fetal size

DELIVERY

Cervical assessment,NST,AFI Weekly at 40 & 41 wks Twice wkly thereafter Ripe cx Oligo Abn NST 42 WKS
29

DELIVERY