Download Prolonged pregnancy

Prolonged pregnancy
Dr.AHMED JASIM
ASS. PROF
MBChB.DOG.FICOG
prolonged Pregnancies,( post-term,
post-dates):
 defined
as pregnancies persists
beyond 42 completed weeks or more
than 294 days from the onset of the
last normal menstrual period (LMP).
 It occurs in 10% of all pregnancies.
 Term is defined as 37-42 weeks
gestation.

Dating by LMP alone has a tendency to
overestimates the gestational age.
 The routine use of early ultrasound to calculate
gestational age significantly reduces incidence
of post-term pregnancy.
 Ultrasound measurements of crown –rump
length of fetus up to about the 14th weeks and of
biparietal diameter of fetal head up to about the
28th weeks give a reliable indication of duration
of gestation.
Risk factors for actual postterm
pregnancy include:

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Primiparity.
prior postterm pregnancy( 30 %).
male gender of the fetus.
genetic factors.
Obesity.
Aetiology of prolonged
pregnancy
 The
cause of postdate pregnancy is not
clear and it may represent simple
biological variation.
 Prolonged pregnancy is common in
association with:
 an anencephalic fetus.
 placental sulphatase deficiency.
 extrauterine pregnancy.
Risks associated with prolonged
pregnancy
 Post
term pregnancy per se is not a
pathological condition and should not be
confused with post maturity syndrome.
Fetal postmaturity syndrome
 occurs
in 20-30% of postterm
pregnancies. It is related to the aging and
infarction of placenta resulting in placental
insufficiency with impaired oxygen
diffusion and decreased transfer of
nutrients to fetus. Fetus is typically has
loss of subcutaneous fat, long fingernails,
dry, peeling skin, and abndant hair.
 Not
every post-term pregnancy is
complicated by post-maturity syndrome.
 Majority of morbidities and mortality
associated with post term pregnancies
arises because of post-maturity.
Fetal macrosomia
 70-80%
of postdates fetuses not affected
by placental insufficiency continuo to grow
in utero, many to point of macrosomia
(birth weight greater than 4000grams) this
result in abnormal labour, shoulder
dystocia, birth trauma, and increased
incidence of caesarean birth.
 Increase perinatal mortality(2-3 times
higher).
 3.
Perinatal mortality (2-3 times
increased risk of perinatal death).
 4. Perinatal morbidity
 a. Birth trauma (skull fracture,
brachial plexus injuries,
intracranial haemorrhage)
 b. Shoulder dystocia
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c. meconium aspiration increased Meconium
aspiration syndrome refers to respiratory
compromise with tachypnea, cyanosis, and
reduced pulmonary compliance in newborns
exposed to meconium in utero and is seen in
higher rates in postterm neonates
d. neonatal seizures.
e. neonatal sepsis.
h. respiratory distress syndrome.
i. Cerebral palsy.
Maternal risk:

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Increased operative delivery.
Haemorrhage.
Maternal infection.
Psychological morbidities anxiety.
Diagnosis

The diagnosis of postterm pregnancy is often
difficult. The accurate dating of gestation is very
important.
 Gestational age unreliable in calculation of
gestational age in women with:
 Irregular cycle.
 Lactataing women.
 Recent cessation of birth control pill
 Thus, not only the LMP date, but the regularity and
length of cycles must be taken into account when
estimating gestational age.

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Ultrasound to establish accurate gestational age
Estimation range varies. For example,
crown-rump length (CRL) is ± 3-5 days,
Ultrasound performed at 12-20 weeks of
gestation is ±7-10 days,
 at 20-30 weeks is ± 2 weeks,
 and after 30 weeks is ± 3 weeks.
 If there is more than one week discrepancy
between LMP and ultrasound finding, then the
ultrasound finding should be used to determine
expected date of delivery (EDD).
 Women
may not know her LMP and has
no early first or second trimester
ultrasound we can use some points which
can exclude risk of prematurity but can not
calculate gestational age accurately by it:
 36 weeks have elapsed since
documentation of a positive human
chorionic gonadotropin (+hCG) test
finding.
 20
weeks of fetal heart tones have been
established by a fetoscope or 13 weeks by
a Doppler examination.
 Antenatal records for bimanual
examination of uterus at an early visit .
between 8th – 14th weeks an accurate
assessment of uterine size can be made.
Management:
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Management option depends on:
Gestational age.
cervical examination findings.
estimated fetal weight.
past obstetric history.
Absence or presence of maternal risk.
Factors or evidence of Fetal compromise.
Maternal preference and informed consent.
Indications of delivery:
 Amniotic
fluid index <5 cm or
maximum pool depth <2 cm
 Abnormal fetal heart rate
(decelerations)
 Biophysical profile of 6/ 10 or less
 Abnormal umbilical artery Dopplers
Management options are:
 1.
Elective induction of labour.
 2. Expectant management with/ without
antepartum testing
 Simple monitoring with Non stress test
(NST) cardiotocography (CTG) and liquor
assessment.
Assessment of post-dates
pregnancy:
 Many
different tests of fetal well-being are
performed for assessment of post-term
fetus. These include:
 Cardiotocography (CTG).
 Ultrasonographic testing.
 Amniotic fluid index.
 Biophysical profiles.
 Umbilical artery Doppler waveform
analyses.
Expectant management
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it consists of:
daily fetal kick count
non stress test (NST) twice/ week to 42 weeks.
ultrasound to assess amniotic fluid volume twice/
week until 42 weeks.
if NST abnormal or amount of liquor is abnormal
induce immediately.
induce at 42 weeks if NST is normal amniotic
fluid volume is normal.
 Take
history examination and investigation
(NST,CTG,amniotic fluid assessment)
Management:
 Elective
induction of labour.
 Expectant management with/ without
antepartum testing
 Simple monitoring with Non stress test
(NST) cardiotocography (CTG) and liquor
assessment.

Management option depends on:
The certainty of gestational age.
cervical examination findings
estimated fetal weight
Absence or presence of maternal risk.
 Factors or evidence of Fetal compromise.
 Maternal preference and informed consent.
 past obstetric history must all be considered
when mapping a course of action.
 Expectant
management:
 Daily fetal kick count
 NST Twice/ week to 42 weeks.
 Ultrasound to assess amniotic fluid volume
twice/ week until 42 weeks.
 If NST abnormal or aount of liquor is
abnormal induce immediately.
 Induce at 42 weeks if NST is normal
AMNIOTIC FLUID VOLUME IS NORMAL.
 Take
history examination and investigation
(NST,CTG,amniotic fluid assessment)
0/7
40
Gestaional age
- 40
weeks gestation:
 A.
6/7
In cases with Healthy , uncomplicated
pregnancy, fetal growth and amount of
liquor was normal:

Wait spontaneous labour
and no need to serial investigations.
 B. Presence of maternal risk factor or
evidence of fetal compromise:
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Delivered by Induction of labour if there
is no obstetrical contraindication
41 weeks gestation:
 After
41 weeks’ gestation, if the dates are
certain, women should be offered elective
delivery.
 routine induction at 41 weeks of gestation
does not increase the cesarean delivery
rate and may decrease it without
negatively affecting perinatal morbidity or
mortality. In fact, both the woman and
the neonate benefit from a policy of routine
induction of labor in well-dated, low-risk
pregnancies at 41 weeks' gestation.
42 weeks
 delivery
 there
are multiple reasons not to allow a
pregnancy to progress beyond 42 weeks.
 Obstetricians re unable to offer complete
reassurance to expectant mother who
continues to awaite spontaneous onset of
labour.
Intrapartum management:

Continuous electronic fetal monitoring must be
employed during induction of labour.
 Fetal membranes should be ruptured as early as
possible to see color of amniotic fluid.casearean
section is indicated for fetal distress and should
not to be delayed because of decreased
capacity of postterm fetus to tolerate asphyxia
and increased risk of meconium aspiration.
 If meconium is present neonatiologist should be
present at time of delivery.
 Be prepared for shoulder dystocia.
Prevention :
 *Stripping
or sweeping of the fetal
membranes refers to digital separation of
the membrane.
 *Unprotected sexual intercourse.