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Prolonged Pregnancy
Prolonged Pregnancy
(Evidence Based)
Valleria, Sp.OG
Sources
RCOG 2003 ACOG (SEPTEMBER 2004) COCHRANE LIBRARY 2006 AFP (AMERICAN FAMILY PHYSICIAN) (May 15, 2005) PUBMED (MEDLINE)
DEFINITION
Prolonged pregnancy
( postterm pregnancy )
It is one that has lasted longer than
DEFINITION
Post-maturity syndrome
3. Fetal distress
4. Evidence of loss of subcutaneous fat and 5. Dry, cracked skin
Etiologic Factors
error in dating.
is unknown.
Etiologic Factors
Male sex also has been associated. Genetic predisposition may play a role .
EPIDEMIOLOGY
> 42 weeks twice that at term > 43 weeks > 6-fold that at term
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
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 .
Oligohydramnios
U/S diagnosis : No vertical pocket > 2 cm or Amniotic fluid index (AFI) 5 cm or less . It is considered an indication for delivery.
Fetuses born postterm also are at increased risk of : Sudden infant death syndrome (death within the first year of life).
Maternal risks
1) Labor dystocia 2) Severe perineal injury related to macrosomia
Women who attend late for ANC may be of uncertain gestation and may be over-represented in populations of postterm pregnancies.
Dating by the last menstrual period (LMP) alone has a tendency to overestimate the gestational age.
Because actual dates of conception are rarely known, the LMP is used as the reference point. This can make the accuracy of gest. age determination unreliable because of :
1. Irregular menses .
Transcerebellar diameter
When composite biometry is not consistent in all of the parameters (i.e. BPD, head circumference, abdominal circumference, femur length),
Transcerebellar diameter
are
that
spontaneously significantly
reduced the postterm rate
from 10 % to 1.5 %.
RCOG (GRADE A)
Accurate dating on the basis of ultrasonography performed early in pregnancy . Breast and nipple stimulation at term have not been shown to affect the incidence of postterm pregnancy. Sweeping of the membranes at term : the data are still conflicting .
ACOG Guidelines 2004
and / or
3) Evidence of fetal compromise, and
4) Maternal preferences .
Successful management depends on effective counselling of women and their full involvement in the decision making process.
A recent review in the Cochrane Library concluded that routine induction in low-risk pregnancies at or after 41 weeks' gestation is associated with : A reduction in perinatal mortality,
1.
2.
Contrary to what many obstetricians believe, induction of labor for prolonged pregnancy does not increase the rate of cesarean section, rather, it decreases it.
There is insufficient evidence to indicate whether routine antenatal surveillance of low-risk patients between 40 and 42 weeks of gestation improves perinatal outcome but it is often performed during this period.
The condition of the fetus can change quickly and thus, monitoring should be at frequent intervals, and that none of the tests are immune from false positives, false negatives Boehm et al, demonstrated that twiceweekly testing of patients at risk for fetal distress was superior to weekly testing.
FETAL SURVEILLANCE
A modified biophysical profile
consisting of a:
non stress test and amniotic fluid index
an
Favorable cervix : Labor generally is induced because the risk of failed induction and subsequent cesarean delivery is low. Unfavorable cervix :a small advantage to labor induction using cervical ripening agents (prostaglandins), when indicated, regardless of parity or method of induction. ACOG 2004 (Level C)
thick meconium.
If meconium is present then consider risk of meconium aspiration , continuous fetal assessment with electronic fetal monitoring (EFM) is recommended. Be prepared for shoulder dystocia and neonatal resuscitation at delivery.
If Expectant management (41- 42 weeks) is chosen, the fetus should be monitored with twice weekly non-stress test , amniotic fluid index . - However, evidence of benefit is lacking.
(RCOG Grade C )
Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.