PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)
Index Case:
 A primigravid came to your office for consult.
 She claimed that her last menstrual period was June 29, 2020
 Her prenatal course was unremarkable
 However, she is now worried at this time for the health of her baby.
What is her AOG? Roughly it is 42 weeks and 2/7 or 3/7 days AOG  this is
already a postterm pregnancy
POSTTERM PREGNANCY
The international definition of prolonged pregnancy is:
 One that exceeds 42 0/7 weeks
 294 days or more from the first day of the last menstrual period
 Assumes that the LMP was followed by ovulation 2 weeks later
Lecture Discussion:
When asking for the LMP of the patient, we ask “When is your last NORMAL
menstrual period/flow?” because if it was preceded by irregularity in menses,
we may not get the correct AOG computation
But remember we can also get the AOG by other means:
 Early ultrasound  at 9 weeks AOG, we get a close to accurate
account of AOG. Just take note that we sometimes get a margin of
error of around 5 days
 1st few weeks of missed menses and getting a (+) pregnancy test
 if she misses at least around 7-10 days from the expected
menstruation = from here we can compute the AOH
 At midpregnancy  Quickening – can also tell the AOG. It is around
16-18 weeks (if dealing with multiparous woman) and 18-20 (if
dealing with nulliparous woman)
 Ultrasound at 2nd and 3rd trimester – can be used to correct the
initial AOG
 Fundic height measurement – at around 18-32 weeks AOG, the
height of the fundus in “cm/centimeters” will equal the gestation.
Example, for an 18 weeks AOG = 18 cm fundic height
o 12 weeks AOG = fundus felt just above the symphysis pubis
o 16 weeks AOG = fundus is midway between the symphysis
pubis and umbilicus
o 20 weeks AOG = fundus is at the level of the umbilicus
Therefore if we compute the AOG from the aforementioned techniques and
then we got an estimated date of confinement for her labor  if she goes
beyond the estimated date of labor = means we are dealing with postterm
pregnancy
Information from Williams (25th Ed.):
 The adjectives postterm, prolonged, postdates, and postmature are
often loosely used interchangeably to describe pregnancies that have
exceeded a duration considered to be the upper limit of normal.
 Postmature is reserved for the relatively uncommon specific clinical
fetal syndrome in which the newborn has recognizable features
indicating a pathologically prolonged pregnancy.
 Postterm or prolonged pregnancy is our preferred expression for an
extended pregnancy.
 The international definition of prolonged pregnancy, endorsed by the
American College of Obstetricians and Gynecologists (2016) is one that:
o Exceeds 42 0/7 weeks, namely, 294 days or more from the
first day of the last menstrual period.
o Importantly, this is 42 "completed weeks" as pregnancies
between 41 weeks 1 day and 41 weeks 6 days, although in the
42nd week, do not complete 42 weeks until the seventh day has
elapsed. The method that we use widely in this book is to
divide the 42nd week into 7 days, that is, 42 0/7 through 42 6/7
weeks
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It must be admitted that the duration of pregnancy not infrequently exceeds
280 days from the last menstrual period and that when it lasts much longer
large children are developed which are frequently delivered only after great
difficulty. Thus, whenever the menstrual history of the patient indicates that
she has passed much beyond the tenth and is approaching the eleventh lunar
month, we should consider the propriety of the induction of labor, provided
that examination shows the child is larger than usual.
-J. Whitridge Williams (1903)
ESTIMATED GESTATIONAL AGE
 The definition of postterm pregnancy assumes that the last menses was
followed by ovulation 2 weeks later.
 Some pregnancies may not actually be postterm. Instead, the
calculation may reflect an error in gestational age estimation because
of faulty menstrual date recall or delayed ovulation.
 Pregnancies that reach 42 completed weeks are
o Truly 40 weeks past conception
o Those of less-advanced gestation but with inaccurately
estimated gestational age.
 First-trimester sonography to be the most accurate method to
establish or confirm gestational age.
PREDISPOSING FACTORS TO POSTTERM PREGNANCY
 BMI of >/= 25
It has something to do with altered metabolic status when one is
obese or overweight
 Nulliparity
It is harder for the musculature to effect adequate contraction. It
is hard to initiate in nulliparous woman. The saying of old people
“Matatagal pa ang pagbubuntis mo bago ka manganak kasi 1 st
baby mo yan”  there may be some truth to this because in
multiparous women, there would already be higher gap junctions
in the myometrium = easier to stimulate and therefore will have
a shorter second stage of labor
 Nulliparous women with long cervix at mid pregnancy
 Biologic predisposition – mother that has been a product of
prolonged pregnancy is increased risk for a postterm pregnancy
herself
If the mother was delivered at postterm when she was a baby,
then if she gets pregnant there is ↑ chance of her having a
postterm pregnancy also
 Fetal and placental factors:
1. Anencephaly
2. Adrenal hypoplasia
3. X linked placental sulfatase deficiency
End point: estrogen precursors are not produced due to the
aforementioned abnormalities  if there is no estrogen = no
contraction of uterus
Information from Williams (25th Ed.):
 In the past, the proportion was much higher. This trend suggests earlier
intervention; however, the added accuracy from earlier sonographic
dating of gestational age is another factor.
 Olesen and associates (2006): Only pre-pregnancy body mass index
(BMI) ≥25 and nulliparity were significantly associated with prolonged
pregnancy.
 In nulliparas, those whose cervical length at midpregnancy is longer,
that is, in the third or fourth quartile, are twice as likely to deliver after
42 weeks (van der Ven, 2016).
 The tendency for some mothers to have repeated postterm births
suggests that some prolonged pregnancies are biologically determined.
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 PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)

 Oberg and colleagues (20 1 3) reported that when mother and daughter
had a prolonged pregnancy, the risk for the daughter to have a
subsequent postterm pregnancy was significantly increased.
 Laursen and associates (2004) found that maternal, but not paternal,
genes influenced prolonged pregnancy.
 Rare fetal-placental factors that predispose to postterm pregnancy
include anencephaly, adrenal hypoplasia, and X-linked placental
sulfatase deficiency (Ayyavoo, 20 14; MacDonald, 1 965).
PERINATAL MORTALITY AND MORBIDITY
 Rates of stillbirth, neonatal death, and infant morbidity all rise after the
expected due date has passed
Information from Williams (25th Ed.):
 The postmature newborn is unique, and features include:
o Wrinkled, patchy, peeling skin
o A long, thin body suggesting wasting
o Advanced maturity in that the infant is open-eyed, unusually
alert, and appears old and worried.
o Skin wrinkling can be particularly prominent on the palms and
soles.
o The nails are typically long
 Most postmature neonates are not technically growth restricted
because their birthweight seldom falls below the 10th percentile for
gestational age.
 Severe growth restriction-which logically must have preceded
completion of 42 weeks-may be present.
 The incidence of postmaturity syndrome in newborns at 41, 42, or 43
weeks, respectively, has not been conclusively determined which
complicates 10 to 20 percent of pregnancies at 42 completed weeks
 Associated oligohydramnios substantially raises the likelihood of
postmaturity.
 Trimmer and associates (1990) reported that 88 percent of fetuses were
postmature if there was oligohydramnios defined by a sonographic
maximal vertical amniotic fluid pocket that measured ≤1 cm at 42 weeks

Placental Dysfunction
 Dysfunctional syncytiotrophoblasts and to some extent,
cytotrophoblasts (explains postmaturity syndrome)  inefficient
placenta to give out nutrients
 Placental senescence
 The major cause of death in these studies includes:  Placental apoptosis
o Gestational hypertension  Increased cord blood erythropoietin (due to ↓ O2)
o Prolonged labor with cephalopelvic disproportion
o Birth injuries Lecture Discussion:
o Hypoxicischemic encephalopathy It is not only at 42 weeks that this placental dysfunction happens. Remember
 Higher rates of cerebral palsy in postterm births and lower intelligence that there will be cell death already (but at a very slow rate) which usually
quotient (IQ) scores at age 6.5 years in children born ≥42 weeks' starts at around 36-39 weeks AOG. This is why when you ask an UTZ
gestation assessment of the placenta, you will be given a Grade 3 placenta  this
 Autism was NOT associated with postterm birth means that the placenta is already “aged” at around 36 weeks. But take note
that the aging and cell death would be increased at around 41-42, which is
 The rate of cesarean delivery for dystocia and fetal distress was
why you end up with a postmature look of the baby
significantly greater at 42 weeks compared with earlier deliveries.
 More newborns of postterm pregnancies were admitted to intensive
Information from Williams (25th Ed.):
care units.
 Limited placental capacity, which is characterized by dysfunctional
 Incidence of neonatal seizures and deaths was doubled at 42 weeks.
syncytiotrophoblast, explains the greater risks of the postmaturity
syndrome.
PATHOPHYSIOLOGY
 Associated skin changes were due to loss of the protective effects of
Postmaturity Syndrome
vernix caseosa. The postmaturity syndrome to placental senescence,
Postmaturity Syndrome Features:
although they did not find placental degeneration histologically.
 Wrinkled, patchy, peeling
 Concept that postmaturity stems from placental insufficiency has
skin (prominent on palms
persisted despite an absence of morphological or significant
and soles)  due to loss of
quantitative findings. (PLACENTAL SENESCENCE)
protection by vernix
 Rate of placental apoptosis—programmed cell death— is significantly
caseosa
greater at 41 to 42 completed weeks compared with that at 36 to 39.
 Long thin body (wasting)
 Several pro-apoptotic genes such as kisspeptin are upregulated in
 Open-eyed
postterm placental explants compared with the same genes in term
 Unusually alert
placental explants. The clinical significance of such apoptosis is currently
 Appears old and worried
unclear.
 Long nails
 The only known stimulator of erythropoietin is decreased partial oxygen
pressure. Cord blood erythropoietin levels were significantly higher in
pregnancies reaching 41 weeks or more.
 Although Apgar scores and acid-base studies were normal, researchers
concluded that fetal oxygenation was decreased in some postterm
gestations.

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 PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)

 Postterm fetus may continue to gain weight and thus be unusually large  Diminished urine production was found to be associated with
at birth. This at least suggests that placental function is not severely oligohydramnios. They hypothesized that decreased fetal urine flow
compromised. was likely the result of preexisting oligohydramnios that limited fetal
 Nahum and colleagues (1995) confirmed that fetal growth continues swallowing.
until at least 42 weeks. However, Link and associates (2007) showed  Using Doppler waveforms, fetal renal blood low is reduced in those
that umbilical blood low did not increase concomitantly. postterm pregnancies complicated by oligohydramnios. As a possible
cause, umbilical blood flow did not increase past term.
Fetal Distress and Oligohydramnios
 A result of cord compression
 Prolonged deceleration on EFM ( not a late deceleration )
So there is >10 minute period of deceleration
Recall:
Cord compression – variable deceleration
Uteroplacental deficiency – late deceleration

Take note that here, it is not late nor variable deceleration. It is just
a simple prolonged deceleration in the electronic fetal monitoring
(EFM)

 ↓ Fetal renal blood flow

Due to very little fluid and inefficient placental nutrition  there will
be ↓ fetal renal blood flow = little urination will happen =
oligohydramnios

Lecture Discussion:
Imagine if a baby during the 36-37 weeks (3rd trimester)  time when
equilibration of amniotic fluid happens due to good urination and swallowing
of the amniotic fluid. But somehow, during the last few weeks after the 40
weeks AOG  you will notice that there will be a ↓ in the amniotic fluid. This
is not because of any pathology involved in the trachea or urinary tract of the
baby. This is because of the drying out and may be due to increased
swallowing of amniotic fluid than urination of the fetus  leads to
oligohydramnios, fetal distress (the cord cannot move freely due to lack of
amniotic fluid)

Information from Williams (25th Ed.):

 Both antepartum fetal jeopardy and intrapartum fetal distress were
found to be the consequence of cord compression associated with
oligohydramnios.
 In their analysis of 727 postterm pregnancies, intrapartum fetal distress
detected with electronic monitoring was not associated with late
decelerations characteristic of uteroplacental insufficiency.
 Instead, one or more prolonged decelerations such as shown in Figure
43-4 preceded three fourths of emergency cesarean deliveries for
nonreassuring fetal heart rate tracings. In all but two cases, there were
also variable decelerations. Fetal Growth Restriction
 Another common fetal heart rate pattern, although not ominous by  Commonly results in stillbirth
itself, was the saltatory baseline. These findings are consistent with  Higher morbidity and mortality rates
cord occlusion as the proximate cause of the nonreassuring tracings.
Other correlates included oligohydramnios and viscous meconium. Information from Williams (25th Ed.):
 Schafer and colleagues (2005) implicated a nuchal cord in abnormal  Stillbirths were more common among growth restricted newborns who
intrapartum fetal heart rate patterns, meconium, and compromised were delivered after 42 weeks. Indeed, a third of postterm stillborn
newborn condition in prolonged pregnancies. neonates were growth restricted.
 The volume of amniotic fluid normally continues to decline after 38  Morbidity and mortality rates were significantly increased in the
weeks and may become problematic. growth-restricted neonates
 Moreover, meconium release into an already reduced amniotic fluid
volume results in thick, viscous meconium that may cause meconium
aspiration syndrome.
 Sonographically measured hourly fetal urine production using
sequential bladder volume measurements in 38 postterm pregnancies.

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 PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)
COMPLICATIONS
 In the event of a medical or other obstetrical complication, it is
generally not recommended that a pregnancy be allowed to continue
past 42 weeks.
 Earlier delivery is indicated.
 Common examples include gestational hypertensive disorders, prior
cesarean delivery, and diabetes. Other clinically important factors
include amniotic fluid volume and potential fetal macrosomia.
Oligohydramnios
 Measure by AFI or deepest vertical pocket </= 1 cm
 ↑ CS and operative vaginal delivery
 Low 5 min Apgar
 Fetal acidemia
 Admission to NICU
Information from Williams (25th Ed.):
 Diminished amniotic fluid determined by various sonographic methods
identifies a postterm fetus with increased risks. Indeed, decreased
amniotic fluid in any pregnancy signifies increased fetal risk.
 Unfortunately, lack of an exact method to define "decreased amniotic
fluid" has limited investigators, and many different criteria for
sonographic diagnosis have been proposed.
 The smaller the amniotic fluid pocket, the greater the likelihood that
there was clinically significant oligohydramnios.
 Importantly, normal amniotic fluid volume did not preclude abnormal
outcomes.
 Amniotic Fluid Index (AFI) overestimated the number of abnormal
outcomes in postterm pregnancies.
 Regardless of the criteria used to diagnose oligohydramnios in postterm
pregnancies, most investigators have found a higher incidence of some
measure of "fetal distress" during labor.
 Reassurance of continued fetal well-being in the presence of "normal"
amniotic fluid volume is tenuous.
 This may be related to how quickly pathological oligohydramnios
develops.
Macrosomia
 Peak of velocity of weight gain is at 37 weeks
 But some continue to grow
 In the absence of diabetes: VAGINAL DELIVERY
Lecture Discussion:
If you noticed, during the 2nd trimester, there will be an increasing growth in
the fundic height and weight of the mother. This is a result of the increasing
weight also of the product of conception (baby). There is an incremental
growth in the baby as the gestation progresses and it peaks at 37 weeks AOG.
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After which, there will be not much growth in the baby. But somehow, babies
who are bound to get into postterm gestation, they grow = macrosomia.
However, macrosomic babies should not be an indication for CS delivery 
if mother has no diabetes = vaginal delivery
Information from Williams (25th Ed.):
 The velocity of fetal weight gain peaks at approximately 37 weeks.
Although growth velocity slows at that time, most fetuses continue to
gain weight.
 The 95th percentile at 42 weeks is 4475 g.
 Intuitively, it seems that both maternal and fetal morbidity associated
with macrosomia would be mitigated with timely induction to preempt
further growth. This, however, does not appear to be the case.
 The American College of Obstetricians and Gynecologists (20 1 6c) has
concluded that current evidence does not support such a practice in
women at term with suspected fetal macrosomia.
 In the absence of diabetes, vaginal delivery is not contraindicated for
women with an estimated fetal weight up to 5000 g. Obvious problems
with all such recommendations are substantive variations in fetal
weight estimation.
ANTEPARTUM MANAGEMENT
 The decision focuses on whether labor induction is warranted or if
expectant management with fetal surveillance is best.
1. Induction Factors
 High failure for unfavorable cervix
 Pre induction cervical ripening agents
o Dinoprostone
Expensive. It can be inserted as a get and delivered through
a syringe intracervically  in 4-8 hours there will be
cervical softening
o Evening primrose
Usually given at around 40 weeks AOG. This agent is usually
given to menopausal women but it was studied and found
to be good in the cervix of patients  causes softening and
effacement of cervix. Can be given oral or transvaginally
From Williams:
 Although all obstetricians know what an "unfavorable cervix" is, the
term unfortunately defies precise objective definition.
 Thus, investigators have used differing criteria for studies of prolonged
pregnancies.
o Harris and coworkers (1983) defined an unfavorable cervix by
a Bishop score < 7 and reported this in 92 percent of women
at 42 weeks.
o Hannah and colleagues (1992) found that 40 percent of 3407
women with a 41-week pregnancy had an "undilated cervix."
o Alexander and associates (2000b) reported that women in
whom there was no cervical dilation had a twofold higher
cesarean delivery rate for "dystocia."
o Yang and coworkers (2004) found that cervical length ≤ 3 cm
measured with transvaginal sonography was predictive of
successful induction.
o Vankayalapati and associates (2008) found that cervical length
≤25 mm was predictive of spontaneous labor or successful
induction.
 PGE2 gel was NOT more effective than placebo.
 Mifepristone was reported to increase uterine activity without
uterotonic agents in women beyond 41 weeks.
 Evening PRIMROSE Intravaginal more potent than oral
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 PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)

2. Sweeping or Stripping of membranes  Concurrently, as expected, the induction rate rose significantly, and this
 Did not induce labor was accompanied by a drop in the perinatal mortality rate-22 to 13 per
Some clinicians do not find sweeping or stripping of membranes 1 000 births. The cesarean delivery rate was not changed.
very effective  A similar before-and-after observational study reported that induction
at ≥42 weeks was associated with a significantly lower cesarean delivery
 Higher rates for cesarean delivery rate.
 Pain, bleeding and irregular contractions  From the foregoing, evidence to substantiate intervention whether
induction or fetal testing-commencing at 41 versus 42 weeks is limited.
Information from Williams: Most evidence used to justify intervention at 41 weeks is from the
 To induce labor and thereby prevent postterm pregnancy randomized
 Drawbacks of membrane stripping included pain, vaginal bleeding, and  Canadian and American investigations cited earlier. No randomized
irregular contractions without labor. studies have specifically assessed intervention at 41 weeks
 The station of the fetal head within the pelvis is another predictor of
successful postterm pregnancy induction. Management Strategies
 The cesarean delivery rate was directly related to station.  The American College of Obstetricians and Gynecologists (2016a)
 The rate was 6 percent if the vertex before induction was at -1 station; defines postterm pregnancies as having completed 42 weeks, namely,
20 percent at -2 station; 43 percent at -3 station; and 77 percent at -4 beyond 420/7 weeks.
station.  After completing 42 weeks, recommendations are for labor induction
as summarized in Figure below.
3. Fetal Testing at 41 weeks  When gestational age is uncertain, the American College of
 FM (fetal movement) counting - 2 hrs / day Obstetricians and Gynecologists (2017b) recommends delivery at 41
 NST (nonstress test) - 3x/week weeks' gestation using the best clinical estimate of gestational age.
 AFV (amniotic fluid volume) assessment – 2-3x/week  The College also recommends against amniocentesis for fetal lung
maturity.
Information from Williams:  At Parkland Hospital, we consider 41-week pregnancies without other
 Implement a strategy of fetal testing beginning at 41 completed weeks. complications to be normal. Thus, no interventions are practiced
 Fetal Testing at 41 weeks:
1) Counting fetal movements during a 2- hour period each day.
2) Nonstress testing three times weekly.
3) Amniotic fluid volume assessment two to three times weekly,
with pockets <3 cm considered abnormal.
 Labor induction resulted in a small but significant reduction in the
cesarean delivery rate compared with fetal testing. This difference was
due to fewer procedures for fetal distress.
 Fetal surveillance included nonstress testing and sonographic
estimation of amniotic fluid volume performed twice weekly in 175
women. Perinatal outcomes were compared with those of 265 women
also at 41 weeks randomly assigned to induction with or without
cervical ripening. There were no perinatal deaths, and the cesarean
delivery rate was not different between management groups. The
results of this study could be used to support the validity of either  With complications such as hypertension, decreased fetal movement,
management scheme. or oligohydramnios, labor induction is carried out
 In an analysis of 22 trials, Gulmezoglu and colleagues (2012) found that  Labor Induction is done:
induction after 41 weeks rather than surveillance was associated with o If gestational age is known, it is induced at the completion of
significantly fewer perinatal deaths and meconium aspiration 42 weeks.
syndrome cases and a lower cesarean delivery rate. o Women with an AFI ≤5 cm
 In most studies, labor induction at 420/7 weeks has a higher cesarean o With reports of diminished fetal movement
delivery rate compared with spontaneous labor. o For those who do not deliver with the first induction, a second
 Alexander and coworkers (2001) evaluated pregnancy outcomes in 638 induction is performed within 3 days.
such women in whom labor was induced and compared them with o Women classified as having uncertain postterm pregnancies
outcomes of 687 women with postterm pregnancies who had are managed with weekly nonstress fetal testing and
spontaneous labor. Cesarean delivery rates were significantly assessment of amniotic fluid volume
increased in the induced group because of failure to progress.
 When these investigators corrected for risk factors, however, they
concluded that intrinsic maternal factors, rather than the induction
itself, led to the higher rate.
o These factors included nulliparity, an unfavorable cervix, and
epidural analgesia.
 Danish national guidelines were changed from labor induction at 420/7
weeks with no fetal surveillance to labor induction at 412/7 to 416/7
weeks with fetal surveillance beginning at 410/7 weeks. Rate of
pregnancies that progressed past 420/7 weeks decreased from 2.85 to
0.62 percent.

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 PATHOLOGIC OBSTETRICS
Topic: Postterm Pregnancy
Lecturer: Dr. Garcia (RCG)

INTRAPARTUM MANAGEMENT
 Labor is a particularly dangerous time for the postterm fetus.
 Women whose pregnancies are known or suspected to be postterm
ideally come to the hospital as soon as they suspect labor

1. Monitor Labor
 Fetal heart rate and uterine contractions be monitored electronically
for variations consistent with fetal compromise.
 Further reduction in fluid volume following amniotomy can enhance
the possibility of cord compression.
 After membrane rupture, a scalp electrode and an intrauterine pressure
catheter can be placed. These usually provide more precise data
concerning fetal heart rate and uterine contractions.

2. Amniotomy
 Aids identification of thick meconium
 Thick meconium in the amniotic fluid is particularly worrisome. The
viscosity probably signifies the lack of liquid and thus
oligohydramnios. Aspiration of thick meconium may cause severe
pulmonary dysfunction and neonatal death.
 Amnioinfusion during labor has been proposed as a way of diluting
meconium to lower the incidence of aspiration syndrome. The benefits
of amnioinfusion remain controversial. Amnioinfusion does not reduce
the risk of meconium aspiration syndrome or perinatal death.
Amnioinfusion does not prevent meconium aspiration, however, it
remains a reasonable treatment approach for repetitive variable
decelerations.
 Successful vaginal delivery is reduced appreciably for the nullipara who
is in early labor with thick, meconium-stained amniotic fluid.

3. Cesarean Section if remote from delivery

 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.

SUMMARY
 Establish the diagnosis of postterm pregnancy
 Assess fetal wellbeing antepartally and intrapartally
 Offer best management option

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