POST TERM PREGNANCY

Ibnu Hasan Mustofa, MD

Preceptor : Fr Hamido H, OBGYN, MD,
DR
 INTRODUCTION
In 4 - 14% of cases, pregnancy can last up to >42 weeks or
more and is called post term pregnancy

The most common cause: inaccurate dating

Post term pregnancy is associated with increased perinatal

morbidities and mortalities
• Fetal: Increased risk of macrosomia, shoulder dystocia,
posterior occipital position, fetal distress, even death
• Maternal : post partum bleeding, caesarean delivery,
prolonged labor
 DEFINITION
Federation of Gynecologist and Obstetricians (FIGO): post term is
pregnancy that has extended to 42 weeks or beyond, calculated from
first day of last menstrual period and 28 days menstrual cycle

American College of Obstetricians and Gynecologists (1997):

postterm is 42 weeks (294 days) of pregnancy or more calculated
from first day of last menstrual period, assuming that ovulation occurs
2 weeks after the last menstruation

Post-mature : overdue pregnancy accompanied by post maturity

syndrome in newborn
 EPIDEMIOLOGY

• Incidence: 4-14%, prevalence: 4-19%

• Those who extend to 43 weeks: 2-7%
• Those who extend to 280 days after last menstrual period: 5%.

• In US: 6% of 4 million babies are born at 42 weeks or more.

• In 2000, incidence was 7.2%, and decreased in 2009 by 5.5%

• High incidence in women who are unsure about their LMP or

when the use of hormonal contraception

• Incidence of post term pregnancy

• 7.5% when calculated based on last menstrual period (LMP)
• 2.6% when examined by ultrasound
• 1.1% when calculated using LMP and ultrasound
 ETHIO-PATHOGENESIS

Remain unclear, some theories include:

• Progesterone effect
• Fetal cortisol ACTH theory
• Uterine nerve
• Hereditary

A pregnancy may prolong because of the pregnancy itself, the

cervical factors, or because of an interruption in both prolong
labor or cervical dilation & interrupted labor efficiency
-Deficiency sulfatase
-Kolagenesis
-Remodelling kolagen
COMPLICATION IN POST TERM PREGNANCY
Alterations in placenta

Calcium accumulation  fetal distress, intrauterine fetal death.

Thickening & decreased amount of vasculo syncytial

membrane  reduction in placental transport.

Degeneration process of placental tissue such as edema,

fibrinoid deposits, fibrosis, intervillous thrombosis, and villous
infarction.

Biochemical changes. Placental insufficiency  decreased level of

placental protein and DNA. Glucose transport is not impaired but
the flow of sodium, potassium, and glucose decrease. High weight
molecular transportation interference  intrauterine fetal growth
interference.
COMPLICATION IN POST TERM PREGNANCY
Effects on fetal
Fetal weight

Post maturity syndrome

•Stage I: loss of vernix caseosa and maceration in the form of dry,

frail skin, and easy to scale
•Stage II: signs above accompanied with meconium staining in skin
•Stage III: accompanied with yellowish staining in nails, skin, and
umbilical cord
Fetal distress or perinatal mortality, due to:
COMPLICATION IN POST TERM PREGNANCY
Effects on maternal

Increased morbidities and mortalities: prolonged labor, post

partum bleeding

Increased risk for caesarean section: CPD & non-

reassuring fetal status

Effects on maternal emotions: anxiety

 DIAGNOSIS

Amnion fluid examination: Post term pregnancy is often associated with a

decrease in amniotic fluid.

Nile blue sulphate test. If fat-containing cells >10% then estimated

gestational age = 36 weeks. If >50% then estimated gestational age = 39
weeks or more

Thromboplastin activity in amnion fluid. It increases as gestational age.

Thromboplastin activity of 42 - 46 ” indicates post term pregnancy

Lecithin–sphingomyelin ratio: only to determine fetal maturity to avoid

problems in terminating pregnancy
 MANAGEMENT
Fetal evaluation and management. Ante and intrapartum evaluations
eliminate fetal mortality and decrease fetal morbidity

Pre-pregnancy

• Post term pregnancy is more common in first pregnancy

• Ensuring accuracy of menstrual date

Prenatal

• Early pregnancy test

• Vaginal examination in the first trimester
• Ultrasonography in first and second trimester

Evaluation of 41 week of pregnancy: to observe risk factor and

counseling: labor induction of conservative management
CONSERVATIVE MANAGEMENT

Maternal weight gain: insignificant indication as

modern fetal observation has developed. Difficult to
apply, particularly in overweight women

Symphysis-fundal height: may be affected by obesity,

amnion fluid, fetal presentation, fetal position, and
abdominal wall tension. It is helpful in identifying growth
retard or macrosomia that missed in the previous
examination
CONSERVATIVE MANAGEMENT

Fetal well-being test

Biochemistry method: include recent fetal states from days

before and not prognostic to fetal health

Fetal movement chart: duration of 10 times fetal

movements is observed.

Maternal Perception of Sound-Provoked Fetal Movement

(mp SPFM): Normal fetus shows flexion-extension of extremity
or positive reflexes to vibroacoustic stimulus response
 CONSERVATIVE MANAGEMENT
Fetal well-being test
Non-stress test (NST): a continuous antepartum fetal heart rate recording
using CTG (cardiotocography) for 20-40 minutes to evaluate fetal well-
being

Result Criteria
Reactive (normal) For 20 seconds, ≥2 FHR acceleration at a minimum
of 15 beat per minute above the baseline, each
acceleration ends at least 15 seconds.
Fetal movements can / cannot be distinguished by
the patient
Non-Reactive No acceleration for more than 40 minutes
(abnormal)
Source: American Family Physician, vol. 71, page:1935-41,1942, 2005
 CONSERVATIVE MANAGEMENT

Fetal well-being test

Contraction Stress Test (CST) or FAST (Fetal Acoustic

Stimulation Test) : a vibroacustic stimulation used to stimulate
FHR acceleration, useful for reducing the number of non-reactive
curves and for shortening test time.

Amniotic volume test: Fetal compromise due to gradual decline in

placental function can be monitored by assessing amniotic fluid
volume.
 CONSERVATIVE MANAGEMENT

Estimated Amniotic Liquid Volume Based on Ultrasound

Examination

Technique Oligohydramnion Normal Polyhydramnion

AFI 0-5 cm 5.1-25 cm > 25 cm
Single deepest 0-2 cm 2.1-8 cm > 8 cm
pocket
Two diameter 0-15 cm 15.1-50 > 50 cm
pocket cm

Source: American Family Physician, vol. 71, hal:1935-41,1942, 2005

 CONSERVATIVE MANAGEMENT
Fetal well-being test
Biophysical profile (BPP)

Components Score 2 Score 0

Amniotic fluid volume Single vertical amniotic Largest vertical amniotic
fluid pocket > 2 cm fluid < 2 cm
Fetal breath 1 or more rhythmic episode abnormal, absent or
movement of 30 ’or more fetal breath inefficient breath
movements movements
Fetal movement ≥3 separate body or abnormal, no or
extremities movements in inefficient movements
30 seconds
Fetal tone At least 1 extension of fetal abnormal, inefficient or
extremity by returning to no fetal tone
flexi or opening/closing the
hand
NST Reactive Non-reactive
 CONSERVATIVE MANAGEMENT
Fetal well-being test

Biophysical profile (BPP)

• Score 8 -10 = fine fetal status

• Score 6 = A repeated examination is necessary in 4-6 hours
later, last examination is taken into account
• Score 4 or less = indication for labor

Modified BPP (mBPP): only ultrasound is evaluated without NST

• AFI < 6 = indication for termination of pregnancy

 MANAGEMENT

Hypertension in pregnancy

Premature membrane rupture

Amniotic infection (chorioamnionitis)

General indications for
pregnancy induction Intra Uterus Growth Restriction ( IUGR )

Iso-immunization

Maternal complication

Intra Uterus Fetal Death ( IUFD )

 MANAGEMENT
Contraindications for pregnancy induction

Absolute Relative
Placenta previa Multiple pregnancy
Vasa previa Polyhydramnios
Breech position Maternal heart disease
Cord prolapse Grande multiparity
History of caesarean section Footling presentation
delivery Fetal floating head
Active genital herpes infection
 MANAGEMENT
Cervical maturation before labor induction

Mechanical method:
• Balloon catheter
• Extra-amniotic saline infusion as modification of balloon catheter
• Laminaria
• Hygroscope cervical dilator
• Stripping membrane
• Accupuncture

Pharmacology method
• Prostaglandin
• Oxytocin
 MANAGEMENT
Cervical maturation before labor induction

Prostaglandin

• Mechanism: changes in the extracellular base substance of the

cervix, stimulation of cervical and uterine smooth muscles, gap
junction formation is important for coordinated uterine
contractions during labor

Oxytocin
• Adverse effects: hyper stimulation, uterine rupture, intoxication
CONCLUSIONS

Post term pregnancy is pregnancy that extend to beyond 42

weeks or 294 days from first day of last menstrual period

Etiology: decreased PGE2 and PGF2a in amnion & decidua

Post term pregnancy affects both fetal and maternal

THANK YOU