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MANAGEMENT OF POST TERM

PREGNANCY

INTRODUCTION/HISTORICAL MILESTONES
1. BALANTYN IN 1902—FIRST REFERENCE TO POST TERM

PREGNANCY
2. CLIFFORD IN 1954—DESCRIBED POSTMATURITY
SYNDROME
3. AUBERG IN 1964 & LANMAN IN 1968—INCREASED
PERINATAL DEATH IN PROLONGED PREGNANCIES
4. PROMINENCE IN LAST DECADE—HIGH RISK CONDITION
5. OPTIMAL MANAGEMENT STILL CONTROVERSIAL
 OLD SCHOOL—EXPECTANT CONSERVATIVE MGT.
 OTHER SCHOOL—“ACTIVE MGT” DELIVERY AT 42/52.
6. MORE RECENTLY, EVIDENCE BASED STUDY—PLANNED
DELIVERY AT 41 WEEKS ( RHL-6)
7. PROLONGED PREGNANCY, POSTTERM, AFTER-TERM
PREGNANCY—SYNONYMS (THE LANCET)
8. POSTMATURITY, HYPERMATURITY & DYSMATURITY—
CLINICAL SYNDROMES IN NEONATES MORE COMMON IN
POSTTERM, BUT ALSO DESCRIBED IN TERM INFANTS.
DIAGNOSIS
SOMETIMES DIFFICULT
 ILLITRACY IS RAMPANT—LMP WILL BE UNKNOWN
 LATE BOOKING
 NO EARLY USS.
HX INVOLVES AMONG OTHER THINGS:
 PARITY— PRIMIGRAVIDAE
 MULTIPS—PREVIOUS HX
 LMP—1ST DAY LMP

-DATE OF MISSED PERIOD AS LMP


- IRREGULAR CYCLES
- MENSTRUAL RECALL INACURRATE IN 20-40%
- TIMING OF OVULATION ERRATIC IN SOME
WOMEN.

EXAMINATION
GENERAL- PALLOR, FEVER, JAUNDICE, PEDAL EDEMA
SYSTEMIC
 CVS- HYPERTENSION=IUGR
 ABD—SIZE,
 ----FH =36/52, <36/52—IUGR, LIGTHENING
----LIE, PRESENTATION, DECENT, FHR
 PELVIC EXAMINATION
--EXCLUDE PELVIC CONTRACTION
--CERVICAL ASSSESMENT
BISHOP SCORING
PARAMETER 0 1 2 3
POSITION OF POSTERIOR CENTRAL ANTERIOR
CX
CONSISTENCY FIRM MEDIUM SOFT
OF CERVIX
CERVICAL 0-40% 40-60% 60-80% +80%
EFFACEMENT
CERVICAL CLOSED 1-2CM 3-4CM 5CM +
DILATATION
STATION OF -3 -2 -1 +1, 2
PP

INTERPRETATION OF BISHOP’S SCORE


 0-4: CERVIX UNFAVORABLE
 5-8: MODERATELY FAVORABLE
 9-13: CERVIX “RIPE” PREDICTIVE OF SUCCESSFUL
INDUCTION

INVESTIGATIONS
GENERAL—HB, GENOTYPE, BLOOD GROUP, CROSSMATCH
2 UNITS OF BLOOD, URINALYSIS
OTHERS:

PREGNANCY DATING
1. CLINICALLY
 LMP-- SPOUSE MAY KNOW

 UNCERTAIN IN, LAM/CONTRACEPTIVES,


 ABORTION PRECEEDING PREGNANCY
ACCURATELY KNOWN IN ASSSISTED
CONCEPTION-INVITRO FERTILIZATION
(38WEEKS).
--QUICKENING
16-18 WEEKS- MULTIPS
18-20 WEEKS- PRIMIPS
--HEGAR’S--- +VE IN 6 WEEKS ( SOFTENING OF Cervix
--FH
PRESENCE OF PELVIC TUMOR, INFLUENCE THE FH
---FETAL HEART SOUNDS
16 WEEKS- WITH SONICAID
24-28 WEEKS- WITH PINARD
2. LABORATORY STUDIES
3. SERUM PT- +VE 6-7 DAYS AFTER CONCEPTION (CHEMICAL
PREGNANCY)
o URINE PT-- +VE IN 5 WEEKS

4. RADIOLOGICAL STUDIES
 ULTRASONOGRAPHY
 1ST TRIMESTER—BEST, MARGIN OF ERROR -3

DAYS
-GESTATIONAL SAC (5-7 WEEKS)
-CRL (8-12 WEEKS)
 2ND TRIMESTER- RELIABLE, MARGIN OF

ERROR- 7 DAYS
--BPD- Preferred,
--FEMUR LENGTH, HEAD CIRCUMFERENCE,
--ABDOMINAL CIRCUMFERENCE
 3rd TRIMESTER- NOT RELIABLE, MARGIN OF

ERROR- 14 DAYS
--ESTIMATION OF FETAL WEIGHT
--BIOPHYSICAL PROFILE SCORING
--PLACENTAL MATURITY
--CONGENITAL ABNORMALITIES

BIOPHYSICAL PROFILE SCORING (MAX= 10)


PARAMETER SCORE 2 SCORE 0
Amniotic fluid volume >2cm pocket <2cm,
oligohydramnious
Fetal movements 3 or more gross body 2 or less
movement
Breathing movements 30seconds of sustained < 30 seconds of
fbm in 30 minutes sustained fbm
Fetal tone One episode No evidence of
flexion/extension in movements
succession
Fetal reactivity( FHR) 2 or more rapid <2 accelerations
accelerations in 40
minutes

Interpretation of score
 8-10 = normal score
 6-7 = repeat
 < 6 =terminate pregnancy

PLACENTAL MATURITY GRADING ( 0-3)


GRADE O 1st trimester. Smooth chorionic plate,
no echogenic areas of calcification
GRADE 1 14- 34 weeks, indentation of
chorionic plate, echogenic areas of
calcification
GRADE 2 26- 36 weeks. More indentation of
chorionic plate, sparing the basal
plate.
GRADE 3 >38 weeks. Indentation to the basal
plate. Extensive echogenic areas of
calcifications

5.ROENTGENOGRAPHY
THE APPEARANCE OF OSSIFICATION CENTRES IN FETAL
BONES MAY BE USED TO DATE PREGNANCY.
 35- 40 WEEKS- distal femoral epiphysis
 37-42 WEEKS- proximal tibial epiphysis appears.
--NO LONGER USED FOR PREGNANCY DATING.
MANAGEMENT OPTIONS
1. “ACTIVE MANAGEMENT”- DELIVERY AT 41/42 WEEKS
2. EXPECTANT CONSERVATIVE MANAGEMENT
THIS ENTAILS FETAL SURVEILLANCE, which include
 Cardiff 10 count—10 fetal kicks in 12hours(normal)
 Regular fundal height estimation
 Non-stress test--normal(110-150bpm, baseline
variability OF 5-25 BPM
 Weekly contraction stress test—time wasting, invasive

 Amnioscopy/ Amniocentesis- L/S ratio, meconium


staining of amniotic fluid
 Weekly fetoplacental function test—plasma free estriol,
HPL. No longer in use, expensive
 USS- As mentioned earlier
 Doppler velocimetry—of umbilical artery= absence of
end diastolic suggests fetal compromise

ACTIVE MANAGEMENT
DELIVERY AT 41/42 WEEKS
 CERVICAL ASSESSMENT/BISHOP’S SCORING
 IF UNFAVORABLE, RIPEN CERVIX WITH
Prostaglandin E1, E2
Forley’s urethral catheter
Laminiara tent
Membrane sweeping
INDUCTION—when cervix is favorable, informed consent
 Surgical method
--Amniotomy
 Medical methods
--Prostaglandin
--Oxytocin infusion
 Synchronous induction
 Time lag between amniotomy/ oxytocin infusion (or
vice versa) is less than 3hours.
LABOUR
Some times prolonged. Increased risk of fetal distress.
At least 2 units of blood should be cross matched.
Senior resident/ experienced midwife, anaesthetist, neonatologist must be
present.
Theatre ideally should be informed.
Vigilant intrapartum monitoring, preferably continuous electronic fetal heart
rate monitoring, intermittent auscultation
Fetal scalp electrode—pH
Meconium staining of amniotic fluid- amnioinfusion with warm normal
saline.
2ND STAGE
Delivery taken by a senior resident. Risk of shoulder dystocia
Neonatologist must be present for possible resuscitation
Suck oropharynx at the delivery of the head if liquor is meconium stained.
Hand over baby to neonatologist if asphyxiated.
3rd STAGE
Should be managed actively.
POST PARTUM
Should be observed for 24 hours, and if satisfactory discharge home.

COMPLICATIONS
ANTENATAL
 Oligohydramnious
 meconium staining of amniotic fluid
 postmaturity
 intra uterine fetal death
 placental insufficiency
INTRAPARTUM
 increased risk of meconium staining of the amniotic
fluid
 increased risk of meconium aspiration
 dystocia
 intrapartum fetal death
NEONATAL
 nerve palsy—Erb’s palsy
 neonatal death
 post neonatal death
MATERNAL COMPLICATIONS
 maternal anxiety
 trauma
 increased caesarean section rate.

CONCLUSION
Post term pregnancy presents a mgt problem. While decision to terminate or
to continue with pregnancy remain controversial, obstetric units should have
policy based on evidence of favorable outcome.