Pathologic Obstetrics

Postterm Pregnancy
 Postterm Pregnancy

 The term postterm, prolonged, postdates, and postmature are often

loosely used interchangeably to signify pregnancies that have
exceeded a duration considered to be the upper limit of normal

 Postmature should be used to described the infant with recognizable

clinical features indicating a pathologically prolonged pregnancy

 Postdates probably should be abandoned, because the real issue in

many postterm pregnancies is “post-what dates?”

 Therefore, postterm or prolonged pregnancy is preferred expression

for an extended pregnancy

 The standard of definition of prolonged pregnancy → 42 completed

weeks (294days) or more from the first day of the last menstrual period
 Postterm Pregnancy

 Estimated Gestational Age Using Menstrual Dates

 Two categories of pregnancies that reach 42 complete
weeks
 Those truly 40 weeks past conception
 Those of less advanced gestation due to inaccurate estimate
of gestational age

 Blondel and colleagues (2002)

 Analyzed postterm pregnancy rates based on either the last
menstrual period, ultrasound at 16 to 18 weeks, or both
 The proportion of births at 42 weeks or longer was 6.4 %
when based on the last menstrual period alone & 1.9 % when
based on USG alone
 This raises the possibility that the menstrual dates are
frequently inaccurate in predicting postterm pregnancy
 Postterm Pregnancy

 Estimated Gestational Age Using Menstrual Dates

 Most pregnancies that are reliably 42 completed weeks

beyond the last menses probably are not biologically
prolonged

 Conversely, a few that are not yet 42 weeks might be

postterm

 Because there is no method to identify pregnancies that

are truly prolonged, all pregnancies judged to be 42
completed weeks should be managed as if abnormally
prolonged
 Incidence

Postterm Pregnancy

 Maternal demographic factors

 Parity, prior postterm birth, socioeconomic class, and age

 The incidence of a subsequent postterm birth

 Increased from 10 to 27% if the first birth was postterm
 ↑ 39% if there had been two previous postterm deliveries
 When mother and daughter had had a prolonged
pregnancy, the risk for a daughter’s subsequent postterm
pregnancy → increased two- to threefold
 Etiology

Postterm Pregnancy

 Etiology
 Genetic factor : maternal genes influenced prolonged
pregnancy

 Fetal-placental factors
- anencephaly
- adrenal hypoplasia
- X-linked placental sulfatase deficiency
⇒ A lack of the usually high estrogen levels of normal
pregnancy

 Reduced cervical nitric oxide (NO) release

Perinatal mortality

Postterm Pregnancy

 Perinatal mortality rate (stillbirths plus

early neonatal deaths)
 At greater than 42 weeks of gestation is
twice that at term
 4-7 deaths versus 2-3 deaths per 1,000
deliveries
 Increases 6-fold and higher at 43
weeks of gestation and beyond
Pathophysiology

Postterm Pregnancy

 The major causes of increased perinatal

mortality (Lucas and co-workers ,1965 )

 Pregnancy hypertension
 Prolonged labor with cephalopelvic
disproportion
 Intrapartum asphyxia
 Meconium aspiration syndrome
 Shoulder dystocia and macrosomia
 Unexplained anoxia
 Malformation
( i.e., anencephaly, adrenal hypoplasia )
Pathophysiology

Postterm Pregnancy

 Postmaturity syndrome
 Postmature infant’s unique &
characteristic appearances
by pathologically prolonged
pregnancy
 Wrinked, patchy, peeling
skin on the palms and soles
 Long, thin body suggesting
wasting
 Long nails
 Open-eyed, unusually alert,
old & worried-looking face
 Incidence : 10% of pregnancies
between 41and 43 weeks
Pathophysiology

Postterm Pregnancy

 Placental dysfunction

 Clifford (1954)
 Proposed the skin change of postmaturity were due to loss of
the protective effects of vernix caseosa

 Stage of postmaturity
 Stage I : clear AF
 Stage II : skin was stained green
 Stage III : skin discoloration – yellow green

 Attributed the postmaturity syndrome to placental

senescence, although did not find placental degeneration
histologically
Pathophysiology

Postterm Pregnancy

 Placental dysfunction

 Jazayeri and co-workers (1998)

 Investigated cord erythropoietin levels in 124 appropriately grown

newborns delivered from 37 to 43 weeks

 To assess whether fetal oxygenation was compromised due to

placental aging in postterm pregnancies

 Decreased partial oxygen pressure is the only known stimulator of

erythropoietin

 Cord erythropoietin levels → significantly increased in pregnancies

reaching 41 weeks or more
Pathophysiology

Postterm Pregnancy

 Placental dysfunction
 The postterm fetus may continue to gain weight,
and thus be an unusually large infant at birth

 This at least suggests that placental function is

not compromised

 Indeed, continued fetal growth, although at a

slower rate, is characteristic between 38 and 42
weeks
Pathophysiology

Postterm Pregnancy

 Fetal distress and oligohydramnios

 Leveno and associates (1984)
 Antepartum fetal jeopardy & intrapartum fetal distress
→ 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

 One or more prolonged decelerations proceeded three fourths of

emergency cesarean deliveries for fetal jeopardy

 In all but two cases, there were also variable decelerations

 Another common fetal heart rate pattern was the saltatory baseline
Pathophysiology

Postterm Pregnancy

 Fetal distress and oligohydramnios

 Decreased amnionic fluid volume commonly develops as

pregnancy advances beyond 42 weeks

 Meconium release into an already reduced amnionic fluid volume

→ causes thick, viscous meconium
→ implicated in meconium aspiration syndrome
Pathophysiology

Postterm Pregnancy

 Fetal growth restriction

 Divon and co-authors (1998) and Clausson and co-workers (1999)

analyzed births of almost 700,000 women between 1991 and 1995
using the National Swedish Medical Birth registry

 Stillbirths were more common among growth-restricted infants who

were delivered at 42 weeks or beyond

 Indeed, one third of the postterm stillbirths were growth restricted

Management
Management

Postterm Pregnancy

 Major issue

 Whether to intervene at 41 or 42 weeks

 Whether labor induction is warranted compared with expectant

management using antepartum fetal testing

 Roussis and colleague (1993)

 Two thirds of respondents induced labor at 41 weeks
if the cervix was favorable
 Antepartum fetal testing was advocated beginning at 41weeks
when the cervix was unfavorable
Management

Postterm Pregnancy

 Unfavorable cervix
: It is difficult to precisely define in prolonged pregnancies

 Harris and colleagues (1983)

 A Bishop score of less than 7

 Hannah and colleagues (1992)

 Undilated cervix

 Alexander and associates (2000)

 Women in whom there was no cervical dilatation had a twofold
increased cesarean delivery rate for “dystocia”

 Yang and co-worker (2004)

 Cervical length of 3cm or less → predictive successful induction
Management

Postterm Pregnancy

 Unfavorable cervix
 Prostaglandin E2
 The American college of obstetrician and Gynecologists (1997)
→ Prostaglandin gel can be safely in postterm pregnancy
 Use of PG for cervical ripening is discussed

 Sweeping of stripping of the membranes

 Boulvain and co-authors (1999)
→ At 38 to 40 weeks decreased the frequency of postterm pregnancy
→ Not modify the risk for cesarean delivery

 Station of the vertex

 The cesarean delivery rate directly related to station
 6% if the vertex was -1, 20% at -2, 43% at -3, and 77% at-4
Management

Postterm Pregnancy

 Induction versus fetal testing

 Hannah and colleagues (1992)
 Labor induction resulted in a significantly lower cesarean rate (21%)
compared with pregnancies managed with antepartum testing (24%)

 Menticoglou and Hall (2002)

 Lamented that induction of labor at 41 weeks has become standard
of care of care in Canada
 Because it caused interference that had the potential to do more
harm than good & have staggering resource implications

 Alexander and colleagues (2001, at Parkland Hospital)

 Rates of cesarean delivery significantly increased in the induced
group because of failure to progress compared with spontaneous
labor (19 versus 14%)
 Risk factors : nulliparity, unfavorable cervix & eipdural analgesia
Management

Postterm Pregnancy

 Induction versus fetal testing

 Evidence to substantiate intervention-whether induction or fetal

testing-commencing at 41 versus 42 weeks is limited

 Usher and colleagues (1988)

 Perinatal death rates, corrected for malformations

→ 1.5, 0.7, and 3.0 per 1000 for 40, 41, and 42 weeks

 Based on results summarized in Table 37-1, 41-week pregnancies

without other complications such as HTN → considered normal
pregnancies at Parkland Hospital
Management

Postterm Pregnancy

 Oligohydramnios

 When amnionic fluid is decreased in a postterm

pregnancy-or for that matter in any pregnancy-the fetus is
at increased risk

 The smaller the amnionic fluid pocket, the greater the

likelihood that there was clinically significant
oligohydramnios

 Amnionic fluid index (AFI) overestimated the number of

abnormal outcomes in postterm pregnancies

 Regardless of the criteria used to diagnosis

oligohydramnios → increased incidence of “fetal distress”
during labor
Management

Postterm Pregnancy

 Macrosomia

 Incidence of macrosomia (defined as birthweight greater than

4500g) → increases from 1.4 % at 37 to 41 weeks to 2.2 %
at 42 weeks or more (Marin and colleagues, 2002)

 Current evidence doesn’t support a policy of early labor

induction in women at term who have suspected fetal
macrosomia

 Cesarean delivery recommended for estimated fetal weights

greater than 4500g in the presence of a prolonged second-
stage labor or a second-stage arrest of descent
Management

Postterm Pregnancy

 Recommendations of the ACOG

(the American College of Obstetricians and Gynecologists)

 Although providing flexibility in the evaluation & management of

pregnancies completing 42weeks
→ Antenatal testing or labor induction should be commenced

 Postterm pregnancy has been identified as high-risk condition

→ twice-weekly antepartum fetal testing may be indicated

 Oligohydramnios defined as no vertical pocket of amnionic fluid

greater than 2 cm or an AFI of 5 cm or less
→ indication for either delivery or close fetal suveillance
Management

Postterm Pregnancy
Management

Postterm Pregnancy

 Management at Parkland Hospital

 In women with a certain gestational age, labor is induced at the

completion of 42 weeks

 90% of such women are induced successfully

 For those who do not deliver with the first induction

→ a second induction is performed within 3 days

 If not delivered, management decisions involve

→ a third (or more) induction versus cesarean delivery
Management

Postterm Pregnancy

 Management at Parkland Hospital

 Women classified having uncertain postterm pregnancies are

followed on a weekly basis & without intervention unless fetal
jeopardy is suspected

 Decreased amnionic fluid volume & diminished fetal movement

→ Labor induction as described previously for the woman with
a certain postterm gestation
Management

Postterm Pregnancy

 Medical or Obstetrical Complications

 In the event of a medical or obstetrical complications

→ unwise to allow a pregnancy to continue past 42 weeks

 In many such instances early delivery is indicated

 Common examples
 Hypertensive disorders due to pregnancy
 Prior cesarean delivery
 Diabetes
Management

Postterm Pregnancy

 Intrapartum Management

 While being observed for possible labor → Continuous electronic

monitoring for variations consistent with fetal distress
(American College of Obstetricians and Gynecologists, 1995)

 Amniotomy

 Reduction in fluid volume → the possibility of cord compression

 Diagnosis of thick meconium to be dangerous to the fetus if
aspirated
 Scalp electrode and intrauterine pressure catheter can be placed
Management

Postterm Pregnancy

 Intrapartum Management

 The viscosity of thick meconium

 Signifies the lack of liquid & oligohydramnios

 Aspiration of thick meconium

→ severe pulmonary dysfunction & neonatal death

 Amnioinfusion during labor as a way of diluting meconium to

decrease
the incidence of meconium aspiration syndrome
Management

Postterm Pregnancy

 Intrapartum Management

 The viscosity of thick meconium

 The likelihood of a successful vaginal delivery is reduced appreciably

for the nulliparous woman who is in early labor with thick, meconium-
stained amnionic fluid

 When the woman remote from delivery → prompt cesarean delivery,

especially when cephalopelvic disproportion is suspected or either
hypertonic or hypertonic dysfunctional labor is evident
Management

Postterm Pregnancy

 Intrapartum Management

 Aspiration of meconium

 Suction of the pharynx as soon as the head is delivered

 If meconium is identified , the trachea should be aspirated

as soon as possible after delivery

 The infant should ventilated as needed

Thank You