DEFINITION
Prolonged pregnancy ( postterm pregnancy ) It is one that has lasted longer than 42 weeks or 294 days beyond the first day of the last menstrual period
DEFINITION
Postdatism is pregnancy lasting beyond the estimated due date at 40 weeks. Postmature is reserved for the Postmature pathologic syndrome in which the fetus experiences placental insufficiency and resultant IUGR .
PostPost-maturity syndrome
1. Meconium -stained amniotic fluid, 2. Oligohydramnios 3. Fetal distress 4. Evidence of loss of subcutaneous fat and 5. Dry, cracked skin
Etiologic Factors
The most frequent cause is an error in dating. When truly exists, the cause usually is unknown.
Primiparity and prior postterm pregnancy are the most common identifiable risk factors.
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 insufficiency, to uteroplacental insufficiency, resulting in fetal hypoxia , meconium restriction, aspiration, 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 eightmeconium aspiration
Macrosomia
- In other cases, continued growth of the fetus leads to macrosomia, macrosomia, increasing the risk of labor abnormalities, abnormalities, shoulder dystocia with resultant risks of orthopedic or neurologic injury. - Macrosomia is far more common in postterm than term pregnancies .
Oligohydramnios
It is a marker for fetal compromise and it puts the fetus at risk for cord accidents. accidents.
U/S diagnosis : No vertical pocket > 2 cm or Amniotic fluid index (AFI) 5 cm or less .
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 3) Doubling in the rate of cesarean delivery. 4) A source of extreme anxiety for the pregnant woman.
Gest. age must be assessed carefully to avoid delivery of a preterm infant. Women who attend late for ANC may be of uncertain gestation and may be overover-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 . 2. Recent cessation of birth control pills. 3. Inconsistent ovulation times.
CrownCrown-rump length (CRL) till 12 weeks is 3-5 days, Biparietal diameter (BPD) at 12-20 weeks is 121 week, week, BPD at 20-30 weeks is 2 weeks, and 20weeks, BPD after 30 weeks is 3 weeks. weeks. If there is more than a one week discrepancy between the LMP and the ultrasound findings, the ultrasound data should be used to determine the EDD .
Transcerebellar diameter
When composite biometry is not consistent in all of the parameters (i.e. BPD, head circumference, abdominal circumference, femur length), using the transcerebellar diameter is a way to more accurately date a pregnancy
Transcerebellar diameter
are that
Early ultrasonography alone is the most accurate method for predicting EDD. EDD.
The use of early ultra-sound alone ultrato calculate the rate of postterm
pregnancy in women who delivered spontaneously significantly reduced the postterm rate from 10 % to 1.5 %.
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 .
Successful management depends on effective counselling of women and their full involvement in the decision making process.
Historically, prolonged pregnancy has been managed in 2 ways , either : a. Inducing labour at 41-42 weeks 41gestation or b. Awaiting the onset of spontaneous labour, while monitoring the fetal wellbeing .
Although postterm pregnancy is defined as a pregnancy of 42 weeks or more of gestation, several large multicenter randomized studies reported
favorable outcomes with routine induction as early as the beginning of 41 weeks of gestation.
A recent review in the Cochrane Library concluded that routine induction in low-risk lowpregnancies at or after 41 weeks' gestation is associated with : A reduction in perinatal mortality, No increase in the rate of instrumental or cesarean delivery.
1. 2.
Contrary to what many obstetricians believe, induction of labor for prolonged pregnancy does not increase the rate of cesarean section, section, rather, it decreases it. The risk of fetal distress from uteroplacental insufficiency due to prolonged pregnancy can be reduced by induction of labor, even to labor, the point of preventing perinatal death from asphyxia.
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 intervals, of the tests are immune from false positives, false negatives
Boehm et al, demonstrated that twicetwiceweekly testing of patients at risk for fetal testing. 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.
Management from 40-41 weeks gestation 40A .Healthy, uncomplicated pregnancy and fetal growth/ amniotic fluid normal:
Management at 40 - 41 weeks gestation B. Presence of maternal risk factors or evidence of fetal compromise : Recommend cervical ripening as necessary and induction of labour
Key Clinical Recommendations Labour induction at 41 weeks gestation is recommended over expectant management in women with postterm pregnancy to reduce the rate of cesarean delivery & perinatal mortality .
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.
Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.
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