4. prolonged pregnancy.ppt

7/25/2019 4. Prolonged pregnancy.ppt

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Prolonged PregnancyProlonged Pregnancy(Evidence Based)(Evidence Based)

Valleria, Sp.OGValleria, Sp.OG


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SourcesSources

RCOG 2003RCOG 2003

ACOG (ACOG (SEPTEMBER 2004)

COCHRANE LIBRARY 2006COCHRANE LIBRARY 2006

AFP (AMERICAN FAMILYAFP (AMERICAN FAMILY

PHYSICIAN) (May 15, 2005)PHYSICIAN) (May 15, 2005)

PUBME (MELINE)PUBME (MELINE)


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Prolonged pregnancyProlonged pregnancy

(( postterm pregnancy )postterm pregnancy )

It is one that has lasted longer thanIt is one that has lasted longer than

42 weeks or 294 days beyond the42 weeks or 294 days beyond the

first day of the last menstrual periodfirst day of the last menstrual period

DEFINITIONDEFINITION

))WH ! "I#WH ! "I#((


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PostdatismPostdatismis pregnancy lastingis pregnancy lastingbeyond the estimated due date atbeyond the estimated due date at

4$ weeks%4$ weeks%

PostmaturePostmatureis reser&ed for theis reser&ed for the

pathologic syndrome in which thepathologic syndrome in which the

fetus e'periencesfetus e'periences placentalplacental

insufficiencyinsufficiencyand resultantand resultant I# %I# %

DEFINITIONDEFINITION


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epresentingepresenting

2$ * cases2$ * cases

of prolongedof prolonged

pregnancy and is associated with +pregnancy and is associated with +

1.1. Meconium -stained amniotic fluid,Meconium -stained amniotic fluid,

2.2. OligohydramniosOligohydramnios3.3. Fetal distressFetal distress

4.4. Evidence of loss of subcutaneous fatEvidence of loss of subcutaneous fat

andand

.. !ry, crac"ed s"in!ry, crac"ed s"in

eflecting placental insufficiency%eflecting placental insufficiency%

Post-maturity syndromePost-maturity syndrome


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Etiologic FactorsEtiologic Factors ,he most fre-uent cause is an

error in dating%

When truly e'ists. the cause usually

is unknown%

Primiparity and prior postterm

pregnancyare the most common

identifiable risk factors%


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Etiologic FactorsEtiologic Factors

arely. it may be associated with

placental sulfatase deficiencyor fetal

anencephaly% /ale se'also has been associated%

#enetic predispositionmay play a

role %


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sing the definition ofsing the definition of 294 days294 days..

thethe incidenceincidence

ofofpostterm pregnancy ispostterm pregnancy is 9 0 1$ *%9 0 1$ *%

EPIDEMIOLOGYEPIDEMIOLOGY


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Risks to the FetusRisks to the Fetus

,he perinatal mortality+

42 weekstwice that at term

43 weeks 0fold that at term


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In some cases. the risks appear to be dueIn some cases. the risks appear to be due

toto uteroplacental insufficiencyuteroplacental insufficiency..resulting inresulting in fetal hypo'iafetal hypo'ia.. meconiummeconium

aspirationaspiration.. growth restrictiongrowth restriction. and. and

oligohydramniosoligohydramnios%% "etal distress and meconium"etal distress and meconiumrelease wererelease were

twicetwiceas common (at or after 42 weeks)as common (at or after 42 weeks)

than at term%than at term% ,here was an,here was aneight0foldeight0fold increase inincrease in

meconium aspirationmeconium aspiration



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0 In other cases. continued growth of the0 In other cases. continued growth of the

fetus leads tofetus leads tomacrosomiamacrosomia..

increasing the risk ofincreasing the risk of

labor abnormalitieslabor abnormalities.. shouldershoulder

dystociadystocia with resultant risks of

orthopedic or neurologic in5ury%

0 /acrosomia is far more common in0 /acrosomia is far more common in

postterm than term pregnancies %postterm than term pregnancies %

MacrosomiaMacrosomia


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OligohydramniosOligohydramnios It is a marker forIt is a marker for fetal compromisefetal compromiseandand

it puts theit puts the fetus at risk for cord accidentsfetus at risk for cord accidents%%

U!S "#a$%&'#' U!S "#a$%&'#'

6o &ertical pocket 2 cm or6o &ertical pocket 2 cm or

7mniotic fluid inde' (7"I) 8 cm or less7mniotic fluid inde' (7"I) 8 cm or less%%

It is considered an indication for deli&ery%It is considered an indication for deli&ery%


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"etuses born postterm also are at increased

risk of + S""*%

#%+a% "*a- 'y%".&/*

(deathwithin the first year of life)% ome of these deaths clearly result from

peripartum complications

(such as meconium aspiration syndrome).

but most ha&e no known cause%



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Maternal risksMaternal risks

1) :abor dystocia

2) e&ere perineal in5ury

related to macrosomia

3) ;oubling in the rate of cesarean

deli&ery%

4) 7 source of e'treme an'iety

for the pregnant woman%


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#est% age must be assessed carefully#est% age must be assessed carefully

to a&oid deli&ery of a preterm infant%to a&oid deli&ery of a preterm infant%

Women whoWomen who attend lateattend latefor 76< mayfor 76< may

be of uncertain gestation and may bebe of uncertain gestation and may beo&er0represented in populations ofo&er0represented in populations of

postterm pregnancies%postterm pregnancies%

;ating by the last menstrual period (:/P);ating by the last menstrual period (:/P)

alonealonehas a tendency tohas a tendency to o&erestimateo&erestimate

the gestational age%the gestational age%

Gestational age calculationGestational age calculation


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Gestational age calculationGestational age calculation =ecause actual dates of conception are=ecause actual dates of conception are

rarely known.rarely known.

thetheLMPLMPis used as the reference point%is used as the reference point%

,his can make the accuracy of gest% age,his can make the accuracy of gest% agedeterminationdetermination unreliableunreliablebecause of +because of +

1%1% Irregular menses %Irregular menses %

2%2% ecent cessation of birth control pills%ecent cessation of birth control pills%

3%3% Inconsistent o&ulation times%Inconsistent o&ulation times%


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Routine early pregnancyRoutine early pregnancy

ultrasoundultrasoundeduces the number of women who

re-uire induction of labour for apparent

postterm pregnancy %

It is recommended that all pregnantladies (and certainly those who do not

ha&e regular menses).should ha&e an

ultrasound e'amination for gestational

age determination. prior to 2$ weeks

RCOG,COCHRANE


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Crown-rump lengthCrown-rump length (CRL)(CRL) tilltill 1212weeks isweeks is

3-5 days,3-5 days, Biparietal diameter (B!)Biparietal diameter (B!) atat12-2"12-2"weeksweeks

isis 1 week1 week,,

B!B! atat 2"-3"2"-3" weeksweeksisis 2 weeks2 weeks, and, and

B!B! a#tera#ter 3" weeks3" weeksisis 3 weeks3 weeks$$

If there is more than a one weekdiscrepancybetween the :/P and the

ultrasound findings. the ultrasound data

should be used to determine the >;; %

Ultrasound biometry margins of error


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Transcerebellar diameter WhenWhen composite biometrycomposite biometryis not consistentis not consistent

in all of the parametersin all of the parameters (i%e% =P;.(i%e% =P;.

head circumference. abdominalhead circumference. abdominal

circumference. femur length).circumference. femur length).using theusing the transcerebellar diametertranscerebellar diameter is a wayis a way

to more accurately date a pregnancyto more accurately date a pregnancy

,he diameter in,he diameter in millimeters correspondsmillimeters corresponds

to weeks ofto weeks of

gestation up to 24 weeks%gestation up to 24 weeks%


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Transcerebellar diameter


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,he a&ailable e&idences are,he a&ailable e&idences are

strongly in support thatstrongly in support that datingdating

byby EarlyEarly

ultrasonogra#hyultrasonogra#hyalonealone

is the mostis the most

accurate method for predictingaccurate method for predicting

>;;>;;%%

RC%& (&R'! ')

i l


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,he use of,he use of early ultraearly ultrasoundsound alonealone toto

calculate the rate of posttermcalculate the rate of postterm

pregnancy in women who deli&eredpregnancy in women who deli&ered

spontaneously significantlyspontaneously significantly

reduced the postterm ratereduced the postterm rate

from 1$ * to 1%8 *%from 1$ * to 1%8 *%

Routine early pregnancyRoutine early pregnancy

ultrasoundultrasound

RC%& (&R'! ')


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re t!ere inter"entions t!at decreasere t!ere inter"entions t!at decrease

t!e rate of postterm pre#nancyt!e rate of postterm pre#nancy??

7ccurate datingon the basis ofultrasonography performed early in

pregnancy %

=reast and nipple stimulation at termha&e notbeen shown to affect the

incidence of postterm pregnancy%

weeping of the membranes at term+the data are

still conflicting %

7


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1) #estational age.

2) 7bsence?presence of maternal risk factors

and ? or

3) >&idence of fetal compromise. and

4) /aternal preferences %

$uccessful management de#ends on$uccessful management de#ends on

effective counselling of %omeneffective counselling of %omenand their full involvement in theand their full involvement in the

decision ma"ing #rocess.decision ma"ing #rocess.

Mana#ement options depend on$Mana#ement options depend on$


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a%a% Inducing labour at 41042 weeksInducing labour at 41042 weeks

gestationgestation oror

b%b% 7waiting the onset of spontaneous7waiting the onset of spontaneous

labour. while monitoring the fetallabour. while monitoring the fetal

wellbeing %wellbeing % ,he decision is difficult and should,he decision is difficult and should

not be taken lightly%not be taken lightly%

%istorically& prolon#ed pre#nancy !as%istorically& prolon#ed pre#nancy !as

been mana#ed in ' (ays & eit!er $been mana#ed in ' (ays & eit!er $


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)outine induction of labour)outine induction of labour

at *+ (eeksat *+ (eeks

7lthough postterm pregnancy is definedas a pregnancy of 42 weeks or more of

gestation. se&eral large multicenter

randomi@ed studies reported fa&orable

outcomes with routine induction as early

as the beginning of 41 weeks ofgestation%

C&-.a%* 2006

i i d i f l b


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7 recent re&iew in the


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,here is insufficient e&idenceto indicate

whether routine antenatal sur&eillance

of low0risk patients between

4$ and 42 weeks of gestation

impro&es perinatal outcome

but it is

often performed during this

period%

NTEP)T,M FETLNTEP)T,M FETL

-,).EILLN/E-,).EILLN/E

NTEP)T,M FETL -,).EILLN/ENTEP)T,M FETL -,).EILLN/E


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,he,he condition of the fetus can changecondition of the fetus can change

-uickly-uicklyand thus. monitoring should beand thus. monitoring should be

at fre-uent inter&alsat fre-uent inter&als. and that none. and that none

of the tests are immune from falseof the tests are immune from false

positi&es. false negati&espositi&es. false negati&es

=oehm et al. demonstrated that=oehm et al. demonstrated that twice0twice0weeklyweeklytesting of patients at risk for fetaltesting of patients at risk for fetal

distress wasdistress was superior to weekly testingsuperior to weekly testing%%

NTEP)T,M FETL -,).EILLN/ENTEP)T,M FETL -,).EILLN/E


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77 modified biophysical profilemodified biophysical profileconsisting of a+consisting of a+

non stress test and annon stress test and an

amniotic fluid inde'amniotic fluid inde'

ha&e been shown toha&e been shown tobebe as sensiti&e as aas sensiti&e as a full biophysicalfull biophysical

profileprofile%%

FETA !UR"E#A$%EFETA !UR"E#A$%E

RC%& &rade 'RC%& &rade '

I d i f l bI d ti f l b


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Fa&.a* *.#Fa&.a* *.# :abor generally isinduced because the risk of failed

induction and subse-uent cesarean

deli&ery is low%

U%+a&.a* *.#U%+a&.a* *.#a small ad&antage

to labor induction using cer&ical ripening

agents (prostaglandins). when indicated.

regardless of parity or

method of induction%

Induction of labour orInduction of labour or

e0pectant mana#ement1e0pectant mana#ement1

'C%& 2""'C%& 2"" (Le*el C)

M f 40 41 kk i


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7 %Healthy. uncomplicated pregnancy and

fetal growth? amniotic fluid normal+

6o e&idence to support electi&e

induction of labour

6o e&idence to support use of serial

antenatal monitoring +non stress test (6,) or

amniotic fluid inde' (7"I) %

Management from 40Management from 40-41-41weeks gestationweeks gestation

0M 40 41 kk i


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=% Presence of maternal risk factors or

e&idence of fetal compromise +

ecommend cer&ical ripening

as necessary and

induction of labour

Management at 40Management at 40 - 41- 41weeks gestationweeks gestation

kM 41 k i


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A H*a-y, %&/#a*" .*$%a%y

Inform the woman of the options and

risks? benefits of labour induction &ersus

e'pectant management. and

offer her labour induction%

>stablish the cer&ical (=ishop) core

and ensure a ripening agent

(prostaglandin)prior to induction%

Management at 41 weeks gestationManagement at 41 weeks gestation

M t t 41 k t tiManagement at 41 eeks gestation


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B I+ /&-*. "*#%*' #%"#&% ,

-*% ."* **a% /a%a$*/*%

;aily fetal mo&ement counts

6on stress test (6,) and 7mniotic fluidinde' (7"I) twice? week to 42 weeks%

If the 6, or 7"I is abnormal .

then initiate induction immediately

Management at 41 weeks gestationManagement at 41 weeks gestation

I%"* a 42 7**8'I%"* a 42 7**8'

**% #+ NST a%" AFI a.* %&./a**% #+ NST a%" AFI a.* %&./a

M t d i l b d d liM t d i l b d d li


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"/)is recommended% =e prepared for shoulder dystociaand

neonatal resuscitationat deli&ery%

Management during labour and deliveryManagement during labour and delivery

2ey /linical )ecommendations2ey /linical )ecommendations


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:abour induction at 41 weeks

gestationis recommended o&er

e'pectant management in women

with postterm pregnancy to reduce

the rate of cesarean deli&ery !

perinatal mortality %


)RCOG G.a"* A(



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If >'pectant management

(410 42 weeks)is chosen.

the fetus should be monitored with

twice weekly non0stress test .

amniotic fluid inde'%

0 Howe&er. e&idence of

benefit is lacking%


(


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Prostaglandincan be used in postterm

pregnancies to promote cer&ical ripening

and induce labor%

;eli&ery should be effected if there is

e&idence of +

fetal compromise or

oligohydramnios%

'C%& 2""'C%& 2"" (Le*el ')



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