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
Risks to the FetusRisks to the Fetus
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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%
Risks to the FetusRisks to the Fetus
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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 %
2ey /linical )ecommendations2ey /linical )ecommendations
)RCOG G.a"* A(
2ey /linical )ecommendations2ey /linical )ecommendations
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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%
2ey /linical )ecommendations2ey /linical )ecommendations
(
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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 ')
2ey /linical )ecommendations2ey /linical )ecommendations
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