Prolonged Pregnancy

(Evidence Based)
Valleria, Sp.OG

Sources

RCOG 2003 ACOG (SEPTEMBER 2004) COCHRANE LIBRARY 2006 AFP (AMERICAN FAMILY PHYSICIAN) (May 15, 2005) PUBMED (MEDLINE)

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

( WHO & FIGO )

DEFINITION

Postdatism is pregnancy lasting

beyond the estimated due date at

40 weeks.

Postmature is reserved for the

pathologic syndrome in which the

fetus experiences placental

insufficiency and resultant IUGR .

Post-maturity syndrome

Representing 20 % cases of prolonged pregnancy and is associated with :

1. Meconium -stained amniotic fluid, 2. Oligohydramnios

3. Fetal distress
4. Evidence of loss of subcutaneous fat and 5. Dry, cracked skin

Reflecting placental insufficiency.

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

Rarely, it may be associated with

placental sulfatase deficiency or fetal

anencephaly.

Male sex also has been associated. Genetic predisposition may play a role .

EPIDEMIOLOGY

Using the definition of 294 days,

the incidence of postterm pregnancy is 9 - 10 %.

Risks to the Fetus

The perinatal mortality:

> 42 weeks twice that at term > 43 weeks > 6-fold that at term

Risks to the Fetus

In some cases, the risks appear to be due to uteroplacental insufficiency, resulting in fetal hypoxia , meconium 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 meconium aspiration

Macrosomia
- In other cases, continued growth of the fetus leads to macrosomia, increasing the risk of labor 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.

U/S diagnosis : No vertical pocket > 2 cm or Amniotic fluid index (AFI) 5 cm or less . It is considered an indication for delivery.

Risks to the Fetus

Fetuses born postterm also are at increased risk of : Sudden infant death syndrome (death within the first year of life).

Some of these deaths clearly result from peripartum complications

(such as meconium aspiration syndrome),

but most have no known cause.

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.

Gestational age calculation

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 over-represented in populations of postterm pregnancies.
Dating by the last menstrual period (LMP) alone has a tendency to overestimate the gestational age.

Gestational age calculation

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.

Routine early pregnancy ultrasound

Reduces the number of women who require induction of labour for apparent postterm pregnancy . It is recommended that all pregnant ladies (and certainly those who do not have regular menses), should have an ultrasound examination for gestational age determination, prior to 20 weeks
RCOG,COCHRANE

Ultrasound biometry margins of error

Crown-rump length (CRL) till 12 weeks is 3-5 days,

Biparietal diameter (BPD) at 12-20 weeks is 1 week,

BPD at 20-30 weeks is 2 weeks, and BPD after 30 weeks is 3 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

The diameter in millimeters corresponds

to weeks of gestation up to 24 weeks.

Transcerebellar diameter

The available evidences

strongly in support dating by

are
that

Early ultrasonography alone

is the most accurate method

for predicting EDD.

RCOG (GRADE A)

Routine early pregnancy ultrasound

The use of early ultrasound alone to

calculate the rate of postterm pregnancy in women who delivered

spontaneously significantly
reduced the postterm rate

from 10 % to 1.5 %.
RCOG (GRADE A)

Are there interventions that decrease the rate of postterm pregnancy?

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 .
ACOG Guidelines 2004

Management options depend on:

1) Gestational age, 2) Absence/presence of maternal risk factors

and / or
3) Evidence of fetal compromise, and

4) Maternal preferences .

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 gestation or b. Awaiting the onset of spontaneous labour, while monitoring the fetal wellbeing .

The decision is difficult and should

not be taken lightly.

Routine induction of labour at 41 weeks

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.
Cochrane 2006

Routine induction of labour at 41 weeks

A recent review in the Cochrane Library concluded that routine induction in low-risk pregnancies at or after 41 weeks' gestation is associated with : A reduction in perinatal mortality,

1.

2.

No increase in the rate of instrumental or cesarean delivery. RCOG Grade A

Routine induction of labour at 41 weeks

Contrary to what many obstetricians believe, induction of labor for prolonged pregnancy does not increase the rate of cesarean 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

the point of preventing perinatal death from asphyxia.

ANTEPARTUM FETAL SURVEILLANCE

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.

ANTEPARTUM FETAL SURVEILLANCE

The condition of the fetus can change quickly and thus, monitoring should be at frequent intervals, and that none of the tests are immune from false positives, false negatives Boehm et al, demonstrated that twiceweekly testing of patients at risk for fetal distress was superior to weekly testing.

FETAL SURVEILLANCE
A modified biophysical profile

consisting of a:
non stress test and amniotic fluid index

an

have been shown to be as sensitive as a full biophysical profile.

RCOG Grade A

Induction of labour or expectant management?

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. ACOG 2004 (Level C)

Management from 40-41 weeks gestation

A .Healthy, uncomplicated pregnancy and fetal growth/ amniotic fluid normal:

No evidence to support elective

induction of labour

No evidence to support use of serial

antenatal monitoring : non stress test (NST) or amniotic fluid index (AFI) .

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

Management at 41 weeks gestation

A. Healthy, uncomplicated pregnancy
Inform the woman of the options and

risks/ benefits of labour induction versus

expectant management, and

offer her labour induction.

Establish the cervical (Bishop) Score

and ensure a ripening agent

(prostaglandin) prior to induction.

Management at 41 weeks gestation

B. If mother declines induction , then provide expectant management:
Daily fetal movement counts
Non stress test (NST) and Amniotic fluid

index (AFI) twice/ week to 42 weeks.

If the NST or AFI is abnormal ,

then initiate induction immediately

Induce at 42 weeks even if NST and AFI are normal.

Management during labour and delivery

Consider amniotomy to diagnose

thick meconium.
If meconium is present then consider risk of meconium aspiration , continuous fetal assessment with electronic fetal monitoring (EFM) is recommended. Be prepared for shoulder dystocia and neonatal resuscitation at delivery.

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 .
(RCOG Grade A)

Key Clinical Recommendations

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.
(RCOG Grade C )

Key Clinical Recommendations

Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.

Delivery should be effected if there is evidence of :

fetal compromise oligohydramnios.

or ACOG 2004 (Level A)