POST TERM

SALWA NEYAZI ASSISTANT PROF.& CONSULTANT OBGYN KSU

INTRODUCTION
Definition 42 completed wks 294 days from LMP Risks adverse neonatal & fetal outcome / perinatal death Now it is believed that the risk is as early as 41 wks Incidence 41 27% 42 4-14% 43 2-7% The incidence is decreasing Dating of pregnancy Accurate dating of pregnancy is essential to avoid unnecessary intervention U/S scan prior to 20 wks gestation is an excellent method of establishing or confirming true gestational age Routine U/S scanning rate of IOL for post-term

ADVERSE PERINATAL OUTCOME ASSOCIATED WITH POST-TERM PREGNANCY

risk of perinatal death (antepartum, intrapartum, postpartum) due to anomalies eg. Anencephaly intrauterine infections asphyxia with or without meconium risk of neonatal morbidity - macrosomia - shoulder dystocia - meconium aspiration - admission to NICU - Rx with +ve pressure oxygen

endotracheal intubation respiratory distress persistent fetal circulation pneumonia seizures

risk of IOL, fetal distress in labor, meconium, & operative deliveries

risk of post-term adverse outcome in women with HPT, PET,DM , abruptio placenta, & IUGR

MANAGEMENT
1-Establishing gestational age HX ( in the 1st visit ) LMP regularity & length of the cycle OCP in the last 3 cycle before conception Exam. Size of the uterus corresponding to dates or not U/S to confirm or establish gestational age especially if LMP uncertain if the cycles were irregular if there is Hx of OCP use if size of the uterus inconsistent with GA The earlier the U/S the more accurate it is for GA determination U/S at 16-20 wks appropriate to assess other parameters of the fetus & placenta

MANAGEMENT
2-Management 39-40 6/7 wks

In uncomplicated pregnancies there is no evidence to support IOL nor fetal surveillance If there are other risk factors including HPT, DM, IUGR, macrosomia, multiple pregnancy, or hydramnios IOL or serial fetal suvillence is indicated

3-Management 41-42 wks

A-IOL or CS if vaginal delivery is contraindicated

Studies have shown that IOL at 41 or> wks CS rate compared to expectant management rate of non-reassuring fetal heart changes meconium staining of the amniotic fluid macrosomia >4000 gms rate of fetal or neonatal death ( mostly stillbirth due to asphyxia & meconium aspiration )

3-Management 41-42 wks

B-Expectant management with fetal surveillance

There are exceptions to the above recommendations (3A) if the mother refuses IOL despite full explanation of the risks

Fetal surveillance Minimally fetal surveillance should include twice weekly amniotic fluid volume estimation by U/S Fetal movement, NST, BPP, doppler Monitoring should be at frequent intervals All of the tests have false +ve & false ve

IOL

INTRODUCTION
DEFINITION Artificial initiation of labor before its spontaneous onset for the purpose of delivery of the fetoplacental unit INDICATIONS Post-term pregnancy most common PROM IUGR Non-reassuring fetal suvillence Maternal medical conditions DM, renal disease, HPT, gestational HPT, significant pulmonary disease, antiphospholipid syndrome Chrioamnionitis Abruption Fetal death

RISKS of IOL rate of operative vaginal deliveries rate of CS Excessive uterine activity Abnormal fetal heart rate patterns Uterine rupture Maternal water intoxication Delivery of preterm infant due to incorrect estimation of GA Cord prolapse with ARM

CONTRAINDICATIONS (Contraindications to labor or vaginal delivery) Previous myomectomy entering the cavity Previous uterine rupture Fetal transverse lie Placenta previa Vasa previa Invasive Cx Ca Active genital herpes Previous classical or inverted T uterine incision 2 or more CS

PREREQUISITES To assess the following Indication / any contraindications GA Cx favourability (Bishop score) Pelvis, fetal size & presentation Membranes status Fetal heart rate monitoring prior to IOL Elective induction should be avoided due the potential complications

Cx ripening prior to IOL

Indication if the Bishop score is 6 The state of the Cx is an important predictor of successful IOL Methods : Intracervical PGE2 gel 0.5 mg/6hrs----3 doses Intravaginal PGE2 gel 1-2 mg/6hrs----3doses PGE2 gel the rate of not being delivered in 24 hrs the use of oxytocin for augmentation of labor PGE2 gel the rate of uterine hyperstimulation Misoprostol Should not be used for term fetuses Mechanical methods

Cx ripening prior to IOL

Mechanical methods

Foley Catheter It is introduced into the cervical canal past the internal os, the bulb is inflated with 30-60 cc of water It is left for up to 24 hrs or until it falls out Contraindications Low laying placenta, antepartum Hg, ROM, or cervicitis No difference in operative delivery rate, or maternal or neonatal morbidity compared to PG gel
Hydroscopic dilators (Eg.Laminaria tents) Higher rate of infections

IOL
1-Oxytocin with Amniotomy IV Half life 5-12 min A steady state uterine response occurs in 30 min or > Fetal heart rate & uterine contractions must be monitored

If there is hyperstimulation or nonreassuring fetal heart rate pattern D/C infusion

Women who receive oxytocin were more likely to be delivered in 12-24 hrs than those who had amniotomy alone & less likely to have operative delivery

IOL
2-PGE2 For women with favorable Cx PGE2 the rate of operative delivery & failed IOL when compared to Oxytocin PGE2 GIT side-effects, pyrexia & uterine hyperactivity 3-Sweeping of the membranes Vaginally the examining finger is placed through the os of the Cx & swept around to separate the membranes from the lower uterine segment local PGF2 production & release from decidua & membranes onset of labor the rate of delivery in 2-7 days the rate of post-term the use of formal induction methods If there is urgent indication for IOL sweeping is not the method of choice

Specific circumstances or indications

Prelabor SROM at term 6-19% IOL with oxytocin risk of maternal infections (chorioamnionitis& endometritis) & neonatal infections PG also maternal infections & neonatal NICU admissions IOL after CS PG should not be used as it can result in rupture uterus Oxytocin or foley catheter may be used