POSTTERM PREGNANCYPOSTTERM PREGNANCY

By :By :

dr. Adhitya Maharani, SpOGdr. Adhitya Maharani, SpOG

TERMINOLOGITERMINOLOGI

Postmature : The infant with recognizable Postmature : The infant with recognizable clinical fetures indicating a pathologically clinical fetures indicating a pathologically prolonged pregnancyprolonged pregnancy

Postterm or Prolonged pregnancy : Postterm or Prolonged pregnancy : expressions for extended pregnancyexpressions for extended pregnancy

Postdates : should probably be Postdates : should probably be abandonedabandoned

It is important to realize that few It is important to realize that few infant from prolonged pregnancies infant from prolonged pregnancies are postmatureare postmature

DEFINITIONDEFINITION

42 completed weeks (294 days) 42 completed weeks (294 days) or more from the first day of the or more from the first day of the last menstrual periodlast menstrual period (ACOG, (ACOG, 1997)1997)

There is no exact method to identify There is no exact method to identify pregnancies that are truly prolongedpregnancies that are truly prolonged

Incidence : ± 10 %Incidence : ± 10 %All pregnancies judge to be 42 completed All pregnancies judge to be 42 completed

weeks should be managed as if weeks should be managed as if abnormally prolongedabnormally prolonged

Intrapartum perinatal risk is incresead, Intrapartum perinatal risk is incresead, particularly when meconium is presentparticularly when meconium is present

POSTMATURITY SYNDROMEPOSTMATURITY SYNDROME

A characteristic :A characteristic :- Wrinkled- Wrinkled

- Patchy- Patchy

- Peeling skin- Peeling skin

- a long and thin wasting body- a long and thin wasting body

- serious ill due to birth asphyxia and - serious ill due to birth asphyxia and meconium aspirationmeconium aspiration

POSTMATURITY SYNDROMEPOSTMATURITY SYNDROME

Placental senescence ???Placental senescence ??? In fact, the postterm fetus continues to In fact, the postterm fetus continues to

gain weight, although at slower rate than gain weight, although at slower rate than at earlier gestational age and is at risk for at earlier gestational age and is at risk for macrosomiamacrosomia

PERINATAL MORTALITY AND PERINATAL MORTALITY AND MORBIDITYMORBIDITY

INTRAPARTUM FETAL DISTRESSINTRAPARTUM FETAL DISTRESS

- Cord compression- Cord compression

- Oligohidramnion- Oligohidramnion

- Prolonged/variable decelerations- Prolonged/variable decelerations IUGR/MACROSOMIAIUGR/MACROSOMIASTILLBIRTHSTILLBIRTH

MANAGEMENTMANAGEMENT

ANTEPARTUM INTERVENTION :ANTEPARTUM INTERVENTION :

- Elective induction of labor- Elective induction of labor

- Antepartum fetal testing- Antepartum fetal testingExact timing and type of intervention ??Exact timing and type of intervention ??Cesarean section vs induction ? Cesarean section vs induction ? fetal fetal

testingtesting

MANAGEMENTMANAGEMENT

Intervention at 41 versus 42 weeks ?Intervention at 41 versus 42 weeks ?

- Evidence : limited- Evidence : limited

- NO Randomized study : Before 42 weeks - NO Randomized study : Before 42 weeks is beneficialis beneficial

- In fact : intervension prior to 42 weeks - In fact : intervension prior to 42 weeks may cause some harm through may cause some harm through incresed cesareans without incresed cesareans without improvement in neonatal outcomeimprovement in neonatal outcome

OLIGOHYDRAMNIONOLIGOHYDRAMNION

Fetal jeopardy is complicated by Fetal jeopardy is complicated by oligohydramnionoligohydramnion

The standart to use for diagnosis is not The standart to use for diagnosis is not universally agreeduniversally agreed

Criteria USG : The largest vertical pocket Criteria USG : The largest vertical pocket less than 1 or 2 cm, a four-quadrant AFI of less than 1 or 2 cm, a four-quadrant AFI of less than 5 or 6 cm or an AFI less than the less than 5 or 6 cm or an AFI less than the 55thth percentil percentil

RECOMMENDATIONRECOMMENDATION(ACOG, 1997)(ACOG, 1997)

1.1. Antenatal surveillance of postterm Antenatal surveillance of postterm pregnancies should be initiated by 42 pregnancies should be initiated by 42 weeks despite a lack of evidence that weeks despite a lack of evidence that monitoring improves outcomemonitoring improves outcome

2.2. There is insufficient evidence that There is insufficient evidence that initiating antenatal surveillance between initiating antenatal surveillance between 40 and 42 completed weeks improves 40 and 42 completed weeks improves outcomesoutcomes

3.3. No single antenatal surveillance protocol No single antenatal surveillance protocol for monitoring fetal well-being in a for monitoring fetal well-being in a postterm pregnancy appears superior to postterm pregnancy appears superior to anotheranother

4.4. It is unknow whether induction or It is unknow whether induction or expectant management (antenatal expectant management (antenatal surveillance) is preferable in the postterm surveillance) is preferable in the postterm patient with patient with a favorable cervixa favorable cervix

5.5. There is good evidence that either There is good evidence that either induction or expectant management will induction or expectant management will result in good outcomes in postterm result in good outcomes in postterm patient with patient with unfavorable cervicesunfavorable cervices

6.6. Prostaglandin gel can be used safely in Prostaglandin gel can be used safely in postterm pregnancies to promote postterm pregnancies to promote cervical changes and induce laborcervical changes and induce labor

Plus

42 Completed weeks

CertainUncertain

Stated LMP

1. Auscultated FHR 17-20 weeks, or

2. Fundal height between 18-30 weeks ± 2 cm to LMP weeks, or

3. Ultrasound before 26 weeks

Induction of labor

Oligohydramnion ? Decreased fetal movement?

Yes No YesNo

Weekly visits

Induction of labor

Labor is a particularly dangerous time for Labor is a particularly dangerous time for the postterm fetus.the postterm fetus.

FHR and uterine contractions should be FHR and uterine contractions should be monitoredmonitored

Identification of thick meconiumIdentification of thick meconiumManagement neonatusManagement neonatusRisk of postpatum and shoulder dystociaRisk of postpatum and shoulder dystocia