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TOPIC: PROLONGED PREGNANCY

presented by: DR REEMA SAMO FCPS 2 Trainee OBG/GYN - 2

OBJECTIVESTo review theDefinition Difference between post term and post maturity syndrome.Incidence, Aetiology of prolong pregnancyRisks associated with prolonged pregnancyManagement

.Term: EARLY TERM: Gestational period b/w 37 to 38+6 weeks FULL TERM: Gestational period b/w 39 to 40+6 weeks LATE TERM: Gestational period b/w 41 to 41+6 weeks

Preterm: Gestational period b/w 24 to 36+6 weeks MILDLY PRETERM BIRTHS: b/w 32 to 36+6 weeks VERY PRETERM BIRTHS: b/w 28 to 31+6 weeks EXTREMELY PRETERM BIRTHS: b/w 24 to 27+6 weeks

PROLONGED PREGNANCYDEFINATION its is defined as the pregnancy progressing to 42 weeks (294 days) or beyond

It is also called post-dates or post-term pregnancy.

POST MATURITY SYNDROMEIt develops in 20% of pregnancies Newborn who has :dry peeling skin coated with meconiumovergrown nail & scalp hairwell developed creases on the Palm & soleslittle vernix minimal subcutaneous fat with apprehensive look.Such picture indicates intrauterine malnourishment and independent of duration of gestation.

INCIDENCE OF PROLONGED PREGNANCYIs 5 to 10%Many prolonged pregnancies are due to misdatingAccuracy of gestational age is an important factor in determining the prolonged pregnancy.LMP and early U/S has tendency to estimate the gestational age.Early U/S decreases the incidence of prolonged pregnancy from 12 to 3%

AETIOLOGYIt is not clear and it may represents simple biological variation.It is commonly seen inPrimigravida womenPrevious history of prolonged pregnancy, have 30% chances of recurrence.Positive family historyCongenital anomalies i.e. fetal anencephaly, congenital adrenal hypoplasia, and placental sulphatase deficiency.

.Low vaginal levels of fetal fibronectin at 39 weeks increase risk of prolonged pregnancy.Variation in corticotrophin releasing hormone (CRH) during pregnancy, such as alteration in number or expression of myometrium receptors, altered signal transduction or increase in CRH binding protein.Male fetusesmaternal obesity nulliparity and white race.

RISKS ASSOCIATED WITH PROLONGED PREGNANCY Fetal risks:Prolonged pregnancy is associated with Increase risk or perinatal mortality including antepartum stillbirths and infant death. It is 0.86/1000 at 40 weeks and 2.12/1000 at 43 weeks, almost 3 folds increase.Fetal distress is more common B/C of placental insufficiency and cord compression d/t oligohydrominos.

.3. Large size baby is associated with increase incidence of birth trauma(skull fracture, brachial plexus injury, intracranial hemorrhage) and shoulder dystocia.Meconium aspiration syndrome b/c fetal parasympathetic system matures which causes physiological passage of meconium. Neonatal encephalopathy which leads to cerebral palsy as a result of neurological insult during labour.Respiratory distress syndrome, neonatal sepsis, neonatal acidemia & low Apgar score.

MATERNAL RISKS It includes:AnxietyOperative deliveryProlong labour and instrumental deliveryHemorrhage infection

MANAGEMENT It includesExpectant observational management with fetal assessment testsInduction of labour (IOL)C-Section

SOGC GUIDELINESAfter 41 weeks gestation, if the dates are certain, women should be offered Elective delivery.If the cervix is unfavorable, cervical ripening should be undertaken.If expectant management is chosen, assessment of fetal health should be initiated.

RCOG GUIDELINES

U/S should be offered to confirm the pregnancy before 20 weeks of gestation.Women with uncomplicated pregnancy should be offered induction of labour beyond 41 weeks.From 42 week, women who decline IOL should be offered increased antenatal monitoring(CTG & U/S twice weekly.

.All possible attempts should be made for accurate pregnancy dating. take detailed history ask for LMP, regularity of periods, early U/S, past and family history of prolonged pregnancy. P/A Examination P/V ExaminationOnce prolonged pregnancy is diagnosed..Pt: should be counselled for benefits and risk factors of both IOL & expectant management.Let the patient to take her own decision regarding treatment.

EXPECTANT OBSERVATIONAL MANAGEMENTWomen with prolonged pregnancy, who refuse for IOL are kept under strict monitoring.Many different tests are performed for assessment of post-term fetus. These includesCTGUltrasound examination that include Amniotic fluid index (AFI) Biophysical profile umbilical artery doppler waveform analysisThese tests should be performed twice in a week.

INDICATION OF DELIVERY IN EXPECTANT MANAGEMENTAmniotic fluid index