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Prolonged pregnancy
- 2. TOPIC: PROLONGED PREGNANCY presented by: DRREEMA SAMO FCPS –2 Trainee OBG/GYN - 2
- 3. OBJECTIVES To review the Definition Difference between post term and post maturity syndrome. Incidence, Aetiology of prolong pregnancy Risks associated with prolonged pregnancy Management
- 4. . Term: EARLY TERM: Gestationalperiod 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
- 5. PROLONGED PREGNANCY DEFINATION “its is defined as the pregnancy progressing to 42 weeks (294 days) or beyond” It is also called post-dates or post-term pregnancy.
- 6. POST MATURITY SYNDROME It develops in 20% of pregnancies Newborn who has : dry peeling skin coated with meconium overgrown nail & scalp hair well developed creases on the Palm & soles little vernix minimal subcutaneous fat with apprehensive look. Such picture indicates intrauterine malnourishment and independent of duration of gestation.
- 7. INCIDENCE OF PROLONGED PREGNANCY Is 5 to 10% Many prolonged pregnancies are due to misdating Accuracy 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%
- 8. AETIOLOGY It isnot clear and it may represents simple biological variation. It is commonly seen in 1. Primigravida women 2. Previous history of prolonged pregnancy, have 30% chances of recurrence. 3. Positive family history 4. Congenital anomalies i.e. fetal anencephaly, congenital adrenal hypoplasia, and placental sulphatase deficiency.
- 9. . 5. Low vaginallevels of fetal fibronectin at 39 weeks increase risk of prolonged pregnancy. 6. 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. 7. Male fetuses 8. maternal obesity 9. nulliparity and white race.
- 10. RISKS ASSOCIATED WITH PROLONGEDPREGNANCY Fetal risks: Prolonged pregnancy is associated with 1. 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. 2. Fetal distress is more common B/C of placental insufficiency and cord compression d/t oligohydrominos.
- 11. 3. Large sizebaby is associated with increase incidence of birth trauma(skull fracture, brachial plexus injury, intracranial hemorrhage) and shoulder dystocia. 4. Meconium aspiration syndrome b/c fetal parasympathetic system matures which causes physiological passage of meconium. 5. Neonatal encephalopathy which leads to cerebral palsy as a result of neurological insult during labour. 6. Respiratory distress syndrome, neonatal sepsis, neonatal acidemia & low Apgar score.
- 12. MATERNAL RISKS It includes: 1.Anxiety 2. Operative delivery 3. Prolong labour and instrumental delivery 4. Hemorrhage 5. infection
- 13. MANAGEMENT It includes 1.Expectant observational management with fetal assessment tests 2. Induction of labour (IOL) 3. C-Section
- 14. SOGC GUIDELINES 1. After41 weeks gestation, if the dates are certain, women should be offered Elective delivery. 2. If the cervix is unfavorable, cervical ripening should be undertaken. 3. If expectant management is chosen, assessment of fetal health should be initiated.
- 15. RCOG GUIDELINES 1. U/Sshould be offered to confirm the pregnancy before 20 weeks of gestation. 2. Women with uncomplicated pregnancy should be offered induction of labour beyond 41 weeks. 3. From 42 week, women who decline IOL should be offered increased antenatal monitoring(CTG & U/S twice weekly.
- 16. All possibleattempts 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 Examination Once 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.
- 18. EXPECTANT OBSERVATIONAL MANAGEMENT Womenwith prolonged pregnancy, who refuse for IOL are kept under strict monitoring. Many different tests are performed for assessment of post-term fetus. These includes 1. CTG 2. Ultrasound examination that include Amniotic fluid index (AFI) Biophysical profile umbilical artery doppler waveform analysis These tests should be performed twice in a week.
- 21. INDICATION OF DELIVERYIN EXPECTANT MANAGEMENT 1. Amniotic fluid index <5cm 2. Maximum pool depth <2cm 3. Higher rates of fetal heart rate decelerations. 4. Meconium staining of amniotic fluid.
- 22. Induction of labour 1.Mechanical intervention 2. biochemical intervention 3. Traditionally utilized methods acupuncture herbal remedies breast and nipple stimulation sexual intercourse
- 23. MECHANICAL INTERVENTION 1. Membranesweeping 2. Amniotomy
- 24. BIOCHEMICAL INTERVENTION 1. PROSTAGLANDINS: are long chain fatty acids derived from COX-2 pathway. It exerts a powerful effect on cervix and myometrium at all stages of gestation. PGs not only modify the ground substance of cervix but stimulate the onset of uterine contraction & induce labour. It is used for induction of labour when cervix is unfavourable. These are PG E2 , F2a & E1 (misoprostol)
- 25. . ADVANTAGES OFPGs 1. Increase successful vaginal delivery within 24 hrs 2. Decrease incidence of c-section 3. Reduce epidural usage DISADVANTAGES OF PGs 1. GIT side effects 2. Uterine hypertonus 3. Wound dehiscence in women with previous c- section
- 26. PG E2 DOSAGE TYPEINTERVAL DOSE REGIME TOTAL DOSE tablets 6 hourly 3mg-3mg 6mg all women gel 6 hour Nulliparous 2mg-1mg Multiparous 1mg-1mg 3mg 2mg
- 27. 2.OXYTOCIN it isoctapeptide hormone secreted from supraoptic and paraventricular nuclei of hypothalamus. It is stored in posterior pituitary gland and secreted in pulsatile manner. It causes uterine contraction. It is given as 5 to 10IU in 1 liter of N/S with 8 to 10 drops / minute when cervix is >6cm. Dose is increased according uterine contraction.
- 28. INDICATION OF C-SECTION MATERNAL INDICATIONS: 1. Maternal distress 2. Failure of IOL 3. Failure of progress of labour 4. CPD 5. Maternal demand FETAL INDICATION 1. Fetal distress 2. Fetal malpresentation. 3. Macrosomia, Cord prolapse