DISCUSSION

Patient, 41 years old weeks of gestation Decrease of amnionic fluid AFI = 6 Postterm Pregnancy Oligohydramnion reduction in renal artery end- diastolic velocity increased arterial impedance increased the cesarean delivery rate CTG: Late Deceleration Fetoplacental circulation disturbance Intrauterine/fetal hypoxia Discussion Genetic high pre-pregnancy BMI Fetal abnormality Placental sulphatase deficiency

Diagnosis G3P2 pregnant weeks, fetus with head presentation, singleton, alive – LMP (Feb 12 th 2010)  Nov 29 th – Uterus Fundal Height : 36 cm – US G Decreased amniotic fluid – AFI : 6 Fetal hypoxia – CTG: Late deceleration

Fig 1. Normal percentiles for the amnionic fluid index (AFI) from 1400 women P 25th

Oligohydramnion AFI estimation: – deepest vertical pocket method – 4 abdomen quadrant Normal : 8-18, poly: > 18-22, oligo : < 5-6 Single Deepest Pocket (<2cm) Oligohydramnion – >> cesarean delivery – >> fetal distress – << 5-minute Apgar score – >> perinatal morbidity and mortality

Late Deceleration Variable Deceleration

Interpretation Base frequency: 150 bpm Variability: 5-10 bpm Acceleration: + Deceleration: + (late) His: + Fetal movement: +  Fetal hypoxia ec placental insufficiency

Complications Fetal Stillbirth IUGR Fetal malforamtion Perinatal mortality (10%) A female baby was born, birth weight 2900 g, Maternal Dysfunctional labor Shoulder dystocia Obstetric trauma PPH Bleeding is 300 cc Neonatal Mortality Low apgar score MAS Clavicular fracture Erb’s Palsy AS 7/10 Amniotic fluid is was green, and watery

Management Routine induction Expectant treatment (close surveillance) with active management by induction of labor or CS  both are acceptable, depends on the local capacities to diagnose the conditions with increased risks to monitor the fetal well-being if expectant management is preferred.

Management Induction – Bishop’s score, <= F4  unfavorable for labor induction. – transvaginal US assessment of the Cervical ripening – transcervical Foley catheter – sweeping of the membranes – Laminaria (tents) – pharmacological (PGE 2 or PGE Methods for induction – Oxytocin, with or without amniotomy and prostaglandin – !!! : myometrial hyperstimulation  tachycardia, non-reassuring CTGs and uterine rupture. Expectant Management Close fetal surveillance should be offered during either spontaneous or induced labor Amnioinfusion in case of meconium stained liquor for preventing MAS is controversial If specific risks are present, a prompt delivery should be performed  fetal hypoxia based on CTG

5 or less : labour is unlikely to start without induction. 9 or more : labour will most likely commence spontaneously

References Cunningham FG, et al. Williams Obstetrics 22 nd Edition. McGraw Hill, Phil [e-book] Mandruazo, et al. Guidelines for the management of postterm pregnancy. J. Perinat. Med. 2010; 38: 111–119. Hutter D. et.al. Causes andMechanisms of Intrauterine Hypoxia and Its Impact on the Fetal Cardiovascular System: A Review. J. Perinat. Med. 2008; 33: 120–129. Divon MY, Haglund B, Nisell H, Otterblad PO, Westgren M. Fetal and neonatal mortality in the postterm pregnancy: the impact of gestational age and fetal growth restriction. Am J Obstet Gynecol 1998;178: Olesen AW, Westergaard JG, Olsen J. Perinatal and maternal complications related to postterm delivery: a national register-based study, Am J Obstet Gynecol 2003;189: Intrauterine hypoxia. [downloaded at Nov 30 th 2010]