Prolonged Pregnancy

Post term pregnancy: Pregnancies of 294 days duration or more from the onset of last menstrual Period are defined as Post term,post-date (prolonged) pregnancy Incidence : 6 – 12 % of all pregnancies .

Risk factors/associations Poor (wrong) dating; prior post-termpregnancy;long (> 28 days) cycles without early ultrasound; placental sulfatase deficiency; anencephaly; male fetus .Prolonged pregnancy is increased in first pregnancies,but is not related to maternal age. Women with a body mass index greater than30 are at increased risk of prolonged pregnancy. The cause is unknown in most instances

Complications Perinatal Meconium aspiration, intrauterine infection,oligohydramnios,macrosomia, non-reassuring fetal heart testing low umbilical artery pH, and low 5-minute Apgar score Maternal Women giving birth post-term are at increased risk of labor dystocia, perineal injury, and cesarean delivery

pathophysiology of post term pregnancy : 1-Postmaturity(dysmaturity) syndrome : Occuring in 20-30% of post term infants present a unique & characterstic appearance which includes wrinkled (prominent in palms &soles) ,patchy peeling skin ,long nails ,a long ,thin body suggesting wasting &advanced maturity because the infant is open- eyed allert warry appearance. 2-placental dysfunction /insufficiency : related to placental aging and infarction result into. Intrauterine hypoxia may be manifested as meconium staining. 3-fetal distress &ligohydrmnio 4-fetal grwth restriction

Factors evaluated in dating pregnancy Accurate date of Lmp. Uterus size by (bimanual Pelvic examination 1st trimester( Gestational age when the fetal heart beats first heard (doppler ultrasound at 12-14 weeks). Gestational age when the fetal heart first heard (stethoscope 18-20 weeks). Date of quickening(18-20 w in primi 16-18 in multi) Sonographic parameters

Management of post term pregnancy Antepartum management ; Decision of delivery If the patient is 42 weeks with engaged head and favorable cervix then labour should be induced .

Management of post term pregnancy Women with post-term pregnancies who have unfavourable cervices also should undergo labour induction. • Prostaglandin can be used to promote cervical ripening and induce labour. • Delivery should be effected if there is evidence of fetal compromise or oligohydramnios. If induction leads to fetal distress at any stage, cesarean section should be done

Continuous electronic fetal monitoring during induction of labour. Intrapartum management Continuous electronic fetal monitoring during induction of labour. Membranes should be ruptured early in labour to assess the color of amniotic fluid and to apply internal electrodes. If there is fetal distress (fetal blood sampling) then C.S. is indicated .

Practical management of prolonged pregnancy The RCOG recommendations are an excellent guide to practice. Every effort should be made to ensure that dates are as accurate as possible. When the woman reaches 41 weeks she should meet with a consultant obstetrician. Women have a right to be informed of the small increase in risk associated with continuing the pregnancy after41 weeks.

Following a vaginal examination, induction of labour should be offered on a date after 41 weeks that is Acceptable to both the woman’s wishes and the hospital resources. The vaginal examination could be accompanied by sweeping of the membranes. Which reduces The need for ‘formal’ induction of labour

Patients with<42 week and unfavorable cervix, refuse labour induction Twice weekly NST and BPP. AFI amniotic fluid index If the result is reassuring follow up and delivery is indicated : -until the cervix is favorable . -result is abnormal (deceleration, AFI is oligohydramnia <=5) . -Fetal macrosomia .

women with a prior cesarean delivery In, induction is associated with a higher incidence of uterine rupture, especially in the nulliparous woman with an unfavorable cervix. Therefore, if the woman desires vaginal birth after cesarean ,it seems reasonable to wait until 40–41 weeks for spontaneous labor, but then a repeat cesarean delivery can be offered to avoid the induction risks.

Unfavorable cervix: routine induction of labor at ≥ 41 weeks Compared with expectant management, routine induction of labor at ≥ 41 weeks reduces perinatal mortality by 80%. decrease in the incidence of cesarean delivery in women who are nulliparous,≥ 41 weeks, induced with prostaglandins . more cost-effective than expectant management. Women are more satisfied

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