POSTTERM PREGNANCY: THE IMPACT ON MATERNAL AND FETAL OUTCOME Dr. Hussein. S. Qublan- Al-Hammad Jordanian Board in Obstet &Gynecology European Board in Obstet & Gynecology Subspecialty in IVF and Andrology

Introduction  Postterm pregnancy is defined as a pregnancy that continues from the last menstrual period to or beyond 42 weeks of gestation or that continues from the time of ovulation to or beyond 40 weeks of gestation.  It complicates 10% of all pregnancies and is associated with increased risks fro both mother and fetus.  The prevalence of postterm pregnancy depends on the patient population, including such factors as the percentage of primigravida women, women with pregnancy complications and the prevalence of ultrasound assessment of gestational age.

Introduction  In most cases of true post-term pregnancy, the cause is not known. Different risk factors were reported.  These include nulliparity and prior postterm pregnancy.  Recently, the genetic contribution was reported to play a role in prolonging pregnancy.

Objective  We conducted this retrospective analysis to determine the effect of postterm pregnancy on both mother and fetus

Patients and Methods  This retrospective analysis included 100 pregnant women who delivered at Prince Rhashed Hospital (PHH) during the period from January 2000 to December  Patients were allocated into two groups; Group I (n=50) includes pregnant women who delivered their babies after 40 weeks of gestation (study group), and group II (n=50) who delivered their babies between 37 and 40 weeks of gestation (Control group).

Patients and Methods  Exclusion criteria included previous cesarean delivery, chronic hypertension, preeclampsia, placenta previa, gestational diabetes, fetal anomalies and malpresentation.  The data were obtained from the patient's files and delivery logbook. Information extracted included age of patient, parity, level of education, mode of delivery, labor characteristics and complications, gestational age, birth weight, and neonatal outcome.

Patients and Methods  Prolonged gestation was considered in those patients who by menstrual history and early examination, began labor or had induction of labor after completed 40 weeks of gestation measured from the time of ovulation.

Results  Table 1. Demographic data of the study groups. P- Value Weeks (n=50) > 40 Weeks (n=50 NS (31.2) 19 (38) 31 (62) 1 (2) 11 (22) 26 (52) 12 (24) 3 (6) 47 (94 (31.7) 18 (36) 32 (64) 2 (4) 7 (14) 27 (54) 14 (28) 2 (4) 48 (96) Age (year) Parity - Primiparas - Multiparas Education - Illiterate - Primary - Secondary - College or University Smoking - Yes - No

Results  Table 2. Labor characteristics P- Value Weeks (n=50) > 40 Weeks (n=50 <0.05 <0.001 <0.01 <0.05 <0.001 <0.05 <0.001 <0.05 NS < ± (6) 4 (8) 6.3 ± (84) 3 (6) 5 (10) 2 (4) 0 1 (2) 2 (4) 3.2 ± (34) 11 (22) 8.2 ± (44) 8 (16) 17 (34) 7 (14) 1 (2) 2 (4) 7 (14) Bishop ’ s Score* Induction of labor By Foleys catheter By prostaglandin Mean(SD) length of first stage (hr) Mode of delivery Spontaneous vaginal delivery Instrumental delivery Cesarean section because of - Fetal distress - Failed induction - Failure to progress - Macrosomia

Results  Table 3. Maternal and Neonatal outcome. P- Value Weeks (n=50) > 40 Weeks (n=50 <0.001 <0.01 <0.05 NS <0.001 <0.05 <0.01 <0.05 NS 45 (90) 5 (10) 1 (2) ± (4) 1 2 (4) 1 (2) 0 33 (66) 17 (34) 6 (12) 2 (4) 3 (6) 4100 ± (22) 6 (12) 9 (18) 7 (14) 2 (4) Maternal Delivery: - Vaginal delivery - Cesarean section Post-partum hemorrhage Chorioamnionitis Puerperal pyrexia Perineal injury* Neonatal Fetal weight (gm) Apgar score ≤ 5 at 1-minute ≤ 5 at 5-minute Meconium aspiration Admission to NICU Perinatal death

Discussion  The results of this study showed that the maternal and neonatal morbidity are increased in pregnancies with gestational age of > 40 weeks as compared with weeks.  The rates of instrumental deliveries, cesarean section, labor abnormalities and post-partum hemorrhage and uterine infection were increased in women with prolonged gestation.  These results are in agreement with those reported by others. Coughey and Bishop reported an incidence of 9% vs.2% for labor dystocia and 3.3% vs. 2.6% for severe perineal injury due to macrosomia.  The cesarean section rate was doubled in their series in postterm pregnancies compared to term pregnancies (14% vs. 7%).  Similarly, they observed progressive increase in the rates of chorioamnionitis, endomyometritis and postpartum hemorrhage.

Discussion  In addition, the results of this study demonstrate increase in the perinatal morbidity and mortality. This finding is supported by previous reports.  The rates of fetal macrosomia, meconium aspiration and the admission to the NICU were increased significantly in postterm- pregnancy group compared with the controls.  Complications of macrosomia include prolonged labor, cephalo-pelvic disproportion, and shoulder dystocia with resultant risks of orthopedic or neurologic injury.  In our study, 14% of the women in the postterm-group compared to 4% in the control group underwent cesarean delivery because of the macrosomic babies

Conclusion  One limitation of this study is the small- size sample that provide provides small power of calculation.  In summary, postterm pregnancy is associated with increased risks to both mother (cesarean section, uterine infection, perineal injuries and post-partum hemorrhage) and fetus (macrosomia, birth injuries, meconium aspiration and stillbirth).  Policies such as routine induction of labor between 40 and 42 weeks along with strict intra-partum monitoring may decrease in the incidences of these complications.

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