1. POST TERM SALWA NEYAZI ASSISTANT PROF.& CONSULTANT OBGYN KSU

2. INTRODUCTIONDefinition 42 completed wks 42 completed wks 294 days from LMP 294 days from LMPRisks  adverse neonatal & fetal outcome / perinatal death  adverse neonatal & fetal outcome / perinatal death Now it is believed that the risk is  as early as 41 wks Now it is believed that the risk is  as early as 41 wksIncidence 41  27% 41  27% 42  4-14% 42  4-14% 43  2-7% 43  2-7% The incidence is decreasing The incidence is decreasing Dating of pregnancy Accurate dating of pregnancy is essential to avoid unnecessary intervention Accurate dating of pregnancy is essential to avoid unnecessary intervention U/S scan prior to 20 wks gestation is an excellent method of establishing or confirming true gestational age U/S scan prior to 20 wks gestation is an excellent method of establishing or confirming true gestational age Routine U/S scanning   rate of IOL for post-term Routine U/S scanning   rate of IOL for post-term

3. ADVERSE PERINATAL OUTCOME ASSOCIATED WITH POST-TERM PREGNANCY  risk of perinatal death (antepartum, intrapartum, postpartum) due to  anomalies eg. Anencephaly  risk of perinatal death (antepartum, intrapartum, postpartum) due to  anomalies eg. Anencephaly intrauterine infections intrauterine infections asphyxia with or without meconium asphyxia with or without meconium  risk of neonatal morbidity   risk of neonatal morbidity  - macrosomia - macrosomia - shoulder dystocia - shoulder dystocia - meconium aspiration - meconium aspiration - admission to NICU - admission to NICU - Rx with +ve pressure oxygen - Rx with +ve pressure oxygen  risk of  IOL, fetal distress in labor, meconium, & operative deliveries  risk of  IOL, fetal distress in labor, meconium, & operative deliveries  risk of post-term adverse outcome  in women with  risk of post-term adverse outcome  in women with HPT, PET,DM, abruptio placenta, & IUGR HPT, PET,DM, abruptio placenta, & IUGR - endotracheal intubation - endotracheal intubation - respiratory distress - respiratory distress - persistent fetal circulation - persistent fetal circulation - pneumonia - pneumonia - seizures - seizures

4. MANAGEMENT 1-Establishing gestational age HX ( in the 1 st visit ) HX ( in the 1 st visit )  LMP  LMP  regularity & length of the cycle  regularity & length of the cycle  OCP in the last 3 cycle before conception  OCP in the last 3 cycle before conception Exam.  Size of the uterus corresponding to dates or not Exam.  Size of the uterus corresponding to dates or not U/S  to confirm or establish gestational age U/S  to confirm or establish gestational age especially if  LMP uncertain especially if  LMP uncertain  if the cycles were irregular  if the cycles were irregular  if there is Hx of OCP use  if there is Hx of OCP use  if size of the uterus inconsistent with GA  if size of the uterus inconsistent with GA The earlier the U/S the more accurate it is for GA determination The earlier the U/S the more accurate it is for GA determination U/S at 16-20 wks appropriate to assess other parameters of the fetus & placenta U/S at 16-20 wks appropriate to assess other parameters of the fetus & placenta

5. MANAGEMENT 2-Management 39-40 6/7 wks In uncomplicated pregnancies there is no evidence to support IOL nor fetal surveillance In uncomplicated pregnancies there is no evidence to support IOL nor fetal surveillance If there are other risk factors including HPT, DM, IUGR, macrosomia, multiple pregnancy, or hydramnios  IOL or serial fetal suvillence is indicated If there are other risk factors including HPT, DM, IUGR, macrosomia, multiple pregnancy, or hydramnios  IOL or serial fetal suvillence is indicated

6. 3-Management 41-42 wks A-IOL or CS if vaginal delivery is contraindicated Studies have shown that IOL at 41 or> wks Studies have shown that IOL at 41 or> wks  CS rate compared to expectant management  CS rate compared to expectant management  rate of non-reassuring fetal heart changes  rate of non-reassuring fetal heart changes  meconium staining of the amniotic fluid  meconium staining of the amniotic fluid  macrosomia >4000 gms  macrosomia >4000 gms  rate of fetal or neonatal death  rate of fetal or neonatal death ( mostly  stillbirth due to  asphyxia ( mostly  stillbirth due to  asphyxia & meconium aspiration ) & meconium aspiration )

7. 3-Management 41-42 wks B-Expectant management with fetal surveillance There are exceptions to the above recommendations (3A)  if the mother refuses IOL despite full explanation of the risks There are exceptions to the above recommendations (3A)  if the mother refuses IOL despite full explanation of the risks Fetal surveillance Minimally fetal surveillance should include twice weekly amniotic fluid volume estimation by U/S Minimally fetal surveillance should include twice weekly amniotic fluid volume estimation by U/S Fetal movement, NST, BPP, doppler Fetal movement, NST, BPP, doppler Monitoring should be at frequent intervals Monitoring should be at frequent intervals All of the tests have false +ve & false –ve All of the tests have false +ve & false –ve

8. IOL

9. INTRODUCTION DEFINITION  Artificial initiation of labor before its spontaneous onset for the purpose of delivery of the fetoplacental unit INDICATIONS Post-term pregnancy  most common Post-term pregnancy  most common PROM PROM IUGR IUGR Non-reassuring fetal suvillence Non-reassuring fetal suvillence Maternal medical conditions  DM, renal disease, HPT, gestational HPT, significant pulmonary disease, antiphospholipid syndrome Maternal medical conditions  DM, renal disease, HPT, gestational HPT, significant pulmonary disease, antiphospholipid syndrome Chrioamnionitis Chrioamnionitis Abruption Abruption Fetal death Fetal death

10. RISKS of IOL  rate of operative vaginal deliveries  rate of operative vaginal deliveries  rate of CS  rate of CS Excessive uterine activity Excessive uterine activity Abnormal fetal heart rate patterns Abnormal fetal heart rate patterns Uterine rupture Uterine rupture Maternal water intoxication Maternal water intoxication Delivery of preterm infant due to incorrect estimation of GA Delivery of preterm infant due to incorrect estimation of GA Cord prolapse with ARM Cord prolapse with ARM

11. CONTRAINDICATIONS (Contraindications to labor or vaginal delivery) Previous myomectomy entering the cavity Previous myomectomy entering the cavity Previous uterine rupture Previous uterine rupture Fetal transverse lie Fetal transverse lie Placenta previa Placenta previa Vasa previa Vasa previa Invasive Cx Ca Invasive Cx Ca Active genital herpes Active genital herpes Previous classical or inverted T uterine incision Previous classical or inverted T uterine incision 2 or more CS 2 or more CS

12. PREREQUISITES To assess the following Indication / any contraindications Indication / any contraindications GA GA Cx favourability (Bishop score) Cx favourability (Bishop score) Pelvis, fetal size & presentation Pelvis, fetal size & presentation Membranes status Membranes status Fetal heart rate monitoring prior to IOL Fetal heart rate monitoring prior to IOL Elective induction should be avoided due the potential complications Elective induction should be avoided due the potential complications

13. Cx ripening prior to IOL Indication  if the Bishop score is ≤ 6 The state of the Cx is an important predictor of successful IOL The state of the Cx is an important predictor of successful IOL Methods : Intracervical PGE2 gel  0.5 mg/6hrs----3 doses Intracervical PGE2 gel  0.5 mg/6hrs----3 doses Intravaginal PGE2 gel  1-2 mg/6hrs----3doses Intravaginal PGE2 gel  1-2 mg/6hrs----3doses PGE2 gel  the rate of not being delivered in 24 hrs PGE2 gel  the rate of not being delivered in 24 hrs  the use of oxytocin for augmentation of labor  the use of oxytocin for augmentation of labor PGE2 gel  the rate of uterine hyperstimulation PGE2 gel  the rate of uterine hyperstimulation Misoprostol  Should not be used for term fetuses Misoprostol  Should not be used for term fetuses Mechanical methods Mechanical methods

14. Cx ripening prior to IOL Mechanical methods Foley Catheter It is introduced into the cervical canal past the internal os, the bulb is inflated with 30-60 cc of water It is introduced into the cervical canal past the internal os, the bulb is inflated with 30-60 cc of water It is left for up to 24 hrs or until it falls out It is left for up to 24 hrs or until it falls out Contraindications  Low laying placenta, antepartum Hg, ROM, or cervicitis Contraindications  Low laying placenta, antepartum Hg, ROM, or cervicitis No difference in operative delivery rate, or maternal or neonatal morbidity compared to PG gel No difference in operative delivery rate, or maternal or neonatal morbidity compared to PG gel Hydroscopic dilators (Eg.Laminaria tents) Higher rate of infections Higher rate of infections

15. IOL 1-Oxytocin with Amniotomy IV IV Half life 5-12 min Half life 5-12 min A steady state uterine response occurs in 30 min or > A steady state uterine response occurs in 30 min or > Fetal heart rate & uterine contractions must be monitored Fetal heart rate & uterine contractions must be monitored If there is hyperstimulation or nonreassuring fetal heart rate pattern  D/C infusion If there is hyperstimulation or nonreassuring fetal heart rate pattern  D/C infusion Women who receive oxytocin were more likely to be delivered in 12-24 hrs than those who had amniotomy alone Women who receive oxytocin were more likely to be delivered in 12-24 hrs than those who had amniotomy alone & less likely to have operative delivery & less likely to have operative delivery

16. IOL2-PGE2 For women with favorable Cx  PGE2  the rate of operative delivery & failed IOL when compared to Oxytocin For women with favorable Cx  PGE2  the rate of operative delivery & failed IOL when compared to Oxytocin PGE2   GIT side-effects, pyrexia & uterine hyperactivity PGE2   GIT side-effects, pyrexia & uterine hyperactivity 3-Sweeping of the membranes Vaginally the examining finger is placed through the os of the Cx & swept around to separate the membranes from the lower uterine segment Vaginally the examining finger is placed through the os of the Cx & swept around to separate the membranes from the lower uterine segment   local PGF2 α production & release from decidua & membranes  onset of labor   local PGF2 α production & release from decidua & membranes  onset of labor  the rate of delivery in 2-7 days  the rate of delivery in 2-7 days  the rate of post-term  the rate of post-term  the use of formal induction methods  the use of formal induction methods If there is urgent indication for IOL sweeping is not the method of choice If there is urgent indication for IOL sweeping is not the method of choice

17. Specific circumstances or indications Prelabor SROM at term 6-19% 6-19% IOL with oxytocin  risk of maternal infections (chorioamnionitis& endometritis) & neonatal infections IOL with oxytocin  risk of maternal infections (chorioamnionitis& endometritis) & neonatal infections PG also  maternal infections & neonatal NICU admissions PG also  maternal infections & neonatal NICU admissions IOL after CS PG should not be used as it can result in rupture uterus PG should not be used as it can result in rupture uterus Oxytocin or foley catheter may be used Oxytocin or foley catheter may be used