Prolonged Pregnancy PDF

PROLONGED PREGNANCY Dr Alaa yousif mahmood obstetric and gynecology department MRCOG (LONDON)/DOG/M.B.ch.B  PROLONGED PREGNANCY Definition Pregnancy that has progressed beyond 42 weeks or 294 days from LMP or the gestational age having been established by ultrasound prior to 16 weeks Inci...

PROLONGED PREGNANCY Dr Alaa yousif mahmood obstetric and gynecology department MRCOG (LONDON)/DOG/M.B.ch.B  PROLONGED PREGNANCY Definition Pregnancy that has progressed beyond 42 weeks or 294 days from LMP or the gestational age having been established by ultrasound prior to 16 weeks Incidence 3-10% dependent on the use of early pregnancy dating by ultrasound scan. There is evidence that early pregnancy dating reduces the need for labour induction for prolonged pregnancy. Recurrence risk is 30% after one prolonged pregnancy and 40% after two prolonged pregnancies.  Clinical scenario 40 years old lady G6P5 all normal vaginal delivery presented to antenatal clinic With history of decrease fetal movement she is 40 weeks pregnant confirmed by LMP and 14 weeks ultrasound…how you mange her? Define post term pregnancy What is the fetal and maternal risk of post term pregnancy  Post maturity syndrome This syndrome is closely resemble to intrauterine growth restriction. It characterized by : Meconium stain amniotic fluid Oligohydramnios Fetal distress Loss of subcutaneous fat Dry cracked skin Not every post term pregnancy is complicated by postmaturity syndrome  Causes of prolonged pregnancies  The most common cause of prolonged pregnancies is inaccurate dating. When prolonged pregnancy truly exists the cause is usually not clear.  It may represent simple biological variation.  Prolonged pregnancy is common in primigravidas.  Women with a single previous prolonged pregnancy have a 27 per cent chance of recurrence and those with two prior prolonged pregnancies a 39 per cent chance.  Male fetuses,  hormonal factors,  genetic predisposition  obesity  Fetal adrenal insufficiency and fetal adrenal hypoplasia are associated with prolonged pregnancies.  Risk of prolonged pregnancy Fetal risks  1) Increased perinatal mortality - ante-partum, intra-partum and neonatal.. Placental insufficiency is thought to be the cause of fetal compromise  2) Increased incidence of meconium stained liquor and meconium aspiration Maternal risks  Increased risk of operative delivery - caesarean section and vaginal operative delivery with their complications for fetal distress (or failure to progress)  Maternal anxiety  MANAGEMENT OPTION Women should be assessed at 40 weeks, with induction of labour if any high risk features are identified (history of antepartum haemorrhage, hypertension, previous stillbirth) Otherwise Induction of labour Should be recommended if pregnancy progresses beyond 41 weeks.induction of labour Associated with  lower caesarean section rate and operative vaginal delivery rate  lower risk of meconium stained liquor  lower perinatal mortality rate  Cost-effective intervention compared to expectant management This, however, is a medical intervention which may be resented by some women  Membrane sweeping Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks and 42 weeks. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping.  Expectant management This is also likely to result in a favourable outcome, and may be undertaken in women who decline labour induction Programme of fetal surveillance needs to be instituted and may include twice weekly CTG,Dopplers of the umbilical arteries, assessment of liquor volume, BPP.. 40-50% of women will deliver 4-5 days after 42 weeks Indication of delivery Reduced amniotic fluid amount on ultrasound scan Reduced fetal growth Reduced fetal movement If the CTG is not perfect  Labour Labour in prolonged pregnancy is ‘high risk’ and continuous electronic fetal monitoring should be recommended especially in the presence of meconium stained liquor or no liquor at membrane rupture Hypoxia and acidosis are particularly undesirable in the presence of meconium stained liquor  The recommendations on prolonged pregnancy At the 38-week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options should be discussed. Women should be informed that membrane sweeping makes spontaneous labour more likely,and therefore reduces the need for formal induction of labour to prevent prolonged pregnancy. Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks. Women who decline induction of labour from 42 weeks should be offered increased antenatal monitoring consisting of at least twice-weekly CTG and US estimation of the maximum amniotic pool depth.