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Prolonged Pregnancy

Prolonged Pregnancy. Dr Khaled Aba-Oub MD FRCOG Consultant O&G Tripoli Fertility Centre Consultant O&G St Helier Hospital,London UK. Posterm pregnancy is defined as a pregnancy that extends to 42 0/7 and beyond

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Prolonged Pregnancy

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  1. Prolonged Pregnancy Dr Khaled Aba-Oub MD FRCOG Consultant O&G Tripoli Fertility Centre Consultant O&G St Helier Hospital,London UK

  2. Posterm pregnancy is defined as a pregnancy that extends to 42 0/7 and beyond • incidence: 3-12% however the actual biologic variation is likely less since the most frequent cause of a postterm pregnancy diagnosis is inaccurate dating

  3. Fetal &Neonatal risks: • Perinatal mortality rate at 42 wks is twice that at 40 wks • increases to 4 folds @ 43 wks and to 5-7 folds at 44 wks

  4. 20% of postterm fetuses have post maturity syndrome,which is characterised with chronic intrauterine growth restriction from uteroplacental insufficiency.These pregnancies are at increased risk of umbilical cord compression from oligohydramnios,non-reassuring CTG,intrauterine passage of mec,hypoglycemia,seizures,and respiratory insufficiency

  5. Macrosomia and bith injury • fetal acidemia • Neonatal death • Cerebral palsy

  6. Maternal Risks increase in labour dystocia (9-12% vs 2-7% at term) Increase in severe perineal injury (3rd and 4th degree tears) related to macrosomia (3.3% vs 2.6% @term) and operative vaginal delivery,and a doubling in the rate of Caesarean delivery (14% vs 7% at term) which is associated with higher risks of endometritis,haemorrhage,and thromboembolic disease

  7. The emotional impact (anxiety and frustration) of carrying a pregnancy 1-2 weeks beyond the estimated du date should not be underestimated

  8. 20% of pregnant women will require IOL,the majority for prolonged pregnancy 58% of women will have delivered by 40 wks of gestation,74% by 41 wks of gestation and 82% by 42 wks of gestation

  9. Ensure that the pregnancy has been dated correctly • Dating U/S in the first trimester reduces rates of IOL for post-term pregnancy NICE advise U/S scans to determine gestational age using: • CRL measurement from 10 wks 0 days to 13 wks 6 days • Head circumference if CRL is above 84 mm • U/S dating should not be postponed further than 24 completed wks irrespective of how sure women are of their menstrual dates

  10. When to Induce Women with uncomplicared pregnancies should be given every opportunity to go into spontaneous labour.Women with uncomplicated pregnancies should usually be offered IOL between 41+0 and 42+0 wks to avoid the risks of prolonged pregnancy,primarily increased intrauterine fetal death

  11. If a woman chooses not to have IOL,her decision should be respected Fom 42 wks,offer increased antenatal monitoring consisting of at least twice weekly cardiotocography and U/S estimation of maximum amniotic pool depth

  12. Why offer IOL As pregnancy continues,the risk of the baby dying in the uterus or soon after delivery increases The stillbirth rate increases fom 1 in 1000 @ 37 wks of gestation to 3 in 1000 @ 42 wks of gestation to 6 per 1000 @ 43 wks of gestation

  13. The reported complications of induction include: Hyperstimulation Fetal distress Failed Induction Caesarean Section Ruptured Uterus Adverse effects of drugs used for induction

  14. Membrane sweeping: During vaginal examination,the clinician's finger is introduced into the cervical os,then the inferior pole of the membranes is detached from the lower uterine segment by a circular movement of the examining finger

  15. Purpose: To initiate labour by increasing local production of prostaglandins and thus,reduce pregnancy duration or pre-empt formal IOL with either oxytocin,prostaglandins or amniotomy

  16. Methods of IOL: • Prostaglandins • Oxytocin • Misoprostol • Isosorbide mononitrate • Mechanical methods

  17. Riks/Benefits of membrane sweep • No increased risk of C.S • Membrane sweep reduces the frequency of pregnancy continuing beyond 41 and 42 wks • No increase in the risk of maternal or neonatal infection • Discomfort during vaginal examination and other adverse effects (bleeding,irregular contractions) more frequently reported by women who undergo membrane sweep

  18. Pre-Induction Assessment: Women are admitted to the maternity unit at around term plus ten days.A cardiotocograph (CTG) to ensure the fetus wellbeing is performed This is followed by a vaginal examination to determine the modified Bishop score and act as a baseline against which to compare subsequent examinations

  19. Prostaglandin induction is commenced on the antenatal ward,IOL should not occur on the antenatal ward if the pregnancy is high risk.These women should be induced on the LW After PG are inserted vaginally,the woman is asked to lie down for half an hour and a cardiotocograph is performed to establish fetal wellbeing;this is essential once uterine activity commences Oxytocin is administered on the LW with continuous fetal heart and uterine activity monitoring and with one to one midwifery care

  20. Thank You

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