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Definition
Postterm pregnancy : is 42 completed weeks (294 days) or more from the first day of the last menstrual period. It is important to emphasize the phrase "42 completed weeks.
(American College of Obstetricians and Gynecologists (2004)
Sonographic at 16 to 18 weeks, or both of gestational age during pregnancy has been used to add precision
The tendency for some mothers to have repeated postterm births Previous 1 postterm : 27 % Previous 2 postterm : 39 %
inciden
By Last menstrual Periode : 7.5 %
By USG : 2.6 %
Risk factor
The most frequent cause is an error in dating ( the first day of last period) Primiparity and prior postterm pregnancy are the most common identifiable risk factors Decreased fetal estrogen production Placental sulfatase deficiency Anencephaly (Deficiency of ACTH in fetus) Fetal adrenal hypoplasia Male sex also has been associated. Genetic predisposition may play a role .
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patofisiology
Risks factor
fetus Doubling of perinatal mortality Asphyxia, meconium aspiration,intrauterine sepsis Fetal macrosomia Fetal dysmaturity syndrome oligohidramnion Fetal trauma brachial plexus injuries, clavicle fracture mother Increased risk of labor abnormalities Anxiety Traumatic vaginal deliveryshoulder dystocia Increased CS rate PPH risk
Perinatal Mortality
Incidence of fetal mortality for all groups is as follows:
40-41 weeks gestation : 1.1% 43 weeks gestation : 2.2% 44 weeks gestation : 6.6% Fetuses born postterm also are at increased risk of : Sudden infant death syndrome (death within the first year of life). Some of these deaths clearly result from peripartum complications (such as meconium aspiration syndrome), but most have no known cause.
Placental Dysfunction
placental apoptosisprogrammed cell death was significantly increased at 41 to 42 completed weeks compared with that at 36 to 39 weeks. The clinical significance of such apoptosis is currently unclear. cord blood erythropoietin. stimulator of erythropoietin is decreased partial oxygen pressure. cord blood erythropoietin levels were significantly increased in pregnancies reaching 41 weeks or more.
Hypoxia, meconium
In some cases, the risks appear to be due to uteroplacental insufficiency, resulting in fetal hypoxia , meconium aspiration, growth restriction, and oligohydramnios . Fetal distress and meconium release were twice as common (at or after 42 weeks) than at term. There was an eight-fold increase in meconium aspiration
oligohidramnion
The volume of amnionic fluid normally continues to decrease after 38 weeks and may become problematic diagnosis :
No vertical pocket > 2 cm or maximum-vertical amnionic fluid pocket measured 1 cm or less at 42 weeks Amniotic fluid index (AFI) 5 cm or less . It is considered an indication for delivery
Moreover, meconium release into an already reduced amnionic fluid volume causes thick, viscous meconium that may cause meconium aspiration syndrome
macrosomia
In other cases, continued growth of the fetus leads to macrosomia, increasing the risk of labor abnormalities, shoulder dystocia with resultant risks of orthopedic or neurologic injury. Macrosomia is far more common in postterm than term pregnancies (45%) 10%-IU malnutrition
Postmaturity syndrome
Features include wrinkled, patchy, peeling skin; a long, thin body suggesting wasting; and advanced maturity because the infant is openeyed, unusually alert, and appears old and worried. Skin wrinkling can be particularly prominent on the palms and soles. The nails are typically long.
B. Biophysical profile (BPP): Composite of tests designed to identify a compromised fetus during antepartum period.
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NST
Breathing
Reactive.
At least 1 episode of breathing lasting at least 30 sec. 3 discrete movements. At least 1 episode of limb extension followed by flexion.
Non-reactive
No breathing
2 No movement
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Score
Interpretation
Mx
8-10
Normal
Repeat BPP as clinically indicated Repeat BPP in 4-6 hours Deliver fetus if mature
0-4
18
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4.
Use the following triage method: Dates are certain & cervix is favorable. Neither the mother nor the fetus benefits from waiting induce labor promptly with IV oxytocin & rupture of membranes. Dates are certain but cervix is unfavorable. Risk of failed induction is high. If fetal macrosomia is suspected SC. Alternatively, if the estimated fetal weight (EFW) is normal, manage expectantly with twice-weekly NSTs & AFIs. Dates are unsure. Because its not known if the patient is post-dates, delivery is not indicated. Manage expectantly with twice-weekly NSTs & AFIs awaiting spontaneous labor.
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5.
Intrapartum: Meconium staining: Prior to delivery Amnio-infusions After delivery of fetal head suctioning meconium from nose & pharynx to prevent aspiration. After delivery of entire fetus, but before the first neonatal breath aspirate neonatal tracheal meconium using laryngoscope.
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When macrosomia is suspected, should be performed to estimate fetal weight. Clinician should always be prepared to deal with a potential shoulder dystocia. Intrapartum asphyxia: Careful monitoring should be instituted when this is suspected.
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Labour induction at 41 weeks gestation is recommended over expectant management in women with postterm pregnancy to reduce the rate of cesarean delivery & perinatal mortality . In the end of postterm pregnancy with oxytocin induction, patient must filled several terms, which is aterm pregnancy, normal pelvic size, no disproportion cephalopelvic, head presentation, cervix is ready (portio feels soft, flatening, and start to open). Beside that, size of pelvic should be done before.
Contraindications:
Placenta Previa and Vasa Fetal position: breech, transverse, mentum Polyhydramnios Abnormal FHTs
Oxytocin Induction
Bishop score > or equal to 6 = Favorable Low Dose Active Management Start oxytocin at 8 milliunits/min and go up 4 miliunits/min by 15 mins (max 40 miliunits/min)
DELIVERY
Cervical assessment,NST,AFI Weekly at 40 & 41 wks Twice wkly thereafter Ripe cx Oligo Abn NST 42 WKS
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DELIVERY