Postterm Pregnancy Alice Stek MD Basics Description Postterm pregnancy is defined as a pregnancy that has extended to or beyond 42 weeks

s O ! o 2"4 days from #MP O

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$DD %&4 days 'see $stablishing $stimated Date of Deli(ery)

Postdates is not the same as postterm!

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Postdates is a poorly defined term and sho*ld be a(oided+ Postdates can mean any ,A after the $DD

$pidemiology Determining the fre-*ency of postterm gestation is diffic*lt d*e to common inability to acc*rately determine ,A+ eported fre-*ency in .S /+01 isk 2actors $rror in dating is the most fre-*ent ca*se+ 3a*se of tr*e postterm gestation is *s*ally *nknown+

Primiparity Prior postterm pregnancy!

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isk of rec*rrence /241

2et*s of male sex ,enetic predisposition eg*lar hea(y exercise may increase risk arely! Placental s*lfatase deficiency5 fetal anencephaly

,enetics Possible paternal component! o ed*ced risk of rec*rrence with new partner

Black mothers ha(e lower risk for postterm deli(ery and rec*rrence

Pathophysiology Pathophysiology is poorly *nderstood6 ca*se is *s*ally *nknown+ 7nown risk factors and ca*ses are listed abo(e+ Associated 3onditions Dysmat*rity syndrome in 241 of postterm deli(eries! o Similar to 8., d*e to *teroplacental ins*fficiency5 with neonatal complications

2etal macrosomia in 2+9:&41

Diagnosis Signs and Symptoms ;istory Acc*rate pregnancy dating is critical! o #MP5 reg*lar cycles5 contraception<
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$arly .S<

e(iew ,A of prior deli(eries e(iew complications of prior deli(eries Same partner as prior pregnancies<

Physical $xam Digital exam of cer(ix=Bishop score $stimate of fetal weight >ests See section on patient monitoring for tests *sed to monitor fetal well?being and to determine timing of deli(ery+ 8maging .S for estimated fetal weight5 A2 (ol*me5 and fetal position Differential Diagnosis 8nacc*rate dates! $DD is most acc*rately determined early in pregnancy+ #MP in women with reg*lar5 normal cycles

&st trimester .S (ariation @0 days6 *p to 24 weeks @0 days6 late 2nd trimester &4 days6 and Ard trimester 2& days 8f discrepancy between #MP and .S estimate of ,A exceeds the abo(e5 pregnancy sho*ld be redated based on .S meas*rements+

>reatment ,eneral Meas*res 3onflicting e(idence from literat*re regarding most appropriate management! o Bhen to start fetal monitoring
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Bhether to manage expectantly or to ind*ce labor Bhen to ind*ce labor isk of complications

Most st*dies show no differences between ind*ced and monitored gro*ps in neonatal o*tcome5 maternal complications5 or mode of deli(ery!
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Deli(ery was effected by 4A weeks in these st*dies+

D*e to increased perinatal mortality5 *teroplacental ins*fficiency5 meconi*m aspiration5 low *mbilical artery p;5 low 9?min*te Apgar scores5 and neonatal mortality with postterm pregnancies5 the c*rrent trend is toward deli(ery at 4& weeks+

Pregnancy?Specific 8ss*es isks for Mother Maternal complications lowest at AC:A" weeks6 highest postterm 'cesarean deli(ery5 operati(e (aginal deli(ery5 hemorrhage) 2et*ses born postterm are often larger6 potentially increasing risk of labor dystocia5 cesarean deli(ery5 perineal inD*ry!
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$arlier ind*ction of labor does not decrease risk of complications d*e to macrosomia+

Maternal anxiety with expectant management

isks for 2et*s Perinatal=Eeonatal complications5 in general5 lowest at A" weeks and higher postterm! o 3omplications incl*de! Death5 low Apgar scores5 low *mbilical cord p;5 meconi*m aspiration

Perinatal mortality do*bles after 42 weeks and increases F?fold after 4A weeks 8nfant mortality increased in postterm deli(eries

Special >herapy 3omplementary and Alternati(e >herapies Breast and nipple stim*lation at term has not decreased incidence of postterm pregnancy+ 3onflicting data on efficacy and safety of stripping=sweeping membranes+ Medication 'Dr*gs) 8nd*ction of labor with oxytocin and amniotomy if cer(ix is fa(orable 8f cer(ix *nfa(orable 'Bishop score @F)5 prostaglandin cer(ical ripening indicated5 followed by oxytocin and=or amniotomy!
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Misoprostol 'effecti(e and inexpensi(e5 b*t not licensed for labor ind*ction5 altho*gh m*ch data exist on this *se) Dinoprostone

Alert A(oid prostaglandins in women with prior cesareans5 d*e to increased risk of *terine r*pt*re in some gro*ps+ P+4&9 S*rgery

Sched*led cesarean for G& prior cesarean or other obstetric indication sho*ld be done prior to $DD+ Altho*gh st*dies are not all in agreement5 ind*ction of labor at H4& weeks does not appear to increase the rate of cesarean deli(ery or operati(e (aginal deli(ery+

2ollow*p Prognosis Bith caref*l monitoring of fetal well?being5 prognosis is good+ Patient Monitoring Mother Monitor closely for signs of preeclampsia or other maternal complications6 at weekly or twice?weekly prenatal clinic (isits+ 2et*s Altho*gh no 3> has demonstrated an effect of fetal monitoring on perinatal mortality5 close monitoring is standard of care+ Most common monitoring is by twice?weekly ES> % A285 starting at 44 weeks+

Other options! BPP5 contraction stress test Deli(er if!

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Oligohydramnios 'A28 @9 or deepest (ertical pocket of A2 @2 cm) Borrisome fetal heart rate tracing 42 or 4A weeks 'c*rrent standard 4& weeks) Some ad(ise deli(ery as soon as cer(ix is fa(orable+

Bibliography A3O, Practice B*lletin Eo+ 99+ Management of postterm pregnancy+ Obstet ,ynecol+ 24446&44!FA":F4F+ ;eimstad 5 et al+ O*tcomes of pregnancy beyond A0 weeks of gestation+ Obstet ,ynecol+ 244F6&4C!944:94C+ ;eimstad 5 et al+ 8nd*ction of labor or serial antenatal fetal monitoring in postterm pregnancy! A randomiIed controlled trial+ Obstet ,ynecol+ 24406&4"!F4":F&0+ Miscellaneo*s 3linical Pearls J 8ncreased risk of maternal and perinatal complications with postterm pregnancies J O*tcomes are good with caref*l s*r(eillance 'ES> % A28 twice weekly)+ J Deli(ery sho*ld be effected if oligohydramnios or fetal compromise+ J $xpectant management with close monitoring is acceptable6 howe(er5 antepart*m testing starting between 44 and 4& weeks5 and deli(ery at 4& weeks has become the most common management+ J 3er(ical ripening with prostaglandins is a (al*able component of ind*ction+ J 3onsider ind*ction once cer(ix is fa(orable after 4& weeks+ Abbre(iations J A2KAmniotic fl*id J A28KAmniotic fl*id index

J BPPKBiophysical profile J $DDK$stimated date of deli(ery6 d*e date6 44 weeks from #MP J ,AK,estational age J 8., K8ntra*terine growth restriction J #MPK#ast menstr*al period6 generally &st day of period J ES>KEonstress test J 3>K andomiIed controlled trial 3odes 83D"?3M F49+2 Prolonged pregnancy Patient >eaching J 8mportance of good fetal mo(ement daily J Eeed for close monitoring5 antepart*m testing J Anticipation of ind*ction of labor at 4&:42 weeks J A3O, Patient $d*cation Pamphlets! : Bhat to $xpect after Lo*r D*e Date : #abor 8nd*ction Pre(ention Acc*rate determination of ,A early in pregnancy will decrease n*mber of pregnancies classified as postterm+