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Post-term Pregnancy - Surveillance Strategies. Dr. Yasir Katib MBBS, FRCSC, Perinatologist. Definitions. Post mature Post dates Post-term Prolonged . Definitions. Post term

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post term pregnancy surveillance strategies

Post-term Pregnancy - Surveillance Strategies

Dr. Yasir Katib

MBBS, FRCSC, Perinatologist

definitions
Definitions
  • Post mature
  • Post dates
  • Post-term
  • Prolonged
definitions1
Definitions

Post term

  • Refers to a pregnancy that has extended to or beyond a gestational age of 42.0 weeks or 294 days from the first day of the LMP
  • Postterm pregnancy is associated with increased perinatal mortality and morbidity
incidence
Incidence

Incidence

Depends upon the patient population

  • Percentage of primigravid women
  • Women with pregnancy complications
  • Ultrasound assessment of GA
  • Frequency of spontaneous preterm birth
incidence1
Incidence

Incidence

      • In the United States, approximately 10% (range 3 to 14 percent) of all singleton pregnancies continue beyond 42 weeks of gestation

WHO (1977), FIGO (1976)

  • 4% (2 to 7 percent) continue beyond 43 completed weeks in the absence of obstetric intervention
definitions2
Definitions
  • “Postdates” : the real issue is “post-what dates?”
  • “Post-term” or “prolonged” pregnancy are the preferred expressions for extended pregnancies
incidence2
Incidence
  • limited reliability with LMP to determine accurate post-term incidence
    • variations in timing of ovulation
    • irregular cycles
    • use of oral contraceptives
  • when early ultrasound dating used in conjunction to LMP, incidence of post-term decreased from 10 % (LMP alone) to 3% (LMP + U/S) (Reuss et. al 1995)
etiology
Etiology
  • The etiology of abnormal prolongation of gestation is not well understood (theories)
  • Hypoplasia of the fetal adrenal gland with or without anencephaly
  • Placental sulfatase deficiency
  • Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency
morbidity and mortality
Morbidity and Mortality
  • Increase mortality > 42 weeks gestation
  • evidence from studies done looking outcome of post-term pregnancies prior to availability of intervention methods
slide10

Perinatal mortality in late pregnancy according to gestational age in Sweden 1943-1952 compared with 1977-1978. Logarithm scale is used for convenience in depiction. (Adapted from Bakketeig and Bergsjø, 1991, and Lindell, 1956.)

slide12

TABLE 3 OUTCOMES IN POSTTERM PREGNANCIES (42 WEEKS OR GREATER) COMPARED WITH PREGNANCIES DELIVERED AT 40 WEEKS

40 Weeks Post-term

(n = 8135) (n = 3457)

Factor a (%) (%)

Meconium 19 27

Oxytocin induction 3 14

Shoulder dystocia 8 18

Cesarean delivery 0.7 1.3

Macrosomia (> 4500 g) 0.8 2.8

Meconium aspiration 0.6 1.6

a For all comparisons between 40- and 42-week groups, P < 0.05.

From Eden RD, Seifert LS, Winegar A, Spellacy WN. Perinatal characteristics of uncomplicated postdate pregnancies. Obstet Gynecol. 69:296, 1987.

macrosomia
Macrosomia
  • Complications associated with fetal macrosomia include
  • prolonged labor
  • cephalopelvic disproportion
  • shoulder dystocia with resultant risks of orthopedic (eg, clavicular fractures) or neurologic injury (eg, brachial plexus palsy)
slide14
IUGR
  • Poor intrauterine growth are at increased risk
  • Umbilical cord compression from oligohydramnios
  • Nonreassuring fetal antepartum or intrapartum assessment
  • Cesarean delivery
dysmaturity syndrome
Dysmaturity syndrome
  • Approximately 20%of postterm fetuses have a syndrome of fetal dysmaturity
  • long, thin, malnourished infant
  • Meconium staining
  • Peeling skin
  • Chronic intrauterine growth restriction from uteroplacental insufficiency
slide16

Postmature infant delivered at 43 weeks’ gestation. Thick, viscous meconium coated the desquamating skin. Note the long, thin appearance and wrinkling of the palms of the hands.

induction vs surveillance
Induction vs. Surveillance
  • Several studies debate routine induction vs. surveillance
  • Hannah (1992)
    • Canadian trial showed routine induction reduced risk of perinatal death after 41 weeks, and not associated with increase risk of Caesarean section
    • cost analysis (Goeree 1995) showed induction less expensive than serial monitoring
induction vs surveillance1
Induction vs.. Surveillance
  • NICH 1994
    • American study showed that active labour induction was not associated with improved outcome when compared to expectant management (at 41 weeks)
  • thus either induction or expectant management acceptable
induction vs surveillance2
Induction vs.. Surveillance
  • No evidence to support elective induction or serial antenatal monitoring for uncomplicated pregnancy from 39-40 6/7 weeks
surveillance methods
Surveillance Methods
  • Biochemical markers
    • Plasma or urine estrogen
    • Human Placental Lactogen
    • Placental proteins

 no evidence to demonstrate benefit as antenatal surveillance for fetal well being in post-term pregnancies

surveillance methods1
Surveillance Methods
  • Non-invasive
    • Fetal movement counts
    • Non stress test (Cardiotocography)
    • Biophysical Profile
    • Amniotic Fluid Volume estimates
    • Doppler Ultrasound
surveillance methods2
Surveillance Methods
  • Others
    • Oxytocin challenge test / Contraction stress test
    • Amniocentesis
      • Knox et al (1979)
        • meconium detected by amniocentesis associated with intrapartum fetal distress; however induction of labour did not improve outcome
surveillance methods3
Surveillance Methods
  • NST
    • False-normal Non-stress Tests (Smith et al.1987)
      • fetal death within 7 days of normal non-stress tests
      • most common indication for testing was prolonged pregnancy
      • mean interval between test and death was 4 days, range of 1-7 days
      • single most common autopsy finding: meconium aspiration
      • investigators concluded that the non-stress test not adequate to preclude an acute asphyxial event
      • other biophysical characteristics might be beneficial adjuncts: For example, assessment of amniotic fluid volume
      • high false negative rates also reported by Miyazaki & Miyazaki (1981)
surveillance methods4
Surveillance Methods
  • Ultrasound assessment of amniotic fluid
    • increased incidence of fetal compromise with oligohydramnios in post-term pregnancies
    • identification of decreased amniotic fluid may identify post-term fetus in jeopardy
surveillance methods5
Surveillance Methods
  • Ultrasound Amniotic Fluid Estimates
    • qualitative (Crowley 1980)
      • presence of amniotic fluid between fetal trunk and limbs or uterine wall
    • quantitative
      • Largest single pocket method
      • Amniotic Fluid Index
amniotic fluid volume estimates
Amniotic Fluid Volume Estimates
  • Largest Pocket measurements
    • usually measured in the vertical
    • in BPP, a score of 2 is given for the presence of a 2x2 amniotic fluid pocket
    • studies of AFV estimation have had different lower limits ranging from 1-3cm (Manning 1980, Chamberlain 1984,Crowley 1984, Phelan 1985, Bochner 1987)
amniotic fluid volume estimate
Amniotic Fluid Volume Estimate
  • studies show that AFV may be effective discriminatory test in post-term pregnancy (Crowley 1984, Phelan 1985, Manning 1980)
  • normal AFV does not preclude absence of adverse outcome
amniotic fluid volume estimate1
Amniotic Fluid Volume Estimate
  • Amniotic Fluid Index
    • first proposed by Phelan (1986) and Rutherford et al (1987)
    • summation of vertical pockets in four quadrants
    • table of gestational age-dependent norm of AFI (Moore 1990); e.g. after 41weeks lower limit is 67 mm.
amniotic fluid volume estimate2
Amniotic Fluid Volume Estimate
  • AFV vs. AFI

which is better???

doppler ultrasound
Doppler ultrasound
  • Fetal application first reported by Fitzgerald and Drumm (1977)
  • non-invasive technique that uses high-frequency sound to investigate blood flow by detecting change in frequency of reflected sound
doppler ultrasound1
Doppler Ultrasound
  • Theoretically, in post-term pregnancy:
    • increasing placental ‘age’ with increasing uteroplacental insufficiency
    • expect diminished uteroplacental flow, increased vascular resistance in umbilical artery and compensatory increased fetal cerebral artery flow (as in IUGR)
doppler ultrasound2
Doppler Ultrasound
  • Several small studies have reported conflicting results
  • positive studies usually small (Devine et al 1994, Anteby et al, 1994) or have strict criteria which are not common e.g. Absent end diastolic flow (Pearce et al, 1991)
doppler ultrasound3
Doppler Ultrasound
  • Negative studies show poor discrimination of potential fetal compromise (Guidetti 1987, Farmakides 1988)
  • Zimmerman et al (1995) showed that Doppler of uterine artery had a sensitivity of 7% in predicting poor outcome
doppler ultrasound4
Doppler Ultrasound
  • Thompson and Trudinger 1990:
    • Observations using placenta and mathematical models
    • the larger the placenta (and its arterial branches), the greater fraction of vessels need to be obliterated before RI becomes abnormal
    • this may explain poor sensitivity of umbilical Doppler in post-term pregnancies
clinical practice guidelines
Clinical Practice Guidelines
  • ACOG Practice Patterns (1997)
    • “Due to ethical and medico-legal concerns, it is highly unlikely that any subsequent studies will include a no-monitoring group”
    • “…antenatal surveillance has become a standard practice on the basis of universal acceptance”
clinical practice guidelines1
Clinical Practice Guidelines
  • ACOG Practice Patterns (1997)
    • Antenatal surveillance should be initiated by 42 weeks of gestation (C:III)
    • No single antenatal surveillance protocol for monitoring fetal well-being in a post-term pregnancy appears superior to another
clinical practice guidelines2
Clinical Practice Guidelines
  • SOGC Committee Opinion (1997)

1. Establish gestational age

2. For uncomplicated pregnancy, no evidence to support elective induction or commencement of serial antenatal monitoring at 39 to 40 6/7 weeks

clinical practice guidelines3
Clinical Practice Guidelines
  • SOGC Committee Opinion (1997):

3. Women who reach 41 to 42 weeks of gestation (uncomplicated pregnancies) should be offered elective delivery

4. Serial fetal surveillance should consist (as a minimum) of an ultrasound assessment of amniotic fluid volume twice weekly…other forms of monitoring may be added to this (BPP, NST and fetal movement count)

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