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POST TERM

POST TERM. Dr. Ahmad S. Alkatheri MD. INTRODUCTION. Definition 42 completed wks 294 days from LMP Risks adverse neonatal & fetal outcome / perinatal death Now it is believed that the risk is  as early as 41 wks Incidence 41  27% 42 4-14% 43 2-7% The incidence is decreasing

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POST TERM

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  1. POST TERM Dr. Ahmad S. Alkatheri MD

  2. INTRODUCTION Definition • 42 completed wks • 294 days from LMP Risks • adverse neonatal & fetal outcome / perinatal death • Now it is believed that the risk is  as early as 41 wks Incidence • 41  27% • 42 4-14% • 43 2-7% • The incidence is decreasing Dating of pregnancy • Accurate dating of pregnancy is essential to avoid unnecessary intervention • U/S scan prior to 20 wks gestation is an excellent method of establishing or confirming true gestational age • Routine U/S scanning   rate of IOL for post-term

  3. ADVERSE PERINATAL OUTCOME ASSOCIATED WITH POST-TERM PREGNANCY •  risk of perinatal death (antepartum, intrapartum, postpartum) due to  anomalies eg. Anencephaly intrauterine infections asphyxia with or without meconium •  risk of neonatal morbidity - macrosomia - shoulder dystocia - meconium aspiration - admission to NICU - Rx with +ve pressure oxygen • risk of  IOL, fetal distress in labor, meconium, & operative deliveries •  risk of post-term adverse outcome  in women with HPT, PET,DM , abruptio placenta, & IUGR - endotracheal intubation - respiratory distress - persistent fetal circulation - pneumonia - seizures

  4. MANAGEMENT 1-Establishing gestational age • HX ( in the 1st visit ) LMP regularity & length of the cycle  OCP in the last 3 cycle before conception • Exam.  Size of the uterus corresponding to dates or not • U/S  to confirm or establish gestational age especially if  LMP uncertain  if the cycles were irregular  if there is Hx of OCP use  if size of the uterus inconsistent with GA • The earlier the U/S the more accurate it is for GA determination • U/S at 16-20 wks appropriate to assess other parameters of the fetus & placenta

  5. MANAGEMENT 2-Management 39-40 6/7 wks • In uncomplicated pregnancies there is no evidence to support IOL nor fetal surveillance • If there are other risk factors including HPT, DM, IUGR, macrosomia, multiple pregnancy, or hydramnios  IOL or serial fetal suvillence is indicated

  6. 3-Management 41-42 wks A-IOL or CS if vaginal delivery is contraindicated • Studies have shown that IOL at 41 or> wks  CS rate compared to expectant management  rate of non-reassuring fetal heart changes  meconium staining of the amniotic fluid  macrosomia >4000 gms  rate of fetal or neonatal death ( mostly  stillbirth due to  asphyxia & meconium aspiration )

  7. 3-Management 41-42 wks B-Expectant management with fetal surveillance • There are exceptions to the above recommendations (3A)  if the mother refuses IOL despite full explanation of the risks Fetal surveillance • Minimally fetal surveillance should include twice weekly amniotic fluid volume estimation by U/S • Fetal movement, NST, BPP, doppler • Monitoring should be at frequent intervals • All of the tests have false +ve & false –ve

  8. IOL

  9. INTRODUCTION DEFINITION Artificial initiation of labor before its spontaneous onset for the purpose of delivery of the fetoplacental unit INDICATIONS • Post-term pregnancy  most common • PROM • IUGR • Non-reassuring fetal suvillence • Maternal medical conditions  DM, renal disease, HPT, gestational HPT, significant pulmonary disease, antiphospholipid syndrome • Chrioamnionitis • Abruption • Fetal death

  10. RISKS of IOL •  rate of operative vaginal deliveries •  rate of CS • Excessive uterine activity • Abnormal fetal heart rate patterns • Uterine rupture • Maternal water intoxication • Delivery of preterm infant due to incorrect estimation of GA • Cord prolapse with ARM

  11. CONTRAINDICATIONS (Contraindications to labor or vaginal delivery) • Previous myomectomy entering the cavity • Previous uterine rupture • Fetal transverse lie • Placenta previa • Vasa previa • Invasive Cx Ca • Active genital herpes • Previous classical or inverted T uterine incision • 2 or more CS

  12. PREREQUISITES To assess the following • Indication / any contraindications • GA • Cx favourability (Bishop score) • Pelvis, fetal size & presentation • Membranes status • Fetal heart rate monitoring prior to IOL • Elective induction should be avoided due the potential complications

  13. Cx ripening prior to IOL Indication  if the Bishop score is ≤ 6 • The state of the Cx is an important predictor of successful IOL Methods : • Intracervical PGE2 gel0.5 mg/6hrs----3 doses • Intravaginal PGE2 gel1-2 mg/6hrs----3doses PGE2 gel  the rate of not being delivered in 24 hrs  the use of oxytocin for augmentation of labor PGE2 gel  the rate of uterine hyperstimulation • Misoprostol Should not be used for term fetuses • Mechanical methods

  14. Cx ripening prior to IOL Mechanical methods Foley Catheter • It is introduced into the cervical canal past the internal os, the bulb is inflated with 30-60 cc of water • It is left for up to 24 hrs or until it falls out • Contraindications Low laying placenta, antepartum Hg, ROM, or cervicitis • No difference in operative delivery rate, or maternal or neonatal morbidity compared to PG gel Hydroscopic dilators (Eg.Laminaria tents) • Higher rate of infections

  15. IOL 1-Oxytocin with Amniotomy • IV • Half life 5-12 min • A steady state uterine response occurs in 30 min or > • Fetal heart rate & uterine contractions must be monitored • If there is hyperstimulation or nonreassuring fetal heart rate pattern  D/C infusion • Women who receive oxytocin were more likely to be delivered in 12-24 hrs than those who had amniotomy alone & less likely to have operative delivery

  16. IOL 2-PGE2 • For women with favorable Cx  PGE2  the rate of operative delivery & failed IOL when compared to Oxytocin • PGE2  GIT side-effects, pyrexia & uterine hyperactivity 3-Sweeping of the membranes • Vaginally the examining finger is placed through the os of the Cx & swept around to separate the membranes from the lower uterine segment   local PGF2 α production & release from decidua & membranes onset of labor •  the rate of delivery in 2-7 days •  the rate of post-term •  the use of formal induction methods • If there is urgent indication for IOL sweeping is not the method of choice

  17. Specific circumstances or indications Prelabor SROM at term • 6-19% • IOL with oxytocin  risk of maternal infections (chorioamnionitis& endometritis) & neonatal infections • PG also maternal infections & neonatal NICU admissions IOL after CS • PG should not be used as it can result in rupture uterus • Oxytocin or foley catheter may be used

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