Post-term Pregnancy

Definition

A pregnancy that persists for 42 weeks or more from the onset of

the last menstrual period. Sometimes called postmaturity or
postdate.

Incidence
5-10%. It is more common in primigravidae.
Etiology
Wrong dates
Biological-previous prolonged pregnacy
Irregular ovulation
Decreased fetal estrogen production
Placental sulfatase deficiency
Anencephaly
Fetal adrenal hypoplasia
 Incidence
There are contradictory findings concerning maternal
demographic factors such as parity, prior postterm birth,
socioeconomic class, and age as risks for postterm
pregnancy.

Only pre- pregnancy body mass index (BMI) 25 and

nulliparity were significantly associated with prolonged
pregnancy.

When mother and daughter had a prolonged pregnancy, the

risk for the daughter to have a subsequent postterm
pregnancy was increased two to threefold.
Perinatal Mortality

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Risk of Post-term
A. Placental insufficiency: which may lead to fetal
hypoxia or even death.
B.Oligohydramnios: with its sequelae particularly cord
compression during labour.
C. Obstructed labour: due to;
* oversized baby,
* no moulding of the skull due to more calcification.
D. Increased incidence of operative delivery.
 Risks to the Fetus
Risk of perinatal mortality (stillbirth and early neonatal deaths)
TWICE that of term.
4-7 deaths vs 2-3 deaths per 1,000 deliveries
Increases SIX fold and higher at 43 weeks
Uteroplacental insufficiency
Meconium aspiration
Intrauterine infection

Post-term pregnancy is an independent risk factor for low

umbilical artery pH at delivery and low 5 min APGAR scores
Higher incidence of fetal macrosomia, although no evidence
supports inducing labor as a preventative measure in such
cases
Prolonged labor, Shoulder Dystocia
 Risks to the fetus
Approximately 20% of post-term fetuses have
dysmaturity syndrome
Infants with characteristics resembling chronic IUGR from
uteroplacental insufficiency
Oligo, meconium aspiration, hypoglycemia, seizures,
respiratory insufficiency, non-reassuring fetal testing
Long term sequelae not clear
One large prospective follow up study of children 1-2 years,
general intelligence, physical milestones, and frequency of
interrecurrent illnesses were not significantly different between
normal infants born at term and those born post-term

Fetuses born post-term are at increased risk of death within

the first year most have no known cause
Risks to the pregnant woman
Increased labor dystocia- 9-12% vs 2-7%
Increased risk in severe perineal injury related to
macrosomia- 3.3% vs 2.6%
Doubled rate of: endometritis, hemorrhage,
thromboembolic events
ANXIETY
 Diagnosis
Antenatal
History: calculation of gestational age (see later).
Examination: larger baby size.
X-ray: large ossification center in the upper end of the
tibia.
Ultrasonography: can detect
Biparietal diameter more than 9.6 cm.
Increased fetal weight.
Oligohydramnios.
Increased placental calcification.

Tests for placental function.

 Diagnosis
Postnatal
a. Baby length: more than 54 cm.
b. Baby weight: more than 4.5 kg.
c. Skull: well ossified with smaller fontanelles.
d. Finger nails: project beyond finger tips.
Management Recommendations

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 Management
Termination of labour is indicated which may be by:

Induction of labour if the condition is favourable for

vaginal delivery using:
> amniotomy oxytocin, or
> prostaglandins oxytocin.
Caesarean section: if conditions are not favourable for
vaginal delivery, or if induction of labour failed.
 MANAGEMENT
Although some form of intervention is considered to be indicated for
prolonged pregnancies, the types and timing of interventions are not
unanimous (Divon, 2008). The decision centers on whether labor
induction is warranted or if expectant management with fetal
surveillance is best.
Prognostic Factors for Successful Induction Unfavorable Cervix
Harris and coworkers (1983) defined an unfavorable cervix by a Bishop
score < 7 and reported this in 92 percent of women at 42 weeks.
Alexander and associates (2000b) reported that women in whom there
was no cervical dilatation had a twofold increased cesarean delivery rate
for dystocia.
Yang and coworkers (2004) found that cervical length 3 cm measured with
transvaginal sonography was predictive of successful induction.
In a similar study, Vankayalapati and associates (2008) found that cervical
length 25 mm was predictive of spontaneous labor or successful induction.
 Cervical Ripening
Alexander and associates (2000c) treated 393 women with a
postterm pregnancy with PGE2, regardless of cervical
favorability, and reported that almost half of the 84 women
with cervical dilatation of 2 to 4 cm entered labor with
prostaglandin E2 use alone.

The American College of Obstetricians and Gynecologists

(2011) previously concluded that PGE2 gel could be used
safely in post-term pregnancies. In another study, mifepristone
was reported to increase uterine activity without uterotonic
agents in women beyond 41 weeks (Fasset, 2008).
 Induction versus Fetal Testing
Because of marginal benefits for induction with an unfavorable cervix
as discussed above, some clinicians prefer to use the alternative
strategy of fetal testing beginning at 41 completed weeks.

In the surveillance group, evaluation included: (1) counting fetal

movements during a 2-hour period each day, (2) nonstress testing three
times weekly, and (3) amnionic fluid volume assessment two to three
times weekly with pockets < 3 cm considered abnormal.

Labor induction resulted in a small but significant reduction in cesarean

delivery rate compared with fetal testing21 versus 24 percent,
respectively. This difference was due to fewer procedures for fetal
distress. Importantly, the only two stillbirths were in the fetal testing
group.