Presentation on theme: "Postterm Pregnancy Ben Branch, DO April 2006"— Presentation transcript:
1Postterm Pregnancy Ben Branch, DO April 2006 To enjoy this presentation completely, make sure your speakers are turned on.
2Case Study: Tina S.Tina is a G5 P4 who is now at 41 3/7 weeks gestation with a male babyWe know that Tina has had 4 children, all vaginally, the largest of which was 8 lbs 6 oz. No complications in prior deliveries. Tina had three term babies and one baby carried to 42 2/7.
3Terminology Should we be concerned about her current gestational age? What do we call a pregnancy that has progressed past the due date?PostdatesPosttermOverdueAny of the above
4Postterm pregnancy“Postterm” (also called prolonged) pregnancy 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 last menstrual periodWe should avoid the term “post dates” pregnancy as it is loosely used and ill-definedIn one study of current OB fellows, 48% defined postterm pregnancy as 41 weeks, although the ACOG definition is as above!
5Causes of Postterm pregnancies By far, inaccurate dating is the most common etiology. So, get the dating correct!In the absence of inaccurate dating we do not yet understand why some pregnancies carry to 42+ gestational weeks although there is data to suggest genetics and paternity play an active role.Click to find out more about dating pregnancies
6Pregnancy DatingWith regards to postterm pregnancy, the EDC from a first trimester ultrasound should not differ more than 7 days from the EDC calculated by FLMP.Accurate dating is critical for determination of postterm status.Incidence of postterm pregnancy with early sonography is as low as 1.1%
7What are Tina’s Risk Factors? What risk factors can you identify that put Tina at higher risk for being postterm?MultiparousMale babyNeitherBoth
8The correct answer is B. Male Sex Other risk factors include: PrimiparupPrior postterm pregnancyMore rarely: fetal anencephaly and placental sulfatase deficiencyClick here to see Tina’s Risk Factors
9Tina’s Risk FactorsTina is a G5 P4 who is now at 41 3/7 weeks gestation with a male babyTina has had 4 children, all vaginally, the largest of which was 8 lbs 6 oz. No complications in prior deliveries. All but one baby was born at or before term. One baby born at 42 2/7 weeks.Two risk factors, the most significant being prior postterm pregnancy
10Putting it all together Tina S. is at 41 3/7 weeks GA as determined by her FLMP, which is not 42 weeks or greaterShe has two risk factors that she will progress to 42 or greater weeks gestationSo, are we concerned? Do we need to induce her?
11As we can see, the risk of perinatal mortality increases just after 40 weeks. More significantly, the risk increases almost another 35% as the pregnancy progresses after 41 weeks
12Postterm pregnancies are higher risk! 90-95% of normal pregnancies will spontaneously enter labor before 42 weeksIn the US, accounting for differences in postterm management styles, about 5-10% (7%) of pregnancies continue to 42 weeks GAOf all postterm pregnancies, 87% delivered spontaneously in the 42nd week.If we wait to deliver Tina at 42 weeks, the risk of an adverse event at delivery and/or in the perinatal period doubles in comparison with a term vaginal delivery.
13Let’s consider the risks Click each of the divisions below to investigateManagement
14Delivery Adverse Events If Tina delivers as postterm, what adverse events or complications might she encounter?Just tell me alreadyA. Shoulder dystociaB. Operative deliveryC. EndometritisD. All of the above
15All of the above!! Postterm Delivery Complications Maternal anxiety and exhaustionLabor dystociaShoulder dystociaPerineal traumaCephalopelvic disproportionAssisted deliveryOperative delivery (2x as likely as term delivery)EndometritisPP hemorrhageIncreased risk for thromboembolic dz
16Fetal Adverse EventsJust tell me alreadyWhat adverse events or complications might postterm gestation have on the fetus?1. Macrosomia2. Congenital heart defects3. Decreased fetal movement4. Fetal tachycardia
17Correct!! Postterm Fetal Complications Fetoplacental insufficiencyFetal growth restriction (IUGR)Macrosomic infant- risk at postterm gestation increases eight fold, approaching 10%Fetal Dysmaturity Syndrome- Triad of long, thin malnourished infant with flaking skin and meconium stained skin (20% of postterm gestations)
19Postterm Infant Complications Which of these are more likely to occur in a postterm baby?A. Meconium Aspiration SyndromeB. HypoglycemiaC. FeversD. None of the above
20CORRECT! More Postterm Infant Complications: Perinatal mortality twice that at term (4-7/1,000 vs 2-3/1,000)Potential for low birth weight infant (associated with increased perinatal mortality)Poor fetal growth places infant at risk for IUGR, oligohydramnios and cord compressionMeconium Aspiration Syndrome more likely, places at risk for hyaline membrane development and subsequent pulmonary HTN and respiratory failurePostterm status is an independent risk factor for low 5 minute APGARS
22Did you review the adverse events and complications associated with postterm status for the delivery, the fetus, and the infant?NOMaybeYES
23What are our options at this point? Expectant managementAdmit Tina for induction of labor at 41 3/7 weeksHow do we decide?
24Review the literatureWe know that the likelihood of adverse events, complications, and perinatal mortality increases after 41 weeks and again more significantly after 42 weeks.Perinatal mortality was decreased without increasing C sxn and other adverse outcome rates when induction of labor (IOL) was initiated at or during week 41 (Crowley et al)Cesarean rate in postterm pregnancies induced before 42 weeks was actually decreased in comparison with expectantly managed postterm pts. (Sanchez et al)The ideal time for IOL is currently being investigated in a Cochrane Review*What does ACOG recommend?Uterine dysfunction leading to higher rates of C sxn Am J Obstet Gynecol Feb;158(2): PMID:Click the paper for some new and interesting news!
25New research suggests that parity may be an important consideration in the decision to induce postterm patients. In one study, primiparous women that were induced before 42 weeks had a higher rate of adverse events, primarily C section deliveries, than did their multiparous counterparts. This is likely due to uterine dysfunction. ACOG has not changed their recommendations with regards to this limited study to date.
26ACOG Postterm Management Recommendations Trend in the past 10 years has been for IOL at 41 completed weeks gestation (42 0/7, 294 days, EDD + 14 days)At MUSC Family Medicine, we try to arrange induction between 41 0/7 and 41 3/7 weeks. If the induction happens later, we have a BPP done between those dates to ensure no complications.However, if favorable cervix in the face of no other complications OR evidence of fetal compromise OR oligohydramnios, delivery should be effected2004 ACOG Practice Guidelines
27Make your decision Expectant Management Induction of Labor Tina is 41 3/7 weeks, by Leopold’s you estimate the fetus to be cephalic in presentation and are unsure of the estimated fetal weight, she has an unfavorable cervix by Bishop’s score. She is very uncomfortable and having lots of body pains. Our ACOG recommendations tell us we can induce her or we can expectantly manage her pregnancy. Which would you like to do?Expectant ManagementInduction of Labor
28Expectant ManagementIf you and the patient desire to wait until 42 0/7 for induction of labor, bi-weekly modified BPP (NST and U/S for AFI) is recommended for fetal assessment.
29Tina S. InductionAt her office visit, Tina is examined. Her cervix is closed and very posterior. You ask her to come to the hospital the next night for cervical ripening. Tina is admitted at 41 3/7 weeks for induction of labor.The next morning, the cervix is soft and 2 cm dilated. She is having irregular contractions. Pitocin is started for labor augmentation.At next check, she is 5 cm. You perform an AROM. Four hours later, she is fully dilated and ready to push.
30Tina S. DELIVERYDuring the delivery, the intern noticed the dreaded turtle head sign.Fortunately, he had reviewed his ALSO manual the day before and knew the HELPERR mnemonic and dystocia maneuvers. With assistance the intern was able to finally deliver the baby by Ruben’s maneuver, but the intern heard a “pop” during the delivery of the anterior shoulder.The baby boy weighed 9 lb 10 oz and caused a grade 1 midline laceration which approximated well and was allowed to heal by primary intent.The newborn exam was completely normal, but the intern was concerned about what three potential injuries to the baby?
31Our intern’s worries Neurologic injury, such as Erb’s palsy Orthopedic injury, such as clavicular or humeral fractureTorticollis is common in shoulder dystocia infants. In some cases, a “pop” is heard which the delivering physician believes is the clavicle being fractured. However, this sound can commonly be the tearing of muscle fibers in the sternocleidomastiod muscle on the ipsilateral side of the dystocia secondary to the downward traction used in delivery. This muscle injury causes a hematoma to develop with in the first 48 hours of life and the infant may subsequently develop torticollis. Treatment lies in early diagnosis and early physical therapy consult for manual therapy to prevent facial asymmetry and postural changes in the infant.References
32ReferencesSielski, Lori A. “Postterm Infant.” Up to Date Online. MUSC Library Apr 2006Norwitz, Errol R. “Postterm Pregnancy.” Up to Date Online. MUSC Library Apr 2006Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term. The Cochrane Database of Systematic Reviews 1997, Issue 1. Art. No.: CD DOI: / CD Apr 2006Gülmezoglu AM, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. (Protocol) The Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD DOI: / CD Apr 2006ACOG Practice Bulletin. Clinical management guidelines for obstetricians-gynecologists. Number 55, September 2004 (replaces practice pattern number 6, October 1997). Management of Postterm Pregnancy.
33ReferencesSanchez-Ramos L, Olivier F, Delke I, Kaunitz AM. Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis. Obstet Gynecol 2003; 101:1312–1318.Macrosomia--maternal characteristics and infant complications. AUSpellacy WN; Miller S; Winegar A; Peterson PQ SOObstet Gynecol 1985 Aug;66(2):G¸lmezoglu AM, Crowther CA. “Induction of labour for improving birth outcomes for women at or beyond term.” (Protocol) The Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD DOI: / CDThomsen, JR. “Sternomastoid Tumor of Infancy.” Ann Otol Rhinol Laryngol Dec;98(12 Pt 1):955-9.