POST TERM

PREGNANCY
Dr. M.C.Bansal
Definition:
 The average duration of pregnancy is 280 days(40
wks), If this period is exceeded by 14 days(2
wks), it is referred to as post term or prolonged
pregnancy.

Incidence:
 5-10% of all pregnancies.
Causes:
 The commonest cause is error in calculation of
gestational age.
 History of post term delivery in previous pregnancy
is the most most significant risk factor.
 Congenital anomalies like anencephaly which
disrupt foetal pitutary adrenal axis and rare
maternal enzyme deficiencie(placental sulphatase.
 In most cases cause is not known.
 Complications:
A. Maternal:
 The placental function declines some time around term.
This exposes fetus to a state of relative hypoxia which
can affect the fetal growth and the biophysical
parameters of fetal well being.
 In pregnancies where placenta continues to function well
beyond due date, fetus continues to grow almost at the
same rate as in third trimester.
 Maternal complications arise from these two
situations.
Maternal risks:

Increased maternal This results in an

morbidity with large increased risk of:
for date or
macrosomic babies • pelvic floor trauma
occurs because of • Instrumental
increased incidence of: deliveries
• Dystocia • Caesarian section
• Prolonged labour (25% incidence)
• Shoulder dystocia
 Maternal risks cont.

Fetal hypoxia and decreased liquor are

associated with increased incidence of:
• Meconium stained liquor
• Abnormal fetal heart rate patterns
during labour

Increased operative deliveries

Increased risk of:

• Post partum hemorrhage
• Endometritis
 B. Fetal risks
 Still birth rate increases significantly at term with advancing
gestation.
 It is 0.35/1000 pregnancies at 37 weeks
 While 2.12/1000 pregnancies at 43 weeks.

 Perinatal complications which occur more frequently in post

term babies are:
 Meconium aspiration
 Asphyxia before, during and after delivery
 Cord complications
 Fractures
 Peripheral nerve injury
 Pneumonia
 Septicaemia
 Intra cranial hemorrhage
Prevention:
 Recording LMP and calculating EDD at the time of first
ANC visit.
 Routine early ultrasound for dating of pregnancy.
 Review of antenatal card and ultra sonographic
reports in terms of fetal growth.
 Sweeping of membranes from 38 wks onwards
decreases number of pregnancies going beyond 41
and 42 wks.
 Breast and nipple stimulation ?
 As soon as prematurity is ruled out in high risk cases
induction of labour will prevent post maturity.
Conditions where Post datism is not
allowed:
1. PIH and eclampsia
2. Rh incompatability
3. Pregnancy with jaundice
4. Previous 2 LSCS
5. Transverse lie
6. Contracted pelvis
7. Precious baby
8. IUGR
9. PROM
10. Previous history of IUFD
11. Bad obstetric history
12. History of APH/ Threatened abortion.
Management:
(A). Assessment of gestational age: gestational age must
be confirmed to avoid unnecessary intervention for
presumed postmaturity.
 Calulation of expected date based on first day of last
menstrual period.
 A record of bimanual examination in the first trimester or
fundal height in the second trimester.
 Ultrasound dating in the first half of pregnancy- much
more reliable than the last menstrual period.
(B). Induction versus expectant management:

 The risk of uteroplacental insufficiency and still birth increases

gradually at term, and termination of pregnancy is one of
the methods to obviate this tragedy.
 Perinatal and neonatal mortality increases significantly in
pregnancies that continue beyond 41 wks.
 The policy of routine induction of labour at 41 wks has
reported reduced caesarian section rate and perinatal
mortality.
(C). Role of fetal surveillance:
 Monitoring is most commonly done by:
 Fetalkick count
 Non stress test

 Biophysical profile

 Delivery is recommended if there is evidence of fetal

compromise or oligohydramnios
 (D). Management of unfavourable
cervix:
 Induction of labour in post dated pregnancies with unripe
cervix may increase the incidence of failed
induction, operative deliveries and caesarian section.
 Prostaglandins are now used as the first choice whenever
cervical ripening is required in nulliparas or multiparas.
 Misoprostol is not prefered in women with previous uterine
scar because of increased risk of scar dehiscence.
Misoprost also causes sudden decrease in foetal heart
activity leading to IUFD.
 Electronic fetal heart monitoring must be used when
prostaglandins are administered because of risk of
hyperstimulation.
INTRAUTERINE FETAL
DEATH (IUFD)
 Definition:
 Foetal Death prior to the complete expulsion or extraction
from its mother’s womb irrespective of the duration of
pregnancy. Foetal Death is indicated by the fact that
after such expulsion or extraction, fetus doesn’t breathe or
show any other evidence of life such as:
-Beating of heart
-Pulsations of umblical cord
-Definite movement of voluntary muscles

 Heart beats must be distinguished from transient cardiac

contractions; and respiration from fleeting resp. efforts and
gasps.
Definition contn.
 For statistical purposes it is recommended by WHO
that Intrauterine death occuring after 20 wks or fetal
wt >500g when gestational age is not known, should
be classified as fetal death, to differentiate from
early pregnancy loss or spontaneous abortion.
 This is further subdivided into:
 Early fetal death(20-27 wks)
 Late fetal death(>= 28 wks)

 Incidence: 6.9 per thousand births. (U.S.)

Aetiology:
 Risk factors associated with still births can be:
 Maternal

 Fetal

 Obstetriccomplications
 Medical disorders complicating pregnancy
 Maternal factors:
 Advance maternal age (>35yrs)-increases risk of
diabetes, hypertension, congenital anomalies etc
 Obesity- increases risk of
diabetes, hypertension, placental dysfunction
 Race- black women have higher still birth rate
 Low Socioeconomic status
 Low educational status
 Smoking, tobacco and drug abuses
Fetal factors:
 Congenital malformations: e.g. anancephaly not
associated with polyhydramnios
 Male sex: chromosomally poor survival rate as
compared to female foetus
Obstetric complications:
 IUGR
 PIH
 Placental abruption
 Rh isoimmunisation
 Multiple pregnancy
 Post term pregnancy
 Infections
 Antepartum asphyxia
 Previous history of stillbirth
 Nuchal cord or knotted cord( true knots)
Infections:
 In utero viral, bacterial and protozoal infections have
been asociated with adverse pregnancy outcomes like
preterm labour, PROM, unexplained still births.
 Viruses most commonly incriminated are- parvovirus
B19, CMV.
 Bacterial infections which contribute to increased risk
are listeria monocytogenes, E.coli, group B-
streptococci, ureaplasma urealyticum, syphilis.
 Still births due to infections usually occur in fetuses
weighing <1000g.
Medical disorders
 Diabetes
 Hypertension
 Chronic nephritis
 SLE
 Thrombophilias
 Cholestasis of pregnancy
 Thrombophilias
 Thrombophilias (both inherited and acquired) because of
their increased tendency for vascular thrombosis, may
cause thrombotic lesions in the placenta causing:
 recurrent miscarriages
 Pre-eclamsia

 IUGR

 Still births
Diagnosis:
 Clinically: IUFD is suspected when-
 The mother reports loss of fetal movements.
 Fundal height on palpation is less for estimated
gestational age or fundal height regresses as compared
to previous documentation.
 Absence of fetal heart sounds on auscultation or doppler.

 Ultrasonography: confirms the diagnosis by noting

absence of fetal heart activity.
 Management:
1. Counseling regarding the probable cause of death, need
for investigations and autopsy of infant after
death, options available for further management should
be sympathetic and unhurried.
2. Termination of labour:
 Spontaneous labour usually ensues after intrauterine death in
80-90% cases within 2 wks.
 In those that do not go in labour there is a risk of
hypofibrinogenemia and consumptive coagulopathy(25%). It
doesn’t usually occur prior to 3-4 wks of retension of the
dead fetus. Infection is a risk if membranes are ruptured.
 Induction of labour:
 Oxytocin infusion in titrating doses
 Prostaglandins: PGE2, PGF2-alpha, misoprostol.

 Mefipristone (RU 486) -an anti progesterone

 Trans cervical extra-amniotic Emcredil instillation.

 Evaluation
 A thorough evaluation must be undertaken in every case
to identify the likely cause of still birth which will help in
counselling the patient regarding the need for prenatal
diagnosis and preconception management in future
pregnancies.
 About one-fourth of fetal deaths remain unexplained
despite adequate evaluation.
 Evaluation includes:
1. Detailed history:
 Relevent maternal and obstetric factors must be reviewed.
 Family history particularly of pregnancy losses, congenital
malformations, consanguinity, mental retardation and
diabetes.
2. Laboratory and cytogenetic evaluation:
 Amniocentesis: for cytogenetic diagnosis
 Bacterial culture
 TORCH serology
 Fasting or random blood glucose level
 HBA1c
 VDRL
 Antiphospholipid antibodies
 Evaluation cont.
3. Post Partum examination:
After delivery, the newborn and placenta must be
examined by an experienced person. Placenta should be
sent for gross and microscopic examination. Culture for
bacteria and viruses should be done. Permission must be
obtained for clinical photographs, X-rays and autopsy.
The time of death may be approximately determined by
examination of the infant and assessing degree of
maceraton:
 Time of fetal death and grade of
maceration:
Grade of features Time since fetal
maceration: death

0 “Parboiled” reddened skin <8hrs

1 Skin slippage and peeling >8hrs

2 Extensive skin peeling; red 2-7 days

serous effusions in chest and
abdomen

3 Liver yellow-brown; turbid >=8 days

effusion
Conclusion:
 Intrauterine death is a tragedy which should be
prevented as far as possible. Nevertheless it occurs
despite best intensions, a thorough search must be
undertaken to identify the cause so that repeated
mishaps can be effectively averted.