FETOMATERNAL OUTCOME OF PREGNANCY BEYOND 40 WEEKS OF GESTATION
Dissertation submitted to
The Tamil Nadu Dr. M.G.R Medical University In partial fulfillment for the award of the Degree of
M.S. OBSTETRICS AND GYNECOLOGY BRANCH II
THE TAMIL NADU Dr.M.G.R MEDICAL UNIVERSITY INSTITUTE OF OBSTETRICS AND GYNAECOLOGY,
GOVT WOMEN AND CHILDREN HOSPITAL, MADRAS MEDICAL COLLEGE AND
RESEARCH INSTITUTE.
APRIL - 2017
BONAFIDE CERTIFICATE
This is to certify that this dissertation entitled “FETOMATERNAL OUTCOME OF PREGNANCY BEYOND 40 WEEKS OF GESTATION” is the bonafide work done by Dr. M. Suganthi , post graduate in the Department of Obstetrics and Gynaecology, Institute of Obstetrics and Gynaecology, Government Women and Children Hospital, Madras Medical College, Chennai, towards partial fulfillment of the requirements of The Tamil Nadu Dr.M.G.R University for the award of M.S Degree in Obstetrics and Gynaecology.
Prof. Dr. T.S.Meena, MD., DGO., Professor,
Institute of Obstetrics and Gynaecology, Govt. Women and Children Hospital, Madras Medical College,
Chennai – 600 005.
Prof.Dr.S.Baby Vasumathi. MD.,DGO., Director and Superintendent
Institute of Obstetrics and Gynaecology, Govt. Women and Children Hospital, Madras Medical College,
Chennai – 600 005.
Dr.M.K. Muralidharan, MS., MCH., Dean
Madras Medical College, Chennai- 600 003
DECLARATION
I, Dr. M. Suganthi, solemnly declare that the dissertation titled,
“FETOMATERNAL OUTCOME OF PREGNANCY BEYOND 40 WEEKS OF GESTATION” has been done by me. I also declare that this bonafide work or part of this work was not submitted by me for any award, degree, diploma to any other university either in India or abroad.
This is submitted to The Tamil Nadu Dr.MGR medical University, Chennai in partial fulfillment of the rules and regulations for the award of M.S Degree (Obstetrics and Gynaecology) held in April 2017.
Place:
Date: Dr. M. SUGANTHI
I gratefully acknowledge and sincerely thank Dr.M.K. Muralidharan, MS., MCH., Dean, Madras Medical College and Research Institute, Chennai for allowing me to use the facilities and clinical materials available in the hospital.
My sincere thanks and gratitude to Dr.S.Baby Vasumathi, M.D., D.G.O., Director and Superintendent, Institute of Obstetrics and Gynaecology, for granting me permission to utilize the facilities of the institute for my study.
I am extremely grateful to our Professor, Dr. T.S. Meena, M.D., D.G.O., Institute of Obstetrics and Gynaecology and Government Women and Children hospital, Egmore, Chennai for her valuable guidance, motivation, and encouragement given during the study.
My sincere thanks to the Professors and Assistant Professors of the Department of Obstetrics and Gynaecology for their help during this study.
My sincere thanks to Mr. Balaji, Statistician for helping me in analysing the results of my study.
I am immensely grateful to all the patients who took part in the study.
ABBREVIATIONS
USG - Ultrasound NST - Non Stress Test AFI - Amniotic Fluid Index BPP - Biophysical Profile
PG - Prostaglandins
IUGR - Intra Uterine Growth Restriction LSCS - Lower Segment Ceasarean Section LMP - Last Menstrual Period
EDD - Expected Date of Delivery NICU - Neonatal Intensive Care Unit CPD - Cephalo Pelvic Disproportion SVD - Spontaneous Vaginal Delivery
S.NO TITLE PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 29
3. MATERIALS AND METHODS 30
4. REVIEW OF LITERATURE 33
5. ANALYSIS OF RESULTS 43
6. OUTCOME IN STUDY 66
7. DISCUSSION 70
8. SUMMARY & CONCLUSION 76
9. BIBLIOGRAPHY 79
10. ANNEXURES
PROFORMA
MASTER CHART
ETHICAL COMMITTEE CERTIFICATE OF APPROVAL
PATIENT INFORMATION & CONSENT FORM
PLAGIARISM SCREENSHOT
DIGITAL RECEIPT
Introduction
1
INTRODUCTION
The definition of prolonged pregnancy according to international guidelines is 42 completed weeks or more than that from the first date of last menstrual period.
Although 42 completed weeks is used as cut off it is not an absolute threshold.
In Indian population fetus mature earlier 1 week than the western population and the risk of still birth began to rise 1 week earlier.
So as per this evidence in our population it is necessary to apply postdate terminology to 41 completed weeks itself.
As per dyson et al study the post maturity problem set earlier in some ethnic groups. So the management of patient as per international guidelines will not be universally applicable to all population.
There are 2 categories of patients to identify 1. Patients with real postdatism and
2. Those that are termed as postdatism due to incorrect calculation of gestational age.
2
According to Benet and josephs 2007 studies most cases of postdated pregnancy is due to inaccurate calculation of EDD.
Though there are identifiable risk factors for post dated pregnancy most of the cases have unknown cause’s .only there are few modifiable risk factors identifiable.
Why only some mothers is having postdated pregnancy? Is it really biological determined? The question is UN answered.
Accurate estimation of gestational age and expected date of delivery is important for successful outcome of pregnancy.
If pregnancy goes beyond the expected date of delivery it is bigchallenge for physician to decide when to deliver the baby. It causes big anguish for the pregnant couple.
Because both maternal and fetal morbidity increase once pregnancy goes beyond the dates.
But there was no tailor made protocol for the management of postdated pregnancy. In these we are discussing and analysis various aspects of postdated pregnancy.
3
DEFINITION
There are various terminologies used for the crossed dates pregnancythese should not be used as interchangeable terms.
Postdated - 40 completed weeks
Late term - 41 weeks to 41+6 weeks
Post term - 42 completed weeks (294 days)
Post maturity - it is features of fetus with 42 completed weeks .
EPIDEMIOLOGY
According to martin et al the post term pregnancy incidence is 7%.
But the incidence of postdated pregnancy is decreasing trend now a days due to accurate estimation of gestational age and early dating scan.
Incidence beyond 41 weeks 8 to 10%
Incidence beyond 42 weeks 6 to 8% in western countries
But in India its only about 2 to 3%
Post maturity syndrome incidence is 18 to 22%.
According to eleven at al post term pregnancy is associated with increased risk of mortality and morbidity to the fetus.
4
The prevalence of post dated pregnancy depends varied for the population characters and the ethnic groups
But the duration of pregnancy and ethnicity link is not clearly understood until now.
ETIOLOGY
The exactcause of post datedpregnancy is unknown in majority of cases.
Inaccurate prediction of gestational age is most common cause of post dated pregnancy.
Both maternal and fetal plays a role in postdated pregnancy.
There are
Maternal cause
Paternal cause
Placental cause
Fetal cause
Maternal cause
The most consistent risk factor is the previous history of postdated pregnancy.
5
1. Previous post term birth- 2 fold increase in risk 2. Previous post term birth-4 fold increases
Maternal age – increased maternal age is one of the associated cause
Ethnicity
Primi gravid
Low socioeconomic status
Maternal weight gain
Obesity
Smoking
Low social economic status
Instead of true casual relation the association of low socioeconomic status with an increased incidence ofpostdatism may reflect access to theprenatal care is delayed in this group of people.
Obesity
Increased Body mass index >30kg/m2
In obese patient there is increased adipose tissue which was harmonically dependent.
Alteredmetabolic status leadsto delayed in the initiation of labour due to altered environment.
6
Obesity is one of modifiable risk factors.
Primi gravid
Postdated pregnancy more common inprimigravidas.
Genetic factor
Monozygotic twins are also has predisposition for postdated pregnancy
Paternal role
There are also some studies supporting paternal role in postdated pregnancy. The rate of postdated pregnancy will be reduced from 20 to 14% if the paternity changes for 1st pregnancy and 2nd pregnancy.
Fetal cause
Anencephaly
Adrenalhypoplasia.
Delayed in initiation of laborin adrenal hypoplasia due to decrease in amount of steroid production which isone of theprecursors for initiation oflabour process.
Placental cause
It is one of the x linked recessive disorder.
7
Due to defect in placental sulphatase activity leads to decrease in estriol production and there is delayed in initiation of spontaneous of labour.
PATH PHYSIOLOGY
The exact mechanism of postdated pregnancy not clearly understood until now.
To understand the mechanism of postdated pregnancy the normal partitrituation mechanism should be enlightened.
PLACENTA
Corticotrophin releasing hormone production from placenta peaks at the time of labour
Leads to increase DHEAS from the fetal adrenals
Increase in estriol production
Leads to initiation of labour.
8
THE myometrium is rendered more response to harmonic change by placenta in term
The uterus should transmuted from quiescent organ to active organ leads to expel the fetus by labour mechanism
It leads to production of high frequency high amplitude uterine contraction.Cervix should undergo metabolic change. Collagen and elastin significant changes for cervical ripening.
PLACENTA
FETAL ADRENAL GLAND
DHEAS PRODUCTION
OESTRIOL PRODUCED
NO PLACENTAL PROGESTRONE PRODUCTION
DECREASE PROGESTRNE
9
POSTDATED PREGNANCY
Placenta
Genetic polymorphism
Alteration in the production of corticotrophin production.
No alteration in harmonic environment
No spontaneous onset of labour
As gestational age increase placental function decrease.
Uterine blood flow decreased by 45% to 50%
Placental blood flow decreased by 45% to 50%
Post maturity syndrome is due to imbalance between the nutrients between placenta and the fetus.
10
Impairment of Placental function
Impairment of transfer of oxygen fuels to the fetus,
As the no of capillaries and intervillous space decrease, fibrin deposits, calcification
Hypoxia, acidosis
Placental blood flow decrease
Renal blood flow decrease
Renal perfusion decrease
Fetal urine output decrease
Olighydraminos
11
GRADING OF PLACENTA
Grannum and co use ultrasonography to grade the severity of placental senescence on a scale of 0–3.
Grade 0 - smooth chorionic plate and homogenous placental tissue.
Grade 1 - slight indentation chorionic plate with randomly dispersed echogenic areas in placental surfaces.
These echoes are bright white and linear to comma shaped.
Grade 2 - comma shaped density from placental substance, presence of basal echogenic, marked indentations in chorionic plate that do not reach the basilar plate.
Grade 3 - marked indentations of chorionic plate linear echogenic densities, probably calcium deposition, dividing the placental bed into much
compartments.
12
Echo lucent areas seen in the central portion of compartments. The incidence of grade 3 placenta increases after 40 weeks, but its presence alone cannot be used to predict the fetal distress or the post maturity syndrome.
However, Yeh and colleagues found that the postmaturity syndrome was more common when both oligohydramnios and a grade 3 placenta were present
COMPLICATION OF POSTDATED PREGNANCY;
Maternal complication
Fetal complication
FETAL COMPLICATION 1. Placental insufficiency 2. Oligohydraminos 3. Meconium passage 4. Fetal distress 5. Birth injuries
6. Post maturity syndrome
Post term pregnancy peruse independent risk of low umblicalcordph, lowapgar, neonatal encephalopathy, (kitlinske et al study)
13
According to Bruckner et al 200l study neonatal academia and meconium aspiration syndrome increase beyond 40 weeks of pregnancy.
Path physiology of fetal complication
Placental blood flow decrease (placental insufficiency)
Renal blood flow decrease
Renal perfusion decrease
Fetal urine output decrease
Olighydraminos
Umbilical cord compression
Presenceofvariabledeclaration
Stimulation of vagal reflex
Passage of meconium
Meconium aspiration syndrome.
14
MACROSOMIA
Suboptimal placental function continues
Fetal macrosomia
Prongedlabour Shoulder dystocia Instrumental delivery Cesarean section Birth injury
15
Clifford described the postmaturity syndrome in detail
Heused this staging system to quantify increasingly severity of clinical manifestations of placental dysfunction.
Stage I
Is typified by a long, lean infant with wrinkled, peeling skin.
Stage II
Includes the clinical findings of stage I and adds greenish meconium staining of amniotic fluid, fetal skin, and placental membranes.
Stage III
Is characterized by a high incidence of fetal distress and yellow- brown meconium staining, indicative of the presence of meconium for several days
16
MATERNAL COMPLICATION
Labour dystocia
Perineal laceration
Postpartum hemorrhage
Instrumental delivery
Cesarean section
Parental anxiety
According to Eden et al study cesarean section is associate with endometritis, higher thromboembolic episode.
According to McCaughey et al study there is increase in maternal complication beyond 40weeks of gestation.
17
DIAGNOSIS OF POSTDATED PREGNANCY It is difficult to diagnose the post term pregnancy
The method of diagnosing by historytaking, clinical and by the investigation.
CLINICAL METHOD HISTORY
It plays an important role in predicting post term pregnancy EDD should be corrected.
1. Menstrual history - regularity of cycle, Duration of cycle,
Last 3 cycle’s regularity, H/o any contraceptive usage
CLINICALFINDING
2.Early palpation of uterine size, 3. Quickening
4. Doppler auscultation of fetal heart tones
5. Follow up fundal height in relation to gestational age 6. Feel of head in per abdomen examination
18
These are less accurate but valuable methods used to determine the estimated date of delivery
Investigation
This is done to confirm
The fetal maturity and
To detect the placental insufficiency.
For assessment of fetal maturity
Non invasive method
Invasive method
NON INVASIVE METHODS Ultrasound
1. First trimester dating scan. This reduces the majority of unnecessary intervention, by correctly predicting the gestational age.
2. The normal physiological variation in follicular phase of menstrual cycle leads to overestimation of gestational age this leads to unnecessary intervention.
3. Measurement of liquor amount. When single deep vertical pocket less than 2 cm –oligohydraminos.
19
4. But instead of single vertical pocket amniotic fluid index is best predictor of oligohydraminos.
5. USG is also one of the components of biophysical profile for fetal well being
Invasive methods
Amniocentesis
Saturated phosphatidyl choline
Amniocentesis
o Orange colored cells
Desquamated fetal cells stained with 0.1% Nile blue sulphate Presence of orange halo cells indicate fetal maturity
L/S ratio
L/s ratio more than 2 indicates pulmonary maturity.
Lamellar body count
The count more than 30000/micro/ml indicates the fetal maturity.
Saturated phosphatidyl choline.
More than 500ng/ml indicatesfetalmaturity
20
DIAGNOSIS OF POST MATURITY AFTER DELIVERY OF BABY- POSSIBLE FEATURES
General appearance of fetus- post maturity syndrome of fetus Liquor- scanty and stained with meconium
Placental inspection – excessive calcification and inspection
Umbilical cord- decreasedWharton’s jelly thus may precipitated cord compression
ANTE PARTUM FETAL SURVILLANCE This is straightforward and in expensive method
The main objective - To prevent fetal demise and
To avoid unnecessary intervention
There is no conclusive evidence to support the fact ofante partum fetal surveillance will decrease perinatal mortality and morbidity.
Several antenatal surveillance schemes are in current usePost term pregnancy is one of the indications for initiating the ante partum fetal surveillance.
21
The tests for fetal well being are 1. Fetal movement count
2. Electronic fetal monitoring orcardiotocography Non stress test
Vibroacoustic stimulation Contraction stress test 3. Ultrasonography
Amniotic fluid volume measurement 4. Biophyscical profile
Components include fetal breathing,fetalmovement,fetaltone, AFI,NST.
5. Doppler Study
Fetalumblical artery
Fetal middle cerebral artery Fetal ductousvenous
FETAL MOVEMENT COUNTING
This felt first at approximately 20 weeks
Felt more earlier by multiparouswomen
Perception of decreased fetal smovements in fetalhypoxia. This may precedes by intrauterine death
22
In hypoxic state the fetus decrease the gross fetal movements to conserve oxygen.
This method is very easy method.
Easily understood by most of the women. Easily interpreted
The following any one of the method can be followed
FETAL MOVEMENT METHOD COUNTING
Cardiff kick chart; : ”count” 10 formula
Counting the fetal movement over 12 hours and noted on a chart
If 10 movements or more in 12 hours – REASSURING PATTERN
Counting the fetal movements while lying on 1 side distingt for 2 hours
If 10movements or more – REASSURING PATTERN
Counting the fetal movements for 1 hour daily
Feeling 4 movements with in 1 hour –reassuring
Counting the fetal movements for 1 hour 3 times/ week
Equal to or exceeds the women’s previously established base line count
23
NON STRESS TEST
NST is performed using an external CTG
Fetal heart rate recording in absence of contraction
Tomonitor fetal heart rate
Most commonly used nowa days.
Thetrace shows
Baseline heart rate
Base line variability
Periodicchanges- acceleration, deceleration.
The healthy fetus will temporarily accelerate the fetal movements.
REACTIVE NON STRESS TEST
2 or more acceleration
- Should be recorded over for 20 minutes - Up to 40 minutes if no acceleration
Peak at least 15bpm above baseline
Lasting at least 15 seconds
NON REACTIVE NON STRESS TEST
No acceleration in40 minutes
Deceleration lasting more than or equal to 1minute
24
Vibroacoustic stimulation test.
In these auditory source placed over maternal abdomen
Burst of short sounds delivered (1 to 2 seconds)
Absence ofacceleration - fetal hypoxia or acidosis.
CONTRACTION STRESS TEST
This test is gold standard test,
It is done by using cardiotocography
Fetal heart rate recording with induced contraction
Done by using intravenous diluted oxytocin infusion or by nipple stimulation.
Results more consistent with perinatal outcome.
Contraction stress test - mechanism
contraction (transint hypoxia)
hypoxic fetus
decresed oxygen reserve
late decelaration
healthy fetus no deceleration
25
Interpretation of contraction stress test.
Positive
Late deceleration following contraction
Negative
No significant variable deceleration Equivocal suspicious
There is intermittent late deceleration
No Significant variable deceleration Equivocal –hyper stimulatory
Deceleration in the presence of hyper stimulation
Contraction lasting more than 90seconds
BIOPHYSCICAL PROFILE.
The most precise meant for predicting the fetal hypoxemia USG observation for 30 minutes for following parameters There are 5 components.
Components (each variable is given a Score of 2 –normal.
Score of 0 –abnormal
Fetal breathing
Fetal tone
fetal movement
26
Amniotic fluid index(AFI) Non stress test
AFI alone indicate chronic fetal acidosis.
BPP is unique as it is blending both USG parameters and fetal heart pattern.
Interpretation of biophysical profile
Score of 8 or more – normal provided amniotic fluid normal
Score of 8 or more – amniotic fluid volume reduced, indicates chronic hypoxia needed for repeated evaluation.
Score of 4or less- immediate delivery indicated
27
Predictive value of biophyscical profile
The false negative rate is low
Low BPP has high predictive value
The earliest manifestation of abnormal BPP- abnormal NST, and loss of breathing movements.
Modified biophysical profile It has 2 components alone AFI- signify chronic hypoxia NST- signify acute hypoxia
Predictive value
The false negative rate is very low
It is a tremendous tool for predicting neonatal outcome
28
DOPPLER USG
The diameter of umbilical artery and venous diameter increase normally
Middle cerebral artery Doppler changes in fetal hypoxia
Flow to brain increased
Diastolic flow increased
Leads to brain sparing effect
Its indicate early sign of hypoxia
Not used as routine in postdated pregnancy
Umbilical artery Doppler changes
Not benefited much in postdated pregnancy
Mainly useful in IUGR fetus.
nonractive nonstress test
doppler changes MCA - brain sparing effect
BPP changes decreased fetal
breathing,fetal movements and
tone,
Aims and objectives
29
AIM OF THE STUDY
To analyses the optimum period of intervention in pregnancy beyond the expected date of delivery
To study the fetal and maternal outcome
To study the mode of delivery in pregnancy beyond dates
Materials and methods
30
MATERIALS AND METHODS
The study done in institute of obstetrics and gynecology in egmore MMC in 2016
It is a prospective study
Pregnant women which includes pregnancy beyond 40 weeks
Patients were recruited based on inclusion criteria
INCLUSION CRITERIA
Women with accurate recall of LMP with at least 3 regular periods before conception
Patients who have not taken any oral contraceptive pill for at least 3 months prior to conception
Single fetus in cephalic presentation.
Those women who met above mentioned criteria who got admitted in labor ward (booked elsewhere) were also included in the study
31
EXCLUSION CRITERIA
Non cephalic presentation of the fetus
Congenital anomalies of the fetus
Pregnancies complicated by placenta previa and abruption placenta
Rh negative complicating pregnancy
Twin pregnancy
Medical disorders complicating pregnancy like cardiac disease, renal disease , preeclampsia, and gestational diabetes mellitus
Previous cesarean delivery
32
PLAN OF ACTION
Confirmation of postdated pregnancy was done according to nageles rule and also by the songraphic gestational age assessment done during the early period of gestation.
Cases evaluated by doing admission NST, USG, and the biophysical profile.
If the patient had any abnormality in initial evaluationdecision to deliver the baby is straight forward.
Admitted prior to the onset of labor and fetal surveillance done untill40 +5 days and was planned for induction of labor at 40 +5 days.
Induct ability is assessed by bishops pelvic scores at 40+5 weeks of gestation
If the bishop score is unfavorable
Improving pre labour bishop score by using ripening agents prostaglandin E2 gel applied intravaginally.
If the patient had favorable bishops score labor acceleration done by using syntocin drip.
Amniotomy done for all cases.
Intrapartum monitoring done
Maternal outcome and fetal outcome analyzed
Review of literature
33
REVIEW OF LITERATURE
Postdatedpregnancy definition was revised byACOG in its latest updates.
1. Most cases of post dated pregnancy are due to inaccuracy in estimating gestational age.
2. According to study of nelson JP; Cochrane data base 2000 routine early first trimester scan seems to be better calculator of EDD.
It also reduce the rate of induction of labor in prolonged gestation
It’s a randomized controlled trial. This study proved the benefit ofearly dating scan.
According to bukowski R; 2001 decrease in the rate of postdated pregnancy is the additional benefit of first trimester screening for aneuploidy.
3. Genetic factors play an important role in postdated pregnancy.
This is proved from the study olesen ; 2004.
23 to 30 % genetic factors liable for postdated pregnancy.
34
4. Both maternal and paternal factors related to the recurrence of post dated pregnancy. The study was conducted by morken 2o11; 118.
In this study they stated both factors plays role in recurrence.
5. Maternal weightsplay an important role postdated pregnancy.
Scotland;Washington; 2007 found that higher BMI is associate with prolonged gestation.
Achieving optimal BMI before conception may reduce the prolong pregnancy rate.
6. Male gender predisposes to prolong pregnancy. This was proved from the DIVON MY; 2002; study.
7. STOKES HJ 1991; 31(1); 27 found that Doppler velocity wave form analysis’s unlikely to be benefited in routine assessment of postdated pregnancy. Doppler analysis is not as influential in prolong pregnancy when compared to IUGR
8. According to NACKLING J, BACB B 2006 prolong pregnancy is associated with both increase perinatal mortality and morbiditythis was proved from various studies.
35
The management of postdated pregnancy in this study is planned by following ways.
First the gestational age estimation done by dating scan.The patent should be categorized as low risk and high risk cases.
If the patient had any co morbid condition that patient will not be included in this study as per exclusion criteria the case belong to high risk category.
In low risk cases admission CTG, USG parameters and biophysical profile done. If everything is normal the patient is included for expectant management.
If any of non reassuring pattern of NST,olighydraminos, IUGR,noted the decision for delivering the fetus was immediate.
If all parameters are normal then the patients in this study is planned by following ways
Thepatients with spontaneous onset of pain in term pregnancy were also analyzed with 37completed weeks.
For post term pregnancy the patients included > 40 weeks but <42 weeks.
36
Unbooked cases with spontaneous onset of pain more than 40 weeks were also analyzed.
0 1 2 3
Dilation <1 1-2 3-4 >5
Length 3 2 1 0
Station -3 -2 -1 +1/+2
Consistency firm medium Soft -
Cx position posterior mid Anterior
Expectant management until 40 +5 .
Wait for spontaneous onset of labor until 40+5.
Antenatal fetal surveillance done by using daily NST, and by modified biophysical profile, daily fetal kick count.
But there was not much difference between fetal and maternal outcome between the populations with spontaneous onset of labor pain in prolong pregnancy compared with expectant management.
In the mean time stripping of membrane is done from 40 weeks.
According to studies stripping of membranes was also a successful mechanical method of induction.
37
It leads to release of prostaglandins which initiate labor pains.
Statically improved rate of spontaneous onset of labor pain proved in various studies.
Elective induction of labor done at 40+5days.The predictor of success of induction is the status of cervix. It is done by modifiedbiophysical profile is used.
Prognosticfactors for successful induction of labour
Gestational age – pregnancy near term or post term is a good indicator of successful indication
Preinduction score- bishops score more than 6
In this cervical dilation is important component
Sensitivityof uterus- positivity oxytocin sensitivity is good prognostic factor for successful induction
Cervicalripening – mostly favorable in multiparous.
Presence of fetal fibronectin –lead to successful induction oflabour
Other factors – increased maternal height Body mass index is within normal limits Estimated fetal weight less than 3 kg .
38
Method of cervical ripening.
Pharmacological
Prostaglandins
Prostaglandin E2 (intracervical, intravaginal) Prostaglandin E1 (vaginal, oral)
Mechanical methods;
Tran’s cervical catheter
Foley’s catheter
Double balloon catheter
Tran’s cervical catheter with extra amniotic saline infusion
Laminaria–this is hygroscopic.
This act by distractingchorioamnioticdecidual surface they cause the release of endogenous prostaglandins and result in cervical ripening.
Pharmacological methods;
Prostaglandins
Prostaglandin E2 (intracervical, intravaginal) prostaglandinE1 (vaginal, oral)
39
Prostaglandins are the most commonlyused.
It cause cervical ripening and improves the cervical score
It also initiates thelabour process
The need for augmentation will be reduced further.
Reduce induction delivery interval.
Contraindicated in scarred uterus.
Prostaglandin E2 (dinoprostal)
FDA approved.
Two formsavailable.
One in the form of preloaded intracervicalgel contains 0.5 mg of dinoprostone in 2.5 mlgel
Otherone is intravaginalinsert which contain 10mg of dinopristol in timely released formulation.Placed high in posterior fornix.easy to remove when there istachsystole
Prostaglandin E1
It is available as both 25 or 100micrograms tablet.
It can be used as both oral or vaginal
It is correlate with tachysystole,fetalheart abnormalities,meconiumstaining
Rarely cause a uterine rupture.
40
Effectiveness depends upon the dose.
For oral 25 microgram .repeated 3 to6 hours.
For vaginal 50 micrograms repeated 4 to 6 hours.
Patients treated with either medications experience a quicker time of vaginal delivery and less need for subsequent use of oxytocin than women with unfavorable Bishop Scores who are not treated.
It is very important to minimize the time spent in labour process, as the postdated fetus has less uteroplacental reserve and may rapidly become hypoxic or asphyxiated.
Once an induction of labour started intrapartummonitoring should be vigilant enough to watch the potential complication in postdated pregnancies which include abnormal heart tracing, shoulder dystocia.
If the physcian cannot find reassurance of the fetus in tolerating labour , immediate caesarian delivery is recommended.
The agent not optional for cervical ripening.
Mifepristone
Oxytocin
Relaxin and
Hylarounidase
41
METHOD OF INDUCTION OF LABOUR
Intravenous oxytocin
Amniotomy
Intravenous oxytocin
It is the most common drug used for induction of labour
It is used intravenously, should not be used orally as it will degrade to inactive form
With ripped cervix induction of labour with oxytocin -rate of success is high.
When syntocin is used uterine activity and fetal heart ate should be monitored.
Amniotomy
To induce labour is done
When progress of labour is slow it is done to augmentlabour.
Early Amniotomy is indicated in postdatedpregnancy toknow theliquor is meconium stained or clear.
But still there are so many debatable questions inAmniotomy.
42
INTRAPATUM MANAGEMENT
Continuous electronic fetalmonitoring shouldbe done.
According tomany studieselectronic fetalmonitoring compared withintermittent fetal auscultation but no statisticdifference in perinatal outcome.
Moreover it will lead toincreased intervention.As the postdated fetus has decreased oxygen reserve latedeceleration will be present in hypoxic fetus.
Whether thelabour is induced or spontaneous the labouris expected to be prolonged because poor molding of head or by a big baby.
Good pain relief to be given
The possibility of shoulder dystociato be kept in mind
Fetal heart rate monitoring should be continued
If any signs of fetal distress appears immediate delivery of the fetus to be done either by caesarian section or by instrumental delivery
Analysis of results
43
ANALYSIS OF RESULTS
DISTRIBUTION BY MATERNAL AGE
AGE_CAT
GROUP
Total p value by χ2test POST EDD TERM
< 20 YEARS 25 (15.72%) 14 (7.44%) 39 (11.23%)
0.018*
21 - 25
YEARS 83 (52.2%) 97 (51.59%) 180 (51.87%)
26 - 30
YEARS 41 (25.78%) 51 (27.12%) 92 (26.51%)
>30 YEARS 10 (6.28%) 26 (13.82%) 36 (10.37%)
Total 159 (100%) 188 (100%) 347 (100%)
44
DISTRIBUTION BY MATERNAL AGE
The Mean Age is 20-25 years of all gestation 0
10 20 30 40 50 60 70 80 90 100
< 20 YEARS
21-25 YEARS
26-30 YEARS
>30 YEARS 25
83
41
10 14
97
51
26
POST EDD TERM
45
DISTRIBUTION OF PARITY IN RELATION TO GESTATIONAL AGE
GESTATIONAL AGE
PARITYSTATUS
Total χ 2(0.05) PRIMIPARA MULTIPARA
37 - 38 WEEKS 55 (23.3%) 32 (28.82%) 87 (25.07%)
0.44 38 - 40 WEEKS 66 (27.96%) 35 (31.53%) 101
(29.1%)
40 - 41 WEEKS 99 (41.94%) 37 (33.33%) 136 (39.19%)
41 - 42 WEEKS 16 (6.77%) 7 (6.3%) 23 (6.62%)
Total 236 (100%) 111 (100%) 347 (100%)
Primi gravid more common in 40to 41 weeks of gestation
46
DISTRIBUTION OF PARITY IN RELATION TO GESTATIONAL AGE
0 10 20 30 40 50 60 70 80 90 100
37 - 38 WEEKS
38 - 40 WEEKS
40 - 41 WEEKS
41 - 42 WEEKS 55
66
99
16
32 35 37
7
PRIMI GRAVIDA MULTI GRAVIDA
47
DISTRIBUTION IN GESTATIONAL AGE IN RELATION TO BOOKED/UNBOOKED CASES
GESTATIONAL AGE
BOOKED
Total χ 2(0.05) BOOKED UNBOOKED
37 - 38 WEEKS 72 (27.8%) 15 (17%) 87 (25.1%)
0.001*
38 - 40 WEEKS 87 (33.6%) 14 (15.9%) 101 (29.1%)
40 - 41 WEEKS 95 (36.7%) 41 (46.6%) 136 (39.2%)
41 - 42 WEEKS 5 (1.9%) 18 (20.5%) 23 (6.6%)
Total 259 (100%) 88 (100%) 347 (100%)
More no unbooked cases seen between 40 to 41 weeks of gestation P value is significant
48
DISTRIBUTION IN GESTATIONAL AGE IN RELATION TO BOOKED/UNBOOKED CASES
More no unbooked cases seen between 40 to 41 weeks of gestation P value is significant
0 10 20 30 40 50 60 70 80 90 100
37 - 38 WEEKS
38 - 40 WEEKS
40 - 41 WEEKS
41 - 42 WEEKS 72
87
95
5
15 14
41
18
BOOKED UNBOOKED
49
DISTRIBUTION OF LIQUOR STATUS IN BOTH GROUPS
AFI GROUP
Total p value by χ2test POST EDD TERM
ADEQUATE 120 (75.47%) 182
(96.8%) 302 (87.03%)
0.001*
INADEQUATE 39 (24.52%) 6 (3.19%) 45 (12.96%)
Total 159 (100%) 188 (100%) 347 (100%)
Oligohydramnios is more common in gestation >40 weeks P value is significant
0 20 40 60 80 100 120
POST EDD TERM
84
111
75 77
BOY GIRL
50
DISTRIBUTION OF LIQUOR STATUS
LIQOUR
GROUP
Total p value by χ2test POST EDD TERM
CLEAR 136 (85.53%) 180 (95.74%) 316 (91.06%)
0.001*
MSL 23 (14.46%) 8 (4.25%) 31 (8.93%)
Total 159 (100%) 188 (100%) 347 (100%)
Meconium stained liquor is more common in gestation >40 weeks.
P value is significant 0
20 40 60 80 100 120
POST EDD TERM
84
111
75 77
BOY GIRL
51
DISTRIBUTION BY SPONTANEOUS AND INDUCED LABOUR
GESTATIONAL AGE
LABOUR
Total χ 2(0.05) SPONTANEOUS INDUCED
37 - 38 WEEKS 61 (29.18%) 26 (18.84%) 87 (25.07%)
0.001*
38 - 40 WEEKS 72 (34.47%) 29 (21.01%) 101 (29.1%)
40 - 41 WEEKS 75 (35.88%) 61 (44.2%) 136 (39.19%)
41 - 42 WEEKS 1 (0.47%) 22 (15.94%) 23 (6.62%)
Total 209 (100%) 138 (100%) 347 (100%)
The induction of labour is more common in gestation >40 weeks This is stastically significant
52
MODE OF DELIVERY IN SPONTANEOUS ONSET OF LABOUR
GESTATIONAL AGE
SPONTANEOUS
P value by chi sq
test MODE_OF_DELIVERY
VAGINAL DELIVERY
ASSISTED - VACUUM DELIVERY
ASSISTED - FORCEPS DELIVERY
CAESEREAN SECTION
37 - 38
WEEKS 51 83.6% 3 4.9% 0 0.0% 7 11.5%
0.001 38 - 40
WEEKS 60 83.3% 4 5.6% 0 0.0% 8 11.1%
40 - 41
WEEKS 43 57.3% 3 4.0% 1 1.3% 28 37.3%
41 - 42
WEEKS 1 100.0% 0 0.0% 0 0.0% 0 0.0%
More number of vaginal delivery between 38 to 40 weeks.
More number ofcesarian section in 40 to 41 weeks.
P value is significant.
53
MODE OF DELIVERY IN SPONTANEOUS ONSET OF LABOUR
More number of vaginal delivery between 38 to 40 weeks.
More number of cesarian section in 40 to 41 weeks.
P value is significant 0
10 20 30 40 50 60
VAGINAL DELIVERY
ASSISTED - VACUUM DELIVERY
ASSISTED - FORCEPS DELIVERY
CAESEREAN SECTION 51
3
0
7 60
4
0
8 43
3 1
28
1 0 0 0
37 - 38 WEEKS 38 - 40 WEEKS 40 - 41 WEEKS 41 - 42 WEEKS
54
MODE OF DELIVERY IN INDUCED PATIENTS
GESTATIONAL AGE
INDUCED
P value by chi sq test MODE_OF_DELIVERY
VAGINAL DELIVERY
ASSISTED - VACUUM DELIVERY
ASSISTED - FORCEPS DELIVERY
CAESEREAN SECTION
37 - 38 WEEKS 20 76.9% 1 3.8% 0 0.0% 5 19.2%
0.001 38 - 40 WEEKS 16 55.2% 5 17.2% 0 0.0% 8 27.6%
40 - 41 WEEKS 27 44.3% 1 1.6% 1 1.6% 32 52.5%
41 - 42 WEEKS 12 54.5% 1 4.5% 1 4.5% 8 36.4%
More number of vaginal delivery between 38 to 40 weeks.
More number of caesarean section between 40 to 41 weeks.
55
MODE OF DELIVERY IN INDUCED PATIENTS
More number of vaginal delivery between 38 to 40 weeks.
More number of caesarean section between 40 to 41 weeks.
0 5 10 15 20 25 30 35
VAGINAL DELIVERY
ASSISTED - VACUUM DELIVERY
ASSISTED - FORCEPS DELIVERY
CAESEREAN SECTION 20
1 0
5 16
5
0
8 27
1 1
32
12
1 1
8
37 - 38 WEEKS 38 - 40 WEEKS 40 - 41 WEEKS 41 - 42 WEEKS
56
INDICATION FOR LSCS ACCORDING TO GESTATIONAL AGE
GESTATI ONAL
AGE
INDICATIONS
Total
p value by χ2
test CPD /
ARRE ST
FAILED INDUC
TION
FETAL DISTR
ESS
MATER NAL
OLIGO HYDRA
MINOS
37 - 38 WEEKS
3 1 10 15 5 34
0.021*
11.5% 12.5% 16.7% 41.7% 33.3% 23.4%
38 - 40 WEEKS
4 2 15 13 3 37
15.4% 25.0% 25.0% 36.1% 20.0% 25.5%
40 - 41 WEEKS
18 5 29 7 6 65
69.2% 62.5% 48.3% 19.4% 40.0% 44.8%
41 - 42 WEEKS
1 0 6 1 1 9
3.8% 0.0% 10.0% 2.8% 6.7% 6.2%
TOTAL
26 8 60 36 15 145
100.0
% 100.0% 100.0% 100.0% 100.0% 100.0%
The rate of failed induction is more in postdated pregnancy.
The fetal distress is more in postdated pregnancy.
57
DISTRIBUTION BY MATERNAL COMPLICATION
MAT_COMP
GROUP
Total
p value by Fisher
exact POST
EDD TERM
NIL 148
(93.08%)
171 (90.95%)
319
(91.9308357348703%)
0.022*
PERINEAL
TEAR 8 (5.03%) 3 (1.59%) 11 (3.17%)
ATONIC PPH 0 (0%) 8 (4.25%) 8 (2.3%) MANUAL
REMOVAL OF PLACENTA
0 (0%) 3 (1.59%) 3 (0.86%)
BLADDER
DISTENSION 3 (1.88%) 0 (0%) 3 (0.86%) CERVICAL
TEAR 0 (0%) 1 (0.53%) 1 (0.28%) ANGLE
EXTENSION 0 (%) 1 (%) 1 (%) VULVAL
HEMATOMA 0 (%) 1 (%) 1 (%)
Total 159 (%) 188 (%) 347 (%)
Maternal complication are more in gestational age >40 weeks.
58
DISTRIBUTION BY MATERNAL COMPLICATION
Maternal complication are more in gestational age >40 weeks.
0 1 2 3 4 5
PERINEAL TEAR ATONIC PPH MANUAL REMOVAL OF PLACENTA BLADDER DISTENSION CERVICAL TEAR ANGLE EXTENTION VULVAL HEMATOMA
PERCENTAGE OF SUBJECTS
MATERNAL COMPLICATIONS
l POST EDD l TERM
59
DISTRIBUTION BY OVERALL FETAL COMPLICATION
FETAL_COMP
GROUP
Total
p value by Fisher
exact POST EDD TERM
NIL 122 (76.72%) 181
(96.27%)
303 (87.31%)
0.001*
BIRTH ASPHYXIA 7 (4.4%) 0 (0%) 7 (2.01%) RESPIRATORY
DISTRESS 24 (15.09%) 2 (1.06%) 26 (7.49%) SEPTICEMIA 2 (1.25%) 1 (0.53%) 3 (0.86%)
SHOULDER
DYSTOCIA 1 (0.62%) 1 (0.53%) 2 (0.57%)
HIE 2 (1.25%) 0 (0%) 2 (0.57%)
TGA 0 (0%) 1 (0.5%) 1 (0.3%)
DUODENAL
ATRESIA 0 (0%) 1 (0.5%) 1 (0.3%)
IUD 0 (0%) 1 (0.5%) 1 (0.3%)
STILL BIRTH 1 (0.6%) 0 (%) 1 (0.3%)
Total 159 (100%) 188 (100%) 347 (100%)
60
DISTRIBUTION BY OVERALL FETAL COMPLICATION
0 5 10 15 20
BIRTH ASPHYXIA RESPIRATORY DISTRESS SEPTICEMIA SHOULDER DYSTOCIA HIE TGA DUODENAL ATRESIA IUD STILL BIRTH
Percentage of subjects
DISTRIBUTION OF FETAL COMPLICATIONS
lPOST EDD l TERM
61
DISTRIBUTION BY SEX OF BABIES
SEX_OF_BABY
GROUP
Total
p value by χ2test POST EDD TERM
BOY 84 (52.83%) 111
(59.04%)
195 (56.19%)
0.245
GIRL 75 (47.16%) 77
(40.95%)
152 (43.8%)
Total 159 (100%) 188 (100%) 347 (100%)
Boy babies are more common in gestation age >40 weeks.
0 20 40 60 80 100 120
POST EDD TERM
84
111
75 77
BOY GIRL
62
DISTRIBUTION BY APGAR SCORE AMONG BOTH GROUPS
APGAR
GROUP
Total p value by χ2test POST EDD TERM
NORMAL 130 (81.76%) 186 (98.93%) 316 (91.06%)
0.001*
ABNORMAL 29 (18.23%) 2 (1.06%) 31 (8.93%)
Total 159 (100%) 188 (100%) 347 (100%)
Low apgar more common in gestational age >40 week.
63
CORRELATION BETWEEN GESTATIONAL AGE AND APGAR SCORE AT 5 MIN
Spearman correlation coefficient, r = -0.489, p = 0.001 Strong negative correlation
64
DISTRIBUTION BY BIRTHWEIGHT AND GESTATIONAL AG
GESTATIONAL AGE
BIRTH WEIGHT
Total
p value
by χ2 test
< 2.5 KG 2.5 - 3 KG 3 - 3.5 KG > 3.5 KG
37 - 38 WEEKS
16 53 18 0 87
0.001*
59.3% 32.5% 16.4% 0.0% 25.1%
38 - 40 WEEKS
10 55 30 6 101
37.0% 33.7% 27.3% 12.8% 29.1%
40 - 41 WEEKS
1 41 56 38 136
3.7% 25.2% 50.9% 80.9% 39.2%
41 - 42 WEEKS
0 14 6 3 23
0.0% 8.6% 5.5% 6.4% 6.6%
TOTAL
27 163 110 47 347
100.0% 100.0% 100.0% 100.0% 100.0%
Increase in birth weight is more common in postdated pregnancy The p valueisstatistically significant
65
DISTRIBUTION BY BIRTHWEIGHT AND GESTATIONAL AGE
Outcome in study
66
OUTCOME IN STUDY
Total number of postdated cases analyzed in this study 159.
Mean age of both term and postdated pregnancy also 21 to 25 years.
Postdated pregnancy between 40 to 41 weeks 39.19%
Postdated pregnancy between 41 to 42 weeks 6.62%
More number postdated pregnancy seen in Primi when compared to muitigravidas.
Number of unbooked cases seen in postdated pregnancy which is seen in low socioeconomic status between 40 to 41 weeks. The incidence rate is 39.19%.
This is statistically significant
OBSTRETIC OUTCOME
Increased incidence of oligohydraminos seen in postdated pregnancy its 24.52 %.
In these study The non reassuring pattern of non stress test seen more in postdated pregnancy 22.64% when compare to 9.04% in term pregnancy.
This is statistically significant.
More number spontaneous onset of labor seen in term pregnancy 63.62%when compared to pregnancy beyond 40 weeks of gestation 36.35%
67
Meconium stained liquor is more common in postdated pregnancy 14.46% when compare to 4.25% in term pregnancy.
Spontaneous onset of labour beyond 40 weeks of gestation -76 cases Out of it 57.3% had vaginal delivery, 37.3% had cesarean section, 4% of patients had vaccum delivery, 1.3% had forceps delivery.
This shows that if patient had spontaneous onset of labour pain beyond 40 weeks the chance of having vaginal delivery was high.
Number of cases induced between 40 to 4o+6 weeks of gestation-61 Out of it 52.5 % of cases had cesarean section,44.3% had vaginal delivery,1.6% had vaccum delivery, 1.6% -forceps delivery.
Number of cases induced between 41 to 42 weeks-22. Out of it 12 cases had vaginal delivery, 8 cases had caesarian section, 1 case-vaccum delivery , 1 case – forceps delivery.
The rate of failed induction is 62.5% in pregnancy beyond 40 weeks of gestation when compared to 37.5% in term pregnancies.
The rate of fetal distress is 58.3% in pregnancy beyond 40 weeks of gestation when compared to 41.7% in term pregnancies.
68
Maternal complication in pregnancy beyond 40 week of gestation.
Perineal tear 5.03%
Bladder distension 1.88%
FETAL OUTCOME
Fetal complication is more in postdated pregnancy
Respiratory distress more common 15.09%
Birth asphyxia 4.4%
Hypoxic ischemic encephalopathy 1.25%
Stillbirth rate o.6% which is significant in postdated pregnancy.
In these studies 39 babies were more than 3.5 kg. This is statistically significant.
Apgar score is low for postdated pregnancy 18.23% when compare 1.06%.
As well the NICU admission is more common in postdated pregnancy.
Allbabies discharged normally.
69
Fetal distress more common in postdated pregnancy 22.01% when compared to term pregnancy 13.29%
In postdated male fetus 52.83% and the girls 47.16%
Discussion
70
DISCUSSION
Post term pregnancy is defined as pregnancy that extends beyond 42 weeks of gestation according to ACOG guidelines.
The incidence of pregnancy varies from 7 to 12 %
According to savitz et al 2002 study most cases of postdated pregnancy is due to inaccurate estimating of expected date of delivery.
1) In This Study 347 antenatal cases analyzed. The study conducted in institute of obstetrics and gynecology egmore in 2016
Out of 347 there are 159 postdated cases and 188 term cases also studied in the same period. From this study the mean age of gestation is 25 to 20 years in both term and postdated cases.
According to various studies post dated pregnancy incidence depends upon the study group and population.
It was consistent with various studies. The incidence and prevalence varies for different ethnic groups
71
2) Incidence of postdated pregnancy is more common in lower socio economic status. This is extracted from the results observed as more number of unbooked cases noted from this study.
This correlates well with Feldman GB 1992; 79(4); 547. Low socioeconomic peoples will have lack of prenatal care as they are unbooked.
And also there will not be any dating scan for accurate estimation of gestational age. The risk of still birth also increased in this group of peoples.
P value is significant.
3) In this study postdated pregnancy were more common in Primi when compared to muitigravidas.
This result is consistent with Eden at al study result. More number of cases seen in 40 to 41 weeks -41.94%.
4)Genetic factors also will also be influencing postdated pregnancy.
According to LAURSEN M.OLERAN A W; 2004,
Genetic factors account for 23 to 32 % of postdated pregnancy.
5) Amniotic fluid volume measurements play a main role in management of postdated pregnancy. It is one of the components of modified biophysical profile.
72
The measurement amniotic fluid volume is better predictor than measuring single deep vertical pocket. This was proved from various studies.
In this study measuring amniotic fluid volume measurement helps to analyses various aspects of postdated pregnancy.
According to study morris J M, Thompson K; 2003 measurement of AFI is superior to single deep vertical pocket but has a poor sensitivity for perinatal outcome
6) Amniotic fiuid volume assessments help in predicting fetal distress in this study.oligohydraminos were seen more in pregnancy beyond 40 weeks of gestation.
In post term 24.52 % when compared to 3.19% in term pregnancy.
This correlates well with tong song srisomboon 1993; 40(3)213 study
This P value is statistically significant.
7) Oligohydraminosis one of the indicator of fetal distress.
In postdated pregnancy 24.52% oligohyraminos compared 3.19%
73
In this study oligohydraminos has more no abnormal heart tracing which indicates fetal distress.
This is consistent with study of phelanjp,pauirh 1985;151 93. From this study reduced amniotic fluid volume should be considered for a trial of labour with continues intrapartum fetal monitoring.
8) In this study oligohydraminos with abnormal NST has high rate of section rate when compare to study group.
This is consistent with study of guildetida, langero which shows increase incidence of abnormal NST with oligohydraminos .
Accordingto Crowley; roylamp; 1984 reduced amniotic fluid statistically increased rate of amniotic stained liquor and more likelyto deliver by caesarean section rates.
9) This study shows increase incidence of meconium stained liquor in oligohydraminos.
In this study postdated pregnancy shows 14.46% meconium stained liquor when compared with 4.25% in term pregnancy.
This is consistent with result from the study of crowleyp, roylamp;
1984.
74
10) According to knoxge study Meconium stained liquor is associate with intrapartum fetal distress and low apgar.
The fetal distress rate is 22.01% in postdated pregnancy when compared to 13.29% in term pregnancy.
P value is significant 0.025%s
11) Number of cases induced between 40 to 4o+6 weeks of gestation-61 Out of it 52.5 % of cases had cesarian section,44.3% had vaginal delivery,1.6% had vaccum delivery, 1.6% -forceps delivery.
Number of cases induced between 41 to 42 weeks-22. Out of it 12 cases had vaginal delivery ,8 cases had cesarian section, 1 case-vaccum delivery, 1 case – forceps delivery.
More number induction is seen in postdated pregnancy in this study.
As with more induction more number of cesarean section rate seen. But this was not correlate with gulmezogiuam; crowter ; 2012
75
12) In this study there are increased neonatal and perinatal morbidity results in fetal distress.
This is consistent with mannin; 1988 study.
13) According to delossantos study increased risk of both perinatal and maternal morbidity.In this study also stastically correlates with other studies in view of both perinatal and fetal outcome.
Summary & Conclusion
76
SUMMARY AND CONCLUSION
According to ACOG recent guidelines the prolonged pregnancy is 42 completed weeks.
This study was conducted in institute of obstetrics and gynecology egmore MMC 2016.
Analysis of 347 antenatal cases. Including both term and postdated.
Even though guidelines have defined prolonged pregnancy as 42 completed weeks this study included cases from 40weeks of gestational age itself. As the maternal and fetal outcome in the earliest period of prolonged pregnancy will also be analyzed.
As fetus well being after 40 weeks is still worrying.
According to study of reids et al, fetal jeopardy increased from 40 weeks itself.
Out of 347 there are 159 postdated cases and 188 term cases also studied in the same period. From this study the mean age of gestation is 20 to 25 years in both groups.
The diagnosis of postdated pregnancy is still debatable and questionable .but still there are some ways to reduce the over estimation or
77
under estimation of gestational age. This can be solved by increasing the regularity of first trimester scanning practice in our population.
But the most frequent consistent factor is a previous post term pregnancy.
In this study once the pregnancy goes beyond dates -ante partum fetal surveillance done until 40+5 days, induction of labour done.
Patients with Spontaneous onset of pain after 40 weeks of pregnancy also analyzed
From this analysis
Postdated pregnancies should be correctly diagnosed.
Properly planned and effective management required.
As the perinatal morbidity is more in postdated pregnancy careful intrapartum monitoring should be done.
Proper monitoring will found that hypoxic fetus at an early time.
But so many studies already proved there was no significant change in perinatal outcome but with monitoring we can able to prevent the intrauterine fetal death.
78
But from this analysis careful monitoring helped to prevent fetal jeopardy
Right time intervention will prevent remote complication of post term fetus.
However it is essential that each case to be individually assessed.
