post term pregnancy, post dated pregnancy, prolonged pregnancy, m.g. reshmi, management of post dated pregnancy,management of post term pregnancy, fetal maturity assesment, post maturity syndrome, mortality and morbidity ,placental dysfunction, aminotic fluid volume in prolonged pregnancy.

1. POST-TERM PREGNANCY
Dr. M. GOKUL RESHMI
PG
OBG

2. DEFINITION…
• Uniform criteria are lacking.
• Post term, prolonged, postdates, and postmature are often loosely
used to describe pregnancies that have exceeded a duration
considered to be the upper limit of normal.
• Any pregnancy beyond EED – Prolonged or Post dated.
• Pregnancy continuing beyond 2 weeks of EDD – Post maturity or post-
term pregnancy.

3. INCIDENCE…
• Pregnancies continuing beyond 42+7 completed weeks (> 294 days)
ranges between 4 and 14 percent.
• The average is about 10 percent.

4. ETIOLOGY…
• Wrong dates: m/c.
• Biological variability: hereditary.
• Maternal factors:
• Primiparity,
• previous prolonged pregnancy,
• sedentary habit,
• elderly multiparae
• Fetal factors:
• Congenital anomalies:
• Anencephaly → abnormal fetal
HPA axis and adrenal hypoplasia →
diminished fetal cortisol response
• Placental factors:
• Sulphatase deficiency → low
estrogen.

5. DIAGNOSIS…
• Important date:
• LMP
• Early ultrasound dating
• Timing of intercourse.
• Menstrual history
• The suggested clinical findings:
• Weight record
• Girth of abdomen
• H/O false pain
• Obstetric palpation
• Internal examination

6. INVESTIGATIONS…
Aim:
• To confirm the fetal maturity
• To detect placental insufficiency
Assessment of fetal maturity:
• Done by twice weekly nonstress
test , biophysical profile and
ultrasonographic estimation of
amniotic fluid volume.
• Modified biophysical profile.

7. ASSESSMENT OF FETAL MATURITY…

8. PATHOPHYSIOLOGY…
Post-maturity Syndrome:
Placental Dysfunction:
• Redman and Staff (2015) posit that limited placental capacity, which is
characterized by dysfunctional syncytiotrophoblast, explains the greater risks
of the postmaturity syndrome.
• Fetal Distress and Oligohydramnios
• Fetal-Growth Restriction

9. POST-MATURITY SYNDROME…
• Neonate delivered at 43 weeks’
gestation with thick, viscous
meconium coating the
desquamating skin.
• Long, thin appearance and
wrinkling of the hands.

10. POST-MATURITY SYNDROME…
• The postmature newborn features include :-
• Wrinkled, patchy, peeling skin;
• A long, thin body suggesting wasting; and
• Advanced maturity in that the infant is open-eyed,
• Unusually alert, and appears old and worried.
• Skin wrinkling can be particularly prominent on the palms and
soles.
• The nails are typically long.

11. POST-MATURITY SYNDROME…
• The syndrome complicates 10 to 20 percent of pregnancies at 42
completed weeks (American College of Obstetricians and
Gynecologists, 2016d).
• Associated oligohydramnios substantially raises the likelihood of post-
maturity.

12. Comparison of the prognostic value of various
sonographic estimates of amnionic fluid volume in
prolonged pregnancies
Abnormal outcomes include:
• cesarean or operative vaginal
delivery for fetal jeopardy,
• 5-minute Apgar score ≤6,
• umbilical arterial blood pH <7.1,
or
• admission to the neonatal
intensive care unit.

13. CLINICAL CONCEPT
• Criteria to establish the diagnosis of postmaturity retrospectively:
Baby:
• General appearance: Baby looks thin and old. Skin is wrinkled. There is
absence of vernix caseosa. Body and the cord are stained with greenish
yellow color. Head is hard without much evidence of moulding. Nails are
protruding beyond the nail beds;
• Weight often more than 3 kg and length is about 54 cm. Both are variable
and even an IUGR baby may be born.

14. CLINICAL CONCEPT
• Criteria to establish the diagnosis of postmaturity retrospectively:
• Liquor amnii: Scanty and may be stained with meconium.
• Placenta: There is evidence of ageing of the placenta manifested by excessive
infarction and calcification.
• Cord: There is diminished quantity of Wharton’s jelly which may precipitate
cord compression.

15. COMPLICATIONS…
• In the event of a medical or other obstetrical complication, it is
generally not recommended that a pregnancy be allowed to continue
past 42 weeks.
• Indeed, in many such instances, earlier delivery is indicated -
gestational hypertensive disorders, prior cesarean delivery, and
diabetes.
• Other clinically important factors include amnionic fluid volume and
potential fetal macrosomia.

16. COMPLICATIONS…
FETAL:
During pregnancy
• There is diminished placental function, oligohydramnios and meconium
stained liquor.
• These lead to fetal hypoxia and fetal distress.

17. COMPLICATIONS…
During labor
• Fetal hypoxia and acidosis;
• Labor dysfunction;
• Meconium aspiration;
• Risks of cord compression due to oligohydramnios;
• Shoulder dystocia;
• Increased incidence of birth trauma due to big size baby and non-moulding
of head due to hardening of skull bones;
• Increased incidence of operative delivery. The main clinical significance of
post-term pregnancy is dysmaturity or macrosomia.

18. COMPLICATIONS…
Following birth
• Chemical pneumonitis, atelectasis and pulmonary hypertension are due to
meconium aspiration;
• Hypoxia (low Apgar scores) and respiratory failure;
• Hypoglycemia and polycythemia;
• Increased NICU admissions.
• Increased Neonatal convulsions.

19. COMPLICATIONS…
MATERNAL :
• There is increased morbidity, incidental to hazards of induction,
instrumental and operative delivery.

20. PERINATAL MORTALITY AND MORBIDITY…
• Mortality is calculated in terms of stillbirth.
• The risk of stillbirth is increased by about 3 fold from 37 weeks (0.4
per 1,000) to 43 weeks (11.5 per 1000).

21. PERINATAL MORTALITY AND MORBIDITY…

22. MANAGEMENT…
• ANTEPARTUM MANAGEMENT
• Induction Factors
• Induction versus Fetal Testing
• Management Strategies
• INTRAPARTUM MANAGEMENT

24. Algorithm for management of post term
pregnancy…