This document discusses prolonged pregnancy, defined as continuing past 42 weeks of gestation. Risks to the fetus include stillbirth, distress, injuries from large size, and meconium-related issues. Maternal risks include anxiety, operative delivery, and infection. Management involves expectant monitoring with tests like CTG and ultrasound or inducing labor. Induction methods include membrane sweeping, amniotomy, prostaglandins like misoprostol, and oxytocin. Caesarean section is indicated if monitoring finds issues or induction fails. Guidelines recommend offering induction from 41 weeks onward.

2. TOPIC:
PROLONGED PREGNANCY
presented by:
DR REEMA SAMO
FCPS –2 Trainee
OBG/GYN - 2

3. OBJECTIVES
To review the
 Definition
 Difference between post term and post maturity
syndrome.
 Incidence, Aetiology of prolong pregnancy
 Risks associated with prolonged pregnancy
 Management

4. .
Term:
EARLY TERM: Gestational period b/w 37 to 38+6 weeks
FULL TERM: Gestational period b/w 39 to 40+6 weeks
LATE TERM: Gestational period b/w 41 to 41+6 weeks
Preterm: Gestational period b/w 24 to 36+6 weeks
MILDLY PRETERM BIRTHS: b/w 32 to 36+6 weeks
VERY PRETERM BIRTHS: b/w 28 to 31+6 weeks
EXTREMELY PRETERM BIRTHS: b/w 24 to 27+6 weeks

5. PROLONGED PREGNANCY
 DEFINATION
“ its is defined as the pregnancy progressing to 42
weeks (294 days) or beyond”
 It is also called post-dates or post-term pregnancy.

6. POST MATURITY SYNDROME
 It develops in 20% of pregnancies
 Newborn who has :
dry peeling skin
coated with meconium
overgrown nail & scalp hair
well developed creases on the
Palm & soles
little vernix
minimal subcutaneous fat with apprehensive look.
 Such picture indicates intrauterine malnourishment
and independent of duration of gestation.

7. INCIDENCE
OF PROLONGED PREGNANCY
 Is 5 to 10%
 Many prolonged pregnancies are due to misdating
 Accuracy of gestational age is an important factor in
determining the prolonged pregnancy.
 LMP and early U/S has tendency to estimate the
gestational age.
 Early U/S decreases the incidence of prolonged
pregnancy from 12 to 3%

8. AETIOLOGY
 It is not clear and it may represents simple biological
variation.
 It is commonly seen in
1. Primigravida women
2. Previous history of prolonged pregnancy, have 30%
chances of recurrence.
3. Positive family history
4. Congenital anomalies i.e. fetal anencephaly,
congenital adrenal hypoplasia, and placental
sulphatase deficiency.

9. .
5. Low vaginal levels of fetal fibronectin at 39 weeks
increase risk of prolonged pregnancy.
6. Variation in corticotrophin releasing hormone
(CRH) during pregnancy, such as alteration in
number or expression of myometrium receptors,
altered signal transduction or increase in CRH
binding protein.
7. Male fetuses
8. maternal obesity
9. nulliparity and white race.

10. RISKS ASSOCIATED WITH
PROLONGED PREGNANCY
Fetal risks:
Prolonged pregnancy is associated with
1. Increase risk or perinatal mortality including
antepartum stillbirths and infant death. It is
0.86/1000 at 40 weeks and 2.12/1000 at 43
weeks, almost 3 folds increase.
2. Fetal distress is more common B/C of placental
insufficiency and cord compression d/t
oligohydrominos.

11. 3. Large size baby is associated with increase
incidence of birth trauma(skull fracture, brachial
plexus injury, intracranial hemorrhage) and
shoulder dystocia.
4. Meconium aspiration syndrome b/c fetal
parasympathetic system matures which causes
physiological passage of meconium.
5. Neonatal encephalopathy which leads to
cerebral palsy as a result of neurological insult
during labour.
6. Respiratory distress syndrome, neonatal sepsis,
neonatal acidemia & low Apgar score.

12. MATERNAL RISKS
It includes:
1. Anxiety
2. Operative delivery
3. Prolong labour and instrumental delivery
4. Hemorrhage
5. infection

13. MANAGEMENT
 It includes
1. Expectant observational management with fetal
assessment tests
2. Induction of labour (IOL)
3. C-Section

14. SOGC GUIDELINES
1. After 41 weeks gestation, if the dates are certain,
women should be offered Elective delivery.
2. If the cervix is unfavorable, cervical ripening
should be undertaken.
3. If expectant management is chosen, assessment
of fetal health should be initiated.

15. RCOG GUIDELINES
1. U/S should be offered to confirm the pregnancy
before 20 weeks of gestation.
2. Women with uncomplicated pregnancy should
be offered induction of labour beyond 41 weeks.
3. From 42 week, women who decline IOL should
be offered increased antenatal monitoring(CTG
& U/S twice weekly.

16.  All possible attempts should be made for accurate
pregnancy dating.
take detailed history
ask for LMP, regularity of periods, early U/S,
past and family history of prolonged pregnancy.
P/A Examination
P/V Examination
 Once prolonged pregnancy is diagnosed..
 Pt: should be counselled for benefits and risk
factors of both IOL & expectant management.
 Let the patient to take her own decision regarding
treatment.

18. EXPECTANT OBSERVATIONAL
MANAGEMENT
 Women with prolonged pregnancy, who refuse for IOL
are kept under strict monitoring.
 Many different tests are performed for assessment of
post-term fetus. These includes
1. CTG
2. Ultrasound examination that include
Amniotic fluid index (AFI)
Biophysical profile
umbilical artery doppler waveform analysis
 These tests should be performed twice in a week.

21. INDICATION OF DELIVERY IN
EXPECTANT MANAGEMENT
1. Amniotic fluid index <5cm
2. Maximum pool depth <2cm
3. Higher rates of fetal heart rate decelerations.
4. Meconium staining of amniotic fluid.

22. Induction of labour
1. Mechanical intervention
2. biochemical intervention
3. Traditionally utilized methods
acupuncture
herbal remedies
breast and nipple stimulation
sexual intercourse

23. MECHANICAL INTERVENTION
1. Membrane sweeping
2. Amniotomy

24. BIOCHEMICAL INTERVENTION
1. PROSTAGLANDINS : are long chain fatty acids
derived from COX-2 pathway. It exerts a powerful
effect on cervix and myometrium at all stages of
gestation.
 PGs not only modify the ground substance of cervix
but stimulate the onset of uterine contraction &
induce labour.
 It is used for induction of labour when cervix is
unfavourable.
 These are PG E2 , F2a & E1 (misoprostol)

25. .
 ADVANTAGES OF PGs
1. Increase successful vaginal delivery within 24 hrs
2. Decrease incidence of c-section
3. Reduce epidural usage
 DISADVANTAGES OF PGs
1. GIT side effects
2. Uterine hypertonus
3. Wound dehiscence in women with previous c-
section

26. PG E2 DOSAGE
TYPE INTERVAL DOSE REGIME TOTAL DOSE
tablets 6 hourly 3mg-3mg 6mg all women
gel 6 hour Nulliparous
2mg-1mg
Multiparous
1mg-1mg
3mg
2mg

27. 2.OXYTOCIN
 it is octapeptide hormone secreted from
supraoptic and paraventricular nuclei of
hypothalamus. It is stored in posterior pituitary
gland and secreted in pulsatile manner.
 It causes uterine contraction.
 It is given as 5 to 10IU in 1 liter of N/S with 8 to 10
drops / minute when cervix is >6cm.
 Dose is increased according uterine contraction.

28. INDICATION OF C-SECTION
 MATERNAL INDICATIONS:
1. Maternal distress
2. Failure of IOL
3. Failure of progress of labour
4. CPD
5. Maternal demand
 FETAL INDICATION
1. Fetal distress
2. Fetal malpresentation.
3. Macrosomia, Cord prolapse