Description
finance
PROLONGED PREGNANCY
Dr. Fatima Shanthini
Definition :
FIGO /WHO
Pregnancy that has completed 42 weeks or 294 days as calculated from the first day of LMP, assuming dates are correct.
Incidence
10%
?
Varies depending on
? Ethnic groups ? Practice of induction ? Reliability of dates .
Physiopharmacology of labor
² Formation of gap junctions increase ² Concentration of oxytocin receptors increase ² PG synthesis by membranes and decidua increase
PRE LABOR
? Cervical ripening LABOR ? Myometrial excitement
ETIOLOGY ? Unknown ? Incorrect dates ? Previous history of prolonged pregnancy ? Primiparity
? Abnormalities in biochemical & physiological mechanisms responsible for initiation of labor ? Placental sulfatase deficiency Synthesis of placental estrogens Development of gap junctions Oxytocin & PG receptors in myometrium
? Anencephaly Lack of devt. of hypothalamus No CRH No stimulation of P-A-P axis No initiation of labor
TYPES
? Placental function is reduced leading to post maturity syndrome ? Placental function is unaffected leading to macrosomia
CHANGES ASSOCIATED WITH PROLONGED PREGNANCY
Amniotic fluid changes Quantitative & Qualitative changes AFVolume - 1000 ml at 38 weeks 800 ml at 40 weeks 500 ml at 42 weeks
CHANGES ASSOCIATED WITH PROLONGED PREGNANCY
Amniotic fluid changes Quantitative & Qualitative changes AFVolume - 1000 ml at 38 weeks 800 ml at 40 weeks 500 ml at 42 weeks
U/S ² AFV 4 quadrant technique Pools of AF 10 ² 15 cm - Normal < 5 cm - Oligohydramnios > 25 cm - Polyhydramnios
? After 38 ² 40 weeks ? Milky & cloudy because of vernix caseosa ? Phospholipid composition - Lamellar bodies from fetal lungs. ? Lecithin / Sphingomyelin ratio ² 4: 1 or greater ? Color ² green or yellow discoloration
PLACENTAL CHANGES
Decrease in diameter & Length of Chorionic villi Fibrinoid necrosis Accelerated atherosis of decidual vessels Hemorrhagic infarcts calcium deposition white infarcts ( 10- 25 at term 60 % ² 80% post term)
COMPLICATIONS Maternal
? Prolonged labor ? Increased risk of operative delivery ? Increased injuries, infections, bleeding in vaginal delivery
Perinatal
? PNM increased after 41 weeks ? Intra partum hypoxia & still births
Placental dysfunction
? Placental perfusion Renal perfusion
?
fetal hypoxia
oligohydramnios cord compression
? Fetal distress Increased IP deaths
- PNM by 8 fold from 37 w(0.7/1000) to 43 w (5.8/1000) - AP,IP & neonatal deaths - Intrapartum deaths ²most significant. - Causes Pregnancy H.T. Prolonged labor C.P.D. µUnexplained anoxiaµ Malformations - Delivery at 38w associated lowest risk
? Meconium aspiration syndrome
? Fetal macrosomia
Fetal trauma
? Postmaturity syndrome
Post maturity syndrome (Clifford) ? Description of a clinical syndrome, where the neonate has the clinical features of a pathologically prolonged pregnancy
? Wrinkled , peeling skin coated with meconium ? Over grown nails ? Well developed palm and sole creases ? Reduced subcutaneous fat ? Wizened old man appearance.
DIAGNOSIS Reliability of GA estimation
1. Menstrual history ² normal regular Unpredictable ²during lactational amenorrhea With withdrawal of pills
2. EDD calculated from M.H coincides with EDD from U/S between 12- 20 weeks 3. EDD established by U/S , CRL between 7 ² 11 weeks 4. EDD by ² 2 or more U/S, 3- 4 weeks apart between 12 ² 28 weeks
5. Pregnancy during infertility treatment with known date of conception 6. EDD corresponds to 36 weeks since positive pregnancy test Confirm maturity if unreliable dates
Signs :
1.Wt stationary or 2.Abdominal girth 3.P/A²Ht of uterus -Hard skull bones -Liquor -Uterus feels ´full of fetusµ 4.P/V² Cervical ripeness ²Bishop·s score
Identification of patients who need to be delivered
1. Women with medical or obstetrical complications 2. Women with favorable cervix 3. Women with oligohydramnios
BISHOP SCORING SYSTEM FOR ASSESSMENT OF INDUCIBILITY
FACTOR SCO RE 0 1 2 3 Dilatation (cm) Closed 1-2 3-4 ?5 Effacement (%) 0-30 40-50 60-70 > 80 Station (-3 to+3) -3 -2 -1 +1,+2 Cervical consistency Firm Medium Soft Cervical Position Posterior Mid position Anterior -
unfavorable cervix
?4
4. EFW ? 4500 gm / IUGR
5. Suspected fetal compromise 6. Fetal congenital abnormalities 7. Advanced placental grade
Expectant Management
? Only between 40 to 41 weeks ? Assess ² cervical ripeness, fetal status, AFI twice weekly
? < 41 weeks ? Normal AFI ? Normal size baby ? Normal CST, BPP , MBPP , Reactive NST ? Unripe cervix
MANAGEMENT
? I . Routine induction at 40 -41 weeks ? II. Antepartum fetal surveillance & induction where indicated
? Induction at 41 weeks ² -
Decreases PNM Decreases LSCS Cost effective
.
RULE OUT COMPLICATIONS
? IUGR ? HT ? DM
IMMEDIATE DELIVERY
Antepartum fetal surveillance
After 40 weeks
1. FMC
2. NST 3. CST 4. AFI 5. BPP 6. MBPP 7. DOPPLER in IUGR
NST
- Reactive ± Baseline FH ± 110-160 bpm - 2 accelerations of 15 or more beats lasting atleast 15 sec.
TIMING OF DELIVERY
? Do S&S at 40 weeks ? Induction at 41 weeks
INTRAPARTUM MANAGEMENT 1 . Mother 2. Fetus 3. Progress of labour
Intrapartum Monitoring ? CTG ? Partogram ? Amnio infusion ? Shoulder dystocia ? MAS
Aim of fetal monitoring: ? Identify fetal problems-if uncorrected could lead to demise or short/long term morbidity ? In labor fetus could become unwell due to³hypoxia³infection³trauma ? Of these hypoxia is the most common
CORD COMPRESSION VARIABLE DECELERATION
PL F E T U S
ACUTE HYPOXIA
UTERUS
RESPONSE TO HYPOXIA DEPENDS ON FETOPLACENTAL UNIT
FH
POSTNATAL MANAGEMENT
? MSA ? Hypoglycemia ? Early feeding
MANAGEMENT
? Fetal maturity confirmed (USG)
Fetal Surveillance (40 wks) - NST - AF volume estimation
- Biophysical profile Uncomplicated group Induction ((7-10 d)
Cx ripe Sweeping or stripping of membranes ARM Cx un ripe PGE2
gel
complicated
Not to go
past date Induction or C.S
Elective c.s
Contracted pelvis
Post Caesars
Malpresentation
or T.PGE1 Cx ripe
PIH DM APH Rh negative
Elderly primi
CX RIPE
ARM
Liquor clear Oxytocin drip
Liq. MSAF (Thick
Amnioinfusion)
Scalp blood PH Vaginal delivery (V.D) Satisfactory V.D Fetal acidosis C.S
? Plays a major role ? Composition: Collagen/smooth muscle/connective or ground substance ? Surprising that smooth muscle is just 2 to 6% of the cervix
The Cervix-- Softening
? Changes occur in collagen,connective tissue and ground substance ? Complimentary changes occur 1. Collagen breakdown /rearrangement of collagen fibers 2. Alterations in relative amounts of various glycosaminoglycans
? Hyaluronic acid ²associated with capacity of tissue to hold water ? Near term: striking increase in relative amount of hyaluronic acid in cervix ? Increase in gap junctions ? Increase in oxytocin receptors
INVESTIGATIONS :
To assess Fetal maturity Fetal well being
. 1.USG ²Early USG ²dating 2. Amniocentesis
Spectrophotometry
3. Straight X- ray abdomen
- Ossification centres in Upper end of tibia (38-40 w)
- Lower end of femur (36-37w)
4.Fetal well ²being - DFMKC - twice weekly NST - twice weekly AF volume (deepest vertical pocket <2cm, AFI ? 5 cm) - Biophysical profile - Doppler - Absence of umbilical artery End - Diastolic frequency
FH Monitoring- Interpretation
? 1.Early deceleration³when they coincide with a contraction³then gradual decline³then recovery mimicking a contraction ? Drop is < 40 b/m² due to head compression and not due to hypoxia ? 2.Variable Deceleration³vary in occurrence in relation to contraction- also in durationshows precipitous fall & rise
FH Monitoring- Interpretation
? Variable deceleration± Severe when drop is >60 bpm± usually due to cord compression Late deceleration-delay of >15secs between nadir of deceleration and peak of contraction²transient fetal hypoxia during contraction due to reduced placental perfusion
FH Monitoring- Interpretation
? Variable decelerations - cord compression ? Late deceleration± inadequate placental gas exchange
Determination of gestational age 1. Clinical dating
? LMP ? Date of positive pregnancy test ? Quickening ? Date on with fetal heart tones were first heard ? Uterine size
2. Dating by U/S
? CRL in I trimester ? 7 ² 10 weeks - + 3 days ? 10 ² 14 weeks - + 5 days ? U/S at 18 ² 24 weeks ? If more than 1 week discrepancy between U/S & clinical dating repeat after 4 weeks
Establish the diagnosis of prolonged pregnancy by accurate dating.
Confirm period of gestation by ? Reliable dates. ? Date of ovulation
² ART
Ovulation induction ? I Trimester ultra sound II Trimester scan at 18 ² 22 weeks
PROLONGED PREGNANCY
Dr. Fatima Shanthini
Excellent dates
? Patient·s with adequate clinical information ? U/S between 16- 24 weeks indicating that the fetal measurements are in agreement with clinical estimation of G.A ? Patient·s with inadequate or incomplete clinical information but with 2 U/S between 16 ² 24 weeks showing linear fetal growth and similar EDD.
Good dates
1. Patients with adequate clinical information, and one confirming U/S after 24 weeks 2. Patient with inadequate or incomplete clinical information & 2 or more U/S exam showing adequate growth and similar EDD.
Poor dates.
? Any clinical situation different from those listed above.
doc_828995116.pptx
finance
PROLONGED PREGNANCY
Dr. Fatima Shanthini
Definition :
FIGO /WHO
Pregnancy that has completed 42 weeks or 294 days as calculated from the first day of LMP, assuming dates are correct.
Incidence
10%
?
Varies depending on
? Ethnic groups ? Practice of induction ? Reliability of dates .
Physiopharmacology of labor
² Formation of gap junctions increase ² Concentration of oxytocin receptors increase ² PG synthesis by membranes and decidua increase
PRE LABOR
? Cervical ripening LABOR ? Myometrial excitement
ETIOLOGY ? Unknown ? Incorrect dates ? Previous history of prolonged pregnancy ? Primiparity
? Abnormalities in biochemical & physiological mechanisms responsible for initiation of labor ? Placental sulfatase deficiency Synthesis of placental estrogens Development of gap junctions Oxytocin & PG receptors in myometrium
? Anencephaly Lack of devt. of hypothalamus No CRH No stimulation of P-A-P axis No initiation of labor
TYPES
? Placental function is reduced leading to post maturity syndrome ? Placental function is unaffected leading to macrosomia
CHANGES ASSOCIATED WITH PROLONGED PREGNANCY
Amniotic fluid changes Quantitative & Qualitative changes AFVolume - 1000 ml at 38 weeks 800 ml at 40 weeks 500 ml at 42 weeks
CHANGES ASSOCIATED WITH PROLONGED PREGNANCY
Amniotic fluid changes Quantitative & Qualitative changes AFVolume - 1000 ml at 38 weeks 800 ml at 40 weeks 500 ml at 42 weeks
U/S ² AFV 4 quadrant technique Pools of AF 10 ² 15 cm - Normal < 5 cm - Oligohydramnios > 25 cm - Polyhydramnios
? After 38 ² 40 weeks ? Milky & cloudy because of vernix caseosa ? Phospholipid composition - Lamellar bodies from fetal lungs. ? Lecithin / Sphingomyelin ratio ² 4: 1 or greater ? Color ² green or yellow discoloration
PLACENTAL CHANGES
Decrease in diameter & Length of Chorionic villi Fibrinoid necrosis Accelerated atherosis of decidual vessels Hemorrhagic infarcts calcium deposition white infarcts ( 10- 25 at term 60 % ² 80% post term)
COMPLICATIONS Maternal
? Prolonged labor ? Increased risk of operative delivery ? Increased injuries, infections, bleeding in vaginal delivery
Perinatal
? PNM increased after 41 weeks ? Intra partum hypoxia & still births
Placental dysfunction
? Placental perfusion Renal perfusion
?
fetal hypoxia
oligohydramnios cord compression
? Fetal distress Increased IP deaths
- PNM by 8 fold from 37 w(0.7/1000) to 43 w (5.8/1000) - AP,IP & neonatal deaths - Intrapartum deaths ²most significant. - Causes Pregnancy H.T. Prolonged labor C.P.D. µUnexplained anoxiaµ Malformations - Delivery at 38w associated lowest risk
? Meconium aspiration syndrome
? Fetal macrosomia
Fetal trauma
? Postmaturity syndrome
Post maturity syndrome (Clifford) ? Description of a clinical syndrome, where the neonate has the clinical features of a pathologically prolonged pregnancy
? Wrinkled , peeling skin coated with meconium ? Over grown nails ? Well developed palm and sole creases ? Reduced subcutaneous fat ? Wizened old man appearance.
DIAGNOSIS Reliability of GA estimation
1. Menstrual history ² normal regular Unpredictable ²during lactational amenorrhea With withdrawal of pills
2. EDD calculated from M.H coincides with EDD from U/S between 12- 20 weeks 3. EDD established by U/S , CRL between 7 ² 11 weeks 4. EDD by ² 2 or more U/S, 3- 4 weeks apart between 12 ² 28 weeks
5. Pregnancy during infertility treatment with known date of conception 6. EDD corresponds to 36 weeks since positive pregnancy test Confirm maturity if unreliable dates
Signs :
1.Wt stationary or 2.Abdominal girth 3.P/A²Ht of uterus -Hard skull bones -Liquor -Uterus feels ´full of fetusµ 4.P/V² Cervical ripeness ²Bishop·s score
Identification of patients who need to be delivered
1. Women with medical or obstetrical complications 2. Women with favorable cervix 3. Women with oligohydramnios
BISHOP SCORING SYSTEM FOR ASSESSMENT OF INDUCIBILITY
FACTOR SCO RE 0 1 2 3 Dilatation (cm) Closed 1-2 3-4 ?5 Effacement (%) 0-30 40-50 60-70 > 80 Station (-3 to+3) -3 -2 -1 +1,+2 Cervical consistency Firm Medium Soft Cervical Position Posterior Mid position Anterior -
unfavorable cervix
?4
4. EFW ? 4500 gm / IUGR
5. Suspected fetal compromise 6. Fetal congenital abnormalities 7. Advanced placental grade
Expectant Management
? Only between 40 to 41 weeks ? Assess ² cervical ripeness, fetal status, AFI twice weekly
? < 41 weeks ? Normal AFI ? Normal size baby ? Normal CST, BPP , MBPP , Reactive NST ? Unripe cervix
MANAGEMENT
? I . Routine induction at 40 -41 weeks ? II. Antepartum fetal surveillance & induction where indicated
? Induction at 41 weeks ² -
Decreases PNM Decreases LSCS Cost effective
.
RULE OUT COMPLICATIONS
? IUGR ? HT ? DM
IMMEDIATE DELIVERY
Antepartum fetal surveillance
After 40 weeks
1. FMC
2. NST 3. CST 4. AFI 5. BPP 6. MBPP 7. DOPPLER in IUGR
NST
- Reactive ± Baseline FH ± 110-160 bpm - 2 accelerations of 15 or more beats lasting atleast 15 sec.
TIMING OF DELIVERY
? Do S&S at 40 weeks ? Induction at 41 weeks
INTRAPARTUM MANAGEMENT 1 . Mother 2. Fetus 3. Progress of labour
Intrapartum Monitoring ? CTG ? Partogram ? Amnio infusion ? Shoulder dystocia ? MAS
Aim of fetal monitoring: ? Identify fetal problems-if uncorrected could lead to demise or short/long term morbidity ? In labor fetus could become unwell due to³hypoxia³infection³trauma ? Of these hypoxia is the most common
CORD COMPRESSION VARIABLE DECELERATION
PL F E T U S
ACUTE HYPOXIA
UTERUS
RESPONSE TO HYPOXIA DEPENDS ON FETOPLACENTAL UNIT
FH
POSTNATAL MANAGEMENT
? MSA ? Hypoglycemia ? Early feeding
MANAGEMENT
? Fetal maturity confirmed (USG)
Fetal Surveillance (40 wks) - NST - AF volume estimation
- Biophysical profile Uncomplicated group Induction ((7-10 d)
Cx ripe Sweeping or stripping of membranes ARM Cx un ripe PGE2
gel
complicated
Not to go
past date Induction or C.S
Elective c.s
Contracted pelvis
Post Caesars
Malpresentation
or T.PGE1 Cx ripe
PIH DM APH Rh negative
Elderly primi
CX RIPE
ARM
Liquor clear Oxytocin drip
Liq. MSAF (Thick
Amnioinfusion)
Scalp blood PH Vaginal delivery (V.D) Satisfactory V.D Fetal acidosis C.S
? Plays a major role ? Composition: Collagen/smooth muscle/connective or ground substance ? Surprising that smooth muscle is just 2 to 6% of the cervix
The Cervix-- Softening
? Changes occur in collagen,connective tissue and ground substance ? Complimentary changes occur 1. Collagen breakdown /rearrangement of collagen fibers 2. Alterations in relative amounts of various glycosaminoglycans
? Hyaluronic acid ²associated with capacity of tissue to hold water ? Near term: striking increase in relative amount of hyaluronic acid in cervix ? Increase in gap junctions ? Increase in oxytocin receptors
INVESTIGATIONS :
To assess Fetal maturity Fetal well being
. 1.USG ²Early USG ²dating 2. Amniocentesis
Spectrophotometry
3. Straight X- ray abdomen
- Ossification centres in Upper end of tibia (38-40 w)
- Lower end of femur (36-37w)
4.Fetal well ²being - DFMKC - twice weekly NST - twice weekly AF volume (deepest vertical pocket <2cm, AFI ? 5 cm) - Biophysical profile - Doppler - Absence of umbilical artery End - Diastolic frequency
FH Monitoring- Interpretation
? 1.Early deceleration³when they coincide with a contraction³then gradual decline³then recovery mimicking a contraction ? Drop is < 40 b/m² due to head compression and not due to hypoxia ? 2.Variable Deceleration³vary in occurrence in relation to contraction- also in durationshows precipitous fall & rise
FH Monitoring- Interpretation
? Variable deceleration± Severe when drop is >60 bpm± usually due to cord compression Late deceleration-delay of >15secs between nadir of deceleration and peak of contraction²transient fetal hypoxia during contraction due to reduced placental perfusion
FH Monitoring- Interpretation
? Variable decelerations - cord compression ? Late deceleration± inadequate placental gas exchange
Determination of gestational age 1. Clinical dating
? LMP ? Date of positive pregnancy test ? Quickening ? Date on with fetal heart tones were first heard ? Uterine size
2. Dating by U/S
? CRL in I trimester ? 7 ² 10 weeks - + 3 days ? 10 ² 14 weeks - + 5 days ? U/S at 18 ² 24 weeks ? If more than 1 week discrepancy between U/S & clinical dating repeat after 4 weeks
Establish the diagnosis of prolonged pregnancy by accurate dating.
Confirm period of gestation by ? Reliable dates. ? Date of ovulation
² ART
Ovulation induction ? I Trimester ultra sound II Trimester scan at 18 ² 22 weeks
PROLONGED PREGNANCY
Dr. Fatima Shanthini
Excellent dates
? Patient·s with adequate clinical information ? U/S between 16- 24 weeks indicating that the fetal measurements are in agreement with clinical estimation of G.A ? Patient·s with inadequate or incomplete clinical information but with 2 U/S between 16 ² 24 weeks showing linear fetal growth and similar EDD.
Good dates
1. Patients with adequate clinical information, and one confirming U/S after 24 weeks 2. Patient with inadequate or incomplete clinical information & 2 or more U/S exam showing adequate growth and similar EDD.
Poor dates.
? Any clinical situation different from those listed above.
doc_828995116.pptx