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PREGNANCY
INTRODUCTION/HISTORICAL MILESTONES
1. BALANTYN IN 1902—FIRST REFERENCE TO POST TERM
PREGNANCY
2. CLIFFORD IN 1954—DESCRIBED POSTMATURITY
SYNDROME
3. AUBERG IN 1964 & LANMAN IN 1968—INCREASED
PERINATAL DEATH IN PROLONGED PREGNANCIES
4. PROMINENCE IN LAST DECADE—HIGH RISK CONDITION
5. OPTIMAL MANAGEMENT STILL CONTROVERSIAL
OLD SCHOOL—EXPECTANT CONSERVATIVE MGT.
OTHER SCHOOL—“ACTIVE MGT” DELIVERY AT 42/52.
6. MORE RECENTLY, EVIDENCE BASED STUDY—PLANNED
DELIVERY AT 41 WEEKS ( RHL-6)
7. PROLONGED PREGNANCY, POSTTERM, AFTER-TERM
PREGNANCY—SYNONYMS (THE LANCET)
8. POSTMATURITY, HYPERMATURITY & DYSMATURITY—
CLINICAL SYNDROMES IN NEONATES MORE COMMON IN
POSTTERM, BUT ALSO DESCRIBED IN TERM INFANTS.
DIAGNOSIS
SOMETIMES DIFFICULT
ILLITRACY IS RAMPANT—LMP WILL BE UNKNOWN
LATE BOOKING
NO EARLY USS.
HX INVOLVES AMONG OTHER THINGS:
PARITY— PRIMIGRAVIDAE
MULTIPS—PREVIOUS HX
LMP—1ST DAY LMP
EXAMINATION
GENERAL- PALLOR, FEVER, JAUNDICE, PEDAL EDEMA
SYSTEMIC
CVS- HYPERTENSION=IUGR
ABD—SIZE,
----FH =36/52, <36/52—IUGR, LIGTHENING
----LIE, PRESENTATION, DECENT, FHR
PELVIC EXAMINATION
--EXCLUDE PELVIC CONTRACTION
--CERVICAL ASSSESMENT
BISHOP SCORING
PARAMETER 0 1 2 3
POSITION OF POSTERIOR CENTRAL ANTERIOR
CX
CONSISTENCY FIRM MEDIUM SOFT
OF CERVIX
CERVICAL 0-40% 40-60% 60-80% +80%
EFFACEMENT
CERVICAL CLOSED 1-2CM 3-4CM 5CM +
DILATATION
STATION OF -3 -2 -1 +1, 2
PP
INVESTIGATIONS
GENERAL—HB, GENOTYPE, BLOOD GROUP, CROSSMATCH
2 UNITS OF BLOOD, URINALYSIS
OTHERS:
PREGNANCY DATING
1. CLINICALLY
LMP-- SPOUSE MAY KNOW
4. RADIOLOGICAL STUDIES
ULTRASONOGRAPHY
1ST TRIMESTER—BEST, MARGIN OF ERROR -3
DAYS
-GESTATIONAL SAC (5-7 WEEKS)
-CRL (8-12 WEEKS)
2ND TRIMESTER- RELIABLE, MARGIN OF
ERROR- 7 DAYS
--BPD- Preferred,
--FEMUR LENGTH, HEAD CIRCUMFERENCE,
--ABDOMINAL CIRCUMFERENCE
3rd TRIMESTER- NOT RELIABLE, MARGIN OF
ERROR- 14 DAYS
--ESTIMATION OF FETAL WEIGHT
--BIOPHYSICAL PROFILE SCORING
--PLACENTAL MATURITY
--CONGENITAL ABNORMALITIES
Interpretation of score
8-10 = normal score
6-7 = repeat
< 6 =terminate pregnancy
5.ROENTGENOGRAPHY
THE APPEARANCE OF OSSIFICATION CENTRES IN FETAL
BONES MAY BE USED TO DATE PREGNANCY.
35- 40 WEEKS- distal femoral epiphysis
37-42 WEEKS- proximal tibial epiphysis appears.
--NO LONGER USED FOR PREGNANCY DATING.
MANAGEMENT OPTIONS
1. “ACTIVE MANAGEMENT”- DELIVERY AT 41/42 WEEKS
2. EXPECTANT CONSERVATIVE MANAGEMENT
THIS ENTAILS FETAL SURVEILLANCE, which include
Cardiff 10 count—10 fetal kicks in 12hours(normal)
Regular fundal height estimation
Non-stress test--normal(110-150bpm, baseline
variability OF 5-25 BPM
Weekly contraction stress test—time wasting, invasive
ACTIVE MANAGEMENT
DELIVERY AT 41/42 WEEKS
CERVICAL ASSESSMENT/BISHOP’S SCORING
IF UNFAVORABLE, RIPEN CERVIX WITH
Prostaglandin E1, E2
Forley’s urethral catheter
Laminiara tent
Membrane sweeping
INDUCTION—when cervix is favorable, informed consent
Surgical method
--Amniotomy
Medical methods
--Prostaglandin
--Oxytocin infusion
Synchronous induction
Time lag between amniotomy/ oxytocin infusion (or
vice versa) is less than 3hours.
LABOUR
Some times prolonged. Increased risk of fetal distress.
At least 2 units of blood should be cross matched.
Senior resident/ experienced midwife, anaesthetist, neonatologist must be
present.
Theatre ideally should be informed.
Vigilant intrapartum monitoring, preferably continuous electronic fetal heart
rate monitoring, intermittent auscultation
Fetal scalp electrode—pH
Meconium staining of amniotic fluid- amnioinfusion with warm normal
saline.
2ND STAGE
Delivery taken by a senior resident. Risk of shoulder dystocia
Neonatologist must be present for possible resuscitation
Suck oropharynx at the delivery of the head if liquor is meconium stained.
Hand over baby to neonatologist if asphyxiated.
3rd STAGE
Should be managed actively.
POST PARTUM
Should be observed for 24 hours, and if satisfactory discharge home.
COMPLICATIONS
ANTENATAL
Oligohydramnious
meconium staining of amniotic fluid
postmaturity
intra uterine fetal death
placental insufficiency
INTRAPARTUM
increased risk of meconium staining of the amniotic
fluid
increased risk of meconium aspiration
dystocia
intrapartum fetal death
NEONATAL
nerve palsy—Erb’s palsy
neonatal death
post neonatal death
MATERNAL COMPLICATIONS
maternal anxiety
trauma
increased caesarean section rate.
CONCLUSION
Post term pregnancy presents a mgt problem. While decision to terminate or
to continue with pregnancy remain controversial, obstetric units should have
policy based on evidence of favorable outcome.