CHAPTER I INTRODUCTION Pregnancy usually lasts 40 weeks or 280 days counted from the first day of last menstrual

period. Pregnancy at term is between 38-42 weeks of gestation and this is the normal delivery period. However, approximately, 3.4-14% or an average of 10% of pregnancies lasted until 42 weeks or more. Post term pregnancies especially affect the fetus. In fact, postterm pregnancy have an influence on fetal development until the death of the fetus. There is a fetus in gestation 42 weeks or more body weight increased steadily, there is not increased, there are born weighing less than it should, or die in utero due to lack of nutrients and oxygen. Postterm pregnancy has a close relationship with mortality, perinatal morbidity, or macrosomia. 1 However, the actual biologic variation is likely less since the most frequent cause of a postterm pregnancy diagnosis is inaccurate dating. Risk factors for actual postterm pregnancy include primiparity, prior postterm pregnancy, male gender of the fetus, and genetic factors. Perinatal mortality (defined as stillbirths plus early neonatal deaths) at 42 weeks of gestation is twice that at 40 weeks (4-7 vs 2-3 per 1,000 deliveries, respectively) and increases 4-fold at 43 weeks and 5- to 7-fold at 44 weeks. These data also demonstrate that, when calculated per 1000 ongoing pregnancies, fetal and neonatal mortality rates increase sharply after 40 weeks. Cotzias et al calculated the risk of stillbirth in ongoing pregnancies for each gestational age from 35-43 weeks. The risk of stillbirth was 1 in 926 ongoing pregnancies at 40 weeks gestation, 1 in 826 at 41 weeks, 1 in 769 at 42 weeks, and 1 in 633 at 43 weeks. Uteroplacental insufficiency, asphyxia (with and without meconium), intrauterine infection, and anencephaly all contribute to excess perinatal deaths, although postterm anencephaly is essentially nonexistent with modern obstetrical care. The maternal risks of postterm pregnancy are often underappreciated. These include an increase in labor dystocia (9-12% vs 2-7% at term), an increase in severe perineal injury (3rd and 4th degree perineal lacerations) related to macrosomia (3.3% vs 2.6% at term) and operative vaginal delivery, and a doubling in the rate of cesarean delivery (14% vs 7% at term). 2 CHAPTER II

LITERATURE VIEW OF POST TERM PREGNANCY

II.1

DEFINITION The international definition of prolonged or post term pregnancy, endorsed by the

American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294 days) or more from the first day of the last menstrual period. It is important to emphasize the phrase "42 completed weeks." 1 II.2 INCIDENCE From their review, Divon and Feldman-Leidner (2008) report that the incidence of postterm pregnancy ranges from 4 to 19 percent. Using criteria that likely overestimate the incidence, approximately 6 percent of 4 million infants born in the United States during 2006 were estimated to have been delivered at 42 weeks or more (Martin and colleagues, 2009). The trend toward fewer births at 42 weeks suggests earlier intervention. Specifically, in 2000, 7.2 percent of births in this country were 42 weeks or beyond, compared with 5.6 percent in 2006. There are contradictory findings concerning the significance of maternal demographic factors such as parity, prior postterm birth, socioeconomic class, and age. Olesen and colleagues (2006) analyzed a variety of risk factors in 3392 participants in the 1998 to 2001.Danish Birth Cohort. They reported that only prepregnancy body mass index (BMI) 25 and nulliparity were significantly associated with prolonged pregnancy. Denison (2008) and Caughey (2009) and their co-workers also reported similar associations. The tendency for some mothers to have repeated postterm births suggests that some prolonged pregnancies are biologically determined. In 27,677 births in Norway, Bakketeig and Bergsj (1991) reported that the incidence of a subsequent post term birth increased from 10 to 27 percent if the first birth was postterm. This was increased to 39 percent if there had been two previous, successive postterm deliveries. Similar results were reported from Missouri by Kistka and colleagues (2007). And Mogren and colleagues (1999) reported that prolonged pregnancy recurred across generations in Swedish women. When mother and daughter had a prolonged pregnancy, the risk for the daughter to have a subsequent post term pregnancy was increased two- to threefold. In another Swedish study, Laursen and associates (2004) found that maternal,
2

but not paternal, genes influenced prolonged pregnancy. Rare fetalplacental factors that have been reported as predisposing to postterm pregnancy include anencephaly, adrenal hypoplasia, and X-linked placental sulfatase deficiency (MacDonald and Siiteri, 1965; Naeye, 1978; Rabe and colleagues, 1983). Boyd et al (1988) found an incidence of post term pregnancy of 7.5% when the diagnosis was based on the menstrual history, 2.6 % when the diagnosis was based on early ultrasound examination, and 1.1% when the diagnosis was based in concurrent menstrual history and ultrasound examination.3 II.3 ETIOLOGY The most common cause of a prolonged pregnancy is an error in the clinical estimation of the gestational age. Other cause are unknown and are probably associated with abnormalities in the biochemical and physiological mechanism responsible for initiation of labor. One example is the prolongation of pregnancy associated with placental sulfatase deficiency. This enzyme plays a critical role in in the synthesis of placental esterogens that are necessary for the development of gap junctions and increased expressions of oxytocin and prostaglandin reseptors in myometrial cells. A second example is the prolongation of pregnancy associated with anencephaly. The lack of development of the fetal hypothalamus negates the production of corticotropinrelasing hormone and the stimulation of the pituitary-adrenal-placental axis necessary for the initiation of partutrition.
Third example is caused by decrease in the pregnancy hormone progesterone is

believed that important events endocrine changes in spurring the process of biomolecular on labor and increases uterine sensitivity to oxytocin, so some authors suspect that the occurrence of postterm pregnancy is still ongoing due to the influence of progesterone.
Fourth example oxytocin is physiologically important role in inducing labor and

oxytocin release from neurohipofisis pregnant women who are less advanced in the pregnancy as one of the factors thought to cause postterm pregnancy.

 Fifth example is pressure on the cervical ganglion of the plexus Frankenhauser will

evoke uterine contractions. In circumstances where there is no pressure on the plexus, such as the location of abnormalities, short cord, and the bottom is still high.
Sixth example is hereditary factor. Some authors claim that a mother who experienced

postterm pregnancy have a tendency to give birth through the month in subsequent pregnancies. Mogren as quoted by Cunningham, states that when a mother experiencing postterm pregnancy when a girl, then most likely his daughter will experience a postterm pregnancy. II.4 DIAGNOSIS

Menstrual History

Some criteria for the diagnosis of postterm pregnancy: the patient must be convinced by her HPHT 28-day cycle and regular Not on the pill contracption at least the last 3 months Further diagnosis is determined by calculating according to formula Naegele. Based on menstrual history, a person designated as postterm pregnancy possibilities are:

No errors determine the last period and it lasts through the month of pregnancy. Errors in determining the date of last menstrual period or due to abnormal menstruation. Date of last period clearly known, but a delay ovulation.

Antenatal history:

Pregnancy can be expressed as postterm pregnancies obtained when 3 or more of the four criteria of examination results as follows:

36 weeks have passed since a positive pregnancy test 32 weeks have passed since the first audible fetal heart rate with Doppler 24 weeks have passed since the first fetal movement felt 22 weeks have passed since hearing the fetal heartbeat with a stethoscope Laennec first.1

 Ultrasonography examination Ultrasonographic dating early in pregnancy can improve the reliability of the EDD (estimated due date). However, it is necessary to understand the margin of error reported at various times during each trimester. A calculated gestational age by composite biometry from a sonogram must be considered an estimate and must take into account the range of possibilities. Measurement of the crownrump length (CRL) at early pregnancy ultrasound has been shown to give a more accurate estimate of gestational age and so decrease the incidence of prolonged pregnancy. However, ultrasound has a degree of error: 7 days up to 20 weeks gestation, 14 days between 20 and 30 weeks and 21 days beyond 30 weeks. It is for these reasons that the National Institute of Clinical Excellence (NICE) recommends a dating ultrasound examination between 10 and 13 weeks to estimate the gestation of a pregnancy.5.7 In addition to the CRL, biparietal diameter and femur length, some parameters in ultrasound examination can also be used such as abdominal circumference, head circumference, and some formulas that are some of the results of the calculation of the parameters mentioned above. In contrast, examination shortly after the third trimester can be used to determine fetal weight, amniotic fluid state, or any state of the placenta is frequently associated with postterm pregnancy, but it's hard to make sure the age of pregnancy. Gestational Age for CRL Age CRL (cm) 6.1 Weeks: 0.4 cm 7.2 Weeks: 1.0 cm 8.0 Weeks: 1.6 cm 9.2 Weeks: 2.5 cm 9.9 Weeks: 3.0 cm 10.9 Weeks: 4.0 cm 12.1 Weeks: 5.5 cm 13.2 Weeks: 7.0 cm 14.0 Weeks: 8.0 cm The following formula is an approximation: Gestational age [weeks of pregnancy] = crown-rump length (cm) + 6.5 4.8

 Laboratory examination

Levels of lecithin / spingomielin. When L / P in the amniotic fluid levels are the same, then about 22-28 weeks gestational age, L = 1.2 P: 28-32 weeks, pregnancy at term on the L / P = 2. This check can not be used to determine the postterm pregnancy, but only used to determine whether the fetus is old enough / mature for birth-related action to prevent errors in termination of pregnancy.

Thromboplastin

activity

of

amniotic

fluid

(ATCA).

Hatswell successfully mebuktikan that amniotic fluid accelerates blood clotting time. This activity increases with gestational age 41-42 weeks ATCA range 45-65 seconds, at the age of more than 42 weeks gestation ATCA obtained less than 45 seconds. When obtained ATCA between 42-46 seconds indicates that pregnancy lasts through time.

Amniotic fluid cytology Painting with nile blue sulphate can see the fat cells in the amniotic fluid. When the number of cells containing fat exceeds 10%, then an estimated 36 weeks gestation and if 50% or more, then the age of 39 weeks' gestation or more.1

II.5 CHANGES ASSOCIATED IN POSTERM PREGNANCY Placental Changes The post term placenta shows decrease in diameter and length of the chorionic villi, fibrinoid necrosis, and accelerated atherosis of the chorionic and decidual vessels. This changes occur simultaneously with or precede of the hemorragic infracts, which are foci for calcium deposition and formation of white infracts. Infracts are present in 10-25% of term and 60-80% of post-term placentas. They are more common at the placental borders. Deposition of calcium in the post-term placenta reaches up to 10 g of dry tissue weight, whereas it is only 2-3 g per 100 g in placentas term. The morphologic changes that occur with placental senescence can be observed by ultrasound and were originally described by Grannum et al (1979). There are several grade of placenta:

During the first part of gestation the ultrasonic appearance of the placenta is homogenous, without echogenic densities, and limited by a smooth chorionic plate (grade 0 placenta).
6

With proggresion of pregnancy the chorionic plate begins acquire subtle undulation, and echogenic densities appear randomly dispersed throughout the organ but sparing its basal layer (grade I placenta).

Near term the indentations in the chorionic plate become more marked, echogenic densities appear in the basal layer, and commalike densities seem to extend from chorionic plate into the substance of the placenta (grade II).

Finally, when the pregnancy is at term or post-term the identation in the chorionic plate become more marked, giving the appearance of cotyledons. This impression is reinforced by increased of confluency of the comma-like densities that become the intercotyledonary septations. Also, characteristically, the central portion of the cotyledons become echo-free (fallour areas), and large irregular densities, capable of casting acoustic shadows, appear in the substance of the placenta (grade III placenta).4

Amniotic Fluid Changes There are quantitative and qualitative changes in the amniotic fluid with prolongation of pregnancy. The amniotic fluid volume reaches a peak of about 1000 ml at 38 weeks of gestation and decreases to about 800 ml at 40 weeks. This reduction in volume continous and the amount of fluid is approximately 480, 250, and 160ml at 42, 43, and 44 weeks, respectively. An amniotic fluid volume under 400 ml at 40 or more weeks is associated with fetal complication. The cause of oligohidramnios in prolonged pregnancy seems to be dismished fetal urine production. The four-quadrant technique (Phelan et al, 1987) is the most popular method to evaluate amniotic fluid volume. The four quadrant technique consist of measuring the vertical diameter of the largest pocket of fluid found in each of the four quadrants of the uterus. The sum of the results is the amniotic fluid index (AFI). An AFI less than 5cm indicates oligohidramnios. An AFI between 5 and 10 cm indicates a decreased fluid volume. An AFI between 10-15 cm is normal. An AFI between 15 and 20 cm indicates increased fluis volume. Finally, an AFI greater than 25 cm is suggestive of polyhidramnion.

Volume of amnionic fluid during the last weeks of pregnancy. (Adapted from The Lancet, Vol. 278, PM Elliott and WHW Inman, Volume of liquor amnii in normal and abnormal pregnancy, pp. 835840, Copyright 1961, with permission from Elsevier.) The volume of amnionic fluid normally continues to decrease after 38 weeks and may become problematic. Moreover, meconium release into an already reduced amnionic fluid volume causes thick, viscous meconium that may cause meconium aspiration syndrome.3 II.6 FETAL AND NEONATAL PROBLEMS IN POST TERM PREGNANCY Fetal Distress The principal reasons for increased risks for postterm fetuses were described by Leveno and associates (1984). They reported that both antepartum fetal jeopardy and intrapartum fetal distress were the consequence of cord compression associated with oligohydramnios. In their analysis of 727 postterm pregnancies, intrapartum fetal distress detected with electronic monitoring was not associated with late decelerations characteristic of uteroplacental insufficiency. Instead, one or more prolonged decelerations such as shown in Figure 37-5 preceded three fourths of emergency cesarean deliveries for nonreassuring fetal heart rate tracings.
8

In all but two cases, there were also variable decelerations (Fig. 37-6). Another common fetal heart rate pattern, although not ominous by itself, was the saltatory baseline shown in Figure 37-7.

Saltatory baseline fetal heart rate showing oscillations exceeding 20 bpm and associated with oligohydramnios in a postterm pregnancy. (This figure was published in American Journal of Obstetrics & Gynecology, Vol. 150, No. 5, pt. 1, KJ Leveno, JG Quirk, Jr., FG Cunningham, et al., Prolonged pregnancy. I. Observations concerning the causes of fetal distress, pp. 465473, Copyright Elsevier 1984.)
9

These findings are consistent with cord occlusion as the proximate cause of the nonreassuring tracings. Other correlates found were oligohydramnios and viscous meconium. Schaffer and colleagues (2005) implicated a nuchal cord in abnormal intrapartum fetal heart rate patterns, meconium, and compromised newborn condition in prolonged pregnancies.4 Postmaturity Sindrome The postmature infant presents a unique and characteristic appearance such as shown in Figure 37-3. Features include wrinkled, patchy, peeling skin; a long, thin body suggesting wasting; and advanced maturity because 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. Most such postmature infants are not technically growth restricted because their birthweight seldom falls below the 10th percentile for gestational age. On the other hand, severe growth restrictionwhich logically must have preceded completion of 42 weeksmay be present.

Postmature infant delivered at 43 weeks' gestation. Thick, viscous meconium coated the desquamating skin. Note the long, thin appearance and wrinkling of the hands. (www.accessmedicine.com) 3

10

Based on the degree of placental insufficiency occurs, the sign postmaturitas can be divided into three stages, namely: Stage I skin showed loss of vernix caseosa and maceration of the skin is dry, brittle, and easy to peel. Stage II of the above symptoms with meconium staining of the skin Stage III accompanied by yellowish staining of the nails, skin, and umbilical cord.1

Fetal Weight If there is a large anatomic changes in the placenta, then decreased fetal weight. From research it appears that Vourherr after 36 weeks gestation srafik average fetal growth leveled off and looked a decrease after 42 weeks. However, often also the placenta was still able to function properly so that the weight of the fetus continues to grow in accordance with increasing gestational age. Zwerdling said that the average fetal weight of more than 3600 grams at 44.5% in postterm pregnancies, while in even-numbered month of pregnancy by 30.6%. The risk of birth to a baby weighing more than 4000 grams at postterm pregnancies increased by 2-4 times greater than at term pregnancy.(sarwono) Divon and associates (1998) and Clausson and co-workers (1999) analyzed births between 1991 and 1995 in the National Swedish Medical Birth Registry. Stillbirths were more common among growth-restricted infants who were delivered after 42 weeks. Indeed, a third of postterm stillborn infants were growth restricted.3

11

Mean daily fetal growth during previous week of gestation. (From Jazayeri and co-workers, 1998, with permission.) Meconium aspiration Beyond term, the fetus is more likely to have a bowel movement, called meconium, into the amniotic fluid. If the fetus is stressed, there is a chance it will inhale some of this meconium stained amniotic fluid, this can cause breathing problems when the baby is born. The problems occurs more frequently when thick meconium, fetal tachychardia and absence of FHR accelerations are present. The further the pregnancy progresses beyond 40 weeks, the more likely it is that significant amounts of meconium will be present. This is due to increased uteroplacental insufficiency, which leads to hypoxia in labor and activation of the vagal system. In addition, the presence of a smaller amount of amniotic fluid increases the relative concentration of meconium in utero.2.7 II.7 MATERNAL COMPLICATION The maternal risks due to a prolonged pregnancy are commonly underappreciated. Prolonged pregnancy is associated with risks to the mother during labour
12

and delivery whether labour is induced or occurs spontaneously. It leads to anxiety in the mother due to a perception of danger to her baby. Fetal macrosomia can lead to a significant increase in prolonged labour, perineal, vaginal and cervical trauma, and postpartum haemorrhage. There is an increase in the rate of deliveries by caesarean section which is associated with potential complications such as haemorrhage, infection and thromboembolism. Maternal complications of prolonged pregnancy

Macrosomic fetus Cephalopelvic disproportion Labour dystocia Perineal, vaginal and cervical trauma Delivery by caesarean section Postpartum haemorrhage Chorioamnionitis Anxiety5

II.8

IDENTIFICATION OF PATIENTS WHO NEED TO BE DELIVERED

High risk pregnancies Patients with high risk pregnancies, especially those with diabetes and hypertension need to be delivered withoud consideration to the favorability of their cervix. Expectant management in these cases is not adequate because prolongation of pregnancy will place their fetuses at additional risk. Women with favorable cervices Multiple studies have shown that the risk of caesarean following induction of labor is directly associated with the status of the cervix. These studies have also shown that women wit favorable cervices are at low risk for abdominal delivery. Fot this reason, the majority of investigators are in favor of induction and delivery of women with favorable cervices who have reached or urpased their EDD.

13

The classical method for evaluation the cervix is the Bishop score. Score Cervical dilatation Cervical effacement (%) Fetal Station Cervical consistency Cervical position From Bishop EH. Pelvic scoring for elective induction Obstet Gynecology 1964;24;266 Bishop modification by dr Gulardi H Winjosastro SpOG.6 Score Cervical position Cervical dilatation Cervical consistency Cervical thickness Head position 0 Posterior Closed Firm 3cm 1 Axial 1-2 cm Soft 2cm Hodge I-II 2 Anterior >3cm Soft 1cm Hodge II-III 0 Closed 0-30 -3 Firm Posterior 1 1-2 40-50 -2 Medium Mid 2 3-4 60-70 -1 or 0 Soft Anterior 3 >= 5 >=80 +1 or +2 Soft Anterior

A Bishop score >= 8 is a good index of inducibility, score 6 or more is a favorable cervix to attempt induction, and score less than 4 is indication to ripening the cervix. Decreased Amniotic fluid volume The evaluation of amniotic fluid volume is of fundamental importance in prolonged pregnancies. Chamberlain et al (1984) demonstrated that perinatal mortality increases dramatically with progressive severity of oligohidramnion. Loveno et al (1984) demostrated that umbilical cord compression secondary to oligohydramnios is the most common cause of intrapartum fetal distress in these patients. For this reasons, women with oligohidramnios need to be delivered.2

14

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 of 6 or less, umbilical arterial blood pH less than 7.1, or admission to the neonatal intensive care unit. (Adapted from Fischer RL, McDonnell M, Bianculli KW, et al: Amniotic fluid volume estimation in the postdate pregnancy: A comparison of techniques, Obstetrics & Gynecology, 1993, vol. 81, no. 5, part 1, pp. 698704, with permission.) Regardless of the criteria used to diagnose oligohydramnios in postterm pregnancies, most investigators have found an increased incidence of "fetal distress" during labor. Clement and co-workers (1987) described six postterm pregnancies in which amnionic fluid volume diminished abruptly over 24 hoursin one of these, the fetus died. Macrosomic fetuses The velocity of fetal weight gain peaks at approximately 37 weeks. Although growth velocity slows at that time, most fetuses continue to gain weight. For example,
15

the percentage of fetuses born in 2006 whose birthweight exceeded 4000 g was 8.5 percent at 37 to 41 weeks and increased to 11.2 percent at 42 weeks or more (Martin and colleagues, 2009). Intuitively at least, it seems that both maternal and fetal morbidity associated with macrosomia would be mitigated with timely induction to preempt further growth. This does not appear to be the case, however, and the American College of Obstetricians and Gynecologists (2000) has concluded that current evidence does not support such a practice in women at term with suspected fetal macrosomia. The importance of the prenatal estimation of fetal weight in women with prolonged pregnancis is to determine the approach to delivery. Pasient with estimated fetal weight more of 4500 grams or more should be causeled to have caesarean delivery because the possibility of traumatic vaginal delivery is substantial. Caesarean section should be offered also to women who have previously delivered infants with similiar or larger birth weight, because prior delivery does not guarantee an easy delivery of another large baby.3 Fetal growth restriction A fetal growth abnormality associated with prolonged pregnancy is poor fetal growth or dysmaturity. Approximately 5-10% of fetuses delivered after their EDD show wasting of their subcutaneus fat characteristic of intrauterine malnutrition and are classified as small for gestasional age by neonatal evaluation. Frequently this fetuses exhibit abnormal FHR patterns before delivery or in the course of labor. The amount of amniotic fluid is reduced in most of these cases and meconium aspiration is a common problem. Fetal manutrition is associated with multiple problems during immediate neonatal period including hypoglicemia, hypocalemia, and hyperviscosity syndrome. 4 II.9 POST TERM PREGNANCY TREATMENT

Antenatal fetal monitoring In most cases, a healthcare provider will recommend tests on the fetus if the pregnancy extends beyond the due date. These tests give information about the health of the fetus and about the risks or benefits of allowing the pregnancy to continue. The
16

American College of Obstetricians and Gynecologists has stated that it is only necessary to start antenatal fetal monitoring after 42 weeks (294 days) of gestation, although many obstetric care providers will start fetal testing at 41 weeks. Many experts recommend twice weekly testing, including a measurement of amniotic fluid volume. Testing may include observing the fetus' heart rate using a fetal monitor (called a nonstress test) or observing the baby's activity with ultrasound (called a biophysical profile). Nonstress testing Nonstress testing is done by monitoring the baby's heart rate with a small device that is placed on the mother's abdomen. The device uses sound waves (ultrasound) to measure the baby's heart rate over time, usually for 20 to 30 minutes. Normally, the baby's baseline heart rate should be between 110 and 160 beats per minute and should increase above its baseline by at least 15 beats per minute for 15 seconds when the baby moves. The test is considered reassuring (called "reactive") if two or more fetal heart rate increases are seen within a 20 minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes. Biophysical profile A biophysical profile (BPP) score is calculated to assess the fetus' health. It consists of five components, nonstress testing and ultrasound measurement of four fetal parameters: fetal body movements, breathing movements, fetal tone (flexion and extension of an arm, leg, or the spine), and amniotic fluid volume. Each component is scored individually, 2 points if normal and 0 points if not normal. The maximum possible score is 10. Amniotic fluid volume is an important variable in the BPP because a low volume (called oligohydramnios) may increase the risk of umbilical cord compression and may be a sign of changes in the feto-uteroplacental circulation. Amniotic fluid level can become reduced within a short time period, even a few days. Contraction stress test A contraction stress test (CST) can also be done to assess fetal health. It involves giving an intravenous medication (oxytocin) to the mother to induce uterine
17

contractions. The fetus' heart rate is monitored in response to the contractions. A fetus whose heart rate slows down during a CST may require a cesarean delivery.7 Inducing of labor Once the decision to deliver a patient has been made, the management of the labor induction depends on the clinical setting, and a brief review of cervical ripening agents and potential complications of induction of labor is appropriate. As many as 80% of patients who reach 42 weeks' gestation have an unfavorable cervical examination (ie, Bishop Score < 7). Many options are available for cervical ripening. The different preparations, indications, contraindications, and multiple dosing regimes of each require practitioners to familiarize themselves with several of the preparations. Currently available chemical preparations include prostaglandin E1 tablets for oral or vaginal use (misoprostol), prostaglandin E2 gel for intracervical application (dinoprostone cervical [Prepidil]), and a prostaglandin E2 vaginal insert (dinoprostone [Cervidil]). Cervidil contains 10 mg of dinoprostone and has a lower constant release of medication than Prepidil. In addition, this vaginal insert device allows for easier removal in the event of uterine hyperstimulation. Many studies have compared the efficacy and risks of various prostaglandin cervical ripening agents. Rozenburg et al performed a randomized trial comparing intravaginal misoprostol and dinoprostone vaginal insert in pregnancies at high risk of fetal distress. They found that both methods were equally safe for the induction of labor and misoprostol was actually more effective. Another method for ripening the cervix is by mechanical dilation. These devices may act by a combination of mechanical forces and by causing release of endogenous prostaglandins. Foley balloon catheters placed in the cervix, extra-amniotic saline infusions, and laminaria have all been studied and have been shown to be effective. Regardless of what method is chosen for cervical ripening, the practitioner must be aware of the potential hazards surrounding the use of these agents in the patient with a scarred uterus. In addition, the potential for uterine tachysystole and subsequent fetal distress requires that care be taken to avoid using too high a dose or too short a dosing
18

interval in an attempt to get a patient delivered rapidly. Care should also be taken when using combinations of mechanical and pharmacologic methods of cervical ripening. Finally, intrapartum fetal surveillance in an attempt to document fetal intolerance to labor before it leads to acidosis is critical. Whether continuous fetal monitoring or intermittent auscultation is used, interpretation of the results by a welltrained clinician is of paramount importance. If the fetal heart rate tracing is equivocal, fetal scalp stimulation and/or fetal scalp blood sampling may provide the reassurance necessary to justify continuing the induction of labor. If the practitioner cannot find reassurance that the fetus is tolerating labor, cesarean delivery is recommended. 4 Antepartum management of post term pregnancy.

Source: Arias F, Daftary S, et al. Practical Guide to high risk pregnancy and delivery. Chapter 11: Prolonged pregnancy. Third edition. 2010. Elsevier: India. Page 286.

CHAPTER III CASE ILUSTRATION I. IDENTITY PATIENT

19

Name Age Religion Tribe Education Occupation Address

: Mrs. IP : 29 yrs : Islam : Betawi : High school : Housewife : Depok

Sign in hospital: Friday, January 6th, 2012, at 11.45 a.m II.ANAMNESIS Autoanamnesis dated, January 6th, 2012, at 11.45 a.m A. Chief complaint referenced from a midwife because of reduced amniotic fluid B. History of Present Illness Patient admit that she has 10 months pregnancy, first day of last menstrual period : February 28th 2011 ~ 44 weeks. Estimated day of delivery : December 5th 2011. Patient complain referenced from a midwife because of reduced amniotic fluid. ANC routinely at Puskesmas, USG 2 times with first on 18thJuly 2011, the result was 20 weeks pregnancy. The last USG was on 2 January 2012 and the results was the baby in good condition, head presentation, reduced amniotic fluid and postmature baby in pregnancy. The patient said there was a little vaginal discharge 1 hours before admitted with no bloody show . Backacghe about a week befor admissions and it become more frequently. History of fever and hypertension during pregnant were denied. Defecate and mixture are no complaints. Patient hasnt a hole tooth. Traumatical history, headache, nausea, vomit, and blur vision was denied. Fetal movement still felt. C. Menstrual History
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Menarche at the age of 15 years, 28 days cycle, regular, duration 7 days, the number of 2-3 pads / day, menstrual pain (+) First day of last menstrual period: February 28th 2011 Estimated day of delivery : December 5th 2011 D. Marital Status Status married, marriage 2x, first 8 years of marriage and then divorced, second marriage for 3 years and still married untill now. E. History of previous pregnancy 1. Normal delivery, , 12 years old, 1700 gram, delivered by doctor 2. Normal delivery, , 6 years old, 3200 gram, delivered by midwife 3. Normal delivery, , 1.5 years old, 3200 gram, delivered by midwife, history with postterm pregnancy43 weeks 4. Current pregnancy F. History of present pregnancy Early pregnancy : Nausea (+), vomits (-), bleeding (-), hypertension (-) Later pregnancy : sweeling foot (-), hypertension (-), dyspnea (-). ANC at Puskesmas monthly. G. History of contraception Injection contraception for every 3 months.The pasient stoped to use contraception, at least 5 months before pregnancy. H. History of Systemic Disease Heart disease (-), respiratory disease (-), hypertension (-), diabetes mellitus (-)
21

I. Surgery History None J. History of Family Disease Heart disease (-), respiratory disease (-), hypertension (-), Diabetes Mellitus (-) K. Habit and Psychosocial History No smoking, drinking alcohol, drugs and drinking herbal medicine. III. PHYSICAL EXAMINATION A. General examination General impression Degree of consciousness Vital signs : moderate illness : compos mentis : BP 120/80 mmHg, HR 80 x/m, RR 20x/', T 36.50C

Body weight before present pregnancy: 50 kg Body weight during present pregnancy: 61 kg Head Eyes Mouth Ears Nose Throat Neck : Normocephali, black hair, straight, uniform distribution : Conjungtiva anemic -/-, sklera not icteric. : Not dry, not Cyanosis. : Normotia, secretions serumen (-/-) : Normosepta, secretions (-/-). : Pharynx not hiperemis. : Enlarged glands (-).

22

Thorax Cor : Regular I-II heart sound, murmurs (-), Gallop (-).

Pulmo : Vesicular breath sound, Rh (-/-), Wh (-/-). Breast : Symmetric, hyperpigmentation on both the areola, retracted nipple (-), mass (-) Extremity : warm extremities, swelling -/-

B. Obstetrical Status Abdomen: Inspection Palpation: - Leopold I : fungal height 30 cm, a hard, round, ballotable, and nodular body not : abdomen enlarged and distended, striae gravidarum (+).

easy to move in palpation - Leopold II Left Right - Leopold III - Leopold IV - His : : a small parts of the fetus is palpable : a hard resistant and board like structure : hard, round, ballotable, moveable, pandular like and nodular body : 5/5 : irreguler : 3410 g

- Fetal weight estimation(FWE)

Auscultation : 2 punctum maximum, fetal heart sound 142 ppm, regular. Anogenital:
23

- Inspection

: Vulva/urethra no sign of inflammation, bleeding (-), edema (-), varicose (-)

- Speculum examination : portio livid, ostium opened, fluor (-), fluxus (-) - VT : firm portio,posterior, cervix dilatation 1 cm, thickness 3 membrane (+), head was palpated on H I-II IV. SUPPORTIVE EXAMINATION A. Laboratory (January 06th, 2011) BLOOD Hb Ht Leukocytes Erythrocyte Platelets Type of blood Spot glucose blood MCV : 77.0 fl MCH : 28.0 pg MCHC : 38.0 g/dl RDW : 25 % URINALYSIS Color : yellow : 10 g/dl : 30 vol% : 10.600 uL : 4.52 billions/ uL Erythrocytes : 292.000 uL :B/+ : 80 mg / dl view field Cylinders Crystal Protein Ketones Blood Bilirubin Urobilinogen Nitrite :::: (-) : +3 : (-) : 1.0 :(-) : 1-2 / magnified Clarity pH Sediments Leukocytes view field : clear : 7.0 : + 1 epithelial cells : 6-8 / magnified cm, amniotic

24

B. US (January 06th, 2011)

Fetus : Alive, Single, Head presentation BPD: 9.38 cm AC: 29.68 cm FL: 6.96 cm FWE: 3410 g Plasenta : right corpus

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AFI: 7.53 cm Aterm

Placenta in right of uterine corpus, does not seem loops of the cord, does not seems major congenital defect. Assessment : appropriate with aterm pregnancy live, single, head presentation, reduced amniotic fluid.

C. CTG (January 06th, 2012)

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 Baseline frequency
Variability

140 dpm 5-20 dpm (+) (-) (+) (-) : Reassuring

Acseleration Deceleration Fetus movement His Assesment

V. RESUME
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Patient admit that she has 10 month pregnancy, first day of last menstrual period : February 28th 2011~ 44 weeks. Estimated day of delivery : December 5th 2012. Patient complain referenced from a midwife because of reduced amniotic fluid. ANC routinely at Puskesmas, USG 2 times with first on 18thJuly 2011, the result was 20 weeks pregnancy. The last USG was on 2 January 2012 and the results was the baby in good condition, head presentation, reduced amniotic fluid and postmature baby in pregnancy. The patient said there was a little vaginal discharge 1 hours before admitted with no bloody show. Backacghe about a week befor admissions and it become more frequently. Fetal movement still felt. In generalist examination are normal. In Obstetrical examination, we finded:

Abdomen enlarged and distended Fungal height 30 cm Irregular contraction Head presentation Fetal Weight Estimation: 3410g On auscultation, there is 2 punctum maximum, fetal heart sound 140 ppm In Anogenital examination we finded no inflammation sign, bleeding, edema, varicose. Speculum examination : portio livid, ostium opened, fluor (-), fluxus (-); VT : firm portio, posterior, cervix dilatation 1 cm, thickness 3 cm, amniotic membrane (+), head was palpated on H I-II.

In USG, placenta in right of uterine corpus, does not seem loops of the cord, does not seems major congenital defect; appropriate with aterm pregnancy, live, singleton, head presentation, reduced amniotic fluid.. In CTG, fetus is reassuring

VI. DIAGNOSIS

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Maternal :
G4P3 Pregnant 44 weeks, reduced amniotic fluid, immature cervix, not yet inpartu

Fetal : singleton live head presentation VII. MANAGEMENT

Induction with folley catheter 1x24 hoursobserve progress of labour re-evaluate

after 24 hours VII. PROGNOSIS Mother: Dubia ad bonam Fetus : Dubia ad bonam VIII. Follow Up Result January 07th 2012 22.00 p.m S O : FC loose spontaneus, fetal movement (+), water brooke (+) : General condition: good Conciousness: compos mentis BP 120/70 mmHg, HR 88x/, RR 20x/, T 36,5oC The general examination: performed revealed stable , Obstetric st. : his 1-2 x/10/20 , FHR : 142 dpm Inspection: V/U calm VT : firm porsio, axial, 4 cm, T =1 cm, amniotic membrane (-), the head was palpated on H I-II

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: latent stage I in delivery G4P3H 44 weeks pregnancy, fetus with singleton live head

presentation P : obs signs of inpartu, his, FHR/hour Pervaginam delivery Acceleration with oksitosin 5 IU/500cc RL start with 8 drops up then 4 drops/30 untill his 3x/10 January 07th, 2012 23.00 p.m. S O : contraction (+), fetus movement (+) : General condition: good Conciousness: compos mentis BP 110/70 mmHg, HR 84x/, RR 20x/, T 36,5oC The general examination: other performed revealed stable Obstetric st. : contraction (+) 3x/10, FHR : 136 dpm Inspection: V/U calm VT : firm porsio, axial, 6 cm, T =1 cm, amniotic membrane (-), the head was palpated on H II-III A P : active stage I in delivery G4P3H 44 mgg fetus singleton live head presentation : obs signs of inpartu.

January 8th, 2011 03.00 a.m. S O : straining (+) , fetus movement (+) : General condition: good

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Conciousness: compos mentis BP 120/80 mmHg, HR 92x/, RR 20x/, T 36,5oC The general examination: performed revealed stable Obstetric st. : his 4x/10/45, FHR : 142 dpm Inspection: vulva perineum VT : firm porsio, axial, 10 cm, T =1 cm, amniotic membrane (-), the head was palpated on H II-III A P : stage II in delivery on G4P3H 44 mgg fetus singleton live head presentation : partus pervaginam FHR/5 January 8th, 2012 04.00 a.m. Spontaneus delivery, born baby girl with AS 8/9, body weight 3500 grams meconium aminiotic fluid Oksitosin 10IU Complete placenta Good fundus contraction IUD post plasenta Intact perineum, bleeding 400cc

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 Features of post-maturity syndrome Wrinkled (sometimes peeling) skin Meconium-stained skin and nails Long nails Calcified skull Little or no vernix No lanugo January 9th, 2012 05.30 a.m. S O : pain (-), bleeding (-) : General condition: good Conciousness: compos mentis BP 100/80 mmHg, HR 86x/, RR 20x/, T 36,7oC The general examination: performed revealed stable
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Obstetric st. : fundus uterine height 3 fingers below umbilicus, contraction normal Inspection: V/U calm, bleeding (-) A : Puerperium day 1, P 4, spontaneus postpartum + IUD Akseptor

: Observe vital sign (blood pressure, pulse, temperature, respiratory rate), bleeding , contraction. Active mobilization High carbohidrate and high protein diet Perineum and vulva hygiene Amoxicillin 3x500 mg SF 1x1 Asam mefenamat 3x500 mg

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CHAPTER IV CASE ANALYSIS In this patient, Mrs IP 29 years, we diagnosed the patient with G4P3 Pregnant 44 weeks, reduced amniotic fluid, immature cervix, not yet inpartu based upon the anamnesa we found that she has 44 weeks pregnancy, which is the first day of last menstrual period was on February 28th 2011 so the estimated day of delivery must be on December 5th 2012. As the definition from the American College of Obstetricians and Gynecologists (2004), international definition of prolonged or postterm pregnancy is 42 completed weeks (294 days) or more from the first day of the last menstrual period. She also has 28 day regular cycle of menstruation and she wasnt has contraception for 5 months before pregnancy. Otherwise, to make complete data of post term pregnancy we should have the record of antenatal examination such as date of test pack a positive pregnancy test, first audible fetal heart rate with Doppler, the first fetal movement felt. Moreover, we need the record of ultrasound examination between 10 and 13 weeks to estimate the gestation of a pregnancy by the Crown-rump length (CRL). Then if there is adequate facilities available we can do some laboratory examination such as levels of lecitin and sphyngomielin, Thromboplastin activity of amniotic fluid (ATCA), and amniotic fluid cytology. Although this patient didnt have that data, we still have diagnose this pregnancy as a post term pregnancy based on anamnesa of menstrual history because this convinced her last menstrual period, 28-day cycle and regular, not on the pill contracption at least the last 3 months. Patient said that she has previous post term pregnancy for 43 weeks before this pregnancy. As research that the tendency for some mothers to have repeated postterm births suggests that some prolonged pregnancies are biologically determined. In 27,677 births in Norway, Bakketeig and Bergsj (1991) reported that the incidence of a subsequent post term birth increased from 10 to 27 percent if the first birth was postterm.

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On physical examination, we found there was a decrease in fundal height, it could be caused by the decrease of amniotic fluid in post term pregnancy. This result confirmed by ultrasonografic and we found that total estimated AFI four quadrant is 7.53 cm. This result showed reduced in amniotic fluid. In post term pregnancy usually we found the decreased amniotic fluid volume which is caused by the decrease of placenta function. Chamberlain et al (1984) demostrated that perinatal mortality increases dramatically with severity if oligohidramnios. This situation can lead to umbilical cord compression of the fetus. This is one of the reason that the patient need to be delivered. In obstetric examination we also found that vaginal touche result is firm portio, posterior, cervix dilatation 1 cm, thickness 3 cm, amniotic membrane (+), head was palpated on HI-II So, the bishop score is 2. This result show us unfavorable cervix for this patient. So to strart the management of delivery we need the cervical ripening before we give induction and lead the patient to delivery. The patient born the baby with postmature syndrome: wrinkled (sometimes peeling) skin, meconium-stained skin and nails, long nails, calcified skull, little or no vernix, no lanugo.

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CHAPTER V CONCLUSION AND SUGGESTION CONCLUSION

A pregnancy that continues for 42 completed weeks ( 294 days) or more is considered

prolonged or post term pregnancy. The recurrence risk for post-term pregnancy is 20%.

Early ultrasound estimation of gestational age (using crownrump length (CRL)) reduces the incidence of prolonged pregnancy and reduces induction rates for prolonged pregnancy. There is an increased risk of perinatal death with increasing gestational age but the absolute risk is very low.

Present evidence favours routine induction of labour after 41 weeks gestation, as this

reduces perinatal mortality.

The management for delivery of this patient was appropriate to the theory.

SUGGESTION The health care should advice the patient to have fetal monitoring for pregnancy over 41 weeks about two times a week. Which is consist of monitoring fetal heart rate with nonstress test and biophusical profile to reduce neonatal mortality in post term pregnancy.

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LITERATURE
1. Prawirohardjo S. Post term pregnancy. Obsetrics. 2009. Second edition. Yayasan Bina

Pustaka Sarwono Prawirohardjo:Jakarta. Page 686-93

2. Aaron B Caughey, MD; Chief Editor: David Chelmow, MD . Updated on 25 March

2011. Post term pregnancy. http://emedicine.medscape.com/article/261369-overview

3. Cunningham, Leveno, et al. Chapter 37. Post term Pregnancy.Williams Obstetrics, 23e.

2011. The McGraw-Hill Companies:United States.

4. Arias F, Daftary S, et al. Practical Guide to high risk pregnancy and delivery. Chapter

11: Prolonged pregnancy. Third edition. 2010. Elsevier: India. Page 277-90
5. Anand J, Sharmila P, Katharine PS. Prolonged pregnancy. Obstetrics, Gynaecology &

Reproductive

Medicine.

2012.

Elsevier.

http://www.sciencedirect.com/science/article/pii/S175172140700228X
6. Bishop score modified by Gulardi. Accessed on January 25, 2012. Published on the

website http://puskesmaspalaran.wordpress.com.
7. Norwitz, Errol. Patient information: Post term pregnancy. Updated in 2012.

http://www.uptodate.com/contents/patient-information-postterm-pregnancy.
8. Wikipedia. Crown-rump length. Update in 9 October 2011. www.wikipedia.com

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