POSTTERM PREGNANCY

BY: MONA LIZA BAQUIRAN PASTRANA MD., FPOGS

 DEFINITION
The term post term, prolonged postdate and post maturity are often
used interchangeably to signify pregnancies that exceed a duration considered
to be the upper limit of normal ( that is the Expected Date of Delivery- EDD ) .
Postdates, postterm and prolonged are used to describe the age of pregnancy.
Post maturity is used to describe an infant with recognizable clinical features
indicating a pathologically prolonged pregnancy, postdate refers to age of
pregnancy that has gone beyond the EDD ( 40 wks ) but less than 42 weeks.
INCIDENCE
The 5 year review of data from 2002-2006 by Torres and Mantaos show
an incidence of 0.83%, and post term stillbirth , neonatal death and perinatal
mortality rates of 0.32/1000 births , 0.12/1000 livebirths and 0.44/1000 births
respectively.
MATERNAL, FETAL AND NEONATAL RISKS AND COMPLICATIONS
Maternal risks associated with prolonged pregnancies are :
1. Operative delivery ( increased cesarean delivery rates because of
macrosomia , failure of induction or fetal distress )
2. Infection and hemorrhage due to prolonged labor
3. Considerable psychological morbidity “passed EDC” maternal anxiety

Fetal and neonatal risks and complications :

1. Macrosomia and possible fetal trauma due to shoulder dystocia
2. Fetal hypoxia ( distress and death )
3. Oligohydramios and associated cord accidents during labor /delivery
4. Meconium aspiration syndrome and neonatal pneumothorax
5. Intrauterine growth restriction ( IUGR )
6. Post maturity syndrome.
 Post maturity syndrome - is a specific syndrome of IUGR associated with prolonged
gestation ( 5-10% ). Fetuss are characterized by decreased amount of subcutaneous fats
and wrinkled skin, because they lose the vernix caseosa and are in direct contact with the
amniotic fluid. They also have long hair and nails and the skin may have greenish / yellowish
staining if they have prolonged exposure to meconium.

Pathophysiology of post term related complications:

When pregnancy becomes prolonged , two things happen to the placenta, it
can still remain healthy or undergo degenerative changes in the vessels ( fibrinoid necrosis
and accelerated atherosclerosis ).
If the placenta remains healthy , there will be progressive delivery of nutrition to
the fetus leading to macrosomia.
If placenta undergoes degenerative changes this will lead to placental
insufficiency -> fetal hypoxia -> fetus responds by reflex redistribution of blood flow from less
vital organs (liver, soft tissues, kidneys, GIT ) by vasoconstriction, to more vital organs ( brain,
heart, adrenals ) by vasodilatation. In the fetal kidneys , there will be decreased renal
perfusion -> decreased fetal urination, decreased amniotic fluid volume -> oligohydramios
and associated risks of cord complications.
Management Principles :
1. Patient Counselling – Discussion of risks and benefits should be done with the
patients family
2. Antepartum evaluation and management
Establishment of accurate AOG
Antenatal Monitoring – pelvic examination, antenatal fetal surveillance,
ultrasound evaluation , Bishop scoring to check ripeness of the cervix.
3. Conservative versus Active induction of labor
Intrapartum Management.
Complications expected during labor and delivery
Fetal Trauma ( shoulder dystocia )
Intrapartum Fetal Distress
Meconium aspiration syndrome
Conclusion
1. Definite / accurate assignment of AOG
2. Thorough discussion on the risks and benefits and management options
3. If conservative management was chosen by the patient, intensive fetal
monitoring ( focus on NST AFI ) must be done 2 x a week starting at 41
weeks
4. Several methods maybe used for active induction of labor.
5. An in depth knowledge on the pathophysiology of the inherent problems
associated with post term pregnancy.