post term px chalie..................pptx

post term px

1. Category X Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

2. …. Example drugs: atorvastatin, simvastatin, finasteride thalidomide , oral contraceptives , misoprostol, valproate , Methotrexate ,Ribavirin, Triazolam , Bosentan , Aliskiren , Emergency contraception, Levonorgestrel , Ulipristal .

3. Post term pregnancy Definition: A pregnancy that has been beyond 42 weeks of gestation(294 days or EDD+14days) from the first day of LMP Definition is endorsed by ACOG, FIGO & WHO Increased perinatal morbidity & mortality Increased maternal morbidity & mortality

4. Prevalence 4-14%, average is 10% Prevalence varies depending on: Use of U/S for GA determination Primi Vs multi Using LNMP Elective C/D Pregnancy complications 2 -7% of pregnancies complete 43 weeks

5. Etiology Mechanism of normal labor not known, thus cause of prolonged pregnancy remains obscure. When post term pregnancy truly exists, the cause is unknown Common causes: Wrong date: poor recall or variation in follicular phase Biologic variability: hereditar

6. … Fetal factors: Anencephaly Placental factor: sulfatase deficiency Maternal factors: Primigravida , past prolonged pregnancy, elderly multiparity

7. Fetal & Maternal risks Fetal risks are usually associated with small fetuses and maternal complications are due to macrosomic fetuses ( 2x term macrosomia ) Fetal risks: Increased perinatal mortality: twice than at term and four times at 43 weeks & 5-7X at 44 wks or above Uteroplacental insufficiency Meconium aspiration Macrosomia : associated with prolonged labor, CPD& shoulder dystocia

8. Dysmaturity syndrome: 10 - 20 % of post term pregnancies Manifestation of chronic IUGR due to placental insufficiency wrinkled , patchy peeling skin long, thin body (wasting) open eyed, alert old and worried looking Long nails

9. Complications of dysmaturity syndrome Increased fetal heart beat abnormalities Meconium aspiration Umblical cord compression Short term complications: hypoglycemia, seizure, respiratory insufficiency Long term complications: neurologic sequaele .

10. … Metabolic complications: hypoglycemia, hypocalcemia , polycythemia MATERNAL RISKS: Increased Maternal morbidity due to: Induction Instrumental delivery Cesarean delivery

11. Effects are: Dystocia Severe perineal injury with macrosomia Increased C/S delivery –doubled Puerperal infection, PPH Anxiety

12. Diagnosis Estimation of accurate gestational age is mandatory by available best methods. Clinical estimation of gestational age is inferior than ultrasound LNMP is inaccurate in 10-40% of cases because of irregular ovulation, oligomenorrhea & unable to recall LNMP LNMP is helpful when the menstrual cycle is regular.

13. … The diagnosis of truly prolonged and post-term pregnancy is based on accurate gestational dating. The two most commonly used methods to determine the GA are : knowledge of the date of the LMP, (2) early ultrasound assessment Basing gestational age solely on the LMP generally results in an overestimation of gestational age => higher frequency of induction of labor

14. Gestational Age Calculation ACOG criteria: Urine/ serum hcG positive first: 36 weeks has to lapse FHB positive 1st : by Doppler (30 weeks), pinnards (20wkS) Ultrasound: 1s trimester(CRL) 2nd Trimester(BPD, AC, FL) Biochemical: L/S, lecithin/ sphingomyelin , lamellar count, shake test etc…

15. Investigations Purpose of investigation: To confirm fetal maturity To detect evidence of placental insufficiency Assessment of maturity Ultrasound/ ACOG criteria Amniocentesis

16. Assessment of fetal wellbeing: Fetal kick count by mother NST- twice weekly BPP Amniotic fluid volume Doppler studies of umbilical arteries

17. Management Be certain about maturity of fetus Expectant or induction In expectant management, start antepartum testing at 41 weeks twice weekly Induce at 42 weeks if cervix is favorable or by priming Induce/ terminate pregnancy if ante partum tests are non reassuring Terminate the pregnancy at 43 weeks irrespective of the cervical status.

18. Care during labor More use of analgesics Consider possibility of shoulder dystocia Strict fetal monitoring

19. Prevention Accurate dating by early ultrasound: decreased incidence by 70% Manual nipple stimulation at term Electrical breast stimulation Sweeping of membranes near or at term.