Prolonged Prolonged pregnancy pregnancy

&&Induction of Induction of

labourlabourDr. Samira Abudia Dr. Samira Abudia MBBCH MDMBBCH MD

Prolonged pregnancyProlonged pregnancy

IntroductionIntroduction-:-:

Prolonged pregnancy is a condition Prolonged pregnancy is a condition that continuous to evoke that continuous to evoke anxiety in clinician and woman anxiety in clinician and woman alike and is perceived as being a alike and is perceived as being a cause of increased risk to the cause of increased risk to the

fetusfetus..

objectiveobjective-:-:

Our aim from this lecture be able toOur aim from this lecture be able to::

Understand the definition of Understand the definition of prolonged pregnancy and prolonged pregnancy and distinguish it from post distinguish it from post maturity syndromematurity syndrome..

Understand the options in the Understand the options in the management of prolonged management of prolonged

pregnancypregnancy . .

Counsel a woman about the risk of Counsel a woman about the risk of prolonged pregnancy prolonged pregnancy..

DefinitionDefinition-:-:

The standard international definition The standard international definition of prolonged pregnancy of prolonged pregnancy by WHO by WHO 42 42 completed weeks or completed weeks or more(more(294294 days or more) from first days or more) from first

day of last menstrual periodday of last menstrual period..

IncidenceIncidence-:-:

Between (Between (4-144-14)% will reach this gestation)% will reach this gestation..

Its recognized that woman who attend late Its recognized that woman who attend late for antenatal care may be for antenatal care may be unsure of her LMPunsure of her LMP..

Dating by last menstrual period alone has Dating by last menstrual period alone has 70%70% tendency to over estimate tendency to over estimate the gestational age (delayed the gestational age (delayed ovulation)ovulation)..

ContCont......

Actual true rate is (Actual true rate is (3-53-5)% when )% when based on ovulation datebased on ovulation date..

Routine use of early ultra sound Routine use of early ultra sound to calculate to calculate gestational age reduce gestational age reduce

incidence from incidence from 9.5%9.5% to to 1.5%1.5%..

Most pregnancies that reliably Most pregnancies that reliably 42 42 weeks probably are not weeks probably are not

biologically prolongedbiologically prolonged..

Aetiology and pathologyAetiology and pathology-:-:

The cause of prolonged pregnancy is not The cause of prolonged pregnancy is not clear may represent simple clear may represent simple biological variationbiological variation..

Prolonged pregnancy more common in Prolonged pregnancy more common in PGPG..

Prolonged pregnancy more common with Prolonged pregnancy more common with H\O previous Prolonged pregnancy H\O previous Prolonged pregnancy 30%30%..

Infant who suffered fetal distress Infant who suffered fetal distress at termat term had had elevatedelevated cortisol levelcortisol level..

ContCont……

Infant who suffered fetal distress at Infant who suffered fetal distress at prolonged prolonged pregnancy pregnancy had had reducedreduced cortisol cortisol levellevel..

Relative Adreno cortical insuffiency delay in Relative Adreno cortical insuffiency delay in onset of labour, increase risk of intra onset of labour, increase risk of intra partum hypoxia, death in prolonged partum hypoxia, death in prolonged

pregnancypregnancy . .

Amniotic fluid fall in prolonged pregnancyAmniotic fluid fall in prolonged pregnancy..

Normal cardiac outputNormal cardiac output..

Doppler velocimetry in uterine, umbilical, Doppler velocimetry in uterine, umbilical, middle cerebral no difference from middle cerebral no difference from term pregnancyterm pregnancy..

Clinical approachClinical approach-:-:

Accurate diagnosis of prolonged Accurate diagnosis of prolonged pregnancy relies up on either pregnancy relies up on either accurate menstrual data or accurate menstrual data or routine ultra sound in routine ultra sound in 11stst or or 22ndnd trimester before trimester before 20 weeks20 weeks if if she is not sure of her date of she is not sure of her date of LMPLMP..

A-HistoryA-History-:-:

Confidence in the menstrual Confidence in the menstrual historyhistory . .

The LMP tend to be accurate ifThe LMP tend to be accurate if-:-:

The patient sure of her dateThe patient sure of her date..

The pregnancy was plannedThe pregnancy was planned..

The cycle was regularThe cycle was regular..

No resent history of oral No resent history of oral contraceptive , abortion or contraceptive , abortion or lactationlactation..

B-Clinical parametersB-Clinical parameters-:-:

Uterine size Uterine size vaginal examination in 1 vaginal examination in 1stst trimester trimester useful in determing gestational ageuseful in determing gestational age..

Fundal height Fundal height abdominal examination abdominal examination..

Quickening Quickening maternal reporting first fetal maternal reporting first fetal movementmovement..

Fetal heart Fetal heart heard by fetoscope at (heard by fetoscope at (18-2018-20)weeks)weeks..

C-Ultra sound parametersC-Ultra sound parameters-:-:

Crown-Rump length (CRL) at (Crown-Rump length (CRL) at (7-7-

10W10W) ) ±± 55daysdays

Biparietal diameter (BPD) at (Biparietal diameter (BPD) at (18-18-

22W22W) ) ±± 7 7daysdays

Fetal and neonatal risks of Fetal and neonatal risks of prolonged pregnancyprolonged pregnancy

11--perinatal morbidity & mortality is increased perinatal morbidity & mortality is increased 2-32-3 times than normal times than normal..

22--post maturity syndromepost maturity syndrome::

Post mature infant features include Post mature infant features include wrinkled, patchy, peeling skin along this wrinkled, patchy, peeling skin along this body suggesting wastingbody suggesting wasting..

Occur in Occur in 20-30 %20-30 % of prolonged pregnancy of prolonged pregnancy characterized by the followingcharacterized by the following-:-:

AA-aging or infarction of placenta lead to -aging or infarction of placenta lead to utero placenta insuffiency which result utero placenta insuffiency which result in decrease oxygenation (fetal in decrease oxygenation (fetal hypoxia) and decrease maturation (decrease hypoxia) and decrease maturation (decrease sub cutaneous tissue) sub cutaneous tissue)..

BB-oligohydramnious which cause -oligohydramnious which cause umbilical cord compressionumbilical cord compression . .

CC-passage of meconium in utero-passage of meconium in utero..

33--macrosomic fetusmacrosomic fetus:: Weight >(Weight >(4000-45004000-4500)gm occur in )gm occur in

7070- - 80%80% leads to leads to : : abnormal labourabnormal labour..

shoulder dystochiashoulder dystochia.. birth traumabirth trauma..

Maternal risks of prolonged Maternal risks of prolonged pregnancypregnancy

Psychological morbidityPsychological morbidity.. The pregnancy is perceived by The pregnancy is perceived by

many woman as becoming many woman as becoming high risk once EDD is passedhigh risk once EDD is passed.. Increased operative delivery (c\s)Increased operative delivery (c\s).. Increased risk of hemorrhage Increased risk of hemorrhage

(prolonged labour)(prolonged labour) . . Increased risk of infectionIncreased risk of infection..

ManagementManagement-:-:Successful management of prolonged Successful management of prolonged pregnancy depend on effective pregnancy depend on effective counselling of a woman and their counselling of a woman and their full involvement in the decision full involvement in the decision

making processmaking process . .A-A-if the date are confirmed and the cervix if the date are confirmed and the cervix are favourableare favourable..

Labour should be inducedLabour should be induced:: artificial rupture of membrane (artificial rupture of membrane (AROMAROM))..

intra venous (intra venous (IVIV) ) oxytocinoxytocin.. Continous intra partum fetal monitoring Continous intra partum fetal monitoring

watching forwatching for-:-: variable deceleration (cord compression)variable deceleration (cord compression)..

late decceleration (Utero Placental late decceleration (Utero Placental Insuffiency)(UPI)Insuffiency)(UPI)..

B-B-if the date are confirmed and the cervix if the date are confirmed and the cervix is unfavourable there is two is unfavourable there is two optionsoptions-:-:

Induce labourInduce labour -: -:

using prostaglandin using prostaglandin E2E2..

ConservationConservation-:-:

both the non stress test both the non stress test NST NST Amniotic fluid index Amniotic fluid index AFI AFI should be performed twice should be performed twice weeklyweekly..

Delivery should take place if the Delivery should take place if the NST NST become non reactive or If the become non reactive or If the AFIAFI is is <5<5 cm or cm or <2<2 cm depth cm depth of largest vertical poleof largest vertical pole..

C-C- if the date are uncertain if the date are uncertain-:-:

Both the Both the NST & AFINST & AFI can be performed can be performed twice weekly while waiting for twice weekly while waiting for

spontaneous labour to occurspontaneous labour to occur . .

Delivery should take place if the Delivery should take place if the NST NST become non reactive or if become non reactive or if the the AFI <5AFI <5 cm cm..

Induction Induction of labourof labour

Definition:-Definition:-

Induction of labour is the Induction of labour is the artificial initiation of artificial initiation of uterine contractions uterine contractions prior to their spontaneous prior to their spontaneous onset leading to onset leading to progressive dilatation and progressive dilatation and delivery of the baby.delivery of the baby.

Incidence:-Incidence:-

Variable (Variable (15-2015-20)%.)%.

IndicationIndication-:-:

The purpose of an induction The purpose of an induction is to achieve benefit to is to achieve benefit to the health of the mother the health of the mother and or baby when their and or baby when their suspected or confirmed risk suspected or confirmed risk to mother and or to mother and or

babybaby . .

11--Maternal diseasesMaternal diseases-: -: DiabetesDiabetes..

Hypertention \ renal diseasesHypertention \ renal diseases.. cardiac diseasecardiac disease..

22--pregnancy – related conditionspregnancy – related conditions-:-: pre eclampsiapre eclampsia..

intra hepatic choleostasis of intra hepatic choleostasis of pregnancypregnancy..

APH at termAPH at term.. placental abruptionplacental abruption..

33--fetal indicationfetal indication-:-: intra uterine growth restrictedintra uterine growth restricted..

oligohydramniousoligohydramnious.. Iso immunizationIso immunization . .

44 - -Pregnancy passing 41 weeksPregnancy passing 41 weeks..

55 - -Pre-labour spontaneous rupture Pre-labour spontaneous rupture of membrane (PLROM)of membrane (PLROM)..

66 - -Maternal requestMaternal request..

**Assessment before induction commenceAssessment before induction commence-:-:

The obstetrician should assess the The obstetrician should assess the balance between the risk associated balance between the risk associated with allowing the pregnancy to continue with allowing the pregnancy to continue and those associated with interrupting and those associated with interrupting itit::

11--confirmation of gestational ageconfirmation of gestational age::

to avoid risk of iatrogenic prematurityto avoid risk of iatrogenic prematurity..

History – LMPHistory – LMP..

ExaminationExamination..

U\S ScanU\S Scan . .

22--Are there mechanical impedance Are there mechanical impedance to deliveryto delivery.?.?

DisproportionDisproportion..

Pelvic tumourPelvic tumour..

Placenta previaPlacenta previa..

33 - -What is the condition of cervix What is the condition of cervix assisted by bishop score assisted by bishop score

(1964)(1964)..

Bishop scoreBishop score

 factors

SCOREDILATATIONEFFACEMENTSTATIONCERVICALCERVICAL

 CM%-(3+ - 3)CONSISTENCYPOSITION

0closed0-30%-3firmposterior

11-240-50%-2mediumMid position

23-460-70%-1softanterior

3≥≥ 5≥≥ 80%+1+,2__

**Methods of inductionMethods of induction-:-: 11--MedicalMedical-: -:

ProstaglandinProstaglandin.. OxytocinOxytocin..

22--SurgicalSurgical-: -: Membrane sweepingMembrane sweeping.. AmniotomyAmniotomy..

33--CombinationCombination 44--Agents currently researchedAgents currently researched-: -:

Nitric oxide donorsNitric oxide donors.. Anti progestogens (Anti progestogens (Ru-486Ru-486)).. Inter-leukin-Inter-leukin-88.. RelaxinRelaxin . .

11 - -Medical methodsMedical methods-:-:If the cervix is unfavorable (un-If the cervix is unfavorable (un-ripe)ripe)-:-:

prostaglandinprostaglandin::

local vaginal administrationlocal vaginal administration-:-:

tablet (tablet (0.5 mg0.5 mg)).. pessary (pessary (3 mg3 mg))..

gelly (gelly (1 mg1 mg))..

side effect of prostaglandinside effect of prostaglandin-:-:

Gastro intestinal upsetGastro intestinal upset.. Uterine hyper stimulation (rare)Uterine hyper stimulation (rare)-:-:

defined as six or more contractions in defined as six or more contractions in 1010 minutes or a single contraction minutes or a single contraction

lasting lasting >> 22 minutes minutes . .

If cervix is favourable (ripe)If cervix is favourable (ripe)-:-:

oxytocinoxytocin::

its octa peptide hormone secreted from para its octa peptide hormone secreted from para ventricular and supra optic nuclei of ventricular and supra optic nuclei of hypothalamus, stored in posterior hypothalamus, stored in posterior

pituitary and released in pulsatile mannerpituitary and released in pulsatile manner . .

Oxytocin is administered in synthetic form Oxytocin is administered in synthetic form pitocin or syntocinon used by pitocin or syntocinon used by continous I.V infusion (pump or drip) continous I.V infusion (pump or drip) after amniotomy to stimulate uterine after amniotomy to stimulate uterine contraction, also used to augment and contraction, also used to augment and accelerate labouraccelerate labour..

The usual dose is The usual dose is 55 IU\ IU\500500 ml normal saline ml normal saline..

rate to be increased every rate to be increased every 3030 minute until minute until satisfactory contraction are satisfactory contraction are establishedestablished . .

not exceeding not exceeding 60 60 Drops\min or Drops\min or 3232 m Unit \ m Unit \ minuteminute..

side effectsside effects-:-:

uterine hyperstimulationuterine hyperstimulation.. poor uterine contractionpoor uterine contraction..

Anti diuretic effectAnti diuretic effect.. rupture of uterusrupture of uterus..

Neonatal hyperbilirubinemiaNeonatal hyperbilirubinemia..

22--Surgical methodsSurgical methods-:-:

A-membrane sweepingA-membrane sweeping-:-:

increased likelihood of spontaneous labour increased likelihood of spontaneous labour within within 4848 hours due to local hours due to local release of prostaglandinrelease of prostaglandin..

B-Amniotomy (AROM)B-Amniotomy (AROM)-:-:

Fore-water amniotomyFore-water amniotomy-:-:

AmniohookAmniohook..

Toothed forcepsToothed forceps..

Hind-water amniotomyHind-water amniotomy-:-:

Drew-somyth catheterDrew-somyth catheter . .

The success of amniotomy is dependent The success of amniotomy is dependent upon the state of cervix, the parity of upon the state of cervix, the parity of woman and the station of presenting woman and the station of presenting

part at time of interventionpart at time of intervention . .ComplicationsComplications-:-:

failure to induce effective contractionsfailure to induce effective contractions..

bleeding bleeding damage to the cervix damage to the cervix..

placental separation due to sudden placental separation due to sudden reduction of the volume of liquorreduction of the volume of liquor..

infectionsinfections..

amniotic fluid embolismamniotic fluid embolism..

33--combined surgical and medical combined surgical and medical inductioninduction-:-:

Surgical amniotomy followed by oxytocin Surgical amniotomy followed by oxytocin useuse..

THE ENDTHE ENDThanks for your attentionThanks for your attention