PROLONGED PREGNANCY (POSTTERM) (Part two)

Complications

1 - Maternal

• Severe perineal injuries (laceration)
• Endometritis (inflammation of the endometrium)
• Chorioamnionitis (inflammation of the chorion and amniotic fluid)
• Thromboembolic disease
• Postpartum hemorrhage
• Increased incidence of cesarean section

2 - Fetal

• Fetal macrosomia (fetus over 4500 gr, prolonged delivery, cephalopelvic disproportion, shoulder dystocia leading to neurological and orthopedic injuries)
• Postmature fetal syndrome (IUGR, cord compression, oligohydramnios, meconium, transient neonatal complications, hypoglycemia, contractions, respiratory insufficiency)
• Meconium aspiration syndrome (tachypnea, cyanosis, decreased pulmonary function)
• Uteroplacental insufficiency
• Intrauterine infections
• Perinatal mortality

Signs and symptoms

• The signs that are most often noted in a postmature baby are: dry skin, increased nail growth, palmar and sole creases, decreased subcutaneous tissue, skin discoloration in brown, green or yellow.
• Some postmature babies may have none or few of the above signs.

Monitoring

Fetal surveillance is recommended in all postterm pregnancies that are not induced.

After 41 weeks the risk increases for the fetus and more frequent follow-up is required.

Evaluation includes:
• Fetal movements (regular fetal movements indicate the baby's well-being, decrease or absence of movements indicate uteroplacental insufficiency that should be evaluated immediately), assessed daily.
• Electronic fetal monitoring with cardiotocography. Fetal heartbeats and uterine contractions and their changes are assessed and monitored for a period of 30 minutes.
• Biophysical profile (assessed by ultrasound fetal heartbeats, muscle tone, fetal movement, breathing, and amniotic fluid), minimum assessed twice a week.
• Ultrasound (assesses the above elements and the placenta)
• Echo Doppler (assesses blood circulation in the umbilical artery and middle cerebral artery. The assessment of their ratio indicates whether the fetus is well-being or suffering).

Management

1. Expectant (the fetus and mother are monitored).
2. Induction of labor when there is a risk to the mother or fetus.
   • Amniotomy (breaking of the membranes and water breaking by the doctor).
   • Stimulation of labor using prostaglandin hormone or oxytocin.
   • Cesarean section.
   • It is advisable for the treatment of postterm pregnancies that a vaginal examination be performed daily starting from week 41 and to induce labor for a Bishop score of 5 or higher.

Prevention of postterm delivery

• Induction of labor before 42 weeks.
• Minimal invasive procedures that induce labor (breaking of membranes, unprotected coitus, stimulation of breast nipples).
• Accurate assessment of pregnancy age based on first trimester pregnancy ultrasounds.