Post Term 08

PRAYER TO ST. THOMAS AQUINAS PATRON OF STUDENTS • Wonderful Theologian and Doctor of the Church, you learned more from the Crucifix than from books. Combining both sources, you left us the marvelous Summa of theology, broadcasting more glorious enlightenment to all. You always sought for the true light and studied for God’s honor and glory. Help us to study without ambition and pride in imitation of you. Amen.

POSTTERM PREGNANCY, FETAL GROWTH RESTRICTION, FETAL DEATH, UMBILICAL CORD PROLAPSE Shirley H. Virata, M.D., FPOGS Dept. of Obstetrics & Gynecology

Postterm Pregnancy

Postterm Pregnancy • • • •

Postterm Prolonged Postdate Postmature

Postterm Pregnancy • Definition (ACOG) – 42 completed weeks (294 days) or more from the 1st day of the LNMP.

Postterm Pregnancy •

The categories of pregnancies that reach 42 completed weeks 1. Those truly 40 wks past conception 2. Those of less advanced gestation due to inaccurate estimation of gestational age a. Faulty recall of date of LNMP b. Variations in menstrual cycle

Postterm Pregnancy • Incidence: – 7% of 4,000,000 infants born on the US were delivered 42 weeks or more – 10-27% if 1st born was postterm – 39% if 2 previous postterm deliveries

Postterm Pregnancy •

Perinatal Mortality – Increased after the expected date due date was passed

•

Major causes of death 1. 2. 3. 4.

pregnancy hypertension prolonged labor with CPD unexplained “anoxia” malformations

Postterm Pregnancy • Pathophysiology: Postmature infants Die

seriously ill (birth asphyxia meconium aspiration)

brain damage

Postterm Pregnancy • Features of Postmaturity Syndrome – Skin: wrinkled, patchy, peeling • Wrinkling prominent in palms and soles

– Long nails – Body: long thin – Open eyed, unusually alert – Appears old and worried looking

Postterm Pregnancy • Placental dysfunction – Placental apoptosis increased  decreased fetal oxygenation in some postterm gestation – Postterm fetuses may continue to gain weight and be unusually large at birth

Postterm Pregnancy • Fetal distress and oligohydramnios decreased amniotic fluid  – antepartum fetal jeopardy and intrapartum fetal distress due to cord compression – Meconium release  meconium aspiration syndrome

Postterm Pregnancy • Fetal growth restriction – 1/3 of postterm stillbirth were growth restricted – Mortality and morbidity were significantly increased in growth restricted infants

Postterm Pregnancy • Management: – Unfavorable cervix (Bishop score of 4 or less) – ACOG (1997) prostaglandin gel can be safely used in postterm pregnancy for cervical ripening

Bishop Scoring System Used for Assessment of Inducibility Factor Score Dilatation (cm) 0

closed

Efface ment (%) 0-30

Station (-3 to +3)

Cervical Consisten cy

Cervical position

-3

firm

posterior

1

1-2

40-50

-2

medium

mid position

2

3-4

60-70

-1

Soft

anterior

3

>5

>80

+1, +2

--

-

Postterm Pregnancy

• Induction of Labor

– Stripping of membranes at 38-40 wks decreased the frequency of postterm pregnancy – Oxytocin drip • • • •

1000 ml D5RL + 10 units oxytocin  10 mu/ml Starting dose 0.5 – 1 mu/min. Incremental dose 1 mu/min every 15 mins. Uterine response within 3-5 mins. of beginning an oxytocin infusion • Discontinue if uterine contractions more than 5/10 mins. or 7/15 mins with a persistent non-reassuring FHR pattern • Half-life approximately 5 mins.

Postterm Pregnancy • CS rate was directly related to station – If vertex is – 1 -2 -3 -4

- 6% - 20% - 43% - 77%

Evaluation & Management of Postterm Pregnancy • Postterm pregnancy is defined as a pregnancy that has extended to or beyond 42 completed weeks • Women with a postterm gestation who have an unfavorable cervix can either undergo labor induction or be managed expectantly. • Prostaglandin can be used for cervical ripening and labor induction.

Evaluation & Management of Postterm Pregnancy • Delivery should be effected if there is evidence of fetal compromise or oligohydramnios. • It is reasonable to initiate antenatal surveillance between 41 and 42 weeks despite lack of evidence that monitoring improves outcomes.

Evaluation & Management of Postterm Pregnancy • A nonstress test and amniotic fluid volume assessment should be adequate, although no single method has been shown to be superior. • Many recommend prompt delivery in a woman with a postterm pregnancy, a favorable cervix, and no other complications.

Postterm Pregnancy • Management at Parkland Hospital – AOG is certain at 42 weeks • Induce labor – 90% successful induction or enter labor within 2 days of induction undelivered

2nd induction within 3 days  almost all are delivered 3rd induction

Postterm Pregnancy • Management at Parkland Hospital – AOG is uncertain at 42 weeks • Weekly follow-up unless fetal jeopardy is suspected based (1) on clinical or sonographic perception of decreased amniotic fluid volume (2) decreased fetal movement • If fetal jeopardy-induce labor

Postterm Pregnancy • Do not allow pregnancy to go beyond 42 weeks in cases of pregnancy induced hypertension, previous cesarean section & diabetes mellitus.

Postterm Pregnancy • Intrapartum Management – Labor is a dangerous time for the postterm infant – Admit as soon as in labor – Electronic fetal monitoring of uterine contractions and FHR – Amniotomy?? • Can increase possibility of cord compression in oligohydramnios • Aids in diagnosis of thick meconium

– Amnioinfusion X

Postterm Pregnancy • Likelihood of successful vaginal delivery is decreased in nulliparous women in early labor with meconium stained amniotic fluid. Therefore, if remote from delivery, consider CS if CPD is suspected or either hypotonic or hypertonic dysfunctional labor is present.

Postterm Pregnancy • Minimize aspiration of meconium by suctioning pharynx as soon as head is delivered but before thorax is delivered. • If meconium found in pharynx aspirate trachea and ventilate infant if needed.

Fetal Growth Restriction

Fetal Growth Restriction • Low birth weight of less than 2500 gms at term • Incidence: 8% • Fetal growth curve (Lubchenco)

3 Phases of Cell Growth Occurrence

1st phase 2nd phase 3rd phase During the 1st Extends to 32 After 32 wks. 16 wks. wks.

Change

Rapid increase in cell number (cellular hyperplasia)

Fetal growth rate

5 gms/day at 15 wks.

Cellular Fetal growth hyperplasia & by cellular hypertrophy hypertrophy Fetal fat & glycogen deposition 15-20 30-35 gms/day at gms/day 24 wks.

Fetal Growth Restriction •

Factors in fetal growth rate 1. 2.

Insulin and insulin-like growth factor Obesity gene and its’ protein product leptin 3. Adequate supply of nutrients

Fetal Growth Restriction •

Perinatal morbidity and mortality 1. 2. 3. 4. 5. 6.

Fetal demise Birth asphyxia Meconium aspiration Neonatal hypoglycemia Neonatal hypothermia Abnormal neurological development

Fetal Growth Restriction •

Postnatal growth and development depends on: 1. Cause of restriction 2. Nutrition in infancy 3. Social environment

Fetal Growth Restriction • Symmetrical vs. asymmetrical growth restriction – Use ultrasound to determine head circumference and abdominal circumference – Symmetrical growth restriction – proportionately small – Asymmetrical growth restriction – disproportionately lagging abdominal growth

Fetal Growth Restriction • Onset of etiology of an insult relates to the type of growth restriction • Early insult  relative decrease in cell number and size  proportionate reduction of head and body size  symmetrical growth restriction • Hypertension  placental insufficiency  ↓ glucose transfer and hepatic storage  decreased liver size  decreased abdominal circumference

Fetal Growth Restriction •

Risk factors: 1. 2. 3. 4. 5. 6. 7. 8.

Constitutionally small mother Poor maternal nutrition Social deprivation Fetal infection Congenital malformation Chromosomal aneuploidies Disorders of cartilage and bone Teratogens

Fetal Growth Restriction •

Risk factors: 1. 2. 3. 4. 5. 6. 7. 8.

Vascular disease Renal disease Chronic hypoxia Anemia Placental and cord abnormalities Multiple fetuses APAS Extrauterine pregnancy

Fetal Growth Restriction •

Identification of fetal growth restriction 1. 2. 3. 4. 5.

Early establishment of gestational age Attention to maternal weight gain Careful measurement of uterine fundal growth Ultrasonic measurements Doppler velocimetry

Fetal Growth Restriction •

Management – Goals • Confirm diagnosis • Assess fetal condition • Evaluate for anomalies • Determine timing of delivery

Fetal Growth Restriction • Near term – Prompt delivery is best – 34 wks. or beyond – deliver if there is clinically significant oligohydramnios – Reassuring FHR pattern – may deliver vaginally

Fetal Growth Restriction • Remote from term (prior to 34 wks.) – – – – –

AFV (Normal) } observe Fetal surveillance (Normal) } Fetal growth continuous }continue until Fetal evaluation (Normal) } fetal maturity Evaluate every 4-6 weeks to predict FGR

Fetal Growth Restriction • Remote from term (prior to 34 wks.) – No specific treatment ameliorates the condition • • • • • • •

Bed rest Nutrient supplementation Plasma volume expansion Oxygen therapy Anti hypertensive drug Heparin Aspirin

} } ineffective } } } } }

Fetal Growth Restriction • Management decision is dependent on assessment of the relative risk of death with expectant management vs. the risk from preterm delivery • Mortality & morbidity is determined primarily by gestational age and birth weight

Fetal Growth Restriction •

Labor and delivery –

•

CS is increased due to: • Placental insufficiency • Decreased AFV  cord compression

Infant morbidity: Causes 1. 2. 3.

Hypoxia and meconium aspiration Hypothermia Hypoglycemia, polycythemia & hyperviscosity 4. Motor and neurological disability

Antepartum Fetal Death

Antepartum Fetal Death •

Etiology: 1. Idiopathic – in half of cases 2. Maternal complication a. b. c. d.

Preeclampsia Placenta previa Abruptio placenta Diabetes

3. Fetal disease a. Congenital anomalies b. Erythroblastosis c. Chorioamnionitis following PROM

Antepartum Fetal Death • Diagnosis: – Symptoms: • • • •

Cessation of fetal movement Disappearance of gestational symptoms Cessation of growth Decreased in size and tenderness of breast

– Signs: • No fetal heart tone • No palpable fetal movement • Size of uterus smaller than expected AOG

Antepartum Fetal Death • Diagnosis: – Ultrasonic technique • Absence of cardiac activity and fetal movement • Loss of clarity of the outline of the body • Increase in no. of echoes coming from the fetal body • Collapse of fetal skull • Failure of fetal growth

Antepartum Fetal Death • Diagnosis: – X-ray of the abdomen • Loss of fetal tone – exaggeration of fetal spine curvature • Spalding sign – overlapping of cranial bone • Robert’s sign - gas bubbles in the fetus

– Negative pregnancy test – Maternal excretion of estriol falls to undetectable levels in 24-48 hours

Categories & Causes of Fetal Death A. Fetal (25-40%) 1. 2. 3. 4.

Chromosomal anomalies Nonchromosomal birth defects Nonimmune hydrops Infections – viruses, bacteria, protozoa

Categories & Causes of Fetal Death A. Placental (25-35%) 1. 2. 3. 4. 5. 6. 7. 8.

Abruption Fetal-maternal hemorrhage Cord accident Placental insufficiency Intrapartum asphyxia Previa Twin-to-twin transfusion Chorioamnionitis

Categories & Causes of Fetal Death A. Maternal (5-10%) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Antiphospholipid antibodies Diabetes Hypertensive disorders Trauma Abnormal labor Sepsis Acidosis Hypoxia Uterine rupture Postterm pregnancy Drugs

B. Unexplained (25-35%)

Antepartum Fetal Death • Management: – Expectant • Spontaneous labor and delivery will take place within 2 weeks of fetal death in 75% of cases and by 3 weeks in 90% of cases

– Active management • First trimester – Dilatation of the cervix and aspiration curettage

• Second and third trimester – Ripe cervix – oxytocin drip – Unripe cervix – prostaglandin

Antepartum Fetal Death • Complication – DIC • It is unlikely that hypofibrogenemia will develop before 4-6 weeks of fetal death has occurred • Weekly measurements of levels of fibrinogen • Management: cryoprecipitate; whole blood

Intrapartum Fetal Death • Definition: – Documentation of fetal heart tones after the onset of labor – No sign of life after delivery of the child

Intrapartum Fetal Death •

Etiology: A. Definite causes of death: 1. 2. 3. 4.

Difficult and traumatic delivery Prolapse of the cord Abruptio placenta Congenital anomalies incompatible with life 5. RH sensitization 6. Ruptured uterus

Intrapartum Fetal Death A. Etiology: 1. Concomitant problems •

Highly significant conditions a. Prolonged gestation

b. PROM c. Tight cord around the neck d. Paracervical block anesthesia

Intrapartum Fetal Death •

Etiology: A. Concomitant problems 1. Mildly significant conditions a. Intrapartum fever b. Preeclampsia c. Maternal hypotension d. Breech e. Abnormal sugar tolerance

Fetal Death •

Evaluation of the stillborn infants – Determining the cause of fetal death 1. Facilitates the psychological adaptation to a significant loss 2. Helps to assuage the guilt that is part of grieving 3. Makes counseling regarding recurrence more accurate 4. May prompt therapy or intervention to prevent a similar outcome in the next pregnancy 5. Identification of inherited syndromes

Fetal Death •

Evaluation of the stillborn infants – Clinical examination 1. Thorough examination of the fetus, placenta and membrane 2. Details of relevant prenatal events 3. Take photographs; perform a full radiograph of the fetus (fetogram)

Protocol for Examination of Stillborn Infants

A. Infant Description – – – –

Malformations Skin staining Degree of maceration Color – pale, plethoric

B. Umbilical cord – – – – – –

Prolapse Entanglement – neck, arms, legs Hematomas or strictures Number of vessels Length Wharton jelly – normal, absent

Protocol for Examination of Stillborn Infants

A. Amniotic fluid – – –

Color – meconium, blood Consistency Volume

B. Placenta – – – – –

Weight Staining – meconium Adherent clots Structural abnormalities – circumvallate or accessory lobes, velamentous insertion Edema – hydropic changes

Protocol for Examination of Stillborn Infants A. Membranes – Meconium stained or cloudy – Thickening

Fetal Death •

Psychological aspects – Psychological trauma and stress results from: 1. More than 24 hours between diagnosis of fetal death and induction of labor 2. Not seeing the infant as long as she desire 3. Having no tokens of remembrance

– Increased risk of postpartum depression

Fetal Death •

Pregnancy after previous stillbirth – Conditions associated with increase recurrent stillbirth: 1. Hereditary disorders 2. Maternal conditions a. Diabetes b. Chronic hypertension

Fetal Death •

Pregnancy after previous stillbirth – Prenatal evaluation 1. Chorionic villous sampling or amniocentesis for aneuploidy 2. Stringent blood pressure control to prevent hypertension and/or abruptio 3. Diabetic screening; intensive glycemic control in preconceptional period 4. Test for APAS

Umbilical Cord Prolapse

Umbilical Cord Prolapse •

•

Definition: presentation of the umbilical cord below or adjacent to the fetal presenting part. Types: 1. Overt umbilical cord prolapse 2. Occult umbilical cord prolapse 3. Funic umbilical cord prolapse

•

Incidence: 0.17% to 0.4% of births

Umbilical Cord Prolapse •

Risk Factors: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Malpresentation Hydramnios Prematurity Grandmultiparity Pelvic tumors Placenta previa and low lying placenta CPD Multiple gestation PROM

Umbilical Cord Prolapse •

Associated obstetrical intervention 1. 2. 3. 4. 5. 6.

Amniotomy Attempted external cephalic version Manual rotation of the fetal head Expectant management of PPROM Scalp electrode application Intrauterine pressure catheter insertion 7. Amnioreduction

Umbilical Cord Prolapse

• Prevention:

– Education of women with risk factors for cord prolapse • • • •

Be aware of the potential for cord prolapse The need to call for help urgently Positions that would be helpful Intervention that would occur in the event of cord prolapse

– Fetal surveillance at time of membrane rupture – Time amniotomy properly & the presenting part should be properly applied to the cervix

Umbilical Cord Prolapse • Mortality & Morbidity – Low apgar scores and low cord pH  significant morbidity – Mortality (perinatal) – 0.02% to 12.6%

Umbilical Cord Prolapse • Diagnosis of overt cord prolapse – Visualizing the cord thru the introitus – Palpation of the cord in the vagina

• Sudden FHR deceleration in rupture of membrane is often the first indication of cord prolapse. Vaginal examination is necessary for nonreassuring fetal surveillance.

Umbilical Cord Prolapse • Diagnosis of occult cord prolapse – Suspect when decelerations are present either by auscultation or electronic fetal monitoring. – Fetal heart monitoring will show variable decelerations during contraction with prompt return to baseline.

Umbilical Cord Prolapse • Diagnosis of funic cord prolapse – Palpation of the cord through the membranes or as an incidental finding on ultrasound

Umbilical Cord Prolapse • Management of overt cord prolapse – Emergency situation • Call for help • Pelvic exam to determine cervical dilatation and effacement, station of the presenting part and the strength and frequency of pulsation within the cord vessel.

Umbilical Cord Prolapse • Management of overt cord prolapse – Cord pulsations present • Leave examining hand in place to elevate or push up the presenting part • Knee chest or Trendelenberg position • Do not attempt to explore the cord. Keep it warm and avoid manipulation of the cord. • Give oxygen • Prepare for CS or transfer to hospital • Prepare for resuscitation of a potentially depressed infant.

Umbilical Cord Prolapse • Management of overt cord prolapse – Cord pulsations present • If transfer unavailable, allow the labor to progress and talk to the woman about the probable death of the baby

Umbilical Cord Prolapse • Management of overt cord prolapse – Cord pulsations present • Imminent delivery – Prepare for vaginal delivery while preparing for a CS » Call for additional help » Prepare for neonatal resuscitation » Woman in upright position or squat position to help in progress of labor » Expedite delivery by encouraging the woman to push with each contraction » Fully dilated cervix with engaged head – assist vaginal delivery with vacuum or forceps

Umbilical Cord Prolapse • Management of overt cord prolapse – Cord pulsations present • If prolonged time to cesarean section or transport to another center – Fill the bladder with 500 – 700 cc NSS – Tocolysis

Umbilical Cord Prolapse • Management of overt cord prolapse – Cord pulsations absent • • •

Explain to the woman that the baby has died Confirm absence of fetal heart tone Discuss options for management – – – –

Wait for labor to begin or progress Induction or augmentation as needed Provide emotional and other support as needed Transfer to a higher level facility if indicated

Umbilical Cord Prolapse • Management of funic cord prolapse – Elective CS prior to rupture of membrane – If diagnosed in the 3rd trimester repeat ultrasound – For viable premature infants - bed rest in Trendelenberg position until the cord moves or the woman is safe to deliver