The American guild of Obstetrician...

The American guild of Obstetricians and Gynecologists (ACOG) lately issued guide-lines for the clinical management of post-term pregnancy. The guidelines appeared in the September 2004 issue of Obstetrics and Gynecology

Post-term pregnancy is defined as a pregnancy that has augmented to or beyond 42 weeks of gestation (294 days, or estimated date of delivery [EDD] plus 14 days). The reported oftenness of post-term pregnancy is approximately 7 percent in the greatest degree cases of post-term pregnancy flow from a prolongation of gestation. Other cases be derived from an inability to accurately define EDD The risk of adverse sequelae may be reduc by way of making an accurate assessment of gestational age and diagnosis of post-term gestation, as well as recognition and management of risk factors. pair strategies that may decrease the risk of an adverse fetal issue include ante-natal surveillance and induction of labor.

Risk factors for post-term pregnancy may include primiparity and previous post-term pregnancy. Placental sulfatase deficiency, fetal anencephaly, and male sex have been associated with prolongation of pregnancy, and genetic predisposition also may play a role

The EDD is greatest in quantity reliably and accurately determined early in the pregnancy and may be based forward the last known menstrual period in women with regular, normal menstrual circle of times Because of normal variations in the size of infants during the third trimester, dating the pregnancy during this period is les reliable. If the estimated gestational age at a patient's last menstrual period is different from the estimate obtained via assessment with ultrasonography, the ultrasound estimate should be used.

Post-term pregnancy is associated with risks to the fetus, including increased perinatal mortality rate, cheap umbilical artery pH levels at delivery, depressed 5-minute Apgar scores, dysmaturity syndrome and increased risk of death within the first year of life. Although post-term infants are larger than mete infants and have an increased incidence of fetal macrosomia, there is no evidence to support induction of labor as a preventive measure in these cases.

Risks of post-term pregnancy to the pregnant woman include an increase in labor dystocia, an increase in exact perineal injury related to macrosomia, and a doubling in the rate of cesarean delivery. Also, post-term pregnancy can cause anxiety for the pregnant woman.

Clinical Considerations and Recommendations

Are there interventions that decrease the rate of post-term pregnancy? Obtaining an accurate EDD using ultrasonography early in the pregnancy can bring to the incidence of pregnancies diagnosed as post-term and minimize unnecessary interventions. However, routine early ultrasonography has not been attract favor toed as standard care in the United States. There is no evidence to exhibit that stimulation of the breasts and nipples affects the incidence of post-term pregnancy. There is conflicting evidence as to the effectiveness of sweeping the membranes at name in reducing post-term pregnancy.

When should antepartum fetal testing begin? Although evidence present to views that antenatal fetal surveillance for post-term pregnancies does not decrease perinatal mortality, it has become a everyday universally accepted practice. Antenatal fetal surveillance also is frequently performed between 40 and 42 weeks of gestation, despite there being no randomized controll trial demonstrating that it inferences in an improvement in perinatal issue There also is insufficient evidence to indicate whether routine antenatal surveillance of low-risk patients between 40 and 42 weeks' gestation improves perinatal issue The authors add that, because of ethical and medicolegal issues, no studies have included post-term patients who were not monitored.

What form of antenatal surveillance should be performed, and for what cause frequently should a post-term patient be reevaluated? Options for evaluating fetal well-being include non-stress testing, biophysical profile (BPP) or modified BPP (nonstress example plus amniotic fluid volume estimation), contraction stres testing, and a combination of these modalities. None of these manners has been shown to be superior. Assessment of amniotic fluid contortion appears to be important; however, a consistent definition of cheap amniotic fluid in the post-term pregnancy has not been established. There is no proven benefit to monitoring the post-term fetus with Doppler velocimetry. The authors state that no recommendation can be made regarding the frequent occurrence of antenatal surveillance; however, many practitioners use twice-weekly testing.

For a post-term patient with a favorable cervix, does the evidence support labor induction or expectant management? Factors to consider in the management of low-risk post-term pregnancy include the following: gestational age; the condition of the cervix; terminates of antepartum fetal testing; and maternal choice after discussion of the risks, benefits, and alternatives to expectant management with antepartum monitoring versus labor induction. There is insufficient data to make a recommendation for labor induction or expectant management in women who are experiencing a post-term pregnancy and have a favorable cervix. Labor usually is induced in post-term pregnancies in which the cervix is favorable because the risk of failed induction and following cesarean delivery is low.