S.G.O.M.
13° NATIONAL CONGRESS OF
GYNECOLOGY AND OBSTETRICS OF
THE TURKISH SOCIETY.
ANTALYA,11-15 MAY
2015
POSTTERM PREGNANCIES:
GUIDELINES FOR MANAGEMENT.
Mandruzzato G.P.
Trieste,Italy
DEFINITION OF PREGNANCIES
ACCORDING TO GESTATIONAL AGE.
• EARLY TERM: 37. 0/7-38. 6/7
• FULL TERM : 39. 0/7-40. 6/7
• LATE TERM : 41. 0/7-41. 6/7
• POSTTERM: 42 0/7 AND BEYOND
• ACOG Committee Opinion N.579
• Obstet.Gynecol. 2013 122,1139
PREVALENCE SWEDEN.
21 % AFTER 41 WEEKS
5.5 % AFTER 42 WEEKS
Oberg AS and co.
Am.J.Epidemiol. 2013,177,531
FROM NATIONAL BIRTH REGISTER.
PREVALENCE IN FRANCE.
LATE TERM: 15-20 %
POSTTERM: 1 %
PREVALENCE :US DATING A ND NO
ROUTINE INDUCTION .
LATE TERM: 17 %
POSTTERM: 7 %
43 gw: 1.4 %
Mandruzzato GP and co.
Br.J.Obstet.Gynecol.
1998,105,356
PREVALENCE OF POSTTERM.
1- 7 %
THE HUGE DIFFERENCE IS
DEPENDENT ON THE PRECISE US
DATING AND THE CHARACTERISTICS
OF THE MANAGEMNT.
CURRENTLY IT IS ASSUMED THAT
PROLONGATION OF THE PREGNANCY
REPRESENTS A PROGRESSIVE INCREASE OF
RISKS FOR THE FETUS, THE NEWBORN AND
THE MOTHER.
MATTER OF CONCERN!
More for the doctor than for the
mother!
LATETERM AND POSTTERM
THE PROBLEMS.
•
•
•
•
•
•
EXACT ASSESSMENT OF GESTATIONAL AGE
FETAL MONITORING INITIATION
FETAL MONITORING FREQUENCY
FETAL MONITORING METHODS
MANAGEMENT LATE TERM
MANAGEMNT POSTTERM
GUIDELINES.
• S.O.G.C. 2008
• W.AP.M. 2010
• C.N.G.O.F. 2013
• A.C.O.G. 2014
RECOMMENDATIONS:
US ASSESSEMENT OF GA
• WAPM: CRL IN THE 1° TRIMESTER (A)
• SOGC : US BETWEEN 11 AND 14 GW (I-A )
• CNGOF: CRL BETWEEN 11.0 AND 13+6
(PROFESSIONAL CONSENSUS )
• A.C.O.G. : ?
US GA ASSESSMENT
WARNING!
ACCURACY IS PLUS OR MINUS 4
DAYS!
FETAL MONITORING.
INITIATION AND FREQUENCY.
•
•
•
•
S.O.G.C. : 41 WEEKS
W.A.P.M. : 41 COMPLETED WEEKS ( B )
C.N.G.O.F. : 41 .0 WEEKS ( C )
A.C.O.G. : 41 0/7 (C )
• TWICE OR THREE TIMES A WEEK.
PROFESSIONAL CONSENSUS
FETAL MONITORING:
METHODS.
• Count of fetal movements,
CTG (NST, Contraction stress test,computer
assisted),
ULTR ASOUND (Malformations, Amniotic fluid,
FetalBiometry, Doppler).
FBP (simple or modified)
TEHERE ARE NO RCT FOR ASSESSING THE VALIDITY
OF ANY METHOD!
METHODS OF FETAL
MONITORING.
WARNING!
NO ONE IS IN CONDITION TO PREDICT
ACUTE EVENTS!
CHRONIC FETAL HYPOXAEMIA CAN BE
DETECTED AND ASSESSED.
MANAGEMENT: LATE TERM
41.0-41+6/7
RECOMMENDATIONS.
• SOGC: WOMEN SHOULD BE OFFERED INDUCTION AT
41+0 TO 42+0 (I-A
)
• WAPM: NONE
• CNOGF: IN ABSENCE OF SPECIFIC DISORDER
INDUCTION CAN BE PROPOSED BETWEEN 41+0 AND
42+6 (B
).
• A.C.O.G.: INDUCTION BETWEEN 41.0/7 AND 42.0/7
CAN BE CONSIDERED (B).
INDUCTION OF LABOUR BEFORE
42+0 CANNOT BE CONSIDERED
MANAGEMNT OF POSTTERM.
AT ITS BE ST IT REPRESENTS A
PREVENTION OF POSTTERM.
PREVENTION OF POSTTERM .
PROPOSED METHODS
• SWEEPING OF THE MEMBRANES(38-41)
• ROUTINE INDUCTION OF LABOR AT 41 AND
BEFORE 42.
COMPLICATIONS.
• FETAL: STILLBIRTH,MECONIUM AMNIOTIC
FLUID,MACROSOMIA
• NEONATAL:M.A.S.,NICU,DEATH
• MATERNAL: CS,PPH,TRAUMATIC DELIVERY
• EPILEPSY?CP?
FETAL COMPLICATIONS.
MECONIUM STAINED FLUID
THE PREVALENCE OF MECONIUM
PASSAGE IS PROPORTIONAL TO
GESTATIONAL AGE
FETAL GUT MATURATION!
STILLBIRTHS.
The belief of the increased risk of fetal
complications and especially stllbirths
is supported by not recent epidemiological
studies based on birth registers covering large
secular periods where
big differences in dating pregnancies, fetal
assessment and monitoring and management
took place.
LEVEL OF EVIDENCE II-B
FETAL/NEONATAL COMPLICATIONS.
The cause of the increased risk has
been attributed to
“placental senescence”
in postterm.
(Vorherr 1977 !)
Does it exist?
UNCOMPLICATED POSTTERM
PREGNACIES.
• FETAL GROWTH UNAFFECTED UNTIL 43
GW
• UA DOPPLER INDICES: NO DIFFERENCE
• FHR PATTERNS: NO DIFFERENCE
• NUCLEATED RED BLOOD CELLS IN CORD:
NO DIFFERENCE
UNCOMPLICATED ?
AFTER EXCLUSION OF
MALFORMATIONS AND GROWTH
RESTRICTION AND MATERNAL
COMPLICATIONS THERE IS NO
DIFFERENCE IN FETAL/NEONATAL
OUTCOME BETWEEN TERM AND
POSTTERM PREGNACIES.
ROUTINR INDUCTION AT 41 VS
EXPECTANT MANAGEMENT.
8 RCT
AFTER EXCLUSION O OF MALFORMATIONS
AND SGA < 10° PERCENTILE NO
DIFFERENCE IN PERINATAL MORTALITY,
CESAREAN AND NEONATAL MORTALITY.
THE REPORTED P.M. RATE IN
POSTTERM IS, IF ANY, EXTREMEELY
LOW.
Routine induction at 41 w. vs expectant
A DEFINITIVE STUDY WOULD REQUIRE A
RANDOMIZATION OF BETWEEN 16.000
AND 30.000 PREGNANCIES.
ROBUST EVIDENCE THAT ROUTINE
INDUCTION IS BENEFICIAL IS LACKING!
NNT
TO AVOID 1 POSSIBLE PERINATAL DEATH
527 INDUCTION AT 41 WEEKS ARE
NEEDED.
17 % OF PREGNANCIES REACHES 41.041.6
75 % OF THEM DELIVER BEFORE 42.0
MANAGEMENT: POSTTERM
42.0 AND BEYOND
• SGOC : NOT CONSIDERED
• W.A.P.M. : AFTER 41 COMPLETED WEEKS
• ROUTINE INDUCTION OR EXPECTANT
MANAGEMENT CAN BE OFFERED ( A )
• CNOGF: IN ABSENCE OF SPECIFIC DISORDER
INDUCTION CAN BE PROPOSED BETWEEN 41.0
AND 42+6 ( B )
• A.C.O.G.: INDUCTION AFTER 42 0/7 WEEKS
AND 42 6/7 IS RECOMMENDED (A ).
POSTTERM.
EXPECTANT MANAGEMENT.
7 %-1.3 % REACH 43 W.
8 STUDIES.
3914 CASES
P.M. 0.05%
INDUCTION.
CHARACTERISTICS OF THE CERVIX.
CERVICAL RIPENING.
• SWEEPING OF THE MEMBRANES.
• TRANSCERVICAL FOLEY (WITH OR WITHOUT
SALINE INFUSION)
• LAMINARIA TENTS.
• PHARMACOLOGICAL (PGE 2 OR PGE 1)
CONCLUSIONS 1.
IN ORDER TO DIAGNOSE PRECISELY
LATE TERM AND POSTTERM
PREGNANCIES AN US ASSESSMENT OF
GA IN EARLY PREGNANCY IS A
FUNDAMENTAL CONDITION.
CONCLUSIONS 2.
THE EVIDENCE THAT PROLONGATION
OF THE PREGNANCY PER SE
CARRIES AN INCREASED
FETAL/NEONATAL RSK IS WEAK.
LEVEL B
CONCLUSIONS 3.
AT 41 WEEKS, IF NOT DONE BEFORE,
FETAL COMPLICATIONS
(MALFORMATIONS, IUGR) AND
MATERNAL (CARBOHYDRATE
INTOLERANCE) MUST BE EXCLUDED.
CONCLUSIONS 4.
ROUTINE INDUCTION AT 41 GW
(LATE-TERM) IS NOT SUPPORTED
BY ROBUST EVIDENCE.
CONCLUSIONS 5.
IF ROUTINE INDUCTION AT 41 IS PERFORMED:
17 % OF PREGNANCIES MUST BE INDUCED.
75 % OF PREGNANCIES REACHING 41 WEEKS
WILL DELIVER BEFORE 42 W. WITHOUT
INTERVENTION.
NNT FOR AVOIDING 1 POSSIBLE ADVERSE
PERINATAL OUTOME
IS 527.
CONCLUSIONS 6.
PROVIDED THE AVAILABILITY OF ADEQUATE
ASSESSMENT AND MONITORING OF FETAL
WELLBEING
EXPECTANT MANAGEMENT CAN BE
CONSIDERED ALSO AT 42 WEEKS (POSTTERM)
5-7 % OF ALL PREGNANCIES.
ONLY 1 % IS UNDELIVERED AT 43
WEEKS (301 DAYS).
THANK YOU FOR
ATTENTION!