S.G.O.M. 13° NATIONAL CONGRESS OF GYNECOLOGY AND OBSTETRICS OF THE TURKISH SOCIETY. ANTALYA,11-15...

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 WEEKS5.5 % 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 POSTTERMTHE 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.

• 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).

MANAGEMENT: LATE TERM41.0-41+6/7

RECOMMENDATIONS.

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 AGEFETAL 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 wherebig 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 RCTAFTER 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 41.0-41.675 % OF THEM DELIVER BEFORE 42.0

MANAGEMENT: POSTTERM42.0 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%

• SWEEPING OF THE MEMBRANES.• TRANSCERVICAL FOLEY (WITH OR WITHOUT

SALINE INFUSION)• LAMINARIA TENTS.• PHARMACOLOGICAL (PGE 2 OR PGE 1)

INDUCTION.CHARACTERISTICS OF THE CERVIX.

CERVICAL RIPENING.

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

WELLBEINGEXPECTANT 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!