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PRESENTASI KASUS
KEHAMILAN POST TERM
Oleh:
Anita Amanda Dewi
107103001461
Pembimbing:
Dr. Harjo Saksomo Bajuadji, SpOG (K) MKes
KEPANITERAAN KLINIK RSUP FATMAWATI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS ISLAM NEGERI SYARIF HIDAYATULLAH
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JAKARTA
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CHAPTER I
INTRODUCTION
The terms postterm, prolonged, postdates, and postmature are often loosely used
interchangeably to signify pregnancies that have exceeded a duration considered to be the
upper limit of normal. Postmature should be used to describe the infant with recognizable
clinical features indicating a pathologically prolonged pregnancy. Postdates probably should
be abandoned, because the real issue in many postterm pregnancies is "post-what dates?"
Therefore, postterm or prolonged pregnancy is the preferred expression for an extended
pregnancy, and "postmature" is reserved for a specific clinical fetal syndrome. Because few
infants from prolonged pregnancies have stigmata of the postmaturity syndrome, use of this
term can falsely imply a pathologically prolonged pregnancy. 1
The standard internationally recommended definition of prolonged pregnancy,
endorsed by the American College of Obstetricians and Gynecologists (1997), is 42
completed weeks (294 days) or more from the first day of the last menstrual period. It is
important to emphasize the phrase "42 completed weeks." Pregnancies between 41 weeks 1
day and 41 weeks 6 days, although in the 42nd week, do not complete 42 weeks until the
seventh day has elapsed. Thus, technically speaking, prolonged pregnancy could begin either
on day 294 or on day 295 following the onset of the last menses. Which is it? Day 294 or
295? We cannot resolve this question, and emphasize this dilemma only to ensure that
litigators and others understand that some imprecision is inevitable when attempting to define
prolonged pregnancy. Amersi and Grimes (1998) have cautioned against use of ordinal
numbers such as "42nd week" because of their imprecision. For example, "42nd week" refers
to 41 weeks and 1 through 6 days, whereas the cardinal number "42 weeks" refers to
precisely 42 completed weeks. 1
Pregnancy usually lasts 40 weeks or 280 days counted from the first day of last
menstrual period. Pregnancy at term is between 38-42 weeks of gestation and this is the
normal delivery period. However, approximately, 3.4-14% or an average of 10% of
pregnancies lasted until 42 weeks or more. Post term pregnancies especially affect the fetus.
In fact, postterm pregnancy have an influence on fetal development until the death of the
fetus. There is a fetus in gestation 42 weeks or more body weight increased steadily, there is
not increased, there are born weighing less than it should, or die in utero due to lack of
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nutrients and oxygen. Postterm pregnancy has a close relationship with mortality, perinatal
morbidity, or macrosomia.1
The maternal risks of postterm pregnancy are often underappreciated. These include
an increase in labor dystocia (9-12% vs 2-7% at term), an increase in severe perineal injury
(3rd and 4th degree perineal lacerations) related to macrosomia (3.3% vs 2.6% at term) and
operative vaginal delivery, and a doubling in the rate of cesarean delivery (14% vs 7% at
term). 2
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CHAPTER II
LITERATURE VIEW OF POST TERM PREGNANCY
II.1 DEFINITION
The international definition of prolonged or post term pregnancy, endorsed by the
American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294
days) or more from the first day of the last menstrual period. It is important to emphasize the
phrase "42 completed weeks." 1
II.2 ESTIMATED GESTATIONAL AGE USING MENSTRUAL DATES
The definition of postterm pregnancy as one that persists for 42 weeks or more from
the onset of a menstrual period assumes that the last menses was followed by ovulation 2
weeks later. This said, some pregnancies may not actually be postterm, but rather are the
result of an error in estimation of gestational age because of faulty recall of the dates of
menstruation or delayed ovulation. Thus, there are two categories of pregnancies that reach
42 completed weeks:
Those truly 40 weeks past conception.
Those of less advanced gestation due to inaccurate estimate of gestational age.
Munster and associates (1992) described a high incidence of large variations in
menstrual cycles in normal women. Boyce and associates (1976) studied 317 French women
with conceptional basal body temperature profiles and found that 70 percent who completed
42 postmenstrual weeks had less advanced gestations based on ovulation dates. Blondel and
colleagues (2002) analyzed postterm pregnancy rates according to six algorithms for
gestational age estimates based on either the last menstrual period, ultrasound at 16 to 18
weeks, or both. This Canadian study included 44,623 women giving birth between 1978 and
1996 at the Royal Victoria Hospital in Montreal. The proportion of births at 42 weeks or
longer was 6.4 percent when based on the last menstrual period alone and 1.9 percent when
based on ultrasound alone. This raises the possibility that the menstrual dates are frequently
inaccurate in predicting postterm pregnancy. The recent study of Bennett and associates
(2004) confirmed this. Because a few women ovulate earlier than expected, it is possible that
40 completed postconceptional weeks could be achieved after 41 weeks of amenorrhea.
Therefore, most pregnancies that are reliably 42 completed weeks beyond the last
menses probably are not biologically prolonged. Conversely, a few that are not yet 42 weeks
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might be postterm. These variations in menstrual cycle likely explain, at least partially, why a
relatively small proportion of fetuses delivered postterm have evidence of postmaturity.
Because there is no method to identify pregnancies that are truly prolonged, all pregnancies
judged to be 42 completed weeks should be managed as if abnormally prolonged.
II.3 INCIDENCE
As shown in Figure 371, approximately 7 percent of 4 million infants born in the
United States during 2001 were estimated to have been delivered at 42 weeks or more. In
comparison, 12 percent of live births were preterm, defined as 36 weeks or less.
Contradictory results have been found concerning the significance of a variety of
maternal demographic factors, such as parity, prior postterm birth, socioeconomic class, and
age. One interesting featurethe tendency for some mothers to have repeated postterm birthssuggests that some prolonged pregnancies are biologically determined. In an analysis of
27,677 births to Norwegian women, the incidence of a subsequent postterm birth increased
from 10 to 27 percent if the first birth was postterm. This was increased to 39 percent if there
had been two previous, successive postterm deliveries (Bakketeig and Bergsj, 1991).
Mogren and colleagues (1999) reported that prolonged pregnancy also recurred across
generations in Swedish women. When mother and daughter had had a prolonged pregnancy,
the risk for a daughter's subsequent postterm pregnancy was increased two- to threefold. In
another Swedish study, Laursen and associates (2004) found that maternal, but not paternal,
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genes influenced prolonged pregnancy. Fetalplacental factors that have been reported as
predisposing to postterm pregnancy include anencephaly, adrenal hypoplasia, and X-linked
placental sulfatase deficiency (MacDonald and Siiteri, 1965; Naeye, 1978; Rabe and
colleagues, 1983). These cause a lack of the usually high estrogen levels of normal pregnancy
(see Chap. 3, Placental Estrogen Production). Finally, reduced cervical nitric oxide release
may be a factor (Vaisanen-Tommiska and co-workers, 2004).
II.4 PERINATAL MORTALITY
The historical basis for the concept of an upper limit of human pregnancy duration
was the observation that perinatal mortality increased after the expected due date was passed.
This is best seen when perinatal mortality is analyzed from times before widespread use of
interventions for pregnancies exceeding 42 weeks. In two large Swedish studies shown in
Figure 372, after reaching a nadir at 39 to 40 weeks, perinatal mortality increased as
pregnancy exceeded 41 weeks. Lucas and co-workers (1965) compared perinatal outcomes in
6624 postterm pregnancies with those of almost 60,000 singleton pregnancies delivered
between 38 and 41 weeks. All components of perinatal mortalityantepartum, intrapartum,
and neonatal deathswere increased at 42 weeks and beyond. The most significant increases
occurred intrapartum. The major causes of death included pregnancy hypertension, prolonged
labor with cephalopelvic disproportion, "unexplained anoxia," and malformations. Similar
outcomes were reported by Olesen and colleagues (2003) in their analysis of 78,022 women
with postterm pregnancies delivered before routine labor induction was adopted in Denmark.
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Alexander and colleagues (2000a) reviewed 56,317 consecutive singleton pregnancies
delivered at 40 or more weeks between 1988 and 1998 at Parkland Hospital. As shown in
Table 371, labor was induced in 35 percent of pregnancies reaching 42 weeks. The rate of
cesarean delivery for dystocia and fetal distress was significantly increased at 42 weeks
compared with that of earlier deliveries. More infants were admitted to intensive care in
postterm pregnancies. The incidence of neonatal seizures and deaths doubled at 42 weeks.
Caughey and Musci (2004) reported similar outcomes in 45,673 pregnancies.
Smith (2001) has challenged analyses such as these because the population at risk for
perinatal mortality in a given week consists of all ongoing pregnancies rather than just the
births in a given week. Figure 373 shows perinatal mortality rates calculated using only
births in a given week of gestation from 37 to 43 completed weeks compared with the
cumulative probability (perinatal index) of death when all ongoing pregnancies are included
in the denominator. Smith found that delivery at 38 weeks was associated with the lowest risk
of perinatal death.
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II.5 ETIOLOGY
The most common cause of a prolonged pregnancy is an error in the clinical
estimation of the gestational age. Other cause are unknown and are probably associated with
abnormalities in the biochemical and physiological mechanism responsible for initiation of
labor.
Associated with placental sulfatase deficiency. This enzyme plays a critical role in the
synthesis of placental estrogens that are necessary for the development of gap
junctions and increased expressions of oxytocin and prostaglandin reseptors in
myometrial cells.
Anencephaly. The lack of development of the fetal hypothalamus negates the
production of corticotropin-relasing hormone and the stimulation of the pituitary-
adrenal-placental axis necessary for the initiation of partutrition.
Decrease in the pregnancy hormone progesterone is believed that important events
endocrine changes in spurring the process of biomolecular on labor and increases
uterine sensitivity to oxytocin, so some authors suspect that the occurrence of
postterm pregnancy is still ongoing due to the influence of progesterone.
Physiologically important role in inducing labor and oxytocin release from
neurohipofisis pregnant women who are less advanced in the pregnancy as one of the
factors thought to cause postterm pregnancy.
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Pressure on the cervical ganglion of the plexus Frankenhauser will evoke uterine
contractions. In circumstances where there is no pressure on the plexus, such as the
location of abnormalities, short cord, and the bottom is still high.
Hereditary factor. Some authors claim that a mother who experienced posttermpregnancy have a tendency to give birth through the month in subsequent
pregnancies. Mogren as quoted by Cunningham, states that when a mother
experiencing postterm pregnancy when a girl, then most likely his daughter will
experience a postterm pregnancy.
II.6 DIAGNOSIS
Menstrual History
Some criteria for the diagnosis of postterm pregnancy:
The patient must be convinced by her LMP
28-day cycle and regular
Not on the pill contracption at least the last 3 months
Further diagnosis is determined by calculating according to formula Naegele. Based on
menstrual history, a person designated as postterm pregnancy possibilities are:
No errors determine the last period and it lasts through the month of pregnancy. Errors in determining the date of last menstrual period or due to abnormal
menstruation.
Date of last period clearly known, but a delay ovulation.
Antenatal history:
Pregnancy can be expressed as postterm pregnancies obtained when 3 or more of the four
criteria of examination results as follows:
36 weeks have passed since a positive pregnancy test 32 weeks have passed since the first audible fetal heart rate with Doppler
24 weeks have passed since the first fetal movement felt
22 weeks have passed since hearing the fetal heartbeat with a stethoscope Laennec
first.1
Ultrasonography examination
Ultrasonographic dating early in pregnancy can improve the reliability of the EDD
(estimated due date). However, it is necessary to understand the margin of error reported at
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various times during each trimester. A calculated gestational age by composite biometry from
a sonogram must be considered an estimate and must take into account the range of
possibilities. Measurement of the crownrump length (CRL) at early pregnancy ultrasound has
been shown to give a more accurate estimate of gestational age and so decrease the incidence
of prolonged pregnancy. However, ultrasound has a degree of error: 7 days up to 20 weeks
gestation, 14 days between 20 and 30 weeks and 21 days beyond 30 weeks. It is for these
reasons that the National Institute of Clinical Excellence (NICE) recommends a dating
ultrasound examination between 10 and 13 weeks to estimate the gestation of a pregnancy.5,7
In addition to the CRL, biparietal diameter and femur length, some parameters in
ultrasound examination can also be used such as abdominal circumference, head
circumference, and some formulas that are some of the results of the calculation of the
parameters mentioned above. In contrast, examination shortly after the third trimester can be
used to determine fetal weight, amniotic fluid state, or any state of the placenta is frequently
associated with postterm pregnancy, but it's hard to make sure the age of pregnancy.
Gestational Age for CRL
Age CRL (cm)
6.1 Weeks: 0.4 cm
7.2 Weeks: 1.0 cm
8.0 Weeks: 1.6 cm9.2 Weeks: 2.5 cm
9.9 Weeks: 3.0 cm
10.9 Weeks: 4.0 cm
12.1 Weeks: 5.5 cm
13.2 Weeks: 7.0 cm
14.0 Weeks: 8.0 cm
The following formula is an approximation:
Gestational age [weeks of pregnancy] = crown-rump length (cm) + 6.5 4.8
Laboratory examination
Levels of lecithin / spingomielin.
When L / P in the amniotic fluid levels are the same, then about 22-28 weeks
gestational age, L = 1.2 P: 28-32 weeks, pregnancy at term on the L / P = 2. This
check can not be used to determine the postterm pregnancy, but only used to
determine whether the fetus is old enough / mature for birth-related action to
prevent errors in termination of pregnancy.
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Thromboplastin activity of amniotic fluid (ATCA).
Hatswell successfully showed that amniotic fluid accelerates blood clotting time.
This activity increases with gestational age 41-42 weeks ATCA range 45-65
seconds, at the age of more than 42 weeks gestation ATCA obtained less than 45seconds. When obtained ATCA between 42-46 seconds indicates that pregnancy
lasts through time.
Amniotic fluid cytology
Painting with nile blue sulphate can see the fat cells in the amniotic fluid. When
the number of cells containing fat exceeds 10%, then an estimated 36 weeks
gestation and if 50% or more, then the age of 39 weeks' gestation or more.1
II.7 CHANGES ASSOCIATED IN POSTERM PREGNANCY
Placental Changes
The post term placenta shows decrease in diameter and length of the chorionic villi,
fibrinoid necrosis, and accelerated atherosis of the chorionic and decidual vessels. This
changes occur simultaneously with or precede of the hemorragic infracts, which are foci
for calcium deposition and formation of white infracts. Infracts are present in 10-25% of
term and 60-80% of post-term placentas. They are more common at the placental borders.
Deposition of calcium in the post-term placenta reaches up to 10 g of dry tissue weight,
whereas it is only 2-3 g per 100 g in placentas term.
Clifford (1954) proposed that the skin changes of postmaturity were due to loss of the
protective effects of vernix caseosa. He also attributed the postmaturity syndrome to
placental senescence, although he did not find placental degeneration histologically. Still,
the concept that postmaturity is due to placental insufficiency has persisted despite an
absence of morphological or significant quantitative findings (Larsen and co-workers,
1995; Rushton, 1991). Of interest, Smith and Baker (1999) reported that placental
apoptosisprogrammed cell deathwas significantly increased at 41 to 42 completed
weeks compared with that at 36 to 39 weeks. The clinical significance of such apoptosis
is unclear at this time.
Jazayeri and co-workers (1998) investigated cord erythropoietin levels in 124
appropriately grown newborns delivered from 37 to 43 weeks. They sought to assess
whether fetal oxygenation was compromised due to placental aging in postterm
pregnancies. Decreased partial oxygen pressure is the only known stimulator of
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erythropoietin. Each woman studied had an uncomplicated labor and delivery. Cord
erythropoietin levels were significantly increased in pregnancies reaching 41 weeks or
more. Although Apgar scores and umbilical cord blood gases were normal in these
infants, the investigators concluded that there was decreased fetal oxygenation in some
postterm gestations.
The postterm fetus may continue to gain weight and thus be an unusually large infant
at birth. This at least suggests that placental function is not compromised. Indeed,
continued fetal growth, although at a slower rate, is characteristic between 38 and 42
weeks (Fig. 375). Nahum and colleagues (1995) confirmed that fetal growth continues
until at least 42 weeks.
There are several grade of placenta:
During the first part of gestation the ultrasonic appearance of the placenta is
homogenous, without echogenic densities, and limited by a smooth chorionic plate
(grade 0 placenta).
With proggresion of pregnancy the chorionic plate begins acquire subtle undulation,
and echogenic densities appear randomly dispersed throughout the organ but sparing
its basal layer (grade I placenta).
Near term the indentations in the chorionic plate become more marked, echogenic
densities appear in the basal layer, and commalike densities seem to extend from
chorionic plate into the substance of the placenta (grade II).
Finally, when the pregnancy is at term or post-term the identation in the chorionic
plate become more marked, giving the appearance of cotyledons. This impression is
reinforced by increased of confluency of the comma-like densities that become the
intercotyledonary septations. Also, characteristically, the central portion of the
cotyledons become echo-free (fallour areas), and large irregular densities, capable of
casting acoustic shadows, appear in the substance of the placenta (grade III placenta).4
Amniotic Fluid Changes
There are quantitative and qualitative changes in the amniotic fluid with prolongation
of pregnancy. The amniotic fluid volume reaches a peak of about 1000 ml at 38 weeks of
gestation and decreases to about 800 ml at 40 weeks. This reduction in volume continous
and the amount of fluid is approximately 480, 250, and 160 ml at 42, 43, and 44 weeks,
respectively. An amniotic fluid volume under 400 ml at 40 or more weeks is associated
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with fetal complication. The cause of oligohidramnios in prolonged pregnancy seems to
be dismished fetal urine production.
The four-quadrant technique (Phelan et al, 1987) is the most popular method to
evaluate amniotic fluid volume. The four quadrant technique consist of measuring the
vertical diameter of the largest pocket of fluid found in each of the four quadrants of the
uterus. The sum of the results is the amniotic fluid index (AFI). An AFI less than 5cm
indicates oligohidramnios. An AFI between 5 and 10 cm indicates a decreased fluid
volume. An AFI between 10-15 cm is normal. An AFI between 15 and 20 cm indicates
increased fluis volume. Finally, an AFI greater than 25 cm is suggestive of
polyhidramnion.
Volume of amnionic fluid during the last weeks of pregnancy. (Adapted from The Lancet,Vol. 278, PM Elliott and WHW Inman, Volume of liquor amnii in normal and abnormal
pregnancy, pp. 835840, Copyright 1961, with permission from Elsevier.)
The volume of amnionic fluid normally continues to decrease after 38 weeks and may
become problematic. Moreover, meconium release into an already reduced amnionic fluid
volume causes thick, viscous meconium that may cause meconium aspiration syndrome.3
II.8 FETAL AND NEONATAL PROBLEMS IN POST TERM PREGNANCY
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Fetal Distress
The principal reasons for increased risks for postterm fetuses were described by Leveno
and associates (1984). They reported that both antepartum fetal jeopardy and intrapartum
fetal distress were the consequence of cord compression associated with oligohydramnios. Intheir analysis of 727 postterm pregnancies, intrapartum fetal distress detected with electronic
monitoring was not associated with late decelerations characteristic of uteroplacental
insufficiency.
Instead, one or more prolonged decelerations such as shown in Figure 376 preceded
three fourths of emergency cesarean deliveries for fetal jeopardy. In all but two cases, there
were also variable decelerations (Fig. 377). Another common fetal heart rate pattern,
although not ominous by itself, was the saltatory baseline shown in Figure 378. These
findings are consistent with cord occlusion as the proximate cause of fetal distress. Other
correlates found were oligohydramnios and viscous meconium.
Prolonged fetal heart rate deceleration prior to emergency cesarean delivery in a
postterm pregnancy with oligohydramnios. (From Leveno and co-workers, 1984.)
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Severeless than 70 bpm for 60 seconds or longervariable decelerations in a
postterm pregnancy with oligohydramnios and cesarean delivery for fetal jeopardy. (From
Leveno and co-workers, 1984.)
Saltatory baseline fetal heart rate showing oscillations exceeding 20 bpm and
associated with oligohydramnios in a postterm pregnancy. (From Leveno and co-workers,
1984).
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These findings are consistent with cord occlusion as the proximate cause of the
nonreassuring tracings. Other correlates found were oligohydramnios and viscous meconium.
Schaffer and colleagues (2005) implicated a nuchal cord in abnormal intrapartum fetal heart
rate patterns, meconium, and compromised newborn condition in prolonged pregnancies.4
Postmaturity Sindrome
The postmature infant presents a unique and characteristic appearance (Fig. 374).
Features include wrinkled, patchy, peeling skin; a long, thin body suggesting wasting; and
advanced maturity because the infant is open-eyed, unusually alert, and appears old and
worried-looking. Skin wrinkling can be particularly prominent on the palms and soles. The
nails are typically quite long. Most such postmature infants are not growth restricted because
their birthweight seldom falls below the 10th percentile for gestational age. Severe growth
restriction, however, which logically must have preceded completion of 42 weeks, may
occur.
The incidence of postmaturity syndrome in infants at 41, 42, or 43 weeks, respectively,
has not been conclusively determined. In one of the rare contemporary reports that chronicle
postmaturity, Shime and colleagues (1984) found this syndrome in about 10 percent of
pregnancies between 41 and 43 weeks. The incidence increased to 33 percent at 44 weeks.
Associated oligohydramnios substantially increases the likelihood of postmaturity. Trimmer
and colleagues (1990) diagnosed oligohydramnios when the ultrasonic maximum vertical
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amnionic fluid pocket measured 1 cm or less at 42 weeks and 88 percent of the infants were
postmature.
Based on the degree of placental insufficiency occurs, the sign postmaturitas can be
divided into three stages, namely:
Stage I skin showed loss of vernix caseosa and maceration of the skin is dry, brittle,
and easy to peel.
Stage II of the above symptoms with meconium staining of the skin.
Stage III accompanied by yellowish staining of the nails, skin, and umbilical cord.1
Fetal Weight
If there is a large anatomic changes in the placenta, then decreased fetal weight. From
research it appears that Vourherr after 36 weeks gestation srafik average fetal growth leveled
off and looked a decrease after 42 weeks. However, often also the placenta was still able to
function properly so that the weight of the fetus continues to grow in accordance with
increasing gestational age. Zwerdling said that the average fetal weight of more than 3600
grams at 44.5% in postterm pregnancies, while in even-numbered month of pregnancy by
30.6%. The risk of birth to a baby weighing more than 4000 grams at postterm pregnancies
increased by 2-4 times greater than at term pregnancy. (Sarwono)
Divon and associates (1998) and Clausson and co-workers (1999) analyzed births
between 1991 and 1995 in the National Swedish Medical Birth Registry. Stillbirths were
more common among growth-restricted infants who were delivered after 42 weeks. Indeed, a
third of postterm stillborn infants were growth restricted.3
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Mean daily fetal growth during previous week of gestation. (From Jazayeri and co-workers,
1998, with permission.)
Meconium aspiration
Beyond term, the fetus is more likely to have a bowel movement, called meconium, into
the amniotic fluid. If the fetus is stressed, there is a chance it will inhale some of this
meconium stained amniotic fluid, this can cause breathing problems when the baby is born.
The problems occurs more frequently when thick meconium, fetal tachychardia and absence
of FHR accelerations are present.
The further the pregnancy progresses beyond 40 weeks, the more likely it is that
significant amounts of meconium will be present. This is due to increased uteroplacental
insufficiency, which leads to hypoxia in labor and activation of the vagal system. In addition,
the presence of a smaller amount of amniotic fluid increases the relative concentration of
meconium in utero.2.7
II.9 MATERNAL COMPLICATION
The maternal risks due to a prolonged pregnancy are commonly under-appreciated.
Prolonged pregnancy is associated with risks to the mother during labour and delivery
whether labour is induced or occurs spontaneously. It leads to anxiety in the mother due to a
perception of danger to her baby. Fetal macrosomia can lead to a significant increase in
prolonged labour, perineal, vaginal and cervical trauma, and postpartum haemorrhage. There
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is an increase in the rate of deliveries by caesarean section which is associated with potential
complications such as haemorrhage, infection and thromboembolism.
Maternal complications of prolonged pregnancy
Macrosomic fetus Cephalopelvic disproportion
Labour dystocia
Perineal, vaginal and cervical trauma
Delivery by caesarean section
Postpartum haemorrhage
Chorioamnionitis
Anxiety5
II.10 IDENTIFICATION OF PATIENTS WHO NEED TO BE DELIVERED
High risk pregnancies
Patients with high risk pregnancies, especially those with diabetes and hypertension need
to be delivered without consideration to the favorability of their cervix. Expectant
management in these cases is not adequate because prolongation of pregnancy will place their
fetuses at additional risk.
Women with favorable cervices
Multiple studies have shown that the risk of caesarean following induction of labor is
directly associated with the status of the cervix. These studies have also shown that women
wit favorable cervices are at low risk for abdominal delivery. Fot this reason, the majority of
investigators are in favor of induction and delivery of women with favorable cervices who
have reached or urpased their EDD.
The classical method for evaluation the cervix is the Bishop score.
Score 0 1 2 3
Cervical
dilatation
Closed 1-2 3-4 >= 5
Cervical
effacement (%)
0-30 40-50 60-70 >=80
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Fetal Station -3 -2 -1 or 0 +1 or +2
Cervical
consistency
Firm Medium Soft Soft
Cervical
position
Posterior Mid Anterior Anterior
From Bishop EH. Pelvic scoring for elective induction Obstet Gynecology 1964;24;266
Bishop modification by dr Gulardi H Winjosastro SpOG.6
Score 0 1 2
Cervical position Posterior Axial Anterior
Cervical dilatation Closed 1-2 cm >3cm
Cervical consistency Firm Soft Soft
Cervical thickness 3cm 2cm 1cm
Head position - Hodge I-II Hodge II-III
A Bishop score >= 8 is a good index of inducibility, score 6 or more is a favorable cervix toattempt induction, and score less than 4 is indication to ripening the cervix.
Decreased Amniotic fluid volume
The evaluation of amniotic fluid volume is of fundamental importance in prolonged
pregnancies. Chamberlain et al (1984) demonstrated that perinatal mortality increases
dramatically with progressive severity of oligohidramnion. Loveno et al (1984) demostrated
that umbilical cord compression secondary to oligohydramnios is the most common cause of
intrapartum fetal distress in these patients. For this reasons, women with oligohidramnios
need to be delivered.2
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Comparison of the prognostic value of various sonographic estimates of amnionic fluid
volume in prolonged pregnancies. Abnormal outcomes include cesarean or operative vaginal
delivery for fetal jeopardy, 5-minute Apgar score of 6 or less, umbilical arterial blood pH less
than 7.1, or admission to the neonatal intensive care unit. (Adapted from Fischer RL,
McDonnell M, Bianculli KW, et al: Amniotic fluid volume estimation in the postdate
pregnancy: A comparison of techniques, Obstetrics & Gynecology, 1993, vol. 81, no. 5, part
1, pp. 698704, with permission.)
Regardless of the criteria used to diagnose oligohydramnios in postterm pregnancies,
most investigators have found an increased incidence of "fetal distress" during labor. Clement
and co-workers (1987) described six postterm pregnancies in which amnionic fluid volume
diminished abruptly over 24 hoursin one of these, the fetus died.
Macrosomic fetuses
The velocity of fetal weight gain peaks at approximately 37 weeks. Although growth
velocity slows at that time, most fetuses continue to gain weight. For example, the percentage
of fetuses born in 2006 whose birthweight exceeded 4000 g was 8.5 percent at 37 to 41 weeks
and increased to 11.2 percent at 42 weeks or more (Martin and colleagues, 2009). Intuitively
at least, it seems that both maternal and fetal morbidity associated with macrosomia would be
mitigated with timely induction to preempt further growth. This does not appear to be the
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case, however, and the American College of Obstetricians and Gynecologists (2000) has
concluded that current evidence does not support such a practice in women at term with
suspected fetal macrosomia.
The importance of the prenatal estimation of fetal weight in women with prolonged
pregnancis is to determine the approach to delivery. Pasient with estimated fetal weight more
of 4500 grams or more should be causeled to have caesarean delivery because the possibility
of traumatic vaginal delivery is substantial. Caesarean section should be offered also to
women who have previously delivered infants with similiar or larger birth weight, because
prior delivery does not guarantee an easy delivery of another large baby.3
Fetal growth restriction
A fetal growth abnormality associated with prolonged pregnancy is poor fetal growth or
dysmaturity. Approximately 5-10% of fetuses delivered after their EDD show wasting of
their subcutaneus fat characteristic of intrauterine malnutrition and are classified as small for
gestasional age by neonatal evaluation. Frequently this fetuses exhibit abnormal FHR patterns
before delivery or in the course of labor. The amount of amniotic fluid is reduced in most of
these cases and meconium aspiration is a common problem. Fetal manutrition is associated
with multiple problems during immediate neonatal period including hypoglicemia,
hypocalemia, and hyperviscosity syndrome. 4
II.11 POST TERM PREGNANCY TREATMENT
Antenatal fetal monitoring
In most cases, a healthcare provider will recommend tests on the fetus if the pregnancy
extends beyond the due date. These tests give information about the health of the fetus and
about the risks or benefits of allowing the pregnancy to continue. The American College of
Obstetricians and Gynecologists has stated that it is only necessary to start antenatal fetal
monitoring after 42 weeks (294 days) of gestation, although many obstetric care providers
will start fetal testing at 41 weeks. Many experts recommend twice weekly testing, including
a measurement of amniotic fluid volume. Testing may include observing the fetus' heart rate
using a fetal monitor (called a nonstress test) or observing the baby's activity with ultrasound
(called a biophysical profile).
Nonstress testing
Nonstress testing is done by monitoring the baby's heart rate with a small device that is
placed on the mother's abdomen. The device uses sound waves (ultrasound) to measure the
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baby's heart rate over time, usually for 20 to 30 minutes. Normally, the baby's baseline heart
rate should be between 110 and 160 beats per minute and should increase above its baseline
by at least 15 beats per minute for 15 seconds when the baby moves. The test is considered
reassuring (called "reactive") if two or more fetal heart rate increases are seen within a 20
minute period. Further testing may be needed if these increases are not observed after
monitoring for 40 minutes.
Biophysical profile
A biophysical profile (BPP) score is calculated to assess the fetus' health. It consists of
five components, nonstress testing and ultrasound measurement of four fetal parameters: fetal
body movements, breathing movements, fetal tone (flexion and extension of an arm, leg, or
the spine), and amniotic fluid volume. Each component is scored individually, 2 points if
normal and 0 points if not normal. The maximum possible score is 10. Amniotic fluid volume
is an important variable in the BPP because a low volume (called oligohydramnios) may
increase the risk of umbilical cord compression and may be a sign of changes in the feto-
uteroplacental circulation. Amniotic fluid level can become reduced within a short time
period, even a few days.
Contraction stress test
A contraction stress test (CST) can also be done to assess fetal health. It involves giving
an intravenous medication (oxytocin) to the mother to induce uterine contractions. The fetus'
heart rate is monitored in response to the contractions. A fetus whose heart rate slows down
during a CST may require a cesarean delivery.7
Inducing of labor
Once the decision to deliver a patient has been made, the management of the labor
induction depends on the clinical setting, and a brief review of cervical ripening agents and
potential complications of induction of labor is appropriate. As many as 80% of patients who
reach 42 weeks' gestation have an unfavorable cervical examination (ie, Bishop Score < 7).
Many options are available for cervical ripening. The different preparations, indications,
contraindications, and multiple dosing regimes of each require practitioners to familiarize
themselves with several of the preparations.
Currently available chemical preparations include prostaglandin E1 tablets for oral or
vaginal use (misoprostol), prostaglandin E2 gel for intracervical application (dinoprostone
cervical [Prepidil]), and a prostaglandin E2 vaginal insert (dinoprostone [Cervidil]). Cervidil
contains 10 mg of dinoprostone and has a lower constant release of medication than Prepidil.
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In addition, this vaginal insert device allows for easier removal in the event of uterine
hyperstimulation.
Many studies have compared the efficacy and risks of various prostaglandin cervical
ripening agents. Rozenburg et al performed a randomized trial comparing intravaginal
misoprostol and dinoprostone vaginal insert in pregnancies at high risk of fetal distress. They
found that both methods were equally safe for the induction of labor and misoprostol was
actually more effective.
Another method for ripening the cervix is by mechanical dilation. These devices may act
by a combination of mechanical forces and by causing release of endogenous prostaglandins.
Foley balloon catheters placed in the cervix, extra-amniotic saline infusions, and laminaria
have all been studied and have been shown to be effective.
Regardless of what method is chosen for cervical ripening, the practitioner must be aware
of the potential hazards surrounding the use of these agents in the patient with a scarred
uterus. In addition, the potential for uterine tachysystole and subsequent fetal distress requires
that care be taken to avoid using too high a dose or too short a dosing interval in an attempt to
get a patient delivered rapidly. Care should also be taken when using combinations of
mechanical and pharmacologic methods of cervical ripening.
Finally, intrapartum fetal surveillance in an attempt to document fetal intolerance to labor
before it leads to acidosis is critical. Whether continuous fetal monitoring or intermittent
auscultation is used, interpretation of the results by a well-trained clinician is of paramount
importance. If the fetal heart rate tracing is equivocal, fetal scalp stimulation and/or fetal
scalp blood sampling may provide the reassurance necessary to justify continuing the
induction of labor. If the practitioner cannot find reassurance that the fetus is tolerating labor,
cesarean delivery is recommended. 4
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II.12 INTRAPARTUM MANAGEMENT
Labor is a particularly dangerous time for the postterm fetus. Therefore, it is
important that women whose pregnancies are known or suspected to be postterm come to the
hospital as soon as they suspect they are in labor. On arrival, while being observed for
possible labor, we recommend that fetal heart rate and uterine contractions be monitored
electronically for variations consistent with fetal distress (American College of Obstetricians
and Gynecologists, 1995).
When to perform amniotomy is problematic. Further reduction in fluid volume
following amniotomy can certainly enhance the possibility of cord compression. Conversely,
amniotomy aids diagnosis of thick meconium, which may be dangerous to the fetus if
aspirated. Moreover, once the membranes are ruptured, a scalp electrode and intrauterine
pressure catheter can be placed, which usually provide more precise data concerning fetal
heart rate and uterine contractions.
Identification of thick meconium in the amnionic fluid is particularly worrisome. The
viscosity probably signifies the lack of liquid and thus oligohydramnios. Aspiration of thick
meconium may cause severe pulmonary dysfunction and neonatal death. Wenstrom and
Parsons (1989) proposed amnioinfusion during labor as a way of diluting meconium to
decrease the incidence of meconium aspiration syndrome. The benefits of amnioinfusion
remain controversial. In a recent randomized trial by Rathore and colleagues (2002),
amnioinfusion was associated with fewer cesarean deliveries for fetal distress and fewer
neonatal intensive care unit admissions for neonates with moderate to thick meconium-
stained amnionic fluid. In contrast, Yoder and colleagues (2002) found that increased use of
amnioinfusion0 to 36 percent of women with moderate to thick amnionic fluid meconium
had no impact on the incidence of meconium aspiration syndrome.
The likelihood of a successful vaginal delivery is reduced appreciably for the
nulliparous woman who is in early labor with thick, meconium-stained amnionic fluid.
Therefore, when the woman is remote from delivery, strong consideration should be given to
prompt cesarean delivery, especially when cephalopelvic disproportion is suspected or either
hypotonic or hypertonic dysfunctional labor is evident. Some practitioners choose to avoid
oxytocin use in these cases.
Aspiration of meconium may be minimized but not eliminated by effective suctioning
of the pharynx as soon as the head is delivered but before the thorax is delivered. If
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meconium is identified, the trachea should be aspirated as soon as possible after delivery.
Immediately thereafter, the infant should be ventilated as needed.
Antepartum management of post term pregnancy.
Source: Arias F, Daftary S, et al. Practical Guide to high risk pregnancy and delivery.
Chapter 11: Prolonged pregnancy. Third edition. 2010. Elsevier: India. Page 286.
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CHAPTER III
CASE ILUSTRATION
I. IDENTITY
Name : Mrs. AF
Age : 22 yrs
Religion : Moslem
Tribe : Betawi
Education : Junior High school
Occupation : Housewife
Address : Kp. Bulak Sign in hospital: Thursday, March 22nd, 2012, at 15.00
II.ANAMNESIS
Autoanamnesis dated, Thursday, March 22nd, 2012, at 15.00
A. Chief complaint
Not yet inpartu in pst term pregnancy, rujukan dr RSUD with 42 weeks pregnancy.
B. History of Present Illness
Patient admit that she has 10 months pregnancy, first day of last menstrual period:
June 1st 2011 ~ 42 weeks. Estimated day of delivery: March 8 th 2012. Patient complain
referenced from a doctor from Depok Hospital because of post term pregnancy and there is
no inpartu signs. ANC routinely once a month at Health Care Centre, USG 1 time and the
results was the baby in good condition, head presentation, and postmature baby in pregnancy.
There is no contraction or abdominal pain, bloody show and water break. History of fever
and hypertension during pregnant were denied. Defecate and mixture are no complaints.
Patient doesnt have a hole tooth. Traumatical history, headache, nausea, vomit, epigastrium
pain and blur vision was denied. Fetal movement still felt.
C. Menstrual History
Menarche at the age of 12 years, the cycle is 28 days, regular, duration 7 days, 2-3
pads/day, menstrual pain (+)
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D. Marital Status
The patient has only been married once and has been married for the past 2 years until
this day.
E. History of previous pregnancy
1.Current pregnancy
F. History of present pregnancy
Early pregnancy : Nausea (+), vomits (+), bleeding (-), hypertension (-)
Later pregnancy : sweeling foot (-), hypertension (-), dyspnea (-).
ANC at Health Care Center monthly.
G. History of contraception
Patient doesnt use any contraception.
H. History of Systemic Disease
Heart disease (-), respiratory disease (-), hypertension (-), diabetes mellitus (-)
I. Surgery History
None
J. History of Family Disease
Heart disease (-), respiratory disease (-), hypertension (-), Diabetes Mellitus (-)
K. Habit and Psychosocial History
No smoking, drinking alcohol, drugs and drinking herbal medicine.
III.PHYSICAL EXAMINATION
A. General examination
General impression : mild illness
Degree of consciousness : compos mentis
Vital signs : BP 120/80 mmHg, HR 80 x/m, RR 20x/', T 36.50C
Body weight before present pregnancy: 50 kg
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Body weight during present pregnancy: 61 kg
Head : Normocephali, black hair, straight, uniform distribution
Eyes : Conjungtiva anemic -/-, icteric sklera -/-
Mouth : Dry (-), sianosis (-)
Ears : Normotia, secretions serumen (-/-)
Nose : Normosepta, secretions (-/-), septum deviation (-)
Throat : Hyperemis pharinx (-)
Neck : Enlarged glands (-).
Thorax
Cor : Regular I-II heart sound, murmurs (-), Gallop (-).
Pulmo : Vesicular breath sound, Rh (-/-), Wh (-/-).
Breast : Symmetric, hyperpigmentation on both the areola, retracted nipple (-), mass
(-)
Extremity : warm extremities, swelling -/-
B.Obstetrical Status
Abdomen:
Inspection : abdomen enlarged and distended, striae gravidarum (+)
Palpation:
- Leopold I : fungal height 32 cm, hard, round, ballotable, and nodular body not easy to
move in palpation
- Leopold II :
Left : a small parts of the fetus is palpable
Right : a hard resistant and board like structure
- Leopold III : hard, round, ballotable, moveable, pandular like and nodular body
- Leopold IV : 5/5
- His : -
- Fetal weight estimation (FWE) : 3100 g
Auscultation : 2 punctum maximum, fetal heart sound 140 dpm, regular
Anogenital:
- Inspection : Vulva/urethra no sign of inflammation, bleeding (-), edema (-), varicose (-)
- Speculum examination : livid portio, ostium opened, fluor (-), fluxus (-)
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- VT : firm portio, posterior, thickness 3 cm, diameter 1 cm, amniotic membrane
(+), head was palpated on H I-II
IV. SUPPORTIVE EXAMINATION
A. Laboratory (March 22nd, 2012)
B. USG (March 22nd, 2012)
31
Examination Result Normal Range
Hematology
Hb 13.2 g/dL 11.7-15.5Ht 39 % 33-45Leucocyte 10.900/ul 5000-10.000Platelet 284.000/ul 150.000-440.000Erythrocyte 4.200.000/ul 3.800.000-5.200.000VER/HER/KHER/RDW
VER 92.1 fl 80.0-100.0HER 31.4 pg 26.0-34.0KHER 34.1 g/Dl 32.0-36.0RDW 13.0 % 11.5-14.5Diabetes
Spot glucose blood 51 mg/dl 70-140Urinalysis
Urobilinogen 0.2
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Fetus : Alive, Single,
Head presentationBPD: 9.5 cmHC: 32.38 cmAC: 31.80 cmFL: 7.14 cmFWE: 3083 gPlasenta : fundus
ICA: 1445 cmAterm
Placenta in the fundus of uterine, does not seem to have loops of the cord and does not seem
to have major congenital defects.
Assessment : appropriate with aterm pregnancy live, single, head presentation.
C. CTG(March 22nd, 2012)
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Baseline frequency 140 dpm
Variability 5-15 dpm
Acseleration (+)
Deceleration (-)
Fetus movement (+)
His (+) Assesment : Reassuring
V.RESUME
The patient admits that she has had a 9 months pregnancy. First day of last menstrual
period: June 1st 2011 ~ 42 weeks. Estimated day of delivery: March 8th 2012. Patient
complain referenced from a doctor from Depok Hospital because of post term pregnancy.
ANC routinely once a month at Health Care Centre, USG once and the results showed thatthe baby was in good condition, head presentation, and postmature baby in pregnancy. There
is no contraction or abdominal pain, bloody show and water break. History of fever and
hypertension during pregnant were denied. Traumatical history including headaches, nausea,
vomiting, epigastrium pain and blured vision was denied. Fetal movement was still felt.
In generalist examination are normal.
In Obstetrical examination, we finded:
Abdomen enlarged and distended Fungal height 32 cm
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Head presentation
Fetal Weight Estimation: 3100 g
On auscultation, there is 2 punctum maximum, fetal heart sound 140 dpm
In Anogenital examination we found no inflammation signs, bleeding, edema or
varicose. Speculum examination : livid portio, ostium opened, fluor (-), fluxus (-);
VT : firm portio, posterior, thickness 3 cm, diameter 1 cm, amniotic membrane (+),
head was palpated on H I-II.
In USG, Placenta is in the fundus of uterine, does not seem to have loops of the cord
and does not seem to have major congenital defects. In CTG, fetus is reassuring.
VI.DIAGNOSIS
Maternal :
G1P0A0 Pregnant 42 weeks, not yet inpartu
Fetal : singleton live head presentation
VII.MANAGEMENT
Induction with folley catheter 1x24 hours observe progress of labour re-evaluate after 24 hours.
VII.PROGNOSIS
Mother: Dubia ad bonam
Fetus : Dubia ad bonam
VIII. Follow Up ResultMarch 23
rd2012 06.00
S : minimal contraction, fetal movement (+)
O : General condition: good
Conciousness: compos mentis
BP 120/80 mmHg, HR 82x/, RR 20x/, T 36,5oC
The general examination: performed revealed stable,
Obstetric st. : irregular contraction, FHR : 150 dpm
Inspection: V/U calm, FC (+)
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A : G1 42 weeks pregnancy, fetus with singleton live head presentation, immature
cervix, not yet inpartu
P : Rdx/ obs vital signs, contraction, FHR
Rth/ Pervaginam delivery, induction for immature cervix with FC 1x24 hours
Re-evaluate at 16.15
March 23rd, 2012, 13.00
S : FC loose spontaneous, minimal contraction (+), fetus movement (+)
O : General condition: good
Conciousness: compos mentis
BP 110/80 mmHg, HR 84x/, RR 20x/, T 36,5oC
The general examination: other performed revealed stable
Obstetric st. : his irregular, FHR : 152 dpm
Inspection: V/U calm
VT : firm porsio, axial, 3 cm, T =1 cm, amniotic membrane (+), the
head was palpated on H I-II
A : mature cervix in delivery G1 42 weeks pregnancy, fetus singleton live head
presentation, post prepared cervix with FC 1x24 hours
P : Rdx/ obs vital signs, his, FHR/hour
Rth/ partus pervaginam
Induction with oxcytocin 5 IU/500cc RL from 4mIU up to 2mIU/30 untill
adequate of his repeated check up after 3 hours
March 23rd 2012, 17.00
His adequate with 20 tpm, check again 3 hours more.
March 23rd 2012, 20.00
S : contraction (+), fetus movement (+)
O : General condition: good
Conciousness: compos mentis
BP 110/80 mmHg, HR 84x/, RR 20x/, T 36,5oC
The general examination: other performed revealed stable
Obstetric st. : his 3x/10/35, FHR : 152 dpm
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Inspection: V/U calm
VT : firm porsio, axial, 8 cm, T =1 cm, amniotic membrane (+), the
head was palpated on H II-III
A : active stage I in delivery G1 42 weeks pregnancy, fetus singleton live head
presentation, not yet inpartu
P : Rdx/ obs vital signs, his, FHR/hour
Rth/ partus pervaginam, repeated check up at 22.00
March 23rd 2012, 22.00
S : contraction (+), fetus movement (+)
O : General condition: good
Conciousness: compos mentis
BP 110/80 mmHg, HR 84x/, RR 20x/, T 36,5oC
The general examination: other performed revealed stable
Obstetric st. : his 4x/10/45, FHR : 150 dpm
Inspection: V/U calm
VT : firm porsio, axial, 10 cm, amniotic membrane (+), the head
was palpated on H III-IV
A : stage II in delivery G1 42 weeks pregnancy, fetus singleton live head presentation,
not yet inpartu
P : Rdx/ obs vital signs, his, FHR/hour
Rth/ partus pervaginam
March 23rd 2012, 22.05
Spontaneus delivery, born baby boy with AS 8/9, baby weight 3060 grams
Meconium aminiotic fluid
Oksitosin 10 IU
Complete placenta
Good fundus contraction
IUD post plasenta
Intact perineum, bleeding 400cc
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Features of post-maturity syndrome
Wrinkled (sometimes peeling) skin
Meconium-stained skin and nails
Long nails Calcified skull
Little or no vernix
No lanugo
March 24th 2012, 00.00
S : pain (-), bleeding (-)
O : General condition: goodConciousness: compos mentis
BP 120/80 mmHg, HR 88x/, RR 20x/, T 36,7oC
The general examination: performed revealed stable
Obstetric st. : fundus uterine height 2 fingers below umbilicus, contraction normal
Inspection: V/U calm, bleeding (-)
A : P1, spontaneus postpartum + IUD Akseptor
P :
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Observe vital sign (blood pressure, pulse, temperature, respiratory rate), bleeding,
contraction.
Active mobilization
High carbohidrate and high protein diet Perineum and vulva hygiene
Amoxicillin 3x500 mg
SF 1x1
Asam mefenamat 3x500 mg
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CHAPTER IV
CASE ANALYSIS
In this patient, Mrs AF 22 years, we diagnosed the patient with G1P0 Pregnant 42weeks, immature cervix, not yet inpartu. Based upon the anamnesa, we found that she has 42
weeks pregnancy, which is the first day of last menstrual period was on June 1st 2011 ~ 42
weeks so the estimated day of delivery must be on March 8th 2012. As the definition from the
American College of Obstetricians and Gynecologists (2004), international definition of
prolonged or postterm pregnancy is 42 completed weeks (294 days) or more from the first
day of the last menstrual period.
Otherwise, to make complete data of post term pregnancy we should have the record
of antenatal examination such as date of test pack a positive pregnancy test, first audible fetal
heart rate with Doppler, the first fetal movement felt. Moreover, we need the record of
ultrasound examination between 10 and 13 weeks to estimate the gestation of a pregnancy by
the Crown-rump length (CRL). Then if there is adequate facilities available we can do some
laboratory examination such as levels of lecitin and sphyngomielin, Thromboplastin activity
of amniotic fluid (ATCA), and amniotic fluid cytology. Although this patient didnt have that
data, we still have diagnose this pregnancy as a post term pregnancy based on anamnesa of
menstrual history because this convinced her last menstrual period, 28-day cycle and regular,
not on the pill contracption at least the last 3 months.
In obstetric examination we also found that vaginal touche result is firm portio,
posterior, cervix dilatation 1 cm, thickness 3 cm, amniotic membrane (+), head was palpated
on HI-II So, the bishop score is 2. This result show us unfavorable cervix for this patient. So
to strart the management of delivery we need the cervical ripening before we give induction
and lead the patient to delivery.
The patient born the baby with postmature syndrome: wrinkled (sometimes peeling)
skin, meconium-stained skin and nails, long nails, calcified skull, little or no vernix, no
lanugo.
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CHAPTER V
CONCLUSION AND SUGGESTION
CONCLUSION
A pregnancy that continues for 42 completed weeks ( 294 days) or more is considered
prolonged or post term pregnancy.
The recurrence risk for post-term pregnancy is 20%.
Early ultrasound estimation of gestational age (using crownrump length (CRL)
reduces the incidence of prolonged pregnancy and reduces induction rates for
prolonged pregnancy.
There is an increased risk of perinatal death with increasing gestational age but theabsolute risk is very low.
Present evidence favours routine induction of labour after 41 weeks gestation, as this
reduces perinatal mortality.
The management for delivery of this patient was appropriate to the theory.
SUGGESTION
The health care should advice the patient to have fetal monitoring for pregnancy over41 weeks about two times a week. Which is consist of monitoring fetal heart rate with
nonstress test and biophusical profile to reduce neonatal mortality in post term pregnancy.
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LITERATURE
1. Prawirohardjo S. Post term pregnancy. Obsetrics. 2009. Second edition. Yayasan Bina
Pustaka Sarwono Prawirohardjo:Jakarta. Page 686-93
2. Aaron B Caughey, MD; Chief Editor: David Chelmow, MD . Updated on 25 March
2011. Post term pregnancy. http://emedicine.medscape.com/article/261369-overview
3. Cunningham, Leveno, et al. Chapter 37. Post term Pregnancy.Williams Obstetrics,
23e. 2011. The McGraw-Hill Companies:United States.
4. Arias F, Daftary S, et al. Practical Guide to high risk pregnancy and delivery. Chapter
11: Prolonged pregnancy. Third edition. 2010. Elsevier: India. Page 277-90
5. Anand J, Sharmila P, Katharine PS. Prolonged pregnancy. Obstetrics, Gynaecology &
Reproductive Medicine. 2012. Elsevier.
http://www.sciencedirect.com/science/article/pii/S175172140700228X
6. Bishop score modified by Gulardi. Accessed on January 25, 2012. Published on the
website http://puskesmaspalaran.wordpress.com
7. Norwitz, Errol. Patient information: Post term pregnancy. Updated in 2012.
http://www.uptodate.com/contents/patient-information-postterm-pregnancy
8. Wikipedia. Crown-rump length. Update in 9 October 2011. www.wikipedia.com