Post Term Bunga

7/27/2019 Post Term Bunga

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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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http://emedicine.medscape.com/article/273053-overviewhttp://emedicine.medscape.com/article/273053-overview


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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 (+)




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 (+)





Obstetric st. : his 3x/10/35, FHR : 152 dpm

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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


Rth/ partus pervaginam, repeated check up at 22.00

March 23rd 2012, 22.00

S : contraction (+), fetus movement (+)





Obstetric st. : his 4x/10/45, FHR : 150 dpm


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


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


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

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