{"id":390,"date":"2020-08-13T20:22:46","date_gmt":"2020-08-13T20:22:46","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=390"},"modified":"2020-10-20T17:01:28","modified_gmt":"2020-10-20T17:01:28","slug":"postterm-pregnancy","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/postterm-pregnancy\/","title":{"rendered":"Postterm Pregnancy"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/i-BVHlx1efw\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 7:24<\/p>\n<p><\/p>\n<input type='hidden' bg_collapse_expand='69e9c8632cf2d4098245429' value='69e9c8632cf2d4098245429'><input type='hidden' id='bg-show-more-text-69e9c8632cf2d4098245429' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8632cf2d4098245429' value='Hide Transcript'><button id='bg-showmore-action-69e9c8632cf2d4098245429' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8632cf2d4098245429' ><\/p>\n<p>00:00<br \/>\nHello.<br \/>\n00:01<br \/>\nI&#8217;m Juan Sebastian Sandoval, one<br \/>\n00:03<br \/>\nof the OBGYN residents<br \/>\n00:04<br \/>\nat Duke University.<br \/>\n00:05<br \/>\nAnd today we&#8217;re going to talk<br \/>\n00:07<br \/>\nabout prolonged pregnancy.<br \/>\n00:08<br \/>\nGiven that this is a review<br \/>\n00:09<br \/>\nof the USMLE,<br \/>\n00:11<br \/>\nwe will pay particular attention<br \/>\n00:12<br \/>\nto the key information<br \/>\n00:13<br \/>\nthat you need to know and not<br \/>\n00:15<br \/>\nthe details<br \/>\n00:16<br \/>\nthat, although are<br \/>\n00:16<br \/>\nimportant for the practice<br \/>\n00:17<br \/>\nof an obstetrician,<br \/>\n00:18<br \/>\nare not<br \/>\n00:19<br \/>\nrelevant for these examinations.<br \/>\n00:20<br \/>\n00:24<br \/>\nDuring this presentation,<br \/>\n00:25<br \/>\nwe are going to define<br \/>\n00:26<br \/>\nprolonged pregnancy,<br \/>\n00:27<br \/>\nrecognize the etiology and risk<br \/>\n00:28<br \/>\nfactors,<br \/>\n00:29<br \/>\nunderstand the consequences<br \/>\n00:31<br \/>\nof this condition,<br \/>\n00:32<br \/>\nand identify management options.<br \/>\n00:34<br \/>\n00:37<br \/>\nA 25-year-old G2P1001 presents<br \/>\n00:41<br \/>\nto your office to establish<br \/>\n00:42<br \/>\nprenatal care.<br \/>\n00:43<br \/>\nShe recently immigrated<br \/>\n00:45<br \/>\nto the United States, hence<br \/>\n00:46<br \/>\nyou don&#8217;t have any<br \/>\n00:47<br \/>\nof her medical records.<br \/>\n00:48<br \/>\nAnd she states she is currently<br \/>\n00:50<br \/>\nat 42 weeks and 5 days<br \/>\n00:51<br \/>\nof gestational age.<br \/>\n00:53<br \/>\nAccording to her, this is based<br \/>\n00:55<br \/>\non her last menstrual period,<br \/>\n00:56<br \/>\nof which she is certain<br \/>\n00:57<br \/>\nbecause ever since her menarche<br \/>\n00:59<br \/>\nshe annotates in a calendar<br \/>\n01:01<br \/>\nthe first day<br \/>\n01:01<br \/>\nof her menstruation.<br \/>\n01:03<br \/>\nOn today&#8217;s ultrasound, the fetus<br \/>\n01:04<br \/>\nhas an estimated gestational age<br \/>\n01:06<br \/>\nof 39 weeks.<br \/>\n01:07<br \/>\nOn examination, you find<br \/>\n01:09<br \/>\nher cervix to be 4 centimeters<br \/>\n01:10<br \/>\ndilated, 60% effaced, anterior,<br \/>\n01:13<br \/>\nand soft.<br \/>\n01:14<br \/>\nThe fetus is cephalic.<br \/>\n01:17<br \/>\nWhat is the next step<br \/>\n01:18<br \/>\nin the management<br \/>\n01:19<br \/>\nof this patient?<br \/>\n01:20<br \/>\n01:23<br \/>\nProlonged pregnancy is defined<br \/>\n01:25<br \/>\nas a gestational equal<br \/>\n01:26<br \/>\nor greater to 294<br \/>\n01:28<br \/>\ndays, which is equivalent to 42<br \/>\n01:31<br \/>\nweeks after the first day<br \/>\n01:33<br \/>\nof the last menstrual period.<br \/>\n01:35<br \/>\nAlthough up until now<br \/>\n01:37<br \/>\nthere is no agreement<br \/>\n01:38<br \/>\non the correct term<br \/>\n01:39<br \/>\nfor this condition, ACOG states<br \/>\n01:41<br \/>\nthat we should use<br \/>\n01:42<br \/>\n&#8220;prolonged pregnancy&#8221;<br \/>\n01:43<br \/>\nto describe a pregnancy that has<br \/>\n01:44<br \/>\nlasted more than the upper limit<br \/>\n01:45<br \/>\nof a normal-term gestational.<br \/>\n01:48<br \/>\nThe 42-week mark is somewhat<br \/>\n01:49<br \/>\narbitrary as it was established<br \/>\n01:52<br \/>\nbefore the widespread use<br \/>\n01:53<br \/>\nof antenatal testing.<br \/>\n01:55<br \/>\nIn fact, recent data shows<br \/>\n01:56<br \/>\nthat there is a marked increase<br \/>\n01:58<br \/>\nin the prenatal morbidity<br \/>\n01:59<br \/>\nand mortality after 41 weeks<br \/>\n02:01<br \/>\nof gestation.<br \/>\n02:03<br \/>\nAnyway, whether it&#8217;s called post<br \/>\n02:04<br \/>\ndates, post terms, post<br \/>\n02:06<br \/>\nmaturity, or prolonged<br \/>\n02:08<br \/>\npregnancy, it is not<br \/>\n02:09<br \/>\nrelevant for the purpose<br \/>\n02:10<br \/>\nof the USMLE.<br \/>\n02:11<br \/>\nWhat you really need to know<br \/>\n02:13<br \/>\nis that this is<br \/>\n02:13<br \/>\na high-risk condition as it puts<br \/>\n02:15<br \/>\nthe fetus at an increased risk<br \/>\n02:17<br \/>\nof poor prenatal outcomes.<br \/>\n02:19<br \/>\nSo is it common?<br \/>\n02:21<br \/>\nYes.<br \/>\n02:22<br \/>\n7% to 12% of pregnancies<br \/>\n02:23<br \/>\nare complicated<br \/>\n02:24<br \/>\nby this condition.<br \/>\n02:25<br \/>\n02:28<br \/>\nWhen it comes to the etiology,<br \/>\n02:30<br \/>\nit&#8217;s key to know that the most<br \/>\n02:31<br \/>\ncommon cause<br \/>\n02:32<br \/>\nof prolonged pregnancy<br \/>\n02:33<br \/>\nis an error in determining<br \/>\n02:34<br \/>\nthe estimated delivery<br \/>\n02:35<br \/>\ndate or gestational age.<br \/>\n02:38<br \/>\nThis is a consequence<br \/>\n02:39<br \/>\nof variations<br \/>\n02:40<br \/>\nin the menstrual cycle length<br \/>\n02:41<br \/>\nand inaccuracy in remembering<br \/>\n02:43<br \/>\nthe date<br \/>\n02:43<br \/>\nof the last menstrual period.<br \/>\n02:45<br \/>\nConversely, the most common<br \/>\n02:46<br \/>\ncause<br \/>\n02:47<br \/>\nof true prolonged pregnancy<br \/>\n02:48<br \/>\nis idiopathic, apparently<br \/>\n02:50<br \/>\ndue to a biological variability<br \/>\n02:52<br \/>\nof the duration of pregnancy.<br \/>\n02:53<br \/>\n02:56<br \/>\nSo who&#8217;s at risk?<br \/>\n02:58<br \/>\nAlthough the exact triggers<br \/>\n02:59<br \/>\nfor initiation of labor<br \/>\n03:00<br \/>\nhave not been completely<br \/>\n03:01<br \/>\ndescribed yet,<br \/>\n03:02<br \/>\nthere are<br \/>\n03:03<br \/>\ncertain fetal and placental<br \/>\n03:04<br \/>\nabnormalities&#8211;<br \/>\n03:05<br \/>\nsuch as anencephaly,<br \/>\n03:06<br \/>\nplacental sulfatase deficiency,<br \/>\n03:08<br \/>\nand fetal adrenal hpyoplasia&#8211;<br \/>\n03:10<br \/>\nthat have been associated<br \/>\n03:11<br \/>\nwith increased risk of prolonged<br \/>\n03:12<br \/>\npregnancy.<br \/>\n03:14<br \/>\nSince there is up to a 50%<br \/>\n03:15<br \/>\nrecurrence risk in mothers who<br \/>\n03:17<br \/>\npreviously had a prolonged<br \/>\n03:18<br \/>\npregnancy,<br \/>\n03:18<br \/>\nthe genetic predisposition<br \/>\n03:19<br \/>\nfor this condition is evident.<br \/>\n03:21<br \/>\n03:24<br \/>\nAmong the most important things<br \/>\n03:25<br \/>\nyou have to know about<br \/>\n03:26<br \/>\nthe entire presentation is<br \/>\n03:27<br \/>\nthat the consequence<br \/>\n03:28<br \/>\nof prolonged pregnancy<br \/>\n03:29<br \/>\nis an increased<br \/>\n03:30<br \/>\nrisk in prenatal morbidity<br \/>\n03:31<br \/>\nand mortality.<br \/>\n03:32<br \/>\nData shows that this effect is<br \/>\n03:34<br \/>\neven greater in fetuses<br \/>\n03:35<br \/>\nsmall for gestational age<br \/>\n03:36<br \/>\nwhen compared to the ones<br \/>\n03:37<br \/>\nadequate for gestational age.<br \/>\n03:40<br \/>\nThe main determinant of the type<br \/>\n03:41<br \/>\nof morbidity and mortality<br \/>\n03:43<br \/>\nassociated with prolonged<br \/>\n03:44<br \/>\npregnancy<br \/>\n03:44<br \/>\nis the placental function.<br \/>\n03:46<br \/>\nThe fetus relies 100%<br \/>\n03:48<br \/>\non the placenta<br \/>\n03:48<br \/>\nfor its nutrition.<br \/>\n03:50<br \/>\nIf it continues to work<br \/>\n03:51<br \/>\nappropriately, he will continue<br \/>\n03:52<br \/>\nto grow, being<br \/>\n03:53<br \/>\nadequate for gestational age<br \/>\n03:55<br \/>\nbut having a high risk<br \/>\n03:56<br \/>\nof macrosomy.<br \/>\n03:57<br \/>\nConversely,<br \/>\n03:58<br \/>\nif the placental function is<br \/>\n04:00<br \/>\ninadequate, the fetus will be<br \/>\n04:02<br \/>\nliterally starving, which<br \/>\n04:04<br \/>\nincreases its risk for being<br \/>\n04:05<br \/>\nsmall for gestational age<br \/>\n04:06<br \/>\nand having dysmaturity syndrome.<br \/>\n04:08<br \/>\n04:11<br \/>\n80% of babies born<br \/>\n04:12<br \/>\nafter a prolonged pregnancy<br \/>\n04:13<br \/>\nwill continue to have<br \/>\n04:14<br \/>\nadequate placental function,<br \/>\n04:16<br \/>\nmaking them macrosomic.<br \/>\n04:17<br \/>\nThe main risk in this group<br \/>\n04:19<br \/>\nof patients<br \/>\n04:19<br \/>\nis labor dysfunction, which<br \/>\n04:21<br \/>\nincreases occurrence of shoulder<br \/>\n04:22<br \/>\ndystocia and its complications;<br \/>\n04:24<br \/>\ncesarean section; postpartum<br \/>\n04:25<br \/>\nhemorrhage;<br \/>\n04:26<br \/>\noperative vaginal deliveries&#8211;<br \/>\n04:27<br \/>\nlike forceps-assisted vaginal<br \/>\n04:28<br \/>\ndelivery<br \/>\n04:29<br \/>\nand vacuum-assisted vaginal<br \/>\n04:30<br \/>\ndelivery;<br \/>\n04:31<br \/>\nand birth trauma in general.<br \/>\n04:32<br \/>\n04:36<br \/>\n20% of babies born<br \/>\n04:37<br \/>\nafter a prolonged pregnancy<br \/>\n04:39<br \/>\nwill have inadequate placental<br \/>\n04:40<br \/>\nfunction, leading them to suffer<br \/>\n04:41<br \/>\nfrom dysmaturity syndrome.<br \/>\n04:43<br \/>\nThese neonates are at a higher<br \/>\n04:45<br \/>\nrisk of being<br \/>\n04:46<br \/>\nsmall for gestational age,<br \/>\n04:47<br \/>\nhaving fetal growth restriction,<br \/>\n04:49<br \/>\noligohydramnios, fetal distress,<br \/>\n04:51<br \/>\nmeconium-stained fluid,<br \/>\n04:53<br \/>\nacidosis, and needing a cesarean<br \/>\n04:55<br \/>\nsection.<br \/>\n04:55<br \/>\n04:58<br \/>\nSo, what will you do<br \/>\n05:00<br \/>\nif your patient suffers<br \/>\n05:01<br \/>\nfrom this condition?<br \/>\n05:03<br \/>\nThe first step is to determine<br \/>\n05:04<br \/>\nif there is good dating.<br \/>\n05:06<br \/>\nSo let&#8217;s assume there&#8217;s poor<br \/>\n05:07<br \/>\ndating.<br \/>\n05:08<br \/>\nThe management should be<br \/>\n05:09<br \/>\nexpectant.<br \/>\n05:10<br \/>\nRemember that the further<br \/>\n05:11<br \/>\nthe gestational age, the less<br \/>\n05:13<br \/>\nreliable an ultrasound is<br \/>\n05:14<br \/>\nfor estimating it.<br \/>\n05:16<br \/>\nIn this case,<br \/>\n05:16<br \/>\nyou have to perform<br \/>\n05:17<br \/>\ntwice-weekly fetal well-being<br \/>\n05:18<br \/>\ntesting<br \/>\n05:19<br \/>\nwith a biophysical profile<br \/>\n05:20<br \/>\nand non-stress tests.<br \/>\n05:23<br \/>\nIf there&#8217;s good dating&#8211; meaning<br \/>\n05:24<br \/>\nthere&#8217;s a reliable LMP and\/or<br \/>\n05:27<br \/>\nearly first trimester<br \/>\n05:28<br \/>\nultrasound&#8211; the next step is<br \/>\n05:30<br \/>\nto evaluate the cervix.<br \/>\n05:32<br \/>\nIf the cervix is favorable,<br \/>\n05:33<br \/>\nthere&#8217;s no benefit of keeping<br \/>\n05:34<br \/>\nthe fetus in utero.<br \/>\n05:36<br \/>\nYou have to manage the patient<br \/>\n05:37<br \/>\nactively to promote labor.<br \/>\n05:39<br \/>\nA first step could be sweeping<br \/>\n05:42<br \/>\nthe amniotic membranes, which<br \/>\n05:43<br \/>\ncan trigger labor by the release<br \/>\n05:45<br \/>\nof factors<br \/>\n05:45<br \/>\nsuch as prostaglandins.<br \/>\n05:48<br \/>\nAnother option is to induce<br \/>\n05:49<br \/>\nlabor with any<br \/>\n05:50<br \/>\nof the multiple mechanical or<br \/>\n05:52<br \/>\npharmaceutical methods<br \/>\n05:53<br \/>\nof labor induction&#8211;<br \/>\n05:55<br \/>\nin example, misoprostol,<br \/>\n05:56<br \/>\npitocin, laminaria, or cervical<br \/>\n05:59<br \/>\nripening balloons.<br \/>\n06:01<br \/>\nNow, if the cervix isn&#8217;t<br \/>\n06:03<br \/>\nfavorable, the management<br \/>\n06:04<br \/>\nis controversial.<br \/>\n06:05<br \/>\nThere are multiple factors that<br \/>\n06:07<br \/>\nhave to be put<br \/>\n06:07<br \/>\ninto consideration in order<br \/>\n06:09<br \/>\nto counsel the patient<br \/>\n06:09<br \/>\nabout management options.<br \/>\n06:11<br \/>\nLuckily for you, it&#8217;s not<br \/>\n06:12<br \/>\ntypical for USMLE<br \/>\n06:13<br \/>\nto include questions<br \/>\n06:14<br \/>\nabout controversial subjects<br \/>\n06:16<br \/>\nwhere there is no consensus<br \/>\n06:18<br \/>\nof only one clear best answer.<br \/>\n06:19<br \/>\n06:23<br \/>\nHaving said all of this,<br \/>\n06:24<br \/>\nthe key elements<br \/>\n06:25<br \/>\nthat you need to know back<br \/>\n06:26<br \/>\nand forth about prolonged<br \/>\n06:28<br \/>\npregnancy are, first, it&#8217;s<br \/>\n06:31<br \/>\ndefined as a pregnancy that has<br \/>\n06:32<br \/>\nreached or exceeded 42 weeks<br \/>\n06:35<br \/>\nof gestational age.<br \/>\n06:37<br \/>\nSecond, the most common cause<br \/>\n06:40<br \/>\nof prolonged pregnancy<br \/>\n06:41<br \/>\nis poor dating.<br \/>\n06:43<br \/>\nThird, morbidity and mortality<br \/>\n06:45<br \/>\ndepend on placental function,<br \/>\n06:47<br \/>\nwhich, if it&#8217;s decreased,<br \/>\n06:50<br \/>\nthe consequence is<br \/>\n06:50<br \/>\ndysmaturity syndrome<br \/>\n06:52<br \/>\nand, if it&#8217;s maintained,<br \/>\n06:53<br \/>\nmacrosomnia syndrome.<br \/>\n06:56<br \/>\nFourth and finally,<br \/>\n06:57<br \/>\nthe management depends<br \/>\n06:59<br \/>\non the dating and the cervix.<br \/>\n07:01<br \/>\nIf poor dating, it should be<br \/>\n07:02<br \/>\nexpectant.<br \/>\n07:03<br \/>\nIf good dating, the next step<br \/>\n07:05<br \/>\nis to check the cervix.<br \/>\n07:06<br \/>\nIf it&#8217;s favorable,<br \/>\n07:07<br \/>\nyou should proceed<br \/>\n07:08<br \/>\nwith induction of labor.<br \/>\n07:09<br \/>\nIf unfavorable, the management<br \/>\n07:11<br \/>\nis controversial.<\/p>\n<p><\/div>\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 7:24<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":160,"menu_order":11,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-390","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/390","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/comments?post=390"}],"version-history":[{"count":2,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/390\/revisions"}],"predecessor-version":[{"id":481,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/390\/revisions\/481"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/media?parent=390"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}