Pregnancy Complications

1
Pregnancy Complications
2
Hydatidiform Mole

• Moore LE, Ware D. Hydatidiform Mole. eMedicine.
  Retrieved 31 January 2006, from
  www.emedicine.com/med/topic1047.htm
• Viera AJ, Clenney TL, Shenenberger DW. Vaginal
  Bleeding at 16 Weeks. Electronic version J Am
  Fam Phys 199959(3), Retrieved 16 November 2005,
  from www.aafp.org/afp/990201ap/photo.html

3
Hydatidiform Mole

• Complete/Classic Mole
• No identifiable fetal tissue
• Partial Mole
• Some recognizable fetal or embryonic tissue

http//www-medlib.med.utah.edu/WebPath/jpeg2/PLAC0
62.jpg
4
Hydatidiform Moles

• 1/1000-1500 pregnancies
• Risk factors
• Teenagers
• Women over 35 (35 2x risk, 40 7x risk)
• Previous miscarriage
• Only 1 of subsequent conceptions result in
  another molar pregnancy

5
Complete Hydatidiform Mole

• Signs Symptoms
• Vaginal bleeding (97)
• most common presenting symptom
• Hyperemesis
• due to elevated HCG
• Hyperthyroidism (7)
• may present with tachycardia, tremor, warm skin
• Preeclampsia (27)
• Large for date uterus

6
Incomplete Hydatidiform Mole

• Signs Symptoms
• (similar to incomplete or missed abortion)
• Vaginal bleeding
• Absence of fetal heart tones
• Uterine enlargement and preeclampsia
• only 3 of patients
• Hyperemesis and hyperthyroidism are rare

7
Hydatidiform Mole

• Diagnosis
• Ultrasound
• vesicular / snowstorm pattern
• HCG levels
• Elevated compared to a normal pregnancy of
  similar gestational age

www.obgyn.net/us/ _uploads/hmole2.jpg
8
Hydatidiform Mole

• Differential Diagnosis
• Painless vaginal bleeding
• Placenta previa
• Missed abortion
• Key Differential?
• Absence of identifiable fetal parts on ultrasound

9
Hydatidiform Mole

• Treatment
• Evacuation and curettage OR
• Hysterectomy
• Must consider
• Age of the patient
• Desire to preserve fertility

10
Hydatidiform Mole

• Potential precursor to gestational trophoblastic
  disease and choriocarcinoma
• 20 develop a malignancy
• metastasis occurs in 4 of complete moles
• Choriocarcinoma may metastasize to
• Lungs
• Vagina
• Brain
• Liver
• Kidney

11
Hydatidiform Mole

• Follow-up
• bHCG tested regularly
• monthly for 6-12 months
• any rise in levels should prompt a chest
  radiograph and pelvic examination
• Contraception
• must be used during the entire follow-up period
• at least 1 year

12
Ectopic Pregnancy

• Lozeau A, Potter B. Diagnosis and Management of
  Ectopic Pregnancy. Am Fam Physician
  200572(9)1707-1714.

13
Ectopic Pregnancy

• Any pregnancy that occurs outside of the uterine
  cavity
• Tubal
• Ampulla (55)
• Isthmus (25)
• Fimbria (17)
• Cervical
• Ovarian
• Abdominal

97
3
14
Ectopic Pregnacy

• 1.9 of reported pregnancies
• Leading cause of pregnancy-related death in the
  first trimester
• Ruptured ectopic pregnancy accounts for 10-15 of
  all maternal deaths

15
Ectopic Pregnancy

• Risk Factors
• Previous tubal surgery
• Previous ectopic pregnancy
• In utero DES exposure
• Previous genital infections
• Infertility
• Current smoking
• Previous IUD use

HIGH
16
Ectopic Pregnancy

• Most common presentation
• Woman of reproductive age
• Abdominal pain
• Vaginal bleeding
• Approx 7 weeks after amenorrhea
• Nonspecific dDx is important

17
Ectopic Pregnancy

• Differential Diagnosis
• Acute appendicitis
• Miscarriage
• Ovarian torsion
• Pelvic inflammatory disease
• Ruptured corpus luteum cyst or follicle
• Tubo-ovarian abcess
• Urinary calculi

18
Ectopic Pregnancy

• Exam Findings
• Normal or slightly enlarged uterus
• Vaginal bleeding
• Pelvic pain with manipulation of the cervix
• Palpable adnexal mass (fallopian tube)

19
Ectopic Pregnancy

• Suspect Rupture If
• Significant abdominal tenderness
• Especially if accompanied by
• Hypotension
• Abdominal guarding
• Rebound tenderness

20
Ectopic Pregnancy

• Diagnositc Tests
• Ultrasound (test of choice)
• No intrauterine gestational sac
• bHCG
• Do not increase appropriately
• Urine pregnancy test
• Pregnant / not pregnant
• Progesterone level (less reliable)

21
Ectopic Pregnancy

• Treatment
• Expectant management
• Monitor progress
• Medical treatment
• Methotrexate folic acid antagonist
• Disrupts rapidly dividing trophoblastic cells
• Surgery
• Laparoscopy with salpingostomy, without fallopian
  tube removal

22
Ectopic Pregnancy

• Long Term
• 30 have later difficulty conceiving
• No difference between treatment options
• 5-20 rate of recurrence
• 32 risk of recurrence if shes had 2 consecutive
  ectopic pregnancies

23
Spontaneous Abortion

• Griebel CP, Halvorsen J, Golemon, TB. Management
  of Spontaneous Abortion. Am Fam Physician 2005
  72(7)1243-50.

24
Spontaneous Abortion

• aka miscarriage, spontaneous pregnacy loss,
  early pregnancy failure
• Pregnancy loss at less than 20 weeks gestation

25
Definitions

• Threatened abortion
• A pregnancy complicated by bleeding before 20
  weeks gestation
• Inevitable abortion
• The cervix has dilated, but the products of
  conception have not been expelled

26
Definitions

• Complete abortion
• All products of conception have been passed
  without need for surgical or medical intervention
• Incomplete abortion
• Some, but not all, of the products of conception
  have been passed retained products may be part
  of the fetus, placenta, or membranes
• Missed abortion
• A pregnancy in which there is a fetal demise
  (usually for a number of weeks) but no uterine
  activity to expel the products of conception

27
Definitions

• Septic abortion
• A spontaneous abortion that is complicated by
  intrauterine infection
• Recurrent spontaneous abortion
• Three (3) or more consecutive pregnancy losses

28
Spontaneous Abortion

• Etiology
• Chromosomal abnormality
• 49 of spontaneous abortions
• most are random events
• NOTE
• Stress
• Marijuana use
• Sexual activity

Do NOT increase risk
29
Spontaneous Abortion
Risk Factors

• Advanced maternal age
• Alcohol use
• Anesthetic gas use (nitrous oxide)
• Caffeine use (heavy)
• Chronic maternal diseases
• poorly controlled diabetes
• celiac disease
• autoimmune diseases
• Cigarette smoking
• Cocaine use
• Conception within 3-6 months after delivery

• IUD use
• Maternal infections
• Bacterial vaginosis
• TORCH
• STDs
• Medications
• Multiple previous elective abortions
• Previous spontaneaous abortions
• Toxins
• Uterine abnormalities

30
Spontaneous Abortion

• Up to 20 of recognized pregnancies
• 30 actual miscarriage rate
• Often mistaken for late onset of menses
• 50 of pregnancies complicated by bleeding
  before 20 weeks gestation will end in
  spontaneous abortion
• dDx?

31
Differential DiagnosisFirst Trimester Vaginal
Bleeding

• Idiopathic bleeding in a viable pregnancy
• Ectopic pregnancy
• Molar pregnancy
• Spontaneous abortion
• Subchorionic hemorrhage
• Infection of the vagina or cervix
• Cervical abnormalities
• Malignancy, polyps, trauma
• Vaginal trauma

32
Spontaneous Abortion

• Diagnosis
• HCG levels
• Progesterone levels
• Ultrasound
• Status of the pregnancy
• Intrauterine? Ectopic?
• Exam dilated cervix gt inevitable abortion
• the risk for spontaneous abortion decreases
  from 50 to 3 when a fetal heartbeat is
  identified on ultrasound

labs
33
Abortion? or not?
Progesterone HCG Ultrasound Abortion?
gt25 ng per mL Increases (48 hours) Normal No
lt5 ng per mL Plateau or decrease Nonviable pregnancy Yes
34
Spontaneous Abortion

• Management
• Surgical evacuation (DC)
• Patient is unstable
• Heavy bleeding
• Septic abortion
• Patient choice
• Medical therapy
• Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion
• No need for surgical intervention 80-95 of the
  time

35
Spontaneous Abortion

• Considerations
• Feelings of guilt
• Grieving process
• Anxiety depression

counseling
www.compassionatefriends.org www.nationalshareoffi
ce.com
36
Spontaneous Abortion - Tips

• Acknowledge and attempt to dispel guilt
• Acknowledge and legitimize grief
• Assess level of grief and adjust counseling
  accordingly
• Counsel how to tell family and friends of the
  miscarriage
• Include the patients partner in psychologic care
• Provide comfort, empathy, and ongoing support
• Reassure about the future
• Warn about the anniversary phenomenon

37
Placenta Previa

• Ko P, Yoon Y. Placenta Previa. eMedicine.
  Retrieved 5 February 2006 from www.emedicine.com/e
  merg/topic427.htm

38
Placenta Previa

• Implantation of the placenta over or near the
  internal os of the cervix
• Vaginal bleeding in the 2nd and 3rd trimesters
• 5/1,000 deliveries
• Maternal mortality rate of 0.03

39
Placenta Previa

• Total placenta previa
• internal os is completely covered by the placenta
• Partial placenta previa
• internal os is partially covered by the placenta
• self-correct? uterus enlarges, placental site
  moves cephalad
• Marginal placenta previa
• placenta is at the margin of the internal os
• Low-lying placenta previa
• placenta is implanted in the lower uterine
  segment
• edge of the placenta is near the internal os but
  does not reach it

40
Placenta Previa

• Risk Factors
• Prior previa
• Multiparity
• Multiple gestations
• Advanced maternal age
• Previous cesarean delivery
• Prior induced abortion
• Smoking

41
Placenta Previa

• History
• Vaginal bleeding
• Bright red and painless (recurrent)
• Occurs on average at 27-32 weeks' gestation
• Contractions may or may not occur simultaneously
  with the bleeding

• Exam Findings
• Profuse hemorrhage
• Hypotension
• Tachycardia
• Soft and nontender uterus
• Normal fetal heart tones (usually)

42
Placenta Previa

• Differentials
• Abruptio Placenta
• Disseminated Intravascular Coagulation
• Pregnancy, Delivery
• Vasa previa
• Infection
• Vaginal bleeding
• Lower genital tract lesions
• Bloody show

43
Placenta Previa

• Diagnosis
• Ultrasound
• Management
• lt37 weeks without hemorrhage
• expectant management
• Hemorrhage or gt37 weeks and in labor
• delivery
• C-section
• trial of labor may be considered for anterior
  marginal previa

44
Abruptio Placentae

• Gaufberg SV. Abruptio Placentae. eMedicine.
  Retrieved 5 February 2006 from www.emedicine.com/e
  merg/topic12.htm

45
Abruptio Placentae

• Separation of the normally located placenta after
  the 20th week of gestation (prior to birth)
• 1 of all pregnancies
• Results in compromised blood supply to the fetus
• Severity of fetal distress correlates with the
  degree of placental separation

46
Abruptio Placentae

• Clinical presentation
• Vaginal bleeding (80)
• Abdominal or back pain and uterine tenderness
  (70)
• Fetal distress (60)
• Abnormal uterine contractions (35)
• Idiopathic premature labor (25)
• Fetal death (15)

47
Abruptio Placentae

• Diagnosis
• Severe uterine pain and tenderness
• Mild vaginal bleeding
• Hypertension (HTN)
• Difficult to identify on ultrasound
• Can help differentiate from other causes of
  bleeding (i.e. placenta previa)

48
Abruptio Placentae (Class 0-3)

• Class 0
• Asymptomatic
• Diagnosis is made retrospectively
• organized blood clot or a depressed area on a
  delivered placenta

49
Abruptio Placentae (Class 0-3)

• Class 1
• Mild
• 48 of all cases
• Characteristics
• No vaginal bleeding to mild vaginal bleeding
• Slightly tender uterus
• Normal maternal BP and heart rate
• No coagulopathy
• No fetal distress

50
Abruptio Placentae (Class 0-3)

• Class 2
• Moderate
• 27 of all cases
• Characteristics
• Vaginal bleeding none to moderate
• Moderate-to-severe uterine tenderness with
  possible tetanic contractions
• Maternal tachycardia with orthostatic changes in
  BP and heart rate
• Fetal distress
• Hypofibrinogenemia (ie, 50-250 mg/dL)

51
Abruptio Placentae (Class 0-3)

• Class 3
• Severe
• 24 of all cases
• Characteristics
• vaginal bleeding none to heavy
• Very painful tetanic uterus
• Maternal shock
• Hypofibrinogenemia (ie, lt150 mg/dL)
• Coagulopathy
• Fetal death

52
Abruptio Placentae

• Causes
• Maternal hypertension (44)
• Maternal trauma (1.5-9.4)
• MVA, assaults, falls
• Cigarette smoking
• Alcohol consumption
• Cocaine use
• Short umbilical cord
• Advanced maternal age
• Retroplacental fibromyoma

• Sudden decompression of the uterus
• premature rupture of membranes, delivery of first
  twin
• Retroplacental bleeding from needle puncture
• postamniocentesis
• Idiopathic
• probable abnormalities of uterine blood vessels
  and decidua

53
Abruptio Placentae

• Maternal complications
• Hemorrhagic shock
• Coagulopathy/DIC
• Uterine rupture
• Renal failure
• Ischemic necrosis of distal organs
• (eg, hepatic, adrenal, pituitary)

• Fetal complications
• Hypoxia
• Anemia
• Growth retardation
• CNS anomalies
• Fetal death

54
Polyhydramnios

• Boyd RL, Carter BS. Polyhydramnios and
  Oligohydramnios. EMedicine. Retrieved 5 February
  2006 from http//www.emedicine.com/ped/topic1854.h
  tm

55
Polyhydramnios

• Abnormally high level of amniotic fluid
• gt2000 mL of fluid
• Normal peaks at 800-1000mL at 36-37 weeks'
  gestation
• 1 of pregnancies
• 20 are born with congenital anomalies

56
Polyhydramnios

• Risk Factors
• Multiple gestations
• twin to twin transfusion
• Maternal diabetes
• Fetal anomolies
• Gastrointestinal system (most common)
• Central nervous system
• swallowing dysfunction
• Cardiovascular system
• Genitourinary system
• Chromosomal abnormalities

57
Polyhydramnios

• Examination
• Rapidly enlarging uterus
• Difficulty identifying fetal parts (Leopolds)
• Fetal ballottement is easier

58
Polyhydramnios

• Complications
• Preterm labor and delivery (26)
• Premature rupture of the membranes (PROM)
• Abruptio placenta
• Malpresentation
• Cesarean delivery
• Postpartum hemorrhage

59
Polyhydramnios

• Considerations
• Management of diabetes
• Steroid therapy
• enhance fetal lung maturity if preterm labor is
  expected
• Genetic counseling
• if congenital anomaly is present

60
Oligohydramnios

• Boyd RL, Carter BS. Polyhydramnios and
  Oligohydramnios. EMedicine. Retrieved 5 February
  2006 from http//www.emedicine.com/ped/topic1854.h
  tm

61
Oligohydramnios

• Inadequate levels of amniotic fluid
• results in poor development of the lung tissue
  and can lead to fetal death
• Affects 4 of pregnancies

62
Oligohydramnios

• Causes
• Fetal urinary tract anomalies
• Renal agenesis
• Polycystic kidneys
• Obstructive urinary lesion
• Postmaturity syndrome
• Possibly caused by a decline in placental function

• Maternal problems
• Placental insufficiency
• Premature rupture of membranes
• Chronic leakage of the amniotic fluid

63
Oligohydramnios

• Fetal mortality rate is high (5-6)
• Increased risk of
• Pulmonary hypoplasia
• Meconium staining of the amniotic fluid
• Fetal heart conduction abnormalities
• Poor tolerance of labor
• Lower Apgar scores
• Fetal acidosis
• Intrauterine growth restriction (IUGR)

64
Oligohydramnios

• Complications
• Fetal distress before or during labor
• Meconium
• potential for aspiration
• Fetal infection
• (prolonged rupture of the membranes)

65
Oligohydramnios

• Management
• Maternal bed rest and hydration
• promote the production of amniotic fluid

66
Oligohydramnios

• Considerations
• Fetal anomaly
• counseling
• Postmaturity
• review pregnancy dating
• deliver the fetus (induction or cesarean)

67
Preeclampsia - Eclampsia

• Morrison EH. Common Peripartum Emergencies. Am
  Fam Physician 1998 58(7). Retrieved 16 November
  2005 from www.aafp.org/afp/981101ap/morrison.html.
  
• Wagner LK. Diagnosis and Management of
  Preeclampsia. Am Fam Physician 2004
  70(12)2317-24.

68
Preeclampsia

• Defined as a pregnancy-specific multisystem
  disorder of unknown etiology.
• New onset of elevated blood pressure and
  proteinuria after 20 weeks gestation

69
Preeclampsia

• Affects 5-7 of pregnancies
• Increased risk of
• Placental abruption
• Acute renal failure
• Cerebrovascular/cardiovascular complications
• Disseminated intravascular coagulation
• Maternal death

70
Preeclampsia

• 3rd leading cause of pregnancy-related deaths
• Maternal death due to
• Cerebrovascular events
• Renal or hepatic failure
• HELLP syndrome
• Complications of hypertension

71
Preeclampsia

• Risk Factors
• Pregnancy-associated
• Maternal-specific
• Paternal-specific

72
Preeclampsia Risk Factors

• 1. Pregnancy-associated
• Chromosomal abnormalities
• Hydatidiform mole
• Hydrops fetalis
• Multifetal pregnancy
• Structural congenital anomalies
• Urinary tract infection

73
Preeclampsia Risk Factors

• 2. Maternal-specific
• Age gt35 years
• Age lt20 years
• Black
• Family history of preeclampsia
• Nulliparity
• Preeclampsia in a previous pregnancy

• Medical conditions
• Gestational diabetes
• Type I diabetes
• Obesity
• Chronic hypertension
• Renal disease
• Stress

74
Preeclampsia Risk Factors

• 3. Paternal-specific
• First-time father
• Previously fathered a preeclamptic pregnancy (in
  another woman)

75
Preeclampsia

• Diagnosis
• Blood pressure 140 mmHg or higher systolic or 90
  mmHg or higher diastolic
• Previously normal blood pressure
• Proteinuria 0.3 g or more of protein in a 24 hr
  urine collection

76
Severe Preeclampsia

• Blood pressure 160 mmHg or higher systolic or
  110 mmHg or higher diastolic
• Proteinuria 5g or more of protein in a 24 hr
  urine collection
• Other
• Oliguria
• Cerebral or visual disturbances
• Pulmonary edema or cyanosis

• Epigastric or R upper quadrant pain
• Impaired liver function
• Thrombocytopenia
• Intrauterine growth restriction

77
Hypertensive Disorders of Pregnancy
78
Preeclampsia

• Clinical Presentation
• Asymptomatic

• Severe Preeclampsia
• Visual disturbances
• Severe headache
• Upper abdominal pain
• HELLP

79
Preeclampsia HELLP Syndrome

• Hemolysis
• Elevated Liver enzymes
• Low Platelet count
• 4-14 of women with preeclampsia
• Mortality or serious morbidity 25

80
Preeclampsia

• History
• Pregnant women should be asked about specific
  symptoms, including visual disturbances,
  persistent headaches, epigastric or R upper
  quadrant pain, and increased edema.

81
Preeclampsia

• Examination
• Blood pressure
• Fundal height
• Growth retardation? Oligohydramnios?
• NOTE
• Increasing maternal facial edema
• Rapid weight gain

Fluid retention is often associated with
preeclampsia
82
Preeclampsia

• Medical Management
• Antihypertensive drug therapy
• 160-180/105-110 or higher
• many are contraindicated for use during
  pregnancy
• Magnesium sulfate
• During labor to prevent seizures

83
Preeclampsia

• Treatment
• If preterm
• Observed on an outpatient basis
• Hospitalized
• Delivery
• Vaginal delivery is preferred
• Avoid added physiological stress of C-section

84
Indications for Delivery

• Fetus
• Severe intrauterine growth retardation
• Nonreassuring fetal surveillance
• Oligohydramnios
• Mother
• Gestational age 38 weeks or greater
• Low platelet count

• Mother (contd)
• Deterioration of hepatic or renal function
• Suspected placental abruption
• Persistent severe HA, visual changes
• Persistent severe epigastric pain, nausea, or
  vomiting
• Eclamspia

85
Preeclampsia

• Risk of recurrence
• Nulliparous may be as high as 40
• Multiparous even higher

86
Eclampsia

• Severe complication of preeclampsia
• New onset of seizures in a woman with
  preeclampsia
• Affects .05 to .3 of pregnancies
• (developed countries)
• Mortality rate 2
• Serious complications up to 35

87
Eclampsia

• Clinical course is usually gradual BUT
• 20 do not have classic preeclamptic triad (or
  only mild)

88
Eclampsia

• Treatment
• Magnesium sulfate
• Controls seizures
• Antihypertensive agents
• Decrease risk of maternal intracranial hemorrhage
  without jeopardizing uterine blood flow
• As soon as the mother is stabledeliver the baby

89
Preterm Labor

• Von Der Pool BA. Preterm labor diagnosis and
  treatment. Am Fam Physician. 1998 May
  1557(10)2457-64.
• Weismiller DG. Preterm Labor. Am Fam Physician.
  1999 Feb 159(3)593-602.

90
Preterm Labor

• Cervical effacement and/or dilatation and
  increased uterine irritability before 37 weeks of
  gestation
• Affects 8-10 of births in the US
• Rate may be worsening but survival rates have
  increased and morbidity has decreased
• Still remains a leading cause of perinatal
  morbidity and mortality in the US

91
Risk Factors

• Previous preterm delivery (greatest risk)
• Low socioeconomic status
• Non-white race
• Maternal age lt18 years or gt40 years
• Preterm premature rupture of the membranes
  (PPROM)
• Multiple gestation
• Maternal history of one or more spontaneous
  second-trimester abortions

92
Risk Factors (contd)

• Maternal complications
• Smoking
• Illicit drug use
• Alcohol use
• Lack of prenatal care
• Uterine causes
• Myomata
• Uterine septum
• Bicornuate uterus
• Cervical incompetence
• Exposure to diethylstilbestrol

• Infectious causes
• Chorioamnionitis
• Bacterial vaginosis
• Acute pyelonephritis
• Fetal causes
• Intrauterine fetal death
• Intrauterine growth retardation
• Congenital anomalies
• Abnormal placentation
• Presence of a retained intrauterine device

93
Preterm Labor

• Predicting preterm labor
• Monitor cervical change, uterine contractions,
  bleeding, and changes in fetal behavioral states
  (?)
• High false positive rate
• Unnecessary and potentially hazardous treatment

94
Preterm Labor

• Management
• Tocolytic therapy
• Inhibit labor, slow down or halt the contractions
  of the uterus
• Delay delivery time to administer corticosteroid
  therapy
• Corticosteroid therapy
• Enhance pulmonary maturity
• Reduce severity of fetal RDS and intraventricular
  hemorrhage
• Antibiotic Therapy
• Women with PPROM sustain the pregnancy longer
• Bed rest(?)
• No conclusive studies documenting its benefit

95
Post-term Pregnancy

• Briscoe D, Nguyen H, Mencer M, Gautam N, Kalb DB.
  Management of pregnancy beyond 40 weeks'
  gestation. Am Fam Physician. 2005 71(10)
  1935-41.  

96
Post-term Pregnancy

• Pregnancy that reaches 42 weeks gestation
  (5-10 of pregnancies)
• Increased risk to the mother and fetus
• Perinatal mortality rate doubles by 42 weeks and
  is 4-6x greater at 44 weeks

97
Risks Associated with Post-term Pregnancy

• Maternal risks
• Acute cesarean delivery
• Cephalopelvic disproportion
• Cervical rupture
• Dystocia
• Fetal death during delivery
• Large fetus
• Postpartum hemorrhage
• Puerperal infection

• Neonatal risks
• Asphyxia
• Aspiration
• Bone fracture
• Perinatal death
• Peripheral nerve paralysis
• Pneumonia
• Septicemia

Briscoe D, Nguyen H, Mencer M, Gautam N, Kalb DB.
Management of pregnancy beyond 40 weeks'
gestation. Am Fam Physician. 2005 May
1571(10)1935-41.  
98
Pregnancy Beyond 40 Weeks

• Challenge
• Accurate assessment of gestational age (?)
• Ultrasound dating at 13-24 weeks is more accurate
  than estimates based on LMP

99
Management?

• Labor induction
• proposed to reduce rates of adverse fetal and
  maternal complications
• Decrease C-section(?)
• Decrease perinatal mortality (?)
• vs. expectant management
• (fetal monitoring)

100
Management?

• Expectant Management
• With fetal monitoring
• Up to 42 weeks gestation
• Indication for labor induction
• Nonreassuring test results
• Oligohydramnios
• 42 weeks gestation

101
Contraindications to Cervical Ripening and Labor
Induction

• Absolute contraindications
• Complete placenta previa
• Previous transfundal uterine surgery
• Transverse fetal lie
• Umbilical cord prolapse
• Vasa previa

• Caution required
• Abnormal fetal heart rate patterns not requiring
  emergent delivery
• Breech presentation
• Maternal heart disease or severe hypertension
• Multifetal pregnancy
• Polyhydramnios
• Presenting part above the pelvic inlet
• One or more previous low-transverse cesarean
  deliveries

102
Higher-risk Pregnancies

• Gestational diabetes
• Hypertension
• Cannot be managed the same way as low-risk
  post-term pregnancies